[Legally capable care refuser has rights as well as responsibilities]. / Wilsbekwame zorgmijder heeft rechten én plichten.

It is hard to determine how a doctor should act when a patient with a somatic condition refuses medical care. The Dutch law obliges a doctor to inform a patient about his condition and the possible treatment options. This includes an effort to reach out and make contact with the patient. But how far should a doctor's responsibility reach when a patient refuses contact? We point out that refusal of medical care can also be seen in the light of a patient's autonomy. We thereby propose that falling ill gives responsibilities to a patient too, which include making the effort to seek medical care and cooperate with treatment.

Characteristics affecting survival after locally advanced colorectal cancer in Quebec.

BACKGROUND: We estimated the relations of sociodemographic, organizational, disease, and treatment variables with the risk of death from colorectal cancer (crc) in a Quebec population-based sample of patients with locally advanced crc (lacrc) who underwent tumour resection with curative intent. METHODS: Information from medical records and administrative databases was obtained for a random sample of 633 patients surgically treated for stages ii-iii rectal and stage iii colon cancer and declared to the Quebec cancer registry in 1998 and 2003. We measured personal, disease, and clinical management characteristics, relative survival, and through multivariate modelling, relative excess rate (rer) of death. RESULTS: The relative 5- and 10-year survivals in this cohort were 67.7% [95% confidence interval (ci): 65.8% to 69.6%] and 61.2% (95% ci: 58.3% to 64.0%) respectively. Stage T4, stage N2, and emergency rather than elective surgery affected 18%, 24% and 10% of patients respectively. Those disease progression characteristics each independently increased the rer of death by factors of 2 to almost 5. Grade, vascular invasion, and tumour location were also significantly associated with the rer for death. Receiving guideline-adherent treatment was associated with a 60% reduction in the rer for death (0.41; 95% ci: 0.28 to 0.61), an effect that was consistent across age groups. Clear margins (proximal-distal, radial) and clinical trial enrolment were each associated with a nonsignificant 50% reduction in the rer. Of patients less than 70 years of age and 70 years of age and older, 81.3% and 42.0% respectively received guideline-adherent treatment. CONCLUSIONS: This study is the first Quebec population-based examination of patients with lacrc and their management, outcomes, and outcome determinants. The results can help in planning crc control strategies at a population level.

No effect of scalp cooling on survival among women with breast cancer.

Scalp cooling can prevent chemotherapy-induced alopecia in some cancer patients. It is not used in all countries. No data are available regarding its impact, if any, on survival. The aim of this study was to compare overall survival according to whether or not scalp cooling was used during neoadjuvant or adjuvant chemotherapy for non-metastatic breast cancer. We conducted a retrospective cohort study of 1,370 women with non-metastatic invasive breast carcinoma who received chemotherapy in the neoadjuvant or adjuvant setting. A total of 553 women who used scalp cooling came from a tertiary breast cancer clinic in Quebec City (diagnosed between 1998 and 2002) and 817 were treated in other hospitals in the province of Quebec (between 1998 and 2003) where scalp cooling was not routinely available. Overall survival of women who used scalp cooling and those who did not was compared using Cox proportional hazards models. Median follow-up for the scalp-cooled and the non-scalp-cooled groups was 6.3 years and 8.0 years, respectively. Overall mortality was no different (adjusted hazard ratio 0.89, 95 % confidence interval: 0.68-1.17, p = 0.40) among scalp-cooled women, compared to those not getting scalp cooling. Among women getting neoadjuvant or adjuvant chemotherapy for non-metastatic breast cancer, scalp cooling used to prevent chemotherapy-induced alopecia had no negative effect on survival. To our knowledge, this is the first study to compare survival of women who used scalp cooling to that of women who did not.

Unresectable pancreatic tumour? The issue is tissue.

The majority of tumours in the pancreas are adenocarcinomas for which therapeutic options are limited and which are associated with an unsatisfactory prognosis. However, alternative diagnoses may result in other therapeutic approaches with often a more favourable outcome. Hence, it is crucial to obtain a histological diagnosis before a definitive therapeutic plan can be devised. In this manuscript, a small series of pancreatic tumours other than adenocarcinoma are described.

The FIGO Save the Mothers Initiative: the Uganda-Canada collaboration.

In 1998, the ob/gyn associations of Uganda and Canada launched, under the umbrella of the FIGO Save the Mothers Initiative, a district-wide intervention which aimed to increase the availability and utilization of emergency obstetric care (EmOC) services in a rural district of Uganda. The article describes the experience of two professional ob/gyn associations in the development, implementation, monitoring and evaluation of the project. Preliminary results after 24 months of intervention indicate important gains in the capacity of health professionals to deliver EmOC, the availability of emergency transportation services and met need for EmOC.

Evaluation of the rubella surveillance system in Quebec.

OBJECTIVE: To evaluate the validity of information in the rubella surveillance system in Quebec. DATA AND METHODS: Cases of rubella in the provincial registry of notifiable diseases, "Maladies à declaration obligatoire" (MADO), from 1994 to 1996 were matched with laboratory-identified cases and with cases in a reference file created from all case investigation records of regional departments of public health for the same period. Sensitivity and the proportion of cases in agreement were calculated. RESULTS: Compared with laboratories, the sensitivity of the provincial registry was 56%. Compared with the reference file, global sensitivity (confirmed cases plus clinical cases) was 58% and the positive predictive value was 50%. Of the 356 cases reported to regional public health departments, 65% were classified in the same diagnostic category (confirmed case, clinical case, excluded case) by public health professionals and a group of experts (weighted kappa=0.32). Information on rubella vaccination status was missing in 25% of cases in the MADO file for rubella. CONCLUSIONS: Notification of positive results for immunoglobulin M antibodies and viral cultures should be required of all laboratories. Uniform procedures should be adopted and applied for the validation of cases that are reported to regional departments of public health. In the context of the rarefaction of rubella, any immunoglobulin M-positive result should be interpreted using all available epidemiological information.

Complex dysrhythmias in infants and children.

Dysrhythmias in infants and children are, in many ways, similar to those in adults, yet several important differences exist in their presentation and management. Complex dysrhythmias most frequently encountered in pediatrics include sinus node dysfunction, chaotic atrial rhythm, atrial flutter, supraventricular tachycardia (including Wolff-Parkinson-White syndrome and junctional ectopic tachycardia), complete atrioventricular block (congenital and acquired), and ventricular dysrhythmias (premature ventricular contractions and ventricular tachycardia). Newer approaches to the diagnosis and management of these dysrhythmias are addressed in this paper.

[Subcutaneous analgesic administration]. / L'administration sous-cutanée d'analgésique.

In March 1989, Saint Luke's Hospital in Montréal piloted the use of continuous and intermittent subcutaneous injection of analgesics. This practice involved patients whose pain could not be relieved by traditional methods of analgesic administration. The article describes the positive results of the project, and clearly identifies suitable patients. It also outlines the advantages, limiting factors and risks involved with each type of infusion. Procedures for set-up and monitoring are briefly explained. The authors conclude that family members of patients can be easily taught to perform the procedure at home.

The role of body fat in insulin sensitivity of endurance athletes.

The purpose of the study was to assess the role of adiposity in the enhanced insulin sensitivity observed in endurance athletes (EA). An oral glucose tolerance test (75 g glucose) was administered to nine EA and to 23 sedentary subjects (SS). Two different strategies were used to investigate the problem. First, body composition indicators and Vo2max were correlated with the delta insulin and delta glucose areas measured for 180 minutes following glucose ingestion. These correlation analyses were performed for the two groups combined (n = 32). No significant correlations were observed between either fat weight or percent body fat versus delta insulin, delta glucose or delta glucose/delta insulin areas. Moreover, no significant correlation was observed between the several subcutaneous fat indicators and delta insulin, delta glucose and delta glucose/delta insulin areas. The second strategy consisted of comparing EA to SS when percent body fat difference was eliminated. This was achieved by two different methods, first by covariance analysis and second by comparing subsamples of trained and non-trained subjects paired with respect to percent body fat. These two comparisons revealed that even when adiposity was equal between the groups, a significantly greater insulin sensitivity was observed in the EA group (p less than 0.01). The present results suggest that adiposity is not the determining factor for the increased insulin sensitivity of trained subjects.

The effect of exercise-training on resting metabolic rate in lean and moderately obese individuals.

Two experiments have been performed to establish whether exercise-training has an influence on resting metabolic rate (RMR). In a first study, RMR was measured in a cohort of 59 individuals comprising 20 trained and 39 non-trained subjects. The absolute level of RMR in trained subjects exceeded by 11 percent that observed in the non-trained individuals (P less than 0.01). When comparing regression lines of RMR versus FFM between the two groups, the intercept with the Y axis (RMR values) was also significantly higher in trained subjects (P less than 0.01). The second experiment was conducted to find out whether the trend for an elevated RMR noted in athletes could be reproduced in obese persons engaging in an exercise-training program. Eight moderately obese women were submitted to an 11-week training programme, including 5 hours of aerobic exercise per week performed at a mean intensity of about 50 percent VO2 max. The results showed that exercise-training induced a significant rise in RMR which corresponded to 8 percent of pretraining value in kcal/kg FFM/min (P less than 0.01). Thus, data reported here suggest that aerobic exercise-training is associated with an elevated RMR per unit of fat free mass in both lean and moderately obese individuals.

Sex differences in the Beck Depression inventory scores of adolescents.

The purpose of the present study is to evaluate the potential differences between male and female adolescents in their performance on the Beck Depression Inventory (BDI) as a function of demographic variables and variables related to their living conditions. Three hundred and twelve adolescents between the ages of 13 and 17 completed the BDI and a questionnaire dealing with the variables mentioned above. All adolescents were from the Western Quebec area and were registered at De l'Ile High School (Hull) or at L'Erablière High School (Gatineau). Differences in the BDI scores were observed between female and male adolescents, with females scoring significantly higher than males. However, none of the variables included in the questionnaire had a differential effect on the BDI scores of either male or female adolescents. The results are discussed in light of their relationship with some adjustment factors in adolescence.

Successful treatment of Pseudomonas meningitis and septicemia in a leukemic neutropenic adult.

Pseudomonas aeruginosa is thought to be one of the main species of bacteria producing infection in leukemic patients, especially in those with neutropenia. Although bacteremia is frequent, hematogenous spread causing secondary meningitis is rarely seen. The mortality rate is extremely high. This is believed to be the first report of a successfully treated secondary meningitis caused by Pseudomonas aeruginosa in an adult leukemic patient with a decreased neutrophil count. The patient was treated with intravenous Carbenicillin and gentamicin, and intrathecal gentamicin. The good clinical response was supported by a prompt return of the CSF to normal and by appropriate CSF antimicrobial concentration and bacteriostatic activity.