[Partial delegation to radiation therapists of the control by cone beam CT of prostate positioning]. / Délégation partielle du contrôle quotidien de position de la prostate par tomographie conique aux manipulateurs en électroradiologie médicale.

PURPOSE: Intensity modulated radiotherapy for prostate cancer involves daily monitoring of the positioning of the prostate, possible with cone beam CT (CBCT). It allows increased accuracy compared to readjustments but induces an increase in the time dedicated to these medical checks. The aim of the study was to evaluate the possibility of delegation of this task to the radiation therapists by comparing their readjustments to the doctors. PATIENTS AND METHODS: Five consecutive patients treated with radiation for prostate cancer (76Gy) were analysed. All had a daily CBCT for position control. The movements of the prostate relative to the bony part, the positional variations of the prostate measured by the radiation therapists and the doctors and medical time required to analyse imagery (filling of the rectum and bladder and perform a recalibration) were measured. RESULTS: One hundred seventy-six CBCT were analysed or 980 steps in the three axes. The movements of the prostate relative to bony part were respectively at least 5mm in 19%, 7% and 3% in the anterior-posterior, upper-lower and right-left axes. Changes readjustments between radiation therapists and doctors were in 95% of cases at the most 4mm in the anterior-posterior and upper-lower axis, and 3mm in the left-right axis. The time for medical use of the CBCT averaged 8min 40 [4 to 22min]. CONCLUSION: The daily readjustment on the prostate using CBCT may be delegated to radiation therapists with acceptable concordance of less than 4mm for 95% of measurements. An initial and ongoing training will ensure treatment safety.

[Prostate cancer boost using high-dose-rate brachytherapy: impact of the learning curve on the dosimetry]. / Curiethérapie de haut débit de dose après radiothérapie externe d'un cancer de prostate : impact de la courbe d'apprentissage sur la dosimétrie.

PURPOSE: To analyse the influence of the learning curve on dosimetric data for high-dose-rate brachytherapy prostate cancer boost. PATIENTS AND METHODS: From February 2009 to May 2012, after a first course of external beam radiation therapy (46Gy/23 fractions), 124 patients underwent high-dose-rate brachytherapy boost using Plato™ (Nucletron, an Elekta company, Elekta AB, Stockholm, Sweden). The impact of the learning curve on the dosimetric quality of the prostate implant was assessed. The dosimetric data have been analysed: clinical target volume (CTV), D90 (dose to 90 % of CTV), D100, V100 (part on the CTV receiving 100 % of the dose), V150, V200 and DHI (dose non-homogeneity index). The doses delivered to 0.1, 1 and 2 cm(3) of the rectum and urethra were calculated. RESULTS: During the study period (39 months), a significant reduction of V150 (P<0.001), V200 (P<0.001), D0.1rectum (P<0.001), D1rectum (P<0.001), D2rectum (P<0.001), D0.1urethra (P<0.001), and D1urethra (P<0.002) was observed associated with a significant degradation of the D90 (P<0.001) but not significant for the V100 (P=0.29) and the D100 (P=0.3). CONCLUSION: This study confirms that the dosimetric quality of high-dose-rate brachytherapy prostate implant is significantly improved during the learning curve period.

[Stereotactic irradiation in head and neck cancers]. / Boost et réirradiation stéréotaxiques des cancers des voies aérodigestives supérieures.

Stereotactic radiotherapy is increasingly used in head and neck tumours, either as a boost for dose escalation/early salvage, or in the reirradiation setting. We aimed to assess the level of evidence for each clinical setting and to discuss the different dose and frationation regimens. A search of the French and English literature was performed on PubMed until December 2013. Stereotactic reirradiation of locally recurrent squamous cell carcinomas can be performed with overall survival rates of about 12 months with good quality of life, and acceptable toxicity, based on several phase 2 trials and retrospective studies. Nasopharyngeal carcinomas may be irradiated with even better control rates. Late severe toxicities yield up to 20-30%. Patient and tumour selection criteria (limited volume) and dose constraints to the carotids (cumulative dose 110 Gy or less, to avoid the risk of potentially lethal carotid blowout) must be carefully chosen. Fractionated regimens (at least five fractions) should be preferred (30 Gy in five fractions to 36 Gy in six fractions). Methods derived from stereotactic, intensity-modulated radiotherapy (IMRT) may be used with conventional fractionation for larger tumours. Stereotactic irradiation may be associated with cetuximab; data with chemotherapy or other targeted therapies are still lacking. Stereotactic irradiation is also used as a boost after 46 Gy IMRT in several institutions or for early salvage (8 to 10 weeks following full dose irradiation with evidence of residual tumour) in squamous or nasopharyngeal carcinomas. Such indications should be evaluated prospectively in clinical trials. Data in salivary gland and sinonasal neoplasms are still scarce. In conclusion, stereotactic body radiation therapy has the potential as a boost or in the reirradiation setting to improve local control in head and neck tumours. Careful hypofractionation with planning caring for the dose to the main vessels is highly recommended. Prospective studies with prolonged follow-up (at least 2 years) should be encouraged.

[Prescribing medication in 2013: legal aspects]. / Prescrire un médicament en 2013: aspects légaux.

AIM: To describe the legal framework of medicine prescription in France in 2013. METHODS: With the assistance of lawyer and forensic pathologist, consultation (legifrance.gouv.fr), analysis, summary of French laws and rules surrounding drugs prescriptions to humans for medical purpose. RESULTS: Free medicine prescription is an essential feature of a doctor's action. To prescribe involve his responsibility at 3 levels: deontological, civilian and penal. Aim of the rules of medicine prescription is to preserve patient's safety and health. Doctors are encouraged to refer to recommendations and peer-reviewed publication every time the prescriptions go out of the case planned by law. CONCLUSION: Knowledge and respect of medicine prescription legal rules is essential for a good quality practice. Medical societies have a major role to improve medicine use among practitioners.

[Image-guided radiotherapy and partial delegation to radiotherapy technicians: Clermont-Ferrand experience]. / Radiothérapie guidée par l'image et partage des tâches avec les manipulateurs en électroradiologie : expérience de Clermont-Ferrand.

The various image-guided radiotherapy techniques raise the question of how to achieve the control of patient positioning before irradiation session and sharing of tasks between radiation oncologists and radiotherapy technicians. We have put in place procedures and operating methods to make a partial delegation of tasks to radiotherapy technicians and secure the process in three situations: control by orthogonal kV imaging (kV-kV) of bony landmarks, control by kV-kV imaging of intraprostatic fiducial goldmarkers and control by cone beam CT (CBCT) imaging for prostate cancer. Significant medical overtime is required to control these three IGRT techniques. Because of their competence in imaging, these daily controls can be delegated to radiotherapy technicians. However, to secure the process, initial training and regular evaluation are essential. The analysis of the comparison of the use of kV/kV on bone structures allowed us to achieve a partial delegation of control to radiotherapy technicians. Controlling the positioning of the prostate through the use and automatic registration of fiducial goldmarkers allows better tracking of the prostate and can be easily delegated to radiotherapy technicians. The analysis of the use of daily cone beam CT for patients treated with intensity modulated irradiation is underway, and a comparison of practices between radiotherapy technicians and radiation oncologists is ongoing to know if a partial delegation of this control is possible.

Medication misuse and abuse: duties and responsibilities of dispensing pharmacists.

Misuse of medications can have major consequences for the consumer or patient's health. In the case of a drug delivered only on medical prescription, the misuse usually results from an error or negligence on the part of the prescribing doctor and/or the pharmacist dispensing the medication. But whereas, under French Law, doctors are regularly prosecuted for their irresponsibility, pharmacists frequently avoid any legal charges. This is even more surprising in view of the fact that French Legislation controls the practice of pharmacy very strictly. The authors discuss four cases that illustrate this issue and present a study of comparative pharmaceutical law requirements.

[The Dintilhac report and its implications for forensic neuropsychological evaluation]. / Implication du rapport Dintilhac dans l'expertise neuropsychologique.

BACKGROUND: When preparing neuropsychological expert reports, the neuropsychologist is asked to make a precise assessment of the victims' cognitive dysfunction, generally after traumatic head injury. The expert is usually required to assess the nature of the neuropsychological deficits, their correlation with any brain lesions and their imputability to the accident or crime in question, to estimate a possible date of stabilisation and to evaluate the heads of damage. The basic principle of compensation for personal injury is to consider the circumstances in which the victim would have been if the prejudicial event (for example, the accident) had not occurred and to assess, on the basis of these various heads of damage, compensation for the injury suffered. While it is not the neuropsychologist's role to evaluate the compensation as such, he or she has however to specify which aspects of cognitive function are deficient and what impact this dysfunction has on a personal and occupational level. Until recently, compensation for personal injury, and notably for cognitive deficits, was assessed with reference to nine principal heads of damage, in particular the conventional concepts of total temporary disability (incapacité temporaire totale [ITT]), defined as the period during which the victim was temporarily unable to carry out their usual occupational and personal activities, and partial permanent disability (incapacité partielle permanente [IPP]), defined as a percentage and corresponding to the reduction, after stabilisation, in the victim's functional capacity - that is, their physical and psychological potential - here again from an occupational and personal viewpoint. However, concretely, the emphasis had shifted to take into account only the pecuniary aspects of injury relating to the domain of "having", that is the loss of income due to cessation of work, while the non-pecuniary aspects relating to the domain of "being" were often ignored. NEW CLASSIFICATION: The Dintilhac report has established a new classification of heads of physical damage which abandons these two ambiguous concepts of ITT and IPP. Damage now includes three categories: pecuniary and non-pecuniary; temporary and permanent and damage to direct and indirect victims. We define the new heads of damage to direct victims, illustrate them with examples from neuropsychological expert reports, compare the old and the new classifications and discuss the implications of the Dintilhac report for expert assessment. The report appears to remove the ambiguities previously mentioned, since ITT has been replaced by two new heads of damage which are clearly defined as pecuniary and non-pecuniary: "loss of present occupational income" (pertes de gains professionnels actuels [PGPA]) and "temporary functional deficiency" (déficit fonctionnel temporaire [DFT]), respectively. Similarly, IPP is replaced by two new heads of damage, which are also clearly defined as pecuniary and non-pecuniary and are the poststabilisation equivalents of PGDA and DFT: these are "loss of future earnings" (pertes de gains professionnels futurs [PGPF]) and "permanent functional deficiency" (déficit fonctionnel permanent [DFP]). Concerning the other heads of damage, the amendments introduced by the new classification do not basically modify the earlier concepts but are nevertheless more precise in certain respects. The "pretium doloris", or "price of pain", is replaced by "suffering sustained" (souffrances endurées [SE]) with little fundamental change. The same is true of "loss of amenity" (préjudice d'agrément [PA]). The term of "aesthetic impairment" (préjudice esthétique [PE]) also remains the same, but whereas it previously related only to permanent impairment, it now includes temporary impairment, before stabilisation. What was formerly termed "loss of sexual function" now consists of "loss of sexual function" (préjudice sexuel [PS]) as well as "loss of the prospect of founding a family" (préjudice d'établissement [PE]), allowing a finer distinction to be made between the damages sustained. The former "third party" (tierce personne) is now covered under the headings of "assistance by a third party" (assistance par tierce personne [ATP]), "expenses of accommodation conversion" (frais de logement adapté [FLA]) and "expenses of vehicle conversion" (frais de véhicule adapté [FVA]), which here again provides greater precision in the heads of compensation. Lastly, what was previously known as "loss of opportunity" (perte de chance) is divided into three different categories: "loss of education, whether at school, university or in training" (préjudice scolaire, universitaire ou de formation [PSU]), "loss of future occupational earnings" (perte de gains professionnels futurs [PGPF]) and in part the "occupational impact" (incidence professionnelle [IP]). CONCLUSION: In summary, these various heads of damage concerning direct victims that are proposed by the Dintilhac report result in a more detailed evaluation of compensation for personal injury. Assessment of a certain number of heads of damage is an integral part of the preparation of a neuropsychological expert report and the fact that these heads of damage are now better defined makes the expert's task easier. As the neuropsychologist, generally called upon to give an expert opinion, now has better knowledge of this new classification, he or she will be able to give clearer and fuller answers to the questions raised and so comply with the principle of civil law relating to compensation for personal injury: "compensate the injury, all the injury, but nothing except the injury".

Dramatic improvement of the enantiomeric excess in the asymmetric conjugate addition reaction using new experimental conditions.

The asymmetric conjugate addition of dialkylzincs is usually performed with Cu(OTf)(2) in toluene. We show that by using a copper carboxylate in Et(2)O, THF, or EtOAc, we strongly improve the enantioselectivity with a given ligand. Ee values up to 99.1% could be reached with new ligands based on the induced atropisomerism of a simple biphenol unit. In addition, we show that the Lewis acid effect of Cu(OTf)(2) is not a significant.

Enantioselective copper-catalyzed conjugate addition of dialkyl zinc to nitro-olefins

[reaction: see text]The copper-catalyzed asymmetric conjugate addition of dialkylzinc onto various nitro-olefins has been carried out with excellent results. An enantiomeric excess of up to 94% was obtained using 0.5% Cu(OTf)2 and 1% of chiral trivalent phosphorus ligand.