Résumé: Notre article tente d’apporter une réponse qualitative à la question de la formation des médecins à « l’annonce », déterminante pour l’alliance thérapeutique. L’objectif de ce dispositif de ...formation consiste à confronter l’ensemble des futurs médecins (DCEM3, année 5) à l’annonce du cancer (ici une pathologie lymphoïde). L’entraînement à l’annonce en petit groupe est filmé avec patients simulés. Il est totalement intégré aux autres activités que le médecin est amené à exercer avec un patient (consultation médicale, interrogatoire et examen clinique, prescription d’examen(s) complémentaire(s), lecture et commentaires de ceux-ci, plan d’annonce et annonce elle-même avec le proche). Les débriefings et le support vidéo permettent de revenir sur des questions soulevées par l’annonce: la mort, l’incertitude, la violence de l’annonce ou la centration sur le patient. Toutes ces dimensions sont appréhendées avec un professeur hospitalier en hématologie et un docteur en psychologie sociale qui accompagnent les étudiants. Ce dispositif met au centre la dimension humaine de la rencontre d’un patient et d’un médecin.
Abstract: This paper aims to provide a qualitative response to the question of training of physicians in “the announcement”, which is critical in the establishment of a therapeutic alliance. Our training approach presents the aim to confront all future doctors (DCEM3, year 5) with announcing a cancer (here a lymphatic pathology). This training exercise in small groups with simulated patients is filmed. It is completely integrated in the other activities which the doctor perform with a patient (medical consultation, interview and clinical examination, prescription of additional tests, reading and commenting these tests, preparation of the announcement, and the announcement itself with close family). The debriefings and the supporting video enable questions raised by the announcement to be revisited: death, uncertainty, the violence of the announcement, or the centering on the patient. All these aspects are treated with a hospital professor in hematology and a doctor in social psychology who accompany the students. This system is focused on the human dimension of the meeting between a patient and a doctor.
An outbreak of Pneumocystis jirovecii infections in renal transplant recipients was investigated using P. jirovecii type identification combined with analysis of patient encounters. The results ...suggest that colonized patients represent infectious sources in a context of nosocomial acquisition of the fungus.
Background.
Eighteen renal transplant recipients (RTRs) developed Pneumocystis jirovecii infections at the renal transplantation unit of Brest University Hospital (Brest, Brittany, France) from May 2008 through April 2010, whereas no cases of P. jirovecii infection had been diagnosed in this unit since 2002. This outbreak was investigated by identifying P. jirovecii types and analyzing patient encounters.
Methods.
The identification of P. jirovecii internal transcribed spacer (ITS) types was performed on P. jirovecii isolates from the 18 RTRs (12 patients with Pneumocystis pneumonia PCP, 6 colonized patients), 22 unlinked control patients (18 patients with PCP, 4 colonized patients), and 69 patients (34 patients with PCP, 35 colonized patients) with contemporaneously diagnosed P. jirovecii infections in the Brest geographic area. A transmission map was drawn up. Its analysis was combined with the results of P. jirovecii typing.
Results.
P. jirovecii ITS type identification was successful in 14 of 18 RTRs, 15 of 22 control patients, and 48 of the 69 patients. Type Eg was the most frequent type in the 3 patient groups. However, its frequency was significantly higher in the first patient group than in the 2 other groups (P < .05 and P < .01, respectively). Fourteen encounters between RTRs who harbored an identical type were observed. Ten patients were considered as possible index patients, of whom 3 were colonized by the fungus, and 7 presented PCP.
Conclusions.
The results provide to our knowledge the first data on the role of colonized patients as potential sources of P. jirovecii in a context of nosocomial acquisition of the fungus.
Objectives:Investigating the relationship between occupational exposure to pesticides and the risk of lymphoid neoplasms (LNs) in men.Methods:A hospital-based case-control study was conducted in six ...centres in France between 2000 and 2004. The cases were incident cases with a diagnosis of LN aged 18–75 years. During the same period, controls of the same age and sex as the cases were recruited in the same hospital, mainly in the orthopaedic and rheumatological departments. Exposures to pesticides were evaluated through specific interviews and case-by-case expert reviews. Four hundred and ninety-one cases (244 cases of non-Hodgkin’s lymphoma (NHL), 87 of Hodgkin’s lymphoma (HL), 104 of lymphoproliferative syndromes (LPSs) and 56 of multiple myeloma (MM) cases) and 456 controls were included in the analyses. The odds ratios (ORs) and 95% CI were estimated using unconditional logistic regressions.Results:Positive associations between HL and occupational exposure to triazole fungicides and urea herbicides were observed (OR = 8.4 (2.2 to 32.4), 10.8 (2.4 to 48.1), respectively). Exposure to insecticides, fungicides and herbicides were linked to a threefold increase in MM risk (OR = 2.8 (1.2 to 6.5), 3.2 (1.4 to 7.2), 2.9 (1.3 to 6.5)). For LPS subtypes, associations restricted to hairy-cell leukaemia (HCL) were evidenced for exposure to organochlorine insecticides, phenoxy herbicides and triazine herbicides (OR = 4.9 (1.1 to 21.2), 4.1 (1.1 to 15.5), 5.1 (1.4 to 19.3)), although based on small numbers. Lastly, despite the increased ORs for organochlorine and organophosphate insecticides, carbamate fungicides and triazine herbicides, no significant associations were evidenced for NHL.Conclusions:The results, based on case-by-case expert review of occupation-specific questionnaires, support the hypothesis that occupational pesticide exposures may be involved in HL, MM and HCL and do not rule out a role in NHL. The analyses identified specific pesticides that deserve further investigation and the findings were consistent with those of previous studies.
Richter syndrome (RS) is an aggressive lymphoma arising on the back of chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) and is the most common B-cell malignancy in the Western ...world. In the majority of cases, RS presents an activated B cell (ABC) phenotype of diffuse large B-cell lymphoma (DLBCL). From the therapeutic point of view, selective inhibition of PI3Kδ with idelalisib represents a valuable addition to available treatment options for patients with CLL/SLL, many of whom do not respond to or cannot tolerate chemoimmunotherapy. However, to our knowledge, there have been no prospective studies evaluating idelalisib efficacy in a DLBCL-ABC form of RS. Here, we present a case of a DLBCL-ABC form of RS achieving a complete response at 3 weeks after initiating idelalisib and rituximab therapy for six cycles. This response was maintained during the idelalisib monotherapy, but the patient relapsed rapidly after treatment was withdrawn, because of a grade three immune colitis that developed at 10 months of treatment. This report demonstrates that idelalisib is highly effective in RS and provides an attractive option in this aggressive disease. This agent could meet an unmet need by providing a treatment option with a tolerable safety profile for elderly patients with RS.
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