Esophageal cancer patients' need for information and support in making a treatment decision between standard surgery and active surveillance

BACKGROUND

This study explores patients' need for information and support in deciding on esophageal cancer treatment, when experimental active surveillance and standard surgery are both feasible.

METHODS

This psychological companion study was conducted alongside the Dutch SANO-trial (Surgery As Needed for Oesophageal cancer). In-depth interviews and questionnaires were used to collect data from patients who declined participation in the trial because they had a strong preference for either active surveillance (n = 20) or standard surgery (n = 20). Data were analyzed using both qualitative and quantitative techniques.

RESULTS

Patients prefer to receive information directly from their doctors and predominantly rely on this information to make a treatment decision. Other information resources are largely used to confirm their treatment decision. Patients highly value support from their loved ones and appreciate emphatic doctors to actively involve them in the decision-making process. Overall, patients' needs for information and support during decision-making were met.

CONCLUSIONS

The importance of shared decision-making and the role doctors have in this process is underlined. The role of doctors is essential at the initial phase of decision-making: Once patients seem to have formed their treatment preference for either active surveillance or surgery, the influence of external resources (including doctors) may be limited.

Patient preferences for active surveillance vs standard surgery after neoadjuvant chemoradiotherapy in oesophageal cancer treatment: The NOSANO-study

Active surveillance may be a safe and effective treatment in oesophageal cancer patients with a clinically complete response after neoadjuvant chemoradiotherapy (nCRT). In the NOSANO-study we gained insight in patients' motive to opt for either an experimental treatment called active surveillance or for standard immediate surgery. Both qualitative and quantitative analyses methods were used. Forty patients were interviewed about their treatment preference, 3 months after completion of nCRT (T1). Data were recorded, transcribed verbatim and analysed according to the principles of grounded theory. In addition, at T1 and T2 (12 months after completion of nCRT) questionnaires on health-related quality of life, coping, anxiety and decisional regret (only T2) were administered. Interview data analyses resulted in a conceptual model with 'dealing with threat of cancer' as the central theme. Patients preferring active surveillance tend to cope with this threat by confiding in their bodies and good outcomes. Their mind-set is one of 'enjoy life now'. Patients preferring surgery tend to cope by minimizing uncertainty and eliminating the source of cancer. Their mind-set is one of 'don't give up, act now'. Furthermore, questionnaire results showed that patients with a preference for standard surgery had a lower quality of life. Patient preferences are individualized and thus difficult to predict. Our model can help healthcare professionals to determine patient preferences for treatment. Coping style and mind-set seem to be determining factors here.

Treatment decision-making during outpatient clinic visit of patients with esophagogastric cancer. The perspectives of clinicians and patients, a mixed method, multiple case study

BACKGROUND

The probability of undergoing treatment with curative intent according to the hospital of diagnosis varies for esophagogastric cancer in the Netherlands. Little is known about the factors contributing to this variation. This study aimed to improve the understanding of the differences between the multidisciplinary team meeting treatment proposal and the treatment that was actually carried out and to qualitatively investigate the differences in treatment decision-making after the multidisciplinary team meeting treatment proposal between hospitals.

METHODS

To gain an in-depth understanding of treatment decision-making, quantitative data (i.e., multidisciplinary team meeting proposal and treatment that was carried out) were collected from the Netherlands Cancer Registry. Changes in the multidisciplinary team meeting proposal and applied treatment comprised changes in the type of treatment option (i.e., curative or palliative, or no change) and were calculated according to the multivariable multilevel probability of undergoing treatment with curative intent (low, middle, and high). Qualitative data were collected from eight hospitals, including observations of 26 outpatient clinic consultations, 30 in-depth interviews with clinicians, seven focus groups with clinicians, and three focus groups with patients. Clinicians and patients' perspectives were assessed using thematic content analysis.

RESULTS

The multidisciplinary team meeting proposal and applied treatment were concordant in 97% of the cases. Clinicians' implementation of treatment decision-making in clinical practice varied, which was mentioned by the clinicians to be due to the clinician's personality and values. Differences between clinicians consisted of discussing all treatment options versus only the best fitting treatment option and the extent of discussing the benefits and harms. Most patients aimed to undergo curative treatment regardless of the consequences, since they believed this could prolong their life.

CONCLUSION

Since changes in the multidisciplinary team meeting-proposed treatment and actual treatment were rarely observed, this study emphasizes the importance of an adequately formulated multidisciplinary team meeting proposal.

Repeated use of rich pictures to explore changes in subjective experiences over time of patients with advanced cancer

BACKGROUND

The combination of verbal and visual tools may help unravel the experiences of advanced cancer patients. However, most previous studies have focused on a specific symptom, at only one moment in time. We recently found that a specific visual tool, originating from systems thinking, that is, rich pictures (RPs), could provide a more comprehensive view of the experiences of patients with advanced cancer.

AIMS

To examine whether the repeated use of RPs can make changes in subjective experiences of patients living with advanced cancer visible over time.

METHODS AND RESULTS

We performed a prospective study with a generic qualitative approach that was mostly informed by the process of grounded theory. We invited patients to make an RP twice, at the start of the study, and again after 2 months. Both RP drawing sessions were directly followed by a semi-structured interview. Patients with all types of solid tumors, above the age of 18, and with a diagnosis of advanced, incurable cancer, were eligible. Eighteen patients participated and 15 patients were able to draw an RP twice. In eight RP-sets, considerable differences between the first and second RP were noticeable. Two patterns were distinguished: (1) a change (decline or improvement) in physical health (five patients), and/or (2) a change in the way patients related to cancer (three patients).

CONCLUSION

RPs are a valuable qualitative research method that can be used to explore the experiences of patients with advanced cancer, not only at a single point in time but also over time.

Narrative recognition and identification: a qualitative pilot study into reading literary texts with advanced cancer patients

Purpose

Patients with advanced cancer can experience their disease as a contingent life event. The sudden interruption of their life stories can obscure life goals and disrupt meaning making. In the context of the research project “In search of stories,” we aim to investigate the reading and discussion of selected stories which present ways of dealing with a contingent life event. In addition, we examine the use of a newly developed guide for reading these exemplary texts together with advanced cancer patients.

Methods

This qualitative study describes the experiences of five patients with advanced cancer who participated in a guided reading and discussion about selected literary texts. The intervention consisted of reading a selected story, after which each patient was interviewed, using the reading guide as a conversation template. The interviews were then thematically analyzed for their conceptual content using a template analysis.

Results

All five conversations showed some form of recognition in reaction to the chosen text, which led to personal identification of experiences of contingency, such as loss of life goals, impending death, or feelings of uncertainty. Besides the important role of identification, revealed by the responses to the questions in the reading guide, the discussion of the text helped them articulate their own experience and sources of meaning. Diverse worldviews came to the fore and concepts of meaning such as fate, life goals, quality of life, and death.

Conclusions

First experiences with our newly developed reading guide designed to support a structured reading of stories containing experiences of contingency suggest that it may help patients to express their own experiences of contingency and to reflect on these experiences.

Implications for Cancer Survivors

The intervention tested in this study may contribute to supportive care for survivors with advanced cancer, but further research is needed to evaluate its effect on quality of life.

Interventions that Facilitate Shared Decision-Making in Cancers with Active Surveillance as Treatment Option: a Systematic Review of Literature

PURPOSE OF REVIEW

Medical decisions concerning active surveillance are complex, especially when evidence on superiority of one of the treatments is lacking. Decision aids have been developed to facilitate shared decision-making on whether to pursue an active surveillance strategy. However, it is unclear how these decision aids are designed and which outcomes are considered relevant. The purpose of this study is to systematically review all decision aids in the field of oncological active surveillance strategies and outcomes used by authors to assess their efficacy.

RECENT FINDINGS

A search was performed in Embase, Medline, Web of Science, Cochrane, PsycINFO Ovid and Google Scholar until June 2019. Eligible studies concerned interventions aiming to facilitate shared decision-making for patients confronted with several treatment alternatives, with active surveillance being one of the treatment alternatives. Twenty-three eligible articles were included. Twenty-one articles included patients with prostate cancer, one with thyroid cancer and one with ovarian cancer. Interventions mostly consisted of an interactive web-based decision aid format. After categorization of outcomes, seven main groups were identified: knowledge, involvement in decision-making, decisional conflict, treatment preference, decision regret, anxiety and health-related outcomes. Although active surveillance has been implemented for several malignancies, interventions that facilitate shared decision-making between active surveillance and other equally effective treatment alternatives are scarce. Future research should focus on developing interventions for malignancies like rectal cancer and oesophageal cancer as well. The efficacy of interventions is mostly assessed using short-term outcomes.

Prevention of incisional hernia after midline laparotomy with prophylactic mesh reinforcement: a meta-analysis and trial sequential analysis

Background

Incisional hernia is a frequent complication after abdominal surgery. The aim of this study was to assess the efficacy of prophylactic mesh reinforcement (PMR) after midline laparotomy in reducing the incidence of incisional hernia.

Methods

A meta‐analysis was conducted following PRISMA guidelines. The primary outcome was the incidence of incisional hernia after follow‐up of at least 12 months. Secondary outcomes were postoperative complications. Only RCTs were included. A random‐effects model was used for the meta‐analysis, and trial sequential analysis was conducted.

Results

Twelve RCTs were included, comprising 1815 patients. The incidence of incisional hernia was significantly lower after PMR compared with sutured closure (risk ratio (RR) 0·35, 95 per cent c.i. 0·21 to 0·57; P < 0·001). Both onlay (RR 0·26, 0·11 to 0·67; P = 0·005) and retromuscular (RR 0·28, 0·10 to 0·82; P = 0·02) PMR led to a significant reduction in the rate of incisional hernia. The occurrence of seroma was higher in patients who had onlay PMR (RR 2·23, 1·10 to 4·52; P = 0·03). PMR did not result in an increased rate of surgical‐site infection.

Conclusion

PMR of a midline laparotomy using an onlay or retromuscular technique leads to a significant reduction in the rate of incisional hernia in high‐risk patients. Individual risk factors should be taken into account to select patients who will benefit most.

[Correction added on 19 February 2020, after first online publication: J. García Alamino has been amended to J. M. Garcia‐Alamino]

Living with advanced cancer: Rich Pictures as a means for health care providers to explore the experiences of advanced cancer patients

Background

To provide holistic care to patients with advanced cancer, health care professionals need to gain insight in patients’ experiences across the different domains of health. However, describing such complex experiences verbally may be difficult for patients. The use of a visual tool, such as Rich Pictures (RPs) could be helpful. We explore the use of RPs to gain insight in the experiences of patients with advanced cancer.

Methods

Eighteen patients with advanced cancer were asked to draw a RP expressing how they experienced living with cancer, followed by a semi‐structured interview. Qualitative content analysis, including the examination of all elements in the drawings and their interrelationships, was used to analyze the RPs, which was further informed by the interviews.

Results

The RPs clearly showed what was most important to an individual patient and made relations between elements visible at a glance. Themes identified included: medical aspects, the experience of loss, feelings related to loss, support from others and meaningful activities, and integration of cancer in one's life. The added value of RPs lies in the ability to represent these themes in one single snapshot.

Conclusions

RPs allow for a complementary view on the experiences of advanced cancer patients, as they show and relate different aspects of patients’ lives. A RP can provide health care professionals a visual summary of the experiences of a patient. For patients, telling their story to health care professionals might be facilitated when using RPs.

The idiosyncratic drug-induced gene expression changes in HepG2 cells

The inflammatory stress has been associated with an increase in susceptibility to idiosyncratic drug-induced liver injury (DILI). However, the molecular mechanisms of this inflammation-associated idiosyncratic drug hepatotoxicity remain unknown. We exposed HepG2 cells with high and low doses of three idiosyncratic (I) and three non-idiosyncratic (N) compounds, in the presence (I+ and N+) or absence (I− and N−) of a cytokine mix for 6, 12 and 24 h. To investigate the genome‐wide expression patterns, microarray was performed using the Agilent 4×44K Whole Human Genome chips. The data presented in this DIB include the expression of genes participating in the ceramide metabolism, ER stress, apoptosis and cell survival pathways. The functions of these genes were illustrated in our associated article (Jiang et al., 2017) [1]. Raw and normalized gene expression data are available through NCBI GEO (accession number GSE102006).

Omics-based identification of the combined effects of idiosyncratic drugs and inflammatory cytokines on the development of drug-induced liver injury

The mechanisms of idiosyncratic drug-induced hepatotoxicity remain largely unclear. It has demonstrated that the drug idiosyncrasy is potentiated in the context of inflammation and intracellular ceramides may play a role in this process. To study the mechanisms, HepG2 cells were co-treated with high and low doses of three idiosyncratic (I) and three non-idiosyncratic (N) compounds, with (I+ and N+) or without (I- and N-) a cytokine mix. Microarray, lipidomics and flow cytometry were performed to investigate the genome-wide expression patterns, the intracellular ceramide levels and the induction of apoptosis. We found that all I+ treatments significantly influenced the immune response- and response to stimulus-associated gene ontology (GO) terms, but the induction of apoptotic pathways, which was confirmed by flow cytometry, only appeared to be induced after the high-dose treatment. The ceramide signaling-, ER stress-, NF-kB activation- and mitochondrial activity-related pathways were biologically involved in apoptosis induced by the high-dose I+. Additionally, genes participating in ceramide metabolism were significantly altered resulting in a measurable increase in ceramide levels. The increases in ceramide concentrations may induce ER stress and activate the JNK pathway by affecting the expression of the related genes, and eventually trigger the mitochondria-independent apoptosis in hepatocytes. Overall, our study provides a potential mechanism to explain the role of inflammation in idiosyncratic drug reactions.

[Correlation between ICIQ-UI-SF score and personality testing results over a urinary incontinent population]

OBJECTIVE

We found out the personality pattern of an incontinent population and proceeded to a correlation between the personality inventory and the ICIQ-UI-SF (International Consultation Incontinence Questionnaire Urinary Incontinence Short Form) to demonstrate reliability and sincerity of the answers and to establish that a personality disturbance may impact the physiopathology of micturition.

MATERIALS AND METHODS

We performed an observational prospective study. It included patient's answers to a computed questionnaire combining a double ICIQ-UI-SF questionnaire and the 71 questions of the Minimult questionnaire. Forty-seven patients were asked to participate.

RESULTS

Over 37 patients included, Wilcoxon-Mann-Whitney non parametric test confirmed agreement of the two ICIQ-UI-SF questionnaires with P=0.1792. Twenty-three patients were validated to the Minimult inventory with F scale<70. We analysed variability of the two global ICIQ-UI-SF score in regard with the validity scale using ROC analysis. We observed an AUC of 0.559 with sensitivity 78.6% and specificity 43.5%. No L score was above 70 demonstrating absence of lie. No personality disturbance was found in 9 cases. We observed six cases with a high hypochondric value, five with a high depressive value, and four with a high hysteric value. This neurotic triad was found in two cases. We noticed five cases with psychopathic deviance relative to antisocial behaviour while values of paranoia and hypomania were high in one case without any association of these personality aspects, which demonstrated absence of behavioural problem. Psychotic profile associating schizophrenia, paranoia, depression and hypomania was not found. We outlined in half of the valid population a significant high psycho-asthenic pattern.

CONCLUSION

We conclude that a correlation between the personality inventory and the ICIQ-UI-SF is feasible. The comparative study demonstrate reliability of answers. Sincerity is established by the Minimult L scale. We confirm and precise literature information over clinical personality pattern of this population and observe relevant elements concerning the psycho-asthenic pattern which depicts an anxious personality with an important feeling of the problem. These elements permit to suspect that a personality disturbance may impact the physiopathology of the micturition.

LEVEL OF EVIDENCE

4.

A systematic review of the surgical treatment of large incisional hernia

PURPOSE

Incisional hernia (IH) is one of the most frequent postoperative complications. Of all patients undergoing IH repair, a vast amount have a hernia which can be defined as a large incisional hernia (LIH). The aim of this study is to identify the preferred technique for LIH repair.

METHODS

A systematic review of the literature was performed and studies describing patients with IH with a diameter of 10 cm or a surface of 100 cm2 or more were included. Recurrence hazards per year were calculated for all techniques using a generalized linear model.

RESULTS

Fifty-five articles were included, containing 3,945 LIH repairs. Mesh reinforced techniques displayed better recurrence rates and hazards than techniques without mesh reinforcement. Of all the mesh techniques, sublay repair, sandwich technique with sublay mesh and aponeuroplasty with intraperitoneal mesh displayed the best results (recurrence rates of <3.6%, recurrence hazard <0.5% per year). Wound complications were frequent and most often seen after complex LIH repair.

CONCLUSIONS

The use of mesh during LIH repair displayed the best recurrence rates and hazards. If possible mesh in sublay position should be used in cases of LIH repair.

The principles of abdominal wound closure

BACKGROUND

Incisional hernia (IH) is a common complication of abdominal surgery. Its incidence has been reported as high as 39.9%. Many factors influence IH rates. Of these, surgical technique is the only factor directly controlled by the surgeon. There is much evidence in the literature on the optimal midline laparotomy closure technique. Despite the high level of evidence, this optimal closure technique has not met wide acceptance in the surgical community. In preparation of a clinical trial, the PRINCIPLES trial, a literature review was conducted to find the best evidence based technique for abdominal wall closure after midline laparotomy.

METHODS

An Embase search was performed. Articles describing closure of the fascia after midline laparotomy by different suture techniques and/or suture materials were selected.

RESULTS

Fifteen studies were identified, including five meta-analyses. Analysis of the literature showed significant lower IH rates with single layer closure, using a continuous technique with slowly absorbable suture material. No significant difference in IH incidence was found comparing slowly absorbable and non absorbable sutures. Furthermore, a suture length to wound length ratio of four or more and short stitch length significantly decreased IH rates.

CONCLUSIONS

Careful analysis of the literature indicates that an evidenced based optimal midline laparotomy closure technique can be identified. This technique involves single layer closure with a running suture, using a slowly absorbable suture with a suture length to wound length ratio of four or more and a short stitch length. We adopt this technique as the PRINCIPLES technique.

Meta-analysis of glue versus sutured mesh fixation for Lichtenstein inguinal hernia repair

Background

Chronic pain remains a frequent complication after Lichtenstein inguinal hernia repair. As a consequence, mesh fixation using glue instead of sutures has become popular. This meta-analysis aimed to clarify which fixation technique is to be preferred for elective Lichtenstein inguinal hernia repair.

Methods

A meta-analysis was conducted according to the PRISMA guidelines. Articles published between January 1990 and April 2012 were searched for in MEDLINE, Embase and the Cochrane Library. Randomized controlled trials (RCTs) comparing glue and sutured mesh fixation in elective Lichtenstein repair for unilateral inguinal hernia were included. The quality of the RCTs and the potential risk of bias were assessed using the Cochrane risk of bias tool.

Results

Of 254 papers found in the initial search, a meta-analysis was conducted of seven RCTs comprising 1185 patients. With the use of glue mesh fixation, the duration of operation was shorter (mean difference −2·57 (95 per cent confidence interval (c.i.) –4·88 to −0·26) min; P = 0·03), patients had lower visual analogue scores for postoperative pain (mean difference −0·75 (−1·18 to −0·33); P = 0·001), early chronic pain occurred less often (risk ratio 0·52, 95 per cent c.i. 0·31 to 0·87; P = 0·01), and time to return to daily activities was shorter (mean difference −1·17 (−2·30 to −0·03) days; P = 0·04). The hernia recurrence rate did not differ significantly.

Conclusion

Elective Lichtenstein repair for inguinal hernia using glue mesh fixation compared with sutures is faster and less painful, with comparable hernia recurrence rates.

The impact of mandibular advancement on articulation, resonance and voice characteristics in Flemish speaking adults: a pilot study

Bilateral saggital split osteotomy (BSSO) of the mandible is a frequently performed mandibular orthognathic procedure, used to resolve mandibular disharmonies. Literature review showed contradictory findings regarding the effect of the orthognathic surgery on speech characteristics. The purpose of the present study was to determine a detailed analysis of the articulation, resonance and voice characteristics after BSSO with mandibular advancement for the treatment of Class II malocclusions using objective and subjective assessment techniques (perceptual evaluations, Dysphonia Severity Index, nasalance scores) in eight subjects. The findings of the present study indicate that before and after BSSO with mandibular advancement three types of articulation disorders may predominate in the Flemish language: the incorrect production of the trill sound /r/ and the /s/ sound and devoicing of the /z/. After orthognathic surgery most patients showed an identical articulation pattern (normal or disturbed pattern) as in the presurgical condition. In this study the BSSO with mandibular advancement had no significant impact on the nasality characteristics and the nasalance values probably due to the competent velopharyngeal valving in the presurgical condition. And, as expected the vocal quality revealed no significant difference. The maxillofacial surgeon and the speech language pathologist must be aware of the persistency of these preoperative articulation errors in the postsurgical condition.

Observation of nurse-patient interaction in oncology: review of assessment instruments

The aim of this review is to identify assessment instruments that can be used for analyzing sequences and can be applied to research into nurse-patient communication in cancer care. A systematic search of the literature revealed a variety of methods and instruments applicable to studies recording nurse-patient interaction. The studies that were qualitative in nature offered valuable information on observational research in general, on procedures relating to informed consent and observational arrangements in nursing practice. The quantitative studies provided an insight into the content and structure of the interaction by describing communication concepts or by frequency counts of previously determined behaviours. Systematic research into interaction sequences was not found. However, some of the quantitative instruments identified could be adapted for this purpose. The complexity and time-consuming nature of observational research highlight the need for efficiency. For instance a combination of quantitative and qualitative instruments could be considered.

Identification and isolation of the indole-3-pyruvate decarboxylase gene from Azospirillum brasilense Sp7: sequencing and functional analysis of the gene locus

The root-associated bacterium Azospirillum brasilense Sp7 produces the growth-stimulating phytohormone indole-3-acetic acid (= IAA) via the indole-3-pyruvate pathway. The DNA region containing ipdC, the structural gene for indole-3-pyruvate decarboxylase, was identified in a cosmid gene library of strain Sp7 by hybridization and has been sequenced. Upstream of the gene, two other ORF homologous to gltX and cysS were sequenced that are transcribed in the opposite direction. A functional analysis of the cloned ipdC region has been performed. To test the expression of the gene, a lacZ-Km cartridge was introduced into the gene. By this construct, tryptophan-dependent stimulation of gene expression in A. brasilense Sp7 was observed. Evidences for the existence of another copy of the ipdC gene in the Azospirillum genome are also reported.

[Methodology of penile isotope imaging. Evaluation]

AIMS

Duplex ultrasonography and pulsed doppler analysis or dynamic infusion cavernosometry and cavernosography are used for functional evaluation of penile arterial or venous dynamics during a pharmacological erection. The accuracy of the echographic investigations is correlated to the investigator experience. Cavernosometry and cavernosography are more invasive technique than the radioisotope erection penogram, which is a reproductive and reliable test.

MATERIAL AND METHODS

We investigate 60 patients. Neurological, psychological and endocrinological etiology are excluded. The technique is described: thyroid is blocked by potassium perchlorate, bloodpool is labelled with Tc99m, a dynamic study is performed over 60 mn with intracavernous injection of PGE1 5g or Papaverine 30 mg at T10mn, ROIS are defined by computer processing, a phalogram curve is provided.

RESULTS

This noninvasive test sorts out arteriogenic, venogenic and psychogenic impotence by a qualitative curve analysis. The quantitative parameters depending on numerous time consuming variables have proved to be of poor clinical use and non significant. We objectivate 20 psychogenic impotence, 27 arteriogenic impotence, 7 venous leakage and 6 mixed (arteriogenic and venogenic) impotence. Statistic evaluation of arteriogenic lesions comparative by doppler technique reveals a sensitivity of 83% and a specificity of 87%. The advantages of the test are; ambulatory, objective, noninvasive and reliable investigation. In the same time, "qualitative" data evaluates the response to a pharmacological induced erection.

CONCLUSIONS

The radioisotope erection penogram is a noninvasive, reproductive and reliable screening test for vasculogenic impotence.

[Liposarcoma of the spermatic cord]

The liposarcoma is mainly located in the retroperitoneum and rarely involves the spermatic cord. Dissemination occurs more often via haematogenous way than by lymphatic way. The incidence of local recurrence is higher than distant metastases. The treatment of choice is the wide excision. Adjuvant radiotherapy is recommended in the well differentiated and myxoid type of tumors if the local control during excision is not complete or wide enough. Benefit of chemotherapy is still controversial and limited. Case report of a stage 1 liposarcoma of the spermatic cord, four years after excision of a large lipoma during a hernia repair. The treatment consisted in radical excision of this liposarcoma without any adjuvant therapy. Follow-up of 30 months without recurrence.

Actigraphic evaluation of handedness

The utility of an objective evaluation of motor activity, actigraphy, was examined in the evaluation of handedness. Hand preference was assessed in a homogeneous group of 190 young volunteers using the Edinburgh Inventory (EI). The EI distribution obtained in the population studied was comparable with distributions cited in the literature. Simultaneous actigraphic recordings from both wrists were made in 58 of these subjects for 20 h, starting at 1000 h, using an epoch length of 4 s. Care was taken to include comparable numbers of right- and left-handers (based on EI score) in this subgroup. Two actigraphic parameters were defined. One of these, the Activity Index (AI[x]), is a measure of the difference in total motor activity between right and left wrist. The other, Movement Index (MIy[x]) is a measure of the difference in movement pattern. AI[x] showed a moderate but significant correlation with EI (r = 0.36, P < 0.005). The correlation between MIy[x] and EI was high (r = 0.65, P < 0.0001). Rebinning of the data into 60 s epochs decreased the degree of linear correlation between MIy[x] and EI. We conclude, in contrast to a previous study, that actigraphy can be used to discriminate between dominant and non-dominant hands; that the difference in movement pattern between right and left hand is larger than the difference in total motor activity; and that epoch lengths shorter than the conventional 60 s are more sensitive for this kind of discrimination.

Technetium-99m HMPAO SPET in acute supratentorial ischaemic infarction, expressing deficits as millilitre of zero perfusion

A comparative interim analysis was performed of clinical parameters, computed tomographic (CT) scan results and technetium-99m hexamethylpropylene amine oxime single-photon emission tomography (SPET) findings obtained within 12 h of acute supratentorial ischaemic infarction. First, the applicability for SPET semiquantification in this study of the "method of Mountz", simultaneously accounting for extent and degrees of hypoperfusion by expressing deficits as millilitre of zero perfusion, was considered. Next, the relative contributions of perfusion SPET and CT scan in the acute stage of ischaemic infarction were compared in 27 patients (mean age 68.8 years). Finally, the correlation of SPET lesions with clinical parameters at onset was evaluated. The method of Mountz represents a workable, accurate virtual parameter, with the assumption that the contralateral brain region remains uninvolved. Interobserver reproducibility in 12 SPET studies, with lesions varying between 6 and 369 cc, showed a correlation coefficient r of 0.99. In practice, because of inconstant distribution of activities in the brain, the method can only be applied slice by slice and not on the total global volume. While the mean delay since the onset of symptomatology was approximately 7 h for both SPET and CT scan, SPET showed lesions concordant with the clinical neurological findings in 100% and CT scan in only 48%. One could hypothesize that SPET examinations performed later would show larger functional defects, because of the development of additional functional changes secondary to biochemical alterations. However, in this regard no statistically significant differences were found between two subproups, taking the median of delay before SPET examination as cut-off.(ABSTRACT TRUNCATED AT 250 WORDS)

[Immediate allergy to latex in urological practice]

Five cases of acute allergic reaction to latex are reported. Four of those were diagnosed during surgery and presented anaphylactic shock. One was suspected before surgery by systematic screening and dramatic presentation was avoided. Increasing frequency of latex allergy is reported in the literature and is usually seen in patients with extensive neurosurgical or urological histories, or by peoples currently exposed to natural rubber products (medical staff). Systematic screening in history before surgery is important so that exposure to latex should be avoided in suspected cases.

[Appendicular mucocele. Report of 2 cases]

We report two cases of mucocele of the appendix produced by a cystadenocarcinoma, with pseudomyxoma peritonei in one. The treatment consisted in appendectomy with partial resection of the caecum, for the first patient. It consisted in wide resection and in local chemotherapy for the second.

[Actinomycosis of the abdominal wall. Report of a case]

We report a primary case of Actinomycosis of the abdominal wall. The diagnosis is obtained on the basis of the CT-scan and the pathological examination. The treatment is a surgical excision and a long term administration of antibiotics.

[First elements of comparison between blood-tissue barriers at cerebral, genital and urinary levels]

Fluorescence microscope observations of Trypan Blue distribution gives the demonstration of the blood-tissue barriers. It reveals the similitude between the barriers in choroid plexus, in testis, epididymis and bladder and the difference with the blood-brain barrier. Electron microscope investigations afford a statistical view of relations between structure and vascular permeability and stress the opposition reported above. Membrane specializations of each epithelium often bring forward those which are involved in the barrier. This function is principally assigned to thight junctions. The different morphological aspects encountered lead to the problem of dynamic variations in the configuration of the junctions.