[French national standard for the treatment of squamous cell carcinoma of upper aero-digestive tract - General principles of treatment]

OBJECTIVES

The management of upper aerodigestive tract cancers is a complex specialty. It is essential to provide an update to establish optimal care. At the initiative of the INCa and under the auspices of the SFORL, the scientific committee, led by Professor Béatrix Barry, Dr. Gilles Dolivet, and Dr. Dominique De Raucourt, decided to develop a reference framework aimed at defining, in a scientific and consensus-based manner, the general principles of treatment for upper aerodigestive tract cancers applicable to all sub-locations.

METHODOLOGY

To develop this framework, a multidisciplinary team of practitioners was formed. A systematic analysis of the literature was conducted to produce recommendations classified by grades, in accordance with the standards of the French National Authority for Health (HAS).

RESULTS

The grading of recommendations according to HAS standards has allowed the establishment of a reference for patient care based on several criteria. In this framework, patients benefit from differentiated care based on prognostic factors they present (age, comorbidities, TNM status, HPV status, etc.), conditions of implementation, and quality criteria for indicated surgery (operability, resectability, margin quality, mutilation, salvage surgery), as well as quality criteria for radiotherapy (target volume, implementation time, etc.). The role of medical and postoperative treatments was also evaluated based on specific criteria. Finally, supportive care must be organized from the beginning and throughout the patients' care journey.

CONCLUSION

All collected data have led to the development of a comprehensive framework aimed at harmonizing practices nationally, facilitating decision-making in multidisciplinary consultation meetings, promoting equality in practices, and providing a state-of-the-art and reference practices for assessing the quality of care. This new framework is intended to be updated every 5 years to best reflect the latest advances in the field.

Anatomy of the biceps brachii osseous footprint: study of 100 radii and literature review

Biceps brachii (BB) tendon rupture is frequent in young males and may require surgical repair. Non-anatomic reinsertion leads to loss of strength in supination. The main aim of the present study was to describe the anatomy of the osseous footprint of the distal BB tendon. The dimensions of the footprint of the distal BB insertion were analyzed in 100 dry cadaver radii, using MicroScribe 3D software. Insertion area, assimilated to an ellipse, was calculated from 4 points (medial, lateral, cranial and caudal) determining the two axes of the ellipse. Mean footprint length, width and area were 18 mm (range, 7-24 mm), 9 mm (range, 4-15 mm), and 129 mm² (range, 46-266 mm²), respectively. Intra- and inter-observer correlation coefficients were satisfactory: κ = 0.75 and κ = 0.7, respectively. The present study reported BB footprint dimensions in 100 radii, providing a basis to guide surgical treatment of distal BB tendon rupture. Non-anatomical restoration of the BB tendon footprint leads to poorer clinical and biomechanical results; precise knowledge of the footprint is necessary for anatomical repair.

[Impact of adapted physical activity on joint pain induced under adjuvant hormone therapy for breast cancer: A review of the literature]

Hormone therapy provides an excellent survival rate after cancer but has many side effects, including joint pain in one out of two women. This leads about 13 % of women to stop their treatment within the first 6 months, impacting on its effectiveness, survival and the risk of recurrence. In order to better manage pain and quality of life, physical activity is highly recommended. In this context, the present review proposes a state of the art on the effects of adapted physical activity, based on the works referenced in PubMed. These studies show that physical activity has proved its worth in the primary prevention of cancer and is being evaluated in secondary prevention, particularly in the reduction of adverse effects. Overall, there is a reduction in joint pain, an improvement in quality of life and fatigue. Physical activity also plays a role in tertiary prevention. Paradoxically, oncologists and educators often note a reduction in the practice of physical activity due to fear of the onset of pain. It seems necessary to reinforce communication with patients and health professionals and to recommend the practice of physical activity in an appropriate setting.

[Comparison of mortality of lung cancer resections in France to other European countries]

BACKGROUND

France is characterized by the dispersion of its technical surgical platforms, and it seemed interesting for us to obtain information on quality of care compared to other European countries, which often have different organizations and practices. The objective of the study was to compare the 30-day mortality of patients operated on for bronchial cancer in France with that of other European countries.

METHOD

We conducted a literature review on practices in different European countries. The terms used for the selection were: lung cancer surgery, 30-day mortality in different hospitals in European countries.

RESULTS

We selected 9 articles corresponding to 9 European countries. The correlation coefficient between the number of lung resections per year and the population of the country was 0.967. The linear regression model between number of annual lung resections and population showed that except for Great Britain, most of the countries were close to the linear regression line. Germany and France had a mortality rate of 2.887% and 2.937% respectively, whereas the average is 2.13%. Following sensitivity analysis, the mortality rates for Germany and France remained higher than the average.

CONCLUSION

France is among the European countries with the highest postoperative mortality rates. These results should induce surgical teams to adopt quality-of-care measures focusing on outcome analysis.

[Roles and impacts of the pharmacist in the management of insomnia: A literature review]

BACKGROUND

Insomnia is a common sleep disorder that affects a large portion of the population in a situational, recurrent, or chronic way. In Canada, it is estimated that 13% of the population suffers from it.

OBJECTIVE

The primary objective of this literature review is to identify and describe studies dealing with the role and impact of the management of insomnia by a pharmacist.

METHOD

PubMed®, EMBASE® and CINALH Complete were searched to extract articles published between January 1st, 1990 and May 28, 2020. Studies on the role and impact of management of insomnia by a pharmacist, in French and English, descriptive or quantitative, with or without control group were included. Articles that did not deal with insomnia as the primary topic or where insomnia is a secondary condition were excluded, conference abstracts and studies showing no concrete results. The following variables were extracted: author, type of study, duration, location, sample size and characteristics of participants, description of pharmacist interventions, limits and biases, outcomes assessed and results. The quality of the pharmacists' interventions description was evaluated with DEPICT2.

RESULTS

Our review identified eight articles published from 2006 to 2018 evaluating 14 types of outcomes and 41 separate outcomes. A total of 37% (7/19) of the quantitative outcomes had statistically significant positive results, regarding insomnia qualification, symptoms and adequate use. Six studies were conducted in community pharmacy. The quality score varied between 8 and 10 out of 11.

CONCLUSION

There is little data on the role and impact of the management of insomnia by a pharmacist. The pharmacist can have a positive impact, particularly when practicing in a community pharmacy. Given the limited data and the prevalence of insomnia, it appears relevant to invest in pharmaceutical evaluative research for this condition.

[Evaluation of the ethics of pharmaceutical practice: A literature review]

INTRODUCTION

Ethics are at the heart of pharmacy practice.

METHOD

This is a literature review. The main objective is to carry out a review of studies relating on the evaluation of ethics in pharmacy practice. Documentary research on Pubmed was carried out from 1990 to 2020. All studies relating to pharmaceutical ethics that may be applied to the pharmacy practice in pharmacies or in health establishments and that conducted a qualitative or quantitative evaluation of pharmaceutical ethics (e.g. surveying pharmacists or pharmacy students, using a measurement tool, quantifying or qualifying a perception or behaviour) were included.

RESULTS

The studies come mainly from Anglo-Saxon countries (29/38). Studies related to pharmacy practice, mainly target pharmacists (n=27) and pharmacy students (n=16), and more often have a quantitative component of (n=28). The main ethical dilemmas observed dealt with emergency oral contraception (EOC), voluntary termination of pregnancy with drugs, euthanasia, commercial practices of the pharmaceutical industry, refusal to dispense a prescription in a broader context and plagiarism or dishonesty in academic settings.

CONCLUSION

Few studies have been conducted on the review of ethics of pharmacy practices from 1990 to 2020. Pharmacy students and practicing pharmacists are regularly exposed to ethical dilemmas and respond to these dilemmas with due consideration, taking into account six principles, eight values and other factors. Exposure to these dilemmas creates inaction, stress and distress. A few possible solutions have been identified.

[Physical activity after breast cancer diagnosis and survival: A systematic review]

INTRODUCTION

The benefits of physical activity (PA) in breast cancer are currently recognized in primary prevention. The World Cancer Research Fund (WCRF) and then the National Cancer Institute (INCa) have reported conflicting results regarding the impact of post-diagnosis PA on breast cancer outcomes. The aim of this systematic review is to assess the association between PA after breast cancer diagnosis and overall mortality, specific mortality and risk of breast cancer recurrence in the literature.

METHODS

Randomized trials, prospective cohorts and meta-analyses studying post-diagnosis PA and overall mortality, breast cancer mortality or risk of recurrence after breast cancer published between January 1, 2014 and October 1, 2019 were included. The articles selected by the INCa report prior to 2014 were included in the literature review.

RESULTS

Eighteen articles have been selected. Studies unanimously concluded that overall mortality was reduced by post-diagnosis PA practice. For specific mortality, 5 meta-analyses showed a significant decrease in breast cancer mortality and 2 found a decrease in the risk of recurrence.

CONCLUSION

Post-diagnosis PA reduces overall mortality and appears to impact specific breast cancer mortality and risk of recurrence. However, these results need to be confirmed by larger randomized trials.

[CNGOF-SFT Expert Report and Guidelines for Smoking Management during Pregnancy-Short Text]

OBJECTIVES

To provide up-to-date evidence-based guidelines for the management of smoking cessation during pregnancy.

METHODS

Systematic review of the international literature. We identified papers published between January 2003 and April 2019 in Cochrane PubMed, and Embase databases with predefined keywords. All reports published in French and English relevant to the areas of focus were included and classified according the level of evidence ranging from 1 (highest) to 4 (lowest). The strength of the recommendations was classified according to the Haute Autorité de santé, France (ranging from A, highest to C, lowest).

RESULTS

"Counseling", involving globally all kind of non-pharmacological interventions, has a modest benefit on smoking cessation, birth weight and prematurity. Moderate physical activity did not show a significant effect on smoking cessation. The systematic use of feedback by measuring the expired air carbon monoxide concentration do not influence smoking abstinence but it may be used in establishing a therapeutic alliance. The use of self-help interventions and health education are recommended in helping pregnant smokers quit. The prescription of nicotine replacement therapies (NRT) may be offered to any pregnant woman who has failed stopping smoking without medication This prescription can be initiated by the health care professional taking care of the pregnant woman in early pregnancy. There is no scientific evidence to propose the electronic cigarette for smoking cessation to pregnant smokers; it is recommended to provide the same advice and to use methods that have already been evaluated. The use of waterpipe (shisha/narghile) during pregnancy is associated with decreased fetal growth. It is recommended not to use waterpipe during pregnancy. Breastfeeding is possible in smokers, but less often initiated by them. Although its benefit for the child's development is not demonstrated to date, breastfeeding allows the mother to reduce or stop smoking. The risk of postpartum relapse is high (up to 82% at 1 year). The main factors associated with postpartum abstinence are breastfeeding, not having a smoker at home, and having no symptoms of postpartum depression.

CONCLUSIONS

Smoking during pregnancy concerns more than hundred thousand women and their children per year in France. It is a major public health burden. Health care professionals should be mobilized for reducing or even eradicating it.

[Acellular dermal matrix and synthetic mesh in implant-based immediate breast reconstruction: Current concepts]

The use of acellular dermal matrices and synthetic meshes is gaining popularity in direct-to-implant breast reconstruction, allowing the complete coverage of the prosthesis with greater pocket control and improved cosmesis. In this concise review, we present the advantages of acellular dermal matrices and resorbable or nonresorbable synthetic meshes in implant-based breast reconstruction, we discuss the risk of postoperative complications, and we raise their contribution in the growing interest of prepectoral breast reconstruction.

[Diving and asthma: Literature review]

INTRODUCTION

Scuba diving has long been contraindicated for asthmatics. Recommendations are evolving towards authorisation under certain conditions. Our objective was to review the literature on the risks associated with scuba diving among asthmatics and about recommendations on this subject.

MATERIALS AND METHODS

We used the MEDLINE and LiSSa databases, until June 2018, in French, English or Spanish language, with the keywords "asthma AND diving" and "asthme plongée" respectively. References to the first degree were analyzed.

RESULTS

We have included 65 articles. Risk of bronchospasm is well documented, particularly in cold and/or deep water, or in the event of exposure to allergens (compressor without filter). Nonasthmatic atopic divers may be at greater risk of developing bronchial hyper-reactivity. Although the theoretical risk exists, epidemiological studies do not seem to show an over-risk of barotrauma, decompression sickness or arterial gas embolism in asthmatics. French, British, American, Spanish and Australian societies agreed on the exclusion of patients with moderate to severe persistent asthma, FEV1<80%, active asthma in the last 48hours, exercise/cold asthma and poor physical fitness.

CONCLUSION

A diver's examination should include a triple assessment: asthma control, number of exacerbations and treatment compliance. Homogenizing the recommendations would improve the framework for the practice of diving among asthmatics and allow larger studies in this population. Communicating the current recommendations remains important to divers, dive instructors and doctors in the context of the development of scuba diving.

Predictors of response to repetitive transcranial magnetic stimulation (rTMS) in the treatment of major depressive disorder

Repetitive transcranial magnetic stimulation (rTMS), based on the principle of electromagnetic induction, consists of applying series of magnetic impulses to the cerebral cortex so as to modulate neurone activity in a target zone. This technique, still experimental, could prove promising in the field of psychiatry, in particular for the treatment of major depressive disorder. It is important for the clinician to be able to assess the response potential of a given patient to rTMS, and this among other things requires relevant predictive factors to be available. This review of the literature aims to determine and analyse reported predictive factors for therapeutic response to rTMS treatment in major depressive disorder. Different parameters are studied, in particular age, the severity of the depressive episode, psychological dimensions, genetic factors, cerebral blood flows via cerebral imagery, and neuronavigation. The factors found to be associated with better therapeutic response were young age, low level of severity of the depressive episode, motor threshold intensity over 100%, more than 1000 stimulations per session, more than 10 days treatment, L/L genotype on the 5-HTTLPR transporter gene, C/C homozygosity on the promotor regions of the 5-HT1A receptor gene, Val/Val homozygosity on the BDNF gene, cordance analyses by EEG, and finally the accurate localisation provided by neuronavigation. The authors conclude that investigations in larger patient samples are required in the future, and that the work already achieved should provide lines of approach for the coming experimental studies.

[Pregnancy in patients with a history of ischaemic heart disease - Case series and literature review]

Heart diseases complicate 1 to 3% of pregnancies and are the leading cause of indirect maternal deaths. Prior ischaemic heart event in pregnant patients is increasing. Most knowledge is based on few reports and there are no French nor international recommendations about the specific management of these patients. The specificity of the management of these patients during pregnancy, delivery and post-partum depends on the severity of the prior cardiac event and its consequences. This will be illustrated by the report of four recent cases managed in our hospital. First patient had myocardial infarction with normal left ventricular ejection fraction (LVEF). Second patient had a Tako-Tsubo syndrome with LVEF 45%. Third patient had ischemic cardiopathy with LVEF 30%. Fourth patient had myocardial infarction with LVEF 20%. A multidisciplinary follow-up should be required, especially in patients with severe ventricular dysfunction. The risk of fetal growth restriction appears to be increased, suggesting that closer ultrasound monitoring is necessary.

[Psychiatric aspects of rheumatoid arthritis: Review of literature]

BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory degenerative disease whose symptoms are mainly joint with significant functional impact, resulting in a restriction of the activities of the patient and increasing the impact on mental well-being. Several studies have been conducted to explore psychiatric disorders comorbid with RA.

OBJECTIVE

The objective of this review is to present the various psychiatric manifestations of RA reported in the medical literature.

METHODS

A literature review was conducted using the Pubmed search with the following keywords: psychiatry, psychiatric manifestations, rheumatoid arthritis. Three hundred and sixty-one articles were reviewed for relevance and 47 references were selected.

RESULTS

Among the major psychiatric disorders found in RA, the anxiety and depressive disorders are prevalent (13 to 48% of patients), as well as suicide, insomnia and tiredness. The impairment of quality of life is markedly after age 65. The association between RA and schizophrenia seems negative so that factors predisposing one is protective for the other.

CONCLUSION

Comorbid psychiatric disorders with RA are prevalent and may increase the impairment of quality of life for patients. The detection and treatment of psychiatric disorders improve the care of patients with RA.

[Cancer stem cells: Radiotherapeutic features and therapeutic targets]. Bull Cancer. 2016;103:48-54. [PMID: 26702506 DOI: 10.1016/j.bulcan.2015.10.018]

Recent evidences suggest that many types of cancers contain a cell population presenting stem cell properties. While the great majority of tumor cells are destined to differentiate, and eventually stop dividing, only a minority population of cells, termed cancer stem cells (CSCs), possesses extensive self-renewal capability and can recapitulate tumor pathophysiology in an immune-compromised animal model. Tumor initiating cells have been identified and isolated in many tumor types including brain, colon and prostate. They are virtually resistant to radiation and may contribute to treatment resistance and recurrence. Therefore, therapies specifically targeting CSCs will likely be needed for complete tumor eradication. The present study reviews published reports identifying the mechanisms of radioresistance of CSCs and potential targets based on the pathways of self-renewal. Further elucidation of pathways that regulate CSCs may provide insights into the development of novel innovative therapies.

[Co-occuring mood and substance use disorders]

Mood and substance use disorders commonly co-occur, yet there is little evidence-based research to guide the pharmacologic management of these comorbid disorders. The authors review the existing empirical findings including current clinical pharmacotherapy practices for treating co-occurring mood and substance use disorders and call into question current clinical practices. The specific mood disorders reviewed are bipolar and major depressive disorders (either one co-occurring with a substance use disorder). The authors also highlight knowledge gaps that may serve as a basis for future research. Findings from the relatively small amount of available data indicate that pharmacotherapy for managing mood symptoms might be effective in patients with substance dependence, although results have not been consistent across all studies. In most studies, medications for managing mood symptoms did not appear to have an impact on the substance use disorder. Research has only begun to address optimal pharmacologic management of co-occurring disorders. In addition, current clinical treatment for drug dependence often exclude new pharmacotherapies approved by the French Haute Autorité de Santé for treating certain types of addiction. With new data becoming available, it appears that we need to revisit current practice in the pharmacological management of co-occurring mood and substance use disorders.

[Court-ordered treatment: Analysing a complex practise through a literature review]

INTRODUCTION

In France, there are two main types of court-ordered treatment (COT) as far as mental health is concerned: obligations of treatment and injunctions of treatment. Obligations of treatment date back from 1958 whereas the law implementing injunctions of treatment is fairly recent as it was passed in 1998. Obligations and injunctions of treatment are two different types of COT that differ in terms of proceedings (obligations of treatment require no preliminary forensic psychiatric assessment; as for injunctions of treatment, they require the appointment of a coordinating medical doctor) and that are applied for different offences. However, both are psychiatric commitment procedures connecting the judicial, medical and social fields and their overall numbers have been on the rise. These common psychiatric practices have seldom been assessed and no review of the literature on the subject has ever been published. Better knowledge of such forensic practices is essential to their improvement and even to adjust the legal framework of these measures that are enjoying a boom. The purpose of this literature review is to define the prevalence of COT as well as the sociodemographic, criminal and psychiatric characteristics of those concerned by such measures.

MATERIAL AND METHODS

A review of the French medical literature on COT was carried out using Science Direct up to December 2013. The results of seven studies were included and analysed. This was completed with a review of the articles listed in social sciences and law databases (Cairn and Dalloz).

RESULTS

It has become increasingly frequent to rely on psychiatric teams to implement COT while at the same time public mental health services have to face a surge in activity with restricted financial means. Obligations of treatment are far more common (about 20,000 court orders a year) than injunctions of treatment (about 4000 measures are currently being enforced). However the latter have showed an increase of 506% over the 2000 decade. Both measures mainly concern men (83-99%) who are rather low on the social scale. In about half of these men, no mental disorder was found, however the prevalence of personality disorders ranged from 22 to 65% while that of psychotic disorders was low. Injunctions of treatment concerned sex offenders (90% of cases) whereas obligations of treatment concern non-sexual abusers (40-70%) rather than sex offenders (20-30%).

DISCUSSION

Psychiatric research on COT is still thin on the ground and its methodology does not allow rigorous evaluation though the use of such measures is growing. When confronted with people who have not sought any care or treatment, healthcare professionals are at a loss. In France, training in forensic psychiatry is inadequate and specialised healthcare (particularly for sex offenders) need improving to reach the level of those found in many other European countries. The purpose of psychiatric treatment differs from that of lawmakers whose aim is to prevent recidivism. However, better treatment consistency requires setting up partnerships between justice, health and social services. To improve connections, there are various avenues of work such as, for instance, the creation of coordinating medical doctors for injunctions of treatment in France or European experiments using a multidisciplinary approach to prevent recidivism in sex offenders. The framework of such a partnership remains to be created as it is part and parcel of COT but has not been provided for in the law. Healthcare jurisdictions as defined in the 2009 French National Health Law might provide an appropriate framework for mental health and law professionals to collaborate.

[Should knowledge of BRCA1 status impact the choice of chemotherapy in metastatic breast cancer: a review]

BRCA1 and BRCA2 mutations account for 40% of cancer predisposition gene mutations identified in the current French diagnostic setting. The proteins encoded by these genes are implicated in DNA repair pathways. As a result, loss of BRCA1 or BRCA2 function may modify chemo-sensitivity. This literature review aims to determine whether BRCA1 mutation status should influence the choice of systemic treatment in breast cancer. Fourteen articles and four abstracts from 12 retrospective analyses and 6 prospective studies were identified in the literature review. CMF-type and taxane-based protocols appear to be insufficiently effective, while anthracycline activity does not seem to be affected by BRCA1 status. BRCA1-mutated tumours appear to be highly sensitive to platinum, in both the neoadjuvant and metastatic setting. Olaparib, a PARP inhibitor, has only been evaluated in one study in metastatic patients, with promising results. The presence of a BRCA1 mutation can lead to an adaptation of therapies in the metastatic stages in breast cancer. The rapid identification of BRCA1 mutations and the adaptation of treatment according to this status in the (neo)adjuvant setting is likely to become a reality in the coming years.

Neurological form of Erdheim-Chester disease : Case report and review of the literature

OBJECTIVE

Report an unusual presentation of Erdheim-Chester disease revealed by a severe hypothalamic syndrome due to a hypothalamic infiltration and a review of the literature.

METHODS

A 28-year-old man was admitted for a previous three-month history of asthenia, weight loss, and polyuria-polydipsia. Magnetic resonance imaging on gadolinium T1-weighted sequence revealed a contrast-enhancing hypothalamic mass extending to the floor of the fourth ventricle. Cerebrospinal fluid examination was not suggestive of a germinal lesion. Lung nodules were found on thoracic CT-scan but due to their small size, brain stereotactic biopsies were required.

RESULTS

Histological examination revealed a diffuse polymorphic inflammatory infiltrate including numerous foamy histiocytes which displayed large eosinophilic CD68-positive, CD1a-negative cytoplasms, and collagen deposition, characteristic of Erdheim-Chester disease. Despite symptomatic and etiologic treatment, death occurred within twelve months.

CONCLUSION

Erdheim-Chester disease is a rare multisystem non-Langerhans cell histiocytosis which typically affects long bones, lung, retroperitoneal and orbital spaces and less frequently primary central nervous system. The pathogenesis of the disease remains unknown and no significant prognostic factor has been correlated with survival time. The recently reported BRAF V600E mutation suggests that specific therapeutics (BRAF inhibitors) should be considered.

[Evaluation of the therapeutic response after stereotactic body radiation therapy for liver tumors]

Stereotactic body radiation therapy takes more and more an important place in the therapeutic arsenal of primitive and secondary liver tumours. The administration of ablative radiation doses can result in specific changes to both the tumour and the healthy hepatic parenchyma, relative to conventional radiation therapy, making the assessment of local changes after stereotactic body radiation therapy, in terms of local control and reaction of healthy tissue, often difficult. It is mandatory to standardize and simplify our evaluation criteria to benefit from a better understanding of the effectiveness of this new treatment modality and allow better reproducibility of available imaging exams. This article presents a literature review of the various radiological changes observed after stereotactic body radiation therapy for liver tumours according to the multiple assessment methods used to determine local control. From the data available, we recommend using modified RECIST criteria proposed by the American Association for the Study of Liver Diseases (AASLD), as objective and relevant criteria of local control after stereotactic body radiation therapy for liver tumours.

[Pharmacological treatments in patients with pervasive developmental disorders: A review]

BACKGROUND

Pervasive developmental disorders (PDD) are neurodevelepmental disorders that are characterized by severe deficits in socialisation and communication, and the existence of repetitive and stereotyped interests and behaviours. It is estimated more than 60/100,000 children are suffering from PDD. Comorbid disorders are common in people with PDD, including intellectual deficiency, symptoms of attention deficit-hyperactivity, aggression and disruption, and pervasive repetitive behaviours or thoughts. These symptoms have a negative impact on the outcome and quality of life of the patients and their caregivers. The first-line management of comorbid disorders in PDD is behavioural intervention, but sometimes this is not sufficient, and the use of pharmacological treatment is needed.

METHOD

We conducted a review of studies of medical treatments used in patients with PDD to establish which treatments show good evidence of efficacy in PDD. We used the Medline database and the following keywords "pervasive development disorders" or "autism spectrum disorders" or "autistic disorder" and "therapy" or "treatment".

RESULTS

The treatments that showed the best efficacy on irritability in well-designed studies are second generation antipsychotics, risperidone and aripiprazole. Some studies indicate that haloperidol is efficient as well, but the very high frequency of extra-pyramidal effects limits its use. Methylphenidate has shown some efficacy on impulsivity and hyperactivity in randomised placebo-controlled studies. First data concerning atomoxetine are promising but better-designed studies are needed. Selective serotonin re-uptake inhibitors: fluvoxamine and fluoxetine have shown some efficacy in the treatment of serious and pervasive repetitive behaviours. Alpha-adrenergic treatments, clonidine and guanfacine, can help in the management of disruptive behaviours in patients with PDD. Data concerning naltrexone are contradictory, indeed many case reports of its efficacy on aggressive (mostly auto-aggressive) behaviours are reported in the literature, but well-designed studies do not find any improvement in patients treated with naltrexone compared with patients treated with placebo. First data concerning ocytocin are promising, indeed, if they were to be confirmed, that would be the first treatment efficient on the core symptoms of PDD.

Giant intracranial aneurysms in the paediatric population: Suggested management and a review of the literature

OBJECTIVES

Intracranial aneurysms are rare in children although giant aneurysms more commonly occur in adolescence. The aims of our study were to perform an extensive review of the literature over the past two decades and assess intracranial aneurysm management.

METHODS

Based on a Pubmed search, we carried out a review of the literature from 1990 to 2012 regarding giant intracranial aneurysms diagnosed in the paediatric population. This descriptive study concerned clinical presentation, cerebral aneurysm characteristics, therapeutic management procedures and outcome.

RESULTS

Forty-six cases were reported in 31 papers. The male/female sex ratio was 1.15, the clinical presentation was a tumour mass syndrome in 56.6%, followed by rupture in 30.4%. The aneurysm location was the posterior circulation in 41.3%, and microsurgical treatment (52.2%) predominated over endovascular coiling (28.3%).

CONCLUSION

To date, no evidence-based medicine recommendation has been accepted for the management of rare intracranial aneurysms. Each reported patient was the object of a multidisciplinary clinical decision. Management of this challenging pathology should be performed on a case-to-case basis.

[Reirradiations of head and neck cancers: state of the concept and ways of development]

The treatment of local recurrence or second primary developed in irradiated area in the field of head and neck carcinoma, should be planned and organized through multidisciplinary discussions. The outcome of such a clinical situations benefits from second line and advanced technology treatments. Only a few patients are amenable to salvage surgery, hence radiation therapy, combined or not with chemotherapy, takes a major role in these indications. This overview of the literature describes recent development in this field, aiming to improve local control while the sparing of organ at risk remains an important goal. Radiation therapy is currently implementing major new technologies set to improve external beam irradiation with new concepts on dose, fractionation, intensity modulated radiation therapy and stereotactic approach - as well as in brachytherapy. Apart from dedicated studies, the great heterogeneity of the treated patients should be underlined and taken into consideration. However, current data confirm the feasibility of reirradiation with acceptable local control and toxicity.

[Particle pollution effects on the risk of cardiovascular diseases]

The effects of air pollution on health are quite well-documented and the influence of particulate pollution on morbidity and mortality from myocardial infarction and stroke is increasingly evident. The objective of this literature review is to identify and synthesize articles on the impact of air pollution by PM10 and PM2.5 of myocardial infarction and stroke. A total of 14 studies were reported on the effects of PM10 and five on the effects of PM2.5. Nine out of 14 studies for PM10 and two studies of five for PM2.5 have found a significant association with myocardial infarction and/or stroke. Particle composition according to location, study period and population must be considered in interpreting the results on the health effects of air pollution. The integration of these elements is important for decision making in tune with social and economic conditions specific to each environment.

Retromolar foramen and canal: a comprehensive review on its anatomy and clinical applications

The retromolar foramen (RMF) and retromolar canal (RMC) are the anatomical structures of the mandible located in retromolar fossa behind the third molar tooth. This foramen and canal contain neurovascular structures which provide accessory/additional innervation to the mandibular molars and the buccal area. These neurovascular contents of the canal gain more importance in medical and dental practice, because these elements are vulnerable to damage during placement of osteointegrated implants, endodontic treatment and sagittal split osteotomy surgeries and a detailed knowledge of this anatomical variation would be vital in understanding failed inferior alveolar nerve blockage, spread of infection and also metastasis. Although few studies have been conducted in the past showing the incidence and types in different population groups, a lacunae in comprehensive review of this structure is lacking. Though this variation posed challenging situations for the practicing surgeons, it has been quite neglected and the incidence of it is not well presented in all the textbooks. Hence, we made an attempt to provide a consolidated review regarding variations and clinical applications of the RMF and RMC.