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Denis Dupoiron,1 Sabrina Jubier-Hamon,1 Valerie Seegers,2 Florent Bienfait,1 Yves Marie Pluchon,3 Nathalie Lebrec,1 Virginie Jaoul,1 Thierry Delorme1 1Département Anesthésie – Douleur, Institut de Cancérologie de l’Ouest, Angers, France; 2Département de biométrie, Institut de Cancérologie de l’Ouest, Angers, France; 3Centre d’étude et de traitement de la douleur (CETD), Centre hospitalier départemental Vendée, La Roche-sur-Yon, FranceCorrespondence: Denis DupoironDépartement Anesthésie – Douleur, Institut de Cancérologie de l’Ouest, Angers, France, Tel +33 2 41 35 28 73, Email denis.dupoiron@ico.unicancer.frPurpose: Data supporting the use of high-concentration capsaicin patches (HCCPs) in breast cancer (BC) patients and BC survivors (BCSs) with peripheral neuropathic pain (PNP) are limited. This observational study evaluated the effectiveness and safety of HCCP applications in BCSs/BC patients with PNP.Patients and Methods: Data from all patients treated with HCCP in the pain department of a French comprehensive cancer centre were collected from 01-Jan-2014 to 14-Oct-2020. Independent pain specialists completed the Clinical Global Impression of Change (CGIC) for each included patient based on data extracted from patient’s electronic medical record compiled by the treating pain specialist after each HCCP application.Results: Patients (N=279; mean age: 59.2 years; previous history of PNP medication: 54.5%) received on average 4.1 repeated HCCP applications (1141 HCCP applications); 68.8% received HCCP as an add-on to systemic therapy and 27.9% as first-line therapy. PNP was most frequently caused by surgery (62.4%) followed by chemotherapy (11.8%) and radiotherapy (6.5%). A complete or important analgesic effect was reported at least once by 82.3% of patients. A 6.0% reported no effect at all. For post-surgical PNP existing for < 12 months and > 10 years an important or complete effect was observed for 70.7% and 56.0% of applications. For chemotherapy- or radiotherapy-induced PNP, this important or complete effect was observed for 52.7% and 52.3% of applications, respectively. HCCP application was associated with site reactions in 54.4% of patients (mainly burning sensation or pain, 45.9%, or erythema, 30.8%) and high blood pressure in 7.2%.Conclusion: This real-world chart review provides important effectiveness and safety information to clinicians when considering topical options to treat PNP in BCSs/BC patients.Keywords: breast cancer, capsaicin, chronic pain, effectiveness, peripheral neuropathic pain, safety, topical administration

Introduction: Chemotherapy-induced peripheral neuropathy (CIPN) is often painful and can arise during or after the end of oncological treatments. They are mostly induced by platinum salts, taxanes, and immunotherapies. Their incidence is estimated between 19 and 85%. They can require a chemotherapy dose reduction or early termination. The European Society for Medical Oncology (ESMO) recommends high-concentration capsaicin patch (HCCP) in second line for the treatment of painful CIPN. This treatment induces a significative pain relief but only shown by low-powered studies. The objective of this study was to evaluate efficacy and tolerability of HCCP applications in CIPN. Methods: This monocentric observational retrospective real-world-data study of the CERCAN cohort took place in the Western Cancer Institute’s Anaesthesiology and Pain Department at Angers, France. Independent pain physicians completed the CGIC (Clinician Global Impression of Change) for each patient who benefited from HCCP applications for painful CIPN starting from 1 January 2014 to 22 December 2021, based on the collected data after every patch application. Results: A total of 57 patients (80.7% women) was treated with HCCP for painful CIPN, and 184 applications were realized, consisting of 296 sessions. CGIC found an important or complete pain relief for 61 applications (33.2%, corresponding to 43.9% patients). We found less efficacy for platinum-salts-induced CIPN compared to others (p = 0.0238). The efficacy was significatively higher for repeated applications when HCCP was used in second line compared to third line (p = 0.018). The efficacy of HCCP was significatively higher starting the third application (p = 0.0334). HCCPs were mainly responsible for local adverse events found in 66.6% patients (65.1% burning or painful sensation, 21.1% erythema). Conclusion: HCCP applications in painful CIPN induce an important pain relief with a global satisfying tolerability.

BACKGROUND Intrathecal drug delivery is widely used for intractable cancer pain treatment. A combination of drugs with morphine and bupivacaine is recommended in first line therapy. In France, we use ropivacaine 10 mg/mL instead of bupivacaine 5 mg/mL, the only concentration available. Bupivacaine 40 mg/mL has been available in France only since July 2020 under temporary authorization of use. OBJECTIVES The main objective of the study was to evaluate the safety, efficacy by pain assessment, to analyze drug dosage changes, to report adverse events (AEs) and conversion ratios switching from ropivacaine to bupivacaine. Secondary objective was to evaluate costs differences. MATERIALS AND METHODS We conducted this retrospective follow-up monocentric study within the Institut de Cancerologie de l'Ouest (ICO) Pain Department in Angers, France. We included 14 patients aged 18 years and above, implanted with an Intrathecal Drug Delivery Systems (IDDS) for cancer pain treatment and followed up at ICO from July 2020 to February 2021 after switching from ropivacaine to bupivacaine. We used a continuous infusion mode and Bolus could be added through Personal Therapy Manager (PTM). RESULTS The median conversion ratio between ropivacaine and bupivacaine was 0.68 (0.65; 0.69) and resulted in no significant change in numeric rating scale evaluation (p = 0.10). We observed moderate and rapidly reversible AEs such as clinical hypotension (29%) and motor block after bolus (21%). The estimated median hospital cost per day was significantly lower (p = 0.05) for the bupivacaine refills than for the last ropivacaine pump refill, decreasing from US$ 61.7 (49.6; 70.5) to US$ 50.4 (45.9; 60.4). The median reimbursement per day from the National Health Insurance (NHI) was three times lower for bupivacaine pump refill when compared to the last ropivacaine pump refill (p

Cerebrospinal fluid (CSF) leakage resulting in post dural puncture headache (PDPH) is a frequent adverse effect observed after intrathecal drug delivery system (IDDS) implantation. CSF leakage symptoms negatively affect patient quality of life and can result in additional complications. Fibrin glue was used to treat CSF leakage syndrome. We developed a procedure to reduce the incidence of PDPH by preventing CSF leakage with the use of fibrin glue during surgery.The main outcome criterion for this study was the incidence of PDPH syndrome after IDDS implantation with or without preventive fibrin glue application during the procedure.We designed a monocentric retrospective cohort study to compare the incidence of PDPH due to CSF leakage syndrome after lumbar puncture in patients with an implanted intrathecal pump, with or without preventive fibrin glue application during the procedure.The study was held in the Anesthesiology and Pain department of the Integrative Cancer Institute (ICO), Angers - France.The study compared 2 patient cohorts over 2 successive periods. Fibrin glue was injected into the introducer needle puncture pathway after placement of the catheter immediately following needle removal.The no-glue group included 107 patients, whereas the glue group included 92 patients.Two application failures were observed (2.04%). Fibrin glue application results in a significant decrease in PDPH incidence, from 32.7% in the no-glue group to 10.92 % (P0.001) in the glue group. In regard to severity, in the no-glue group, 37.1% of PDPH syndromes were mild, 34.3% were moderate, and 28.6% were severe. In the fibrin glue group, 80% of PDPH syndromes were mild, and 20% were moderate. No severe PDPHs were reported after fibrin glue application. Duration of symptoms was also statistically shorter in the fibrin glue group (maximum of 3 days vs. 15 days in the no-glue group). In a univariate analysis, preventive fibrin glue application and age are significant to prevent PDPH. In multivariate analysis, only fibrin glue application was statistically significant (odds ratio, 0.26; P = 0.0008). No adverse effects linked to fibrin glue were observed.The main limitation of this study is its retrospective nature. In addition, this study is from a single center with a potential selection bias and a center effect.The novel use of fibrin glue is promising in terms of its effect on PDPH and its safety profile. Its moderate cost and reproducibility make it an affordable and efficient technique.

Purpose The epidemiological shift in MRSA distribution from healthcare-related facilities to the general population is distressing and requires continuous monitoring to manage and control the rate of incidences. Method The retrospective relationship between genetic and phenotypic variability of methicillin-resistant Staphylococcus aureus (MRSA) isolates was determined in respect to the specimen source, patient location, sex and age. A total of 521 MRSA isolates were classified based on SCCmec, mec, agr, pvl and spa genetic markers using three different multiplex PCRs. Results Based on the genetic variability, the isolates were divided into 97 profiles, of which 59% belonged to only two profiles (P17 and P33). P17 was the predominate profile, harbouring SCCmecIVa, ccr2, mecB, agr1, spa413 and pvl markers. P17 was more prevalent among the younger population (average 33.9 years) from outpatient (77%) locations and wound (88%) sources. The second largest profile was P33, harbouring SCCmecII, ccr2+ccr3, mecA, agr2, spa413 and no PVL. P33 was more prevalent in the older population (average 70.7 years) and more common in females (62%) than males (38%). With respect to antibiotic resistance, P33 exhibited a high rate of resistance to penicillins, cephalosporins, fluoroquinolones and macrolides, and P17 had a lower resistance to fluoroquinolones. Conclusion This report contributes to the existing understanding of evolutionary epidemiology of antibiotic resistance in MRSA. The diversity of MRSA isolates and unique environmental preferences for each profile highlights the importance of epidemiological knowledge of MRSA distribution to determine the best treatment for patients in both community and hospital settings.

Resume Un groupe de travail nomme par les 3 societes impliquees dans la prise en charge de la douleur du cancer, a etabli des recommandations selon la methodologie HAS, en revision des Standards Options Recommandations datant de 2002 et emises par la Federation des centres regionaux de lutte contre le cancer. Apres un rappel des proprietes pharmacologiques et du metabolisme de la morphine, et selon l’AMM francaise de chacun des opioides pour le traitement de la douleur due au cancer, les coefficients de conversion ont ete revus dans le cadre du changement d’opioides de et vers la morphine (oxycodone, hydromorphone, fentanyl, methadone, tapentadol et en fonction de la voie d’administration orale, sous-cutanee ou intraveineuse). Les experts ainsi ont recommande d’abandonner la notion de dose d’equiantalgie utilisee dans la rotation des opioides, car pouvant etre a l’origine de graves erreurs de sur- ou de sous-dosage. Cela, au profit de la notion de changement de traitement opioide selon des coefficients beaucoup plus rigoureux, issus de la litterature parue depuis 2002, pour ensuite proceder a une nouvelle equilibration si l’intensite de la douleur residuelle ou les effets indesirables le requierent. Une application smartphone OpioConvert® sera disponible.

ObjectiveIntrathecal (IT) drug delivery has shown its efficiency in treating refractory cancer pain, but switching opioids from the systemic to the intrathecal route is a challenging phase. Moreover, associations are widely used and recommended. Few data deal with the initial dosage of each drug. Analyzing conversion factors and initial dosages used in intrathecal therapy seems essential to decreasing the length of titration and to delivering quick pain relief to patients.MethodsWe retrospectively analyzed data from consecutive adult patients implanted with an intrathecal device for cancer pain and treated at the Institut de Cancérologie de l’Ouest, in Angers, France, for four years. The main goal was to identify factors associated with early pain relief after intrathecal drug delivery system (IDDS) implantation.ResultsOf the 220 IDDS-treated patients, 70 (32%) experienced early pain relief (EaPR) and 150 (68%) delayed pain relief (DePR). Performance Status stage and initial IT ropivacaine:IT morphine ratio were the variables independently associated with EaPR. The best IT ropivacaine:IT morphine ratio to predict EaPR was 5:1, with a 73% (95% confidence interval [CI] = 64.8% to 79.6%) sensitivity and a 67.1% (95% CI = 54.9% to 77.9%) specificity. EaPR subjects experienced better pain relief (–84% vs –60% from baseline pain score, P ConclusionsLocal anesthetic:morphine ratio should be considered when starting IDDS treatment. EaPR during the IT analgesia titration phase was associated with better pain relief and outcomes in patients with refractory cancer-related pain.

Summary Objective Seasonal variations in temperature exert strong selective pressure on microorganism population dynamics and should be taken into account in epidemiological studies. The objective of the present study was to characterize the seasonal variation of staphylococcal infections in respect to patient location, specimen source, month of year, and temperature variation. Methods A retrospective longitudinal time-series analysis of methicillin-resistant and methicillin-sensitive Staphylococcus aureus (MRSA and MSSA) was conducted in northeastern Ohio over a 5-year period. Multivariable time-series analyses were performed to detect the variations in the monthly incidence based on location of patients (inpatient, outpatient, and nursing homes), source of specimen (wound, respiratory tract, and urine), time of year (January–December), and temperature variation (average monthly over 5 years). Results The results indicated a gradual increase in both MRSA and MSSA infections, with outpatient cases representing the majority of cases. If present, the seasonal nature of MRSA infections varied based on specimen source and patient location, with wound infections from outpatients more prevalent in warmer months, and respiratory infections among inpatients more prevalent during colder months. Conclusions The current report provides a longitudinal analysis of staphylococcal epidemiology, and in the process, identifies the seasonal nature of infections to be multifactorial, depending on such variables as specimen source and patient location. The seasonal nature of staphylococcal infections appears to be the product of a complex interaction among host, pathogen, and environment.

Pancreatic cancer is the fourth leading cause of cancer-related death in Europe and the United States. Studies have demonstrated that patients with pancreatic cancer have a high prevalence of pain, with rates varying from 47% to 82%. Analgesia using intrathecal drug delivery systems (IDDS) has been poorly studied specifically in this population.The IDDS for pancreatic cancer pain was a follow-up observational study designed to evaluate 11-year results of IDDS for refractory pancreatic cancer pain at the Institut de Cancérologie de L'Ouest, Paul Papin in France. Patients were followed from March 2006 to April 2017. Patients were selected for IDDS based on multidisciplinary meeting discussion. All IDDS-treated patients were prescribed a combined intrathecal analgesics regimen through a catheter placed according to painful metameric level. Postimplant assessment of pain was determined using a numerical rating scale (NRS). Patients were followed via day-hospital visits and telephone calls at least monthly until death. Pain scores were compared using the Wilcoxon signed rank test. Overall survival (OS) was estimated using the Kaplan-Meier method and compared between groups by log rank tests.Ninety-three patients received IDDS, and total therapy duration accounts for 10,300 IDDS days. Implanted patients suffered from severe pain before implantation (median presurgical NRS, 8 [interquartile range, 7-9]) despite a median 360 mg (260-600) oral morphine equivalent daily dose. Median OS in the whole cohort after intrathecal treatment start was 82 days (95% confidence interval, 59-95). Median OS after surgery for implantable pump was 91 days (83-111) and for external pump 27 days (20-49; P.0001). IDDS was associated with pain relief with a significant statistical difference between preimplantation NRS pain score and 1 week (median, -6 [-7 to -4]; P.001), 1 month (median, -5 [-6 to -3]; P.001), and 3 months (median, -6 [-7 to -4]; P.001). Severe pain (NRS score, ≥7) decreased from 89.2% before surgery to 4.5% after 1 week, 6.7% after 1 month, and 10.3% after 3 months of IDDS implant (P.01). Global complications rate was low, consistent with published literature.Despite our study's limitations, results suggest that long-term IDDS for refractory malignant pain due to pancreatic cancer was both efficacious and safe in pancreatic cancer pain. We have demonstrated, in the largest series of IDDS for pancreatic cancer pain reported yet, a clinically and statistically significant pain reduction in patients receiving IDDS.

Resume Les traitements topiques representent une nouvelle alternative dans la prise en charge de la douleur neuropathique (DN). Ils agissent de facon ciblee sur la zone douloureuse reduisant ainsi le risque d’effets indesirables systemiques et d’interactions medicamenteuses. Qutenza®, patch de capsaicine a forte concentration (8 %) est indique dans le traitement des DN peripheriques chez l’adulte non diabetique. Ce traitement a obtenu une AMM en 2009 sur la base d’essais cliniques dans les douleurs post-zosteriennes et les neuropathies liees au VIH. La Commission de la transparence precise que Qutenza® doit etre reserve aux patients en echec aux traitements conventionnels. Dans les recommandations de prise en charge de la DN etablies en 2010 par la SFETD, il apparaissait en tant que « traitement emergent » et sa place dans la strategie therapeutique n’etait pas encore clairement definie. Depuis la litterature s’est enrichie de nouvelles etudes et notre experience clinique a augmente. Son positionnement doit etre revu. Ainsi, la prescription des patchs de capsaicine intervient en cas d’inefficacite des traitements de premiere intention. Ils peuvent etre proposes seuls ou en association en cas d’echec ou d’efficacite partielle de traitements de premiere intention. Dans tous les cas, la prescription des patchs de capsaicine doit etre envisagee avant l’instauration des opioides forts dans les douleurs neuropathiques peripheriques.

Purpose. Methicillin-resistant Staphylococcus aureus (MRSA) is one of the leading causes of nosocomial infections. A thorough understanding of the epidemiology and distribution of MRSA allows the development of better preventive measures and helps to control or reduce the rate of infection among the general population. Methodology. A retrospective survey was performed on 511 cases of MRSA infections from inpatient, outpatient and nursing home populations over a 12-month period. To study the relationships between two continuous quantitative variables (patient age vs resistance percentage), a simple linear regression was calculated for each antibiotic to predict the antibiotic resistance percentage with respect to patient age. Results/Key findings. The pattern of antibiotic resistance with respect to the age of patients depended on the antibiotic mode of action. Antibiotics that target DNA synthesis (i.e. fluoroquinolones) display a direct correlation with the age of patients, with higher rates of resistance among the older population, while antibiotics that target ribosomal functions (i.e. aminoglycosides) or cell wall synthesis (i.e. cephalosporin) do not display an age-dependent pattern and have a consistent degree of resistance across all age classes. Conclusion. Antibiotics that target DNA synthesis result in a progressively higher number of resistant isolates among the older population. The results emphasize the importance of patient age on antibiotic selection as a preventive measure to reduce the rate of resistant infections in each susceptible population. This pattern suggests that physicians should take into consideration patient age as another factor in determining the best antibiotic regiment with the aim of curtailing the emergence of newer resistant phenotypes in the future.

This paper reviewed the 2002 guidelines established by the National Federation of Cancer Centres. A group of experts nominated by the 3 French Societies involved in the treatment of cancer pain (AFSOS, SFAP, SFETD), established new guidelines ratios for morphine switching and/or changing of route of administration, in patients for whom either pain was not adequatly managed or adverse effects were unbearable. After a rapid reminder of the pharmacokinetics and metabolism properties of morphine, experts explained why the theory of opioid rotation (oxycodone, hydromorphone, fentanyl, methadone, tapentadol) using fixed equianalgesic ratios is not any more appropriate for a secure clinical practice. In the light of recent publications enhancing our knowledge on the efficacy of new drug switching ratios and for changing the route of administration of morphine, the group of experts recommended to use reconsidered switching ratios favoring security upon efficacy, to minimize overdosing and adverse effects. Consequently, after the new conversion ratio (using slow release opioids) was applied, a second titration should be done by means of normal release rescue formulations for breakthrough pain episodes. A smartphone App. OpioConvert

La douleur est frequemment rencontree en cancerologie, du fait de la maladie, du traitement de la maladie, ou d’une raison intercurrente. Ses mecanismes sont varies, elle peut etre inflammatoire, neuropathique, somatique, viscerale, aigue, chronique. Elle a un impact negatif sur la qualite de vie et potentiellement sur la survie. Son traitement fait appel a diverses approches, symptomatiques ou plus specifiques. La prise en charge est frequemment consideree comme peu satisfaisante, comme cela a ete retrouve en France. Quelques explications et propositions sont avancees.

The current study investigates the role of oxidative stress and calcium homeostasis in the development of selective striatal lesions in metabolic impairment model caused by 3-nitropropionic acid (3NP). In this report, we examined the distribution of oxidative stress markers and the production of mitochondrial reactive oxygen species in the presence of 3NP in male Sprague-Dawley rats. Protein oxidation was assessed using 3-nitrotyrosine immunoreactivity, while DNA oxidative damage was evaluated by poly (ADP-ribose) polymerase-1 activity. The Reactive Oxygen Species (ROS) production was determined in isolated mitochondrial from striatum and cerebellum of two age groups following 3NP and variable calcium concentration. The results demonstrate that increased 3-nitro-tyrosine level is the most robust in the striatum and the least evident in the cerebellum following 4 days of 3NP treatment. No significant change in the levels of poly ADP-ribosylated proteins was observed, likely due to a rapid PARP-1 cleavage as detected by the appearance of 50 kDa necrotic fragment. In mitochondrial isolates, there was no immediate increase in mitochondrial ROS following 3NP in either striatum or cerebellum; however, calcium addition resulted in a concentration dependent increase in reactive oxygen species in striatal mitochondria of the older animals. These results suggest that in aging, mitochondria become more susceptible to the generation of ROS in conditions that cause a concurrent compromised in mitochondrial calcium concentration. This finding implicates mitochondria dysfunction as a key cellular target in pathological states that are associated with metabolic impairment. The results also reinforce the notion that mitochondrial function in the striatum and cerebellum respond differently to the aging process, which may explain the variable regional vulnerability in 3NP model.

A retrospective survey was performed on all staphylococcal infections diagnosed by the Ashtabula County Medical Center (Ashtabula, OH) during 2006 and 2007. Of the 1,612 Staphylococcus aureus isolates evaluated for their antibiotic resistances, 947 were methicillin-resistant S aureus (MRSA). In 2007, MRSA infections reached 589 cases per 100,000 inhabitants, a 77% increase compared with 2006. The increase in MRSA infections was noticeable among youth (6-25 years old), middle-aged people (45-50 years old), and elderly people (86-90 years old). MRSA infections increased among inpatients by 58%, among outpatients by 43%, and among nursing home residents by 183%. More than 66% of MRSA infections were found among healthy people in the community with no apparent risk factors. More than 88.7% of the infections belong to only 9 profiles of antibiotic resistance indiscriminately distributed among inpatients, outpatients, and nursing home residents. This report sheds further light on the rapid spread of MRSA across Northeastern Ohio, stressing the need for better education in preventive measures and infection control at the level of community and health care settings.

Resume Cet article aborde grâce a trois questions cles les challenges actuels et futurs face aux douleurs chroniques et aux acces douloureux paroxystiques (ADP). La premiere question situe la place du fentanyl transdermique dans le traitement des douleurs chroniques intenses. La deuxieme question aborde la problematique des ADP en cancerologie, leur identification et leur prise en charge. La troisieme question est focalisee sur le traitement des ADP avec les possibilites actuelles et futures. Chaque partie de cet article est sous la responsabilite de l’un des trois auteurs qui abordent successivement les reponses aux trois questions posees.

The diversity of 184 isolates from rhizosphere and bulk soil samples taken from the Ni hyperaccumulator Alyssum murale, grown in a Ni-rich serpentine soil, was determined by 16S rRNA gene analysis. Restriction digestion of the 16S rRNA gene was used to identify 44 groups. Representatives of each of these groups were placed within the phyla Proteobacteria, Firmicutes and Actinobacteria by 16S rRNA gene sequence analysis. By combining the 16S rRNA gene restriction data with the gene sequence analysis it was concluded that 44.6% (82/184) of the isolates were placed within the phylum Proteobacteria, among these 35.9% (66/184) were placed within the class α-Proteobacteria, and 20.7% (38/184) had 16S rRNA gene sequences indicative of bacteria within genera that form symbioses with legumes (rhizobia). Of the remaining isolates, 44.6% (82/184) and 5.4% (10/184) were placed within the phyla Actinobacteria and Firmicutes, respectively. No placement was obtained for a small number (10/184) of the isolates. Bacteria of the phyla Proteobacteria and Actinobacteria were the most numerous within the rhizosphere of A. murale and represented 32.1% (59/184) and 42.9% (79/184) of all isolates, respectively. The approach of using 16S rRNA gene sequence analysis in this study has enabled a comprehensive characterization of bacteria that predominate in the rhizosphere of A. murale growing in Ni-contaminated soil.

Resume Dans le cadre d’un service d’urgence, la prise en charge des douleurs aigues chez des patients atteints de cancer comporte des aspects specifiques, qu’il convient de respecter afin d’eviter des consequences deleteres sur l’autonomie et/ou la qualite de vie de ces patients. Le mecanisme generateur de la douleur, la recherche systematique des signes d’une evolution tumorale surtout sous la forme de complications, l’intensite des douleurs ainsi que l’existence des traitements antalgiques preexistants sont autant de facteurs qui doivent etre analyses : en effet, ils contribuent a etablir des decisions therapeutiques et a definir l’orientation des patients pour le suivi de l’episode douloureux. Cet article a pour objectif de souligner les elements specifiques de la prise en charge, dans les services d’accueil des urgences, des douleurs aigues evoluant dans le cadre d’une maladie neoplasique.

The aim of our study was to evaluate pain frequency, intensity, and disability levels in a population with neuromuscular disorders (NMD). Of 862 questionnaires mailed to outpatients treated at 10 centers, 511 (300 men and 211 women) responded with answers suitable for analysis (response rate: 59.3%). Patients had Duchenne or Becker muscular dystrophy, type 1 myotonic muscular dystrophy, facioscapulohumeral muscular dystrophy, metabolic myopathy, or myasthenia gravis (MYA). The questionnaire packet included numeric scales for pain intensity and relief, the Brief Pain Inventory, the Saint Antoine Pain Questionnaire, and a scale to assess disability. More than two-thirds of the 331 patients (67.3%) suffered pain during the last three months. The mean number of days with pain was 18.4±15.1 days. The mean pain intensity was 4.8±2.5. Pain was usually diffuse (153 patients, 44%) and intermittent (228, 71%). Pain intensity varied by the NMD diagnosis; the most severe pain was observed in metabolic myopathy (13/27 patients suffered severe pain, 49%) and in MYA (16/42, 38%). Approximately three-quarters of patients had fewer than 10 days of inactivity due to pain during the last three months, and 98% had fewer than 30 days. Our study indicates that pain is frequent in hereditary muscle disorders and MYA. Mean intensity is moderate. Pain in NMD patients should be systematically assessed.

L’information des personnes malades est un enjeu majeur de sante publique. Elle fait desormais partie des droits des malades, en reponse a leur demande croissante d’etre informes et impliques dans les decisions medicales qui les concernent. Depuis 1998, la Federation nationale des centres de lutte contre le cancer (FNCLCC) a mis en place un programme d’information et d’education des patients atteints de cancer et de leurs proches: les SOR SAVOIR PATIENT (SSP). Ce programme repose sur une methodologie respectant les criteres de qualite en matiere de redaction de documents d’informations destines aux patients. Le guide SSP Douleur et cancer a pour objectif de repondre aux questions des patients sur les douleurs du cancer et de les aider a participer activement a leur prise en charge. Il a ete elabore grâce a un travail pluridisciplinaire incluant des methodologistes, une linguiste, des specialistes de la douleur et du cancer, ainsi qu’une vingtaine de patients et de proches. Des focus groups, des entretiens semi-directifs et des questionnaires ont permis d’analyser et de prendre en compte les besoins d’informations des patients, ainsi que leur vecu de la douleur et leurs preoccupations. Ce guide se compose de huit chapitres qui peuvent se lire de facon independante, en fonction des besoins de chacun. Il aborde de nombreuses questions: qu’est-ce que la douleur ? Quelles sont les causes de douleur pendant un cancer ? La douleur est-elle un signe de gravite ? Comment l’evaluer ? Comment la traiter ? Faut-il avoir peur des opioides ? Comment vivre la douleur au quotidien ? … Dans la prise en charge de la douleur, les patients jouent un role central dont ils n’ont pas toujours conscience. Le guide Douleur et cancer leur donne des informations completes, des conseils et des outils pratiques pour participer, avec l’ensemble des soignants, a la prevention, a l’evaluation et au traitement de leurs douleurs. Ce guide ne se substitue pas a la relation patient-medecin, mais il la complete. Il peut egalement etre utilise dans une demarche d’education therapeutique du patient.

Phytoextraction of soil Cd and Zn may require reduction in soil pH in order to achieve high metal uptake. Reducing the pH of high metal soil, however, could negatively affect soil ecosystem function and health. The objectives of this study were to characterize the quantitative causal relationship between pH and soil biological activities in two Zn and Cd contaminated soils and to investigate the relationship between metals and soil biological activities under low pH. Soils were adjusted to five or six different pH levels by sulfur addition, followed by salt leaching. Thlaspi caerulescens was grown for 6 months, and both the rhizosphere and non-rhizosphere soil biological activities were tested after harvest. Reducing pH significantly lowered soil alkaline phosphatase activity, arylsulphatase activity, nitrification potential, and respiration. However, acid phosphatase activity was increased with decreasing pH. The relationship between soil biological activities and pH was well characterized by linear or quadratic regression models with R 2 values ranging from 0.57 to 0.99. In general, the three enzyme activities, nitrification potential, and the ratio of alkaline phosphatase to acid phosphatase activity were very sensitive indicators of soil pH status while soil respiration was not sensitive to pH change. The rhizosphere soil had higher biological activities than non-rhizosphere soil. The negative effects observed in the non-rhizosphere soil were alleviated by the rhizosphere influence. However, rhizosphere soil after 6 months phytoextraction showed lower nitrification potential than non-rhizosphere soil, probably due to substrate limitation in our study.

For phytoextraction to be successful and viable in environmental remediation, strategies that can optimize plant uptake must be identified. Thlaspi caerulescens is an important hyperaccumulator of Cd and Zn, whether adjusting soil pH is an efficient way to enhance metal uptake by T. caerulescens must by clarified. This study used two soils differing in levels of Cd and Zn, which were adjusted to six different pH levels. Thlaspi caerulescens tissue metal concentrations and 0.1 M Sr(NO3)2 extractable soil metal concentrations were measured. The soluble metal form of both Cd and Zn was greatly increased with decreasing pH. Lowering pH significantly influenced plant metal uptake. For the high metal soil, highest plant biomass was at the lowest soil pH (4.74). The highest shoot metal concentration was at the second lowest pH (5.27). For low metal soil, due to low pH induced Al and Mn toxicity, both plant growth and metal uptake was greatest at intermediate pH levels. The extraordinary Cd phytoextraction ability of T. caerulescens was further demonstrated in this experiment. In the optimum pH treatments, Thlaspi caerulescens extracted 40% and 36% of total Cd in the low and high metal soils, respectively, with just one planting. Overall, decreasing pH is an effective strategy to enhance phytoextraction. But different soils had various responses to acidification treatment and a different optimum pH may exist. This pH should be identified to avoid unnecessarily extreme acidification of soils.

The Ni-hyperaccumulating plant Alyssum murale accumulates exceptionally high concentrations of nickel in its aboveground biomass. The reasons for hyperaccumulation remain unproven; however, it has been proposed that elemental allelopathy might be important. High-Ni leaves shed by the plant may create a “toxic zone” around the plant where germination or growth of competing plants is inhibited. The efficacy of this argument will partially depend upon the rate at which leaves degrade in soil and free metals are released, and the subsequent rate at which metals are bound to soil constituents. To test the degradation of biomass of hyperaccumulators, A. murale was grown on both high- and low-Ni soils to achieve high- (12.0 g Ni/kg) and low- (0.445 g Ni/kg) Ni biomass. Shredded leaf and stem biomass were added to a serpentine soil from Oregon that was originally used to grow high-Ni biomass and a low-Ni control soil from Maryland. Biomass Ni was readily soluble and extractable, suggesting near immediate release ...

All patients have the right to expect to receive the best therapeutic means available to reduce their suffering. Recent evaluation of the French ministerial 3-year plan for the fight against pain by the French Society of Public Health (http://www.sfsp-france.org/Plan-Lutte-Douleur/Plan-Lutte-Douleur.htm) and observations of current practice show that the information and training of health professionals in this area should be continued. The necessity to fight against cancer pain has only recently become a priority. In 1996 a working group, set up by the French National Federation of Cancer Centres (Federation Nationale des Centres de Lutte Contre le Cancer–FNCLCC), published clinical practice guidelines for pain management in adult and paediatric patients with cancer (Krakowski et al, 1996). These guidelines now require updating, but in this document only the pharmacological treatment of pain arising from excess nociception in adults with cancer is covered. The other sections of the original guideline are currently being updated in the context of a collaboration between the FNCLCC and the SETD (Society for the Study and Treatment of Pain (Societe d'Etude et de Traitement de la Douleur) French section of the International Association for the Study of Pain (IASP) subgroup on cancer pain).

Patient information is a major challenge for public health. It has become part of the patients' rights, in response to their need for information and involvement in medical decision-making. Since 1998, the French National Federation of Comprehensive Cancer Centres (FNCLCC) has developed an information and education program dedicated to patients and relatives: the SOR SAVOIR PATIENT program. The methodology of the program adheres to the quality criteria established for the elaboration of documents containing patient information. The SOR SAVOIR PATIENT guide Pain and Cancer aims to answer patients' questions regarding cancer specific pain and to help them become actively involved in their care. It was elaborated by a multidisciplinary workgroup, which included methodologists, one linguist, pain specialists and twenty patients and relatives. Patients' information needs and personal experience of pain were assessed using focus groups, semi-structured interviews and questionnaires. Through eight chapters, which can be read in an independent way, Pain and cancer provides key information on the causes, the mechanisms, the evaluation, the prevention and the treatment of pain. The guide also presents advices and practical tools to facilitate the assessment of the pain and the communication between patients and professionals. Finally, this guide aims to overcome ideas such as that morphine is synonymous of end of life or drug addiction, that pain is a sign of aggravation of cancer and that nurses know how to detect the pain. Intended first for the patients and their close relations, Pain and Cancer is also a useful tool for health professionals. Indeed, it presents knowledge based on the most recent recommendations developed for clinical practice. Thanks to a wide distribution of the guide to patients, their families and the professionals, we trust that this guide will facilitate dialogue around pain, and ultimately its care. This article is an abstract of the guide. The complete SOR SAVOIR PATIENT guide can be downloaded from the SOR website at: www.sor-cancer.fr.

The Ni-hyperaccumulating plant Alyssum murale accumulates exceptionally high concentrations of nickel in its aboveground biomass. The reasons for hyperaccumulation remain unproven; however, it has been proposed that elemental alelopathy might be important. High-Ni leaves shed by the plant may create a "toxic zone" around the plant where germination or growth of competing plants is inhibited. The efficacy of this argument will partially depend upon the rate at which leaves degrade in soil and free metals are released, and the subsequent rate at which metals are bound to soil constituents. To test the degradation of biomass of hyperaccumulators, A. murale was grown on both high- and low-Ni soils to achieve high- (12.0 g Ni/kg) and low- (0.445 g Ni/kg) Ni biomass. Shredded leaf and stem biomass were added to a serpentine soil from Oregon that was originally used to grow high-Ni biomass and a low-Ni control soil from Maryland. Biomass Ni was readily soluble and extractable, suggesting near immediate release as biomass was added to soil Extractable nickel in soil amended with biomass declined rapidly over time due to Ni binding in soil These results suggest that Ni released from biomass of Ni hyperaccumulators may significantly affect their immediate niche only for short periods of time soon after leaf fall, but repeated application may create high Ni levels under and around hyperaccumulators.

TheStandards, Options and Recommendations(SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centres (FNCLCC), the 20 French cancer centres, 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 establish the Standards, Options and Recommendations clinical practice guidelines for the management of procedure related pain (lumbar puncture, bone marrow aspiration or biopsy, blood sampling) in adult oncology patients. To define, on the basis of the critical appraisal of the best available evidence and expert agreement, the clinical situations in which a pain preventive strategy should be implemented. Methods. Medline(R) was searched using specific search strategies from January 1966 to August 2003. Literature monitoring was performed to identify controlled clinical trials published between August 2003 to September 2004. In addition several Internet sites were searched in July 2003. Results. A total of 12 references, corresponding to 10 randomised clinical trials, were identified. Clinical guidelines have been defined for each invasive procedure.

The "Standards, Options and Recommendations" (SOR) project, which started in 1993, is a collaboration between the French Federation of Cancer Centers (FNCLCC), the 20 French Regional 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.To update clinical practice guidelines for the assessment of pain in adult or children with cancer in collaboration with the French society for pain study and treatment.The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts who define the CPGs according to the definitions of the Standards, Options and Recommendations project. Once the guideline has been defined, the document is submitted for review by independent reviewers.This article is a summary version of the full document presenting the clinical practice guidelines with algorithms. The main recommendations concern the means used to evaluate pain and its consequences and their use in specific cases (acute or chronic pain, patients able to communicate or not, children under or over 6 years old). Others recommendations were also established concerning the evaluation ofpsychological, social and family context, the evaluation of pain in hospital or at home, in terminal phase patients and for the establishment of a therapeutic strategy and follow-up of patient with pain.

In the field of neuromuscular diseases, pain and its management remain imperfectly understood and described. We study 68 unselected, consecutive adult patients attending a multidisciplinary consultation for hereditary myopathy. Forty-six (67%) were suffering from chronic pain. Pain was assessed with self report questionnaire and a standardized clinical evaluation. Mean duration of the pain was 7.2 ± 8.9 years, and multiple body sites were involved in 91% of cases. Usual pain intensity (Visual Analogue Scale 0–100) was moderate (39.5 ± 26.2). For 42 patients (91%) the principal cause of the pain was of muscular origin, with frequent features of myofascial pain syndromes (MPS, 50%) and fibromyalgia (FMS, 26%). Pain was the major complaint for 6.3% of the patients. Pain management was essentially based on physiotherapy. Only a minority of patients (38%) has an appropriate drug treatment. Common analgesics appeared to be very effective in these patients.

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.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.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.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).

Quelles sont les pratiques de prise en charge antalgique chez les patients cancereux relevant d’un traitement opioide fort (niveau 3 de l’OMS) hors des structures specialisees de lutte contre la douleur ? Les resultats preliminaires de l’etude OCS (Opioid Care Survey) presentees recemment apportent des renseignements interessants. Pour mieux connaitre les pratiques actuelles de prise en charge antalgique chez les patients cancereux relevant d’un traitement opioide fort (niveau 3 de l’OMS), hors des structures specialisees de lutte contre la douleur, le groupe « douleur et cancer » SFETD a mis en place l’etude OCS (Opioid Care Survey) avec le soutien de Mundiphrama. L’objectif principal de l’etude etait : Observer et decrire les circonstances et les modalites pratiques d’une premiere prescription d’un antalgique de palier 3 destinee a traiter des douleurs severes persistantes d’origine cancereuse en fonction du profil d’etablissement, et du profil d’activite des medecins. Les objectifs secondaires de l’etude etaient : Suivre l’atteinte des objectifs du traitement au cours du premier mois suivant la prescription et comprendre le raisonnement aboutissant a la prescription de l’antalgique de palier 3. Le recueil d’information etait effectue sur un ordinateur de poche de type Palm qui garantissait une saisie rapide et simple des donnees en temps reel. 902 medecins ont ete contactes par mailing postal pour leur proposer de participer a l’enquete. Sur les 902, 147 ont accepte de participer et 122 (dont 84 differents) ont effectivement inclus 1 038 patients au total. L’âge des patients est compris entre 20 et 92 ans ; l’âge moyen est de 61,3 ans ± 12,7. Les hommes sont legerement plus representes que les femmes (53,7 % contre 46,3 %). Concernant le type de prise en charge, il s’agit dans 39,5 % des cas de patients hospitalises, dans 37,9 % des cas d’une consultation externe et dans 22,6 % d’une hospitalisation de jour. Les tumeurs les plus frequentes sont les tumeurs digestives (21,5 %), les tumeurs du poumon (19,5 %) et les tumeurs du sein (13,5 %). 977 patients (94,1 %) ont un traitement specifique en cours. Les resultats definitifs seront presentes lors du congres.

La douleur dans les maladies neuromusculaires (MNM) est peu etudiee. Objectifs de l’etude (2003) determiner la frequence de la douleur, son intensite, son impact et le ressenti de la prise en charge sur un echantillon national significatif. Methode A partir de 10 centres de consultation pour MNM, sur 862 questionnaires anonymes, 511 patients ayant signe un consentement eclaire et souffrant de dystrophie de Duchenne, de Becker ou de Steinert, de FSH, de myopathie metabolique, ou de myasthenie, ont permis d’evaluer les caracteristiques de leur douleur (EN, evolution, soulagement, QDSA), le traitement et leur satisfaction. Resultats Pendant les 3 mois precedents, 67,3 % des patients ont souffert de douleur, avec en moyenne 15,1 jours douloureux ; l’intensite moyenne est 4,8 ±; 2,5, maximale dans les myopathies metaboliques et la myasthenie. Trois patients douloureux sur 4 consultent pour leur douleur, avec une moyenne de 1,4 generaliste et 1,9 specialiste. Seuls 35,6 % recoivent un traitement antalgique ; les deux tiers d’entre eux ont un soulagement significatif de leur douleur. La physiotherapie est employee chez 89 % et permet un soulagement significatif chez 2/3. 70 % des patients douloureux notent un manque d’attention a la douleur de la part de leurs therapeutes et 69 % craignent une addiction aux antalgiques. De facon generale la gestion de douleur est jugee satisfaisante par 66 % des patients. Conclusion La douleur est frequente dans les MNM, son intensite habituellement moderee. La gestion du traitement est jugee satisfaisante, le nomadisme medical reduit. Certaines croyances peuvent constituer un frein a la prise en charge de la douleur dans les MNM.