[Adjustment disorders in oncology: a conceptual framework to be refined]. / Le trouble de l'adaptation en oncologie: un cadre conceptuel à préciser.

The use of stringent sets of diagnostic criteria often represents a daily clinical challenge for mental health professionals caring for cancer patients. Many nosological classification systems were not specifically developed to meet the peculiarities associated with the emotional experience of cancer. In particular, the diagnosis of adjustment disorder according to the Diagnostic and Statistical Manual of mental disorders appears inappropriate in this context. It is questionable, indeed, how to assess the "excessive" nature of psychological distress ari-sing in response to such a burdening event as a cancer diagnosis. Furthermore, the conceptual validity of the adjustment disorder construct may be of poor clinical relevance in patients suffering from a life-threatening medical condition and its widespread consequences. In this paper, we intend to offer an operational definition of adjustment and we argue that a vast majority of cancer patients currently receiving a diagnosis of adjustment disorder actually suffer from either subthreshold depression or from full or partial presentation of post-traumatic stress disorder. We first briefly review some available models of psychological adaptation. We also argue that trying to explain the experience of cancer alongside a continuum of psychological distress does not help us to better understand underlying adjustment processes and to treat emotional disturbances more effectively. The literature is currently scanty about the critical role of a psychological trauma, namely the diagnosis of cancer, in generating emotional, cognitive and behavioral responses. The very fact that an average of 10% of cancer patients have been shown to meet criteria for PTSD might suggest that the existence of a specific trauma stress adaptation process in this particular patient population. The confirmation of these hypotheses by clinical observation, experimental psychology paradigms or functional brain imagery studies could have substantial implications for the treatment of psychological distress in patients with cancer. Issues such as the relevance of pharmacological treatment of subthreshold depression--which has received little attention in the general literature--or the role of psychodynamic approaches in the management of cancer-related traumatic dimensions, should be addressed systematically.

[Diagnosis and treatment of depression in the advanced stage of cancer]. / Le diagnostic et le traitement de la dépression en phase avancée du cancer.

The diagnosis of depression in patients with advanced cancer is a particularly complex task. The lack of diagnostic tools specifically developed for this patient population, the difficulty of interpreting neurovegetative symptoms of depression--which can result from the neoplastic disease--and the "normal and understandable" nature of many symptoms or signs of psychological distress are among the main obstacles to a clear-cut diagnosis of depression. Things go even more complex when it comes about to discuss whether one should treat patients displaying psychological distress that does not meet established criteria for the diagnosis of a depressive illness. When the indication to treat is finally acknowledged, the choice of the optimal antidepressant will depend upon a series of parameters including survival expectancy, tolerance profile and drug interactions. Though we currently lack prospective data about the efficacy and safety of antidepressants in depressed patients with advanced cancer, extrapolation of data available from other patient populations with severe medical conditions and clinical experience allow to draw guidelines aimed at helping healthcare professionals faced with those problems to improve the quality of life of their patients. These elements are presented and discussed in this paper in the light of the recent developments resulting from the growing interest of the medical community to the care to patients with terminal illness.

[Terminal medical interventions: psychosocial, medical, ethical and legal aspects]. / Les interventions médicales de dernier recours: aspects psychosociaux, médicaux, éthiques et juridiques.

We give an overview of the available medical solutions to help a patient with refractory symptoms at the end of his life. Patient "competence" must first be evaluated and, even if their diagnosis is difficult, organic mental disorders and depression must be diagnosed and adequately treated to allow a real, personal and honest dialog. Administration of high doses of morphine is frequently used at the end of life not only to fully relieve pain but also to accelerate death, even if this is not clearly stated. This technique is not devoid of hypocrisy and high doses of morphine can have quite unpleasant side effects. Treatment withdrawal or withholding is generally not sufficient to allow a correct end of life. The arrest of ventilation, dialysis, artificial nutrition and even more hydration must often be coupled with techniques inducing unconsciousness, which makes imprecise the limits between such a "passive" ending of life and "active" euthanasia. The technique of terminal sedation, frequently based on the use of midazolam, has been more recently introduced in some palliative care units. Such a "controlled sedation" is supposed to allow a "natural" death by inducing a profound sleep. In opposition with active euthanasia, which allows a quiet and rapid death at a moment chosen by the patient himself, this technique of "sedation" has an undetermined duration, has legal implications which could be viewed as quite similar as the ones of euthanasia, and, moreover, this prolonged agony can be extremely stressful and distressing for the family. Medical-assisted suicide is allowed in The Netherlands under the same conditions as euthanasia. Death is generally obtained after a few hours but the technique is not always successful and the process of death can sometimes be prolonged and uncomfortable. This technique can nevertheless be preferred by some physicians and patients. As compared to active euthanasia, the proportion of medically-assisted suicides (1/6) is low in The Netherlands. Euthanasia is the only technique able to induce a peaceful and rapid death. The proportion of various techniques to actively induce death is probably quite similar in our country than in The Netherlands but, most of the time, these interventions occur at the very end of life when the patient is no longer able to participate in the decision process and thus occur without his explicit request. We think that, as for all medical decisions, the use of one or the other of these various techniques should be selected after a quiet and free discussion between the patient and his physician, preferably in advance and not in a situation of emergency and panic.

The assessment of serum nontransferrin-bound iron in chelation therapy and iron supplementation.

Nontransferrin-bound iron (NTBI) appears in the serum of individuals with iron overload and in a variety of other pathologic conditions. Because NTBI constitutes a labile form of iron, it might underlie some of the biologic damage associated with iron overload. We have developed a simple method for NTBI determination, which operates in a 96-well enzyme-linked immunosorbent assay format with sensitivity comparable to that of previous assays. A weak ligand, oxalic acid, mobilizes the NTBI and mediates its transfer to the iron chelator deferoxamine (DFO) immobilized on the plate. The amount of DFO-bound iron, originating from NTBI, is quantitatively revealed in a fluorescence plate reader by the fluorescent metallosensor calcein. No NTBI is found in normal sera because transferrin-bound iron is not detected in the assay. Thalassemic sera contained NTBI in 80% of the cases (range, 0.9-12.8 micromol/L). In patients given intravenous infusions of DFO, NTBI initially became undetectable due to the presence of DFO in the sera, but reappeared in 55% of the cases within an hour of cessation of the DFO infusion. This apparent rebound was attributable to the loss of DFO from the circulation and the possibility that a major portion of NTBI was not mobilized by DFO. NTBI was also found in patients with end-stage renal disease who were treated for anemia with intravenous iron supplements and in patients with hereditary hemochromatosis, at respective frequencies of 22% and 69%. The availability of a simple assay for monitoring NTBI could provide a useful index of iron status during chelation and supplementation treatments. (Blood. 2000;95:2975-2982)

The concept of rehabilitation of cancer patients.

The scope of supportive care and cancer rehabilitation is very wide and heterogeneous. In this review we focus on nutritional aspects, sexual and gonadal function, psychological rehabilitation, treatment of cancer pain, and rehabilitation of patients with bone metastases. The anorexia-cachexia syndrome is a particularly frequent manifestation of cancer that profoundly affects body image and significantly impairs quality of life of cancer patients. However, enteral feeding through nasogastric tubes, gastrostomies, or jejunostomies is an efficient method for providing long-term enteral nutrition at home and for contributing to complete rehabilitation after cancer therapy. Recent effort has focused on nutritional pharmacology and on the optimalization of the use of appetite-stimulating drugs, such as progestational agents. The psychological components of cancer, anticancer therapy, and quality of life have now been widely recognized and studied. Effective pharmacological and psychotherapeutic interventions help patients and their family to better adjust to the chronic stress of cancer, but more specific determinants of psychological morbidity should be developed. In particular, the safe and efficient use of the most recent classes of antidepressants and anxiolytics should be urgently studied. More than 90% of cancer patients present one or more pain syndromes during their illness. The adequate use of drugs is the cornerstone of treatment. The development on new molecules and new routes of administration opens interesting perspectives for cancer pain control. Bone metastases are the source of considerable morbidity. Intravenous bisphosphonates have been successfully used for the treatment of the symptoms of metastatic bone disease, especially bone pain. Moreover, monthly pamidronate infusions in addition to chemotherapy reduce the mean skeletal morbidity rate by more than one third and contribute to the rehabilitation of cancer patients with bone metastases from breast cancer or with multiple myeloma.

[Contribution of positron-emission tomography to the study of language]. / Contributions de la tomographie par émission de positrons à l'étude du langage.

Language is the most evolved and complex of cognitive functions. During recent years, its study has largely benefited from new medical imaging technologies among which positron emission tomography (PET), allowing for direct observation of in vivo human brain activity. This paper reviews some of the important advances in the understanding of single-word processing provided by PET, integrating them in the context of other fields of investigation such as cognitive neuropsychology. It also points out the limitations of the technique and some of its recent developments, opening the way for further comprehension of language processing.