Objectives: This study explored the clinical impacts of the white coat given its widespread use in psychiatry departments. We attempted to elucidate the underlying rationale for this phenomenon, which seems paradoxical given that research on hospital sanitation suggests white coats are associated with infection risk. Methods: Our study was multicentric, exploratory, and non-interventional. We invited seven certified psychiatrists, representing different professional domains, to participate in semi-structured interviews focused on their experiences with clothing in psychiatric settings. This exploration included the uses and potential impacts of clothing on the therapeutic relationship and the effectiveness of patient care. The resulting data were analyzed using an inductive thematic approach based on grounded theory. Results: We observed a unique interplay between utility and symbolism in the use of clothing in the hospital setting. Professional attire or work clothing (depending on the case) served as a way to embody the role of psychiatrist. The physician's attire was linked to daily hygiene rituals and spatial delineation, separating personal and professional life as well as ordinary and therapeutic spaces and thus marking the boundaries of distinct symbolic spheres. The use of the white coat facilitated physical examinations and created distance during certain appearance-related aspects of encounters. These uses were ultimately connected to the vehicle of care as a whole. The voluntary use of objects, such as clothing, contributed to the theatricalization of care, which imposes itself as the mode of operation in the everyday therapeutic approach. Discussion: Despite the contemporary dominance of instrumental reasoning in the organization of care, the return of the white coat in psychiatry-persisting despite available scientific evidence-points to a logic of care that cannot be reduced to scientific rationality. This practice has implications for the type of therapeutic, or transferential, relationship it induces. Beyond non-specific factors underlying care effectiveness, the care context characteristic of the so-called modern medical order can thus be understood as a therapeutic system of influence, comparable to traditional systems previously studied. Within this system, the placebo function designates the mediating role through which a biologically measurable effect may be produced, and may thereby contribute to amplifying the effects of biological therapeutic interventions, as suggested by the identification of the white coat effect. Conclusion: The perspectives developed in this study expand existing research on the placebo effect in conventional medicine, which is broadly defined as the biological effect of the overall psychosocial context. Our work invites further reflection on the impacts of medical systems for receiving patients, particularly with the anticipated rise of precision psychiatry, with a view to better understanding and enhancing the effectiveness of biological medical interventions.
BACKGROUND AND AIMS:Current evidence on catheter ablation for patients with congenital heart disease (CHD) is derived from small, retrospective studies. This study aims to provide insights from a nationwide contemporary registry. METHODS:This prospective study included all CHD patients referred for catheter ablation from 2020 to July 2024 across 28 French centres. The primary outcome was the rate of per-procedural acute success. Secondary outcomes included complications as well as freedom from arrhythmia recurrence. RESULTS:A total of 1135 consecutive catheter ablation procedures were performed in 998 patients (mean age 46.1 ± 16 years, 55.5% male). The main primary clinical arrhythmias targeted were atrial flutter/tachycardia in 677 (59.6%), atrial fibrillation in 195 (17.2%), ventricular arrhythmia in 188 (16.6%), and atrioventricular reentrant tachycardia in 38 (3.3%), with significant variations in patterns observed based on the underlying substrate. Clinical arrhythmia was successfully ablated in 1071 patients (94.4%). The mean number of arrhythmias targeted per procedure was 1.5 ± 0.7, with overall acute success rates exceeding 90% for all arrhythmias except for ventricular arrhythmias (86.7%). Acute complication occurred in 43 procedures (3.8%), including 1 (0.1%) death. The overall 1- and 2-year recurrence-free rates were 77.3% (95% confidence interval 74.2%-80.4%) and 68.4% (95% confidence interval 64.7%-72.3%), respectively. Significant variations in recurrence rates were noted based on the type of arrhythmia and the underlying CHD. CONCLUSIONS:Catheter ablation in patients with CHD demonstrates highly favourable acute outcomes and a low complication rate. Recurrence rates during follow-up vary depending on the targeted arrhythmia and the underlying CHD. These findings should be considered in the benefit-risk assessment.
PURPOSE:Mismatch repair deficiency (dMMR) or microsatellite instability (MSI) represents a distinct phenotype among solid tumors resulting in the generation of highly immunogenic neoantigens. Pembrolizumab has been approved in first-line unresectable or metastatic dMMR/MSI colorectal cancers (CRC). We aimed to assess efficacy and tolerance of perioperative pembrolizumab in dMMR/MSI CRC. PATIENTS AND METHODS:The prospective multicenter phase II trial IMHOTEP enrolled patients with localized resectable dMMR/MSI CRC to receive one or two cycles of IV pembrolizumab 400 mg once every 6 weeks before surgery and 1-year total duration thereafter. The primary end point was pathologic complete response (pCR) rate (ypT0N0). Secondary objectives included safety, event-free survival, and overall survival. RESULTS:IMHOTEP enrolled 81 patients with dMMR/MSI CRC who received at least one cycle of pembrolizumab from November 26, 2021, to February 22, 2023: median age was 66 (21-89) years, 46 (52%) were women, and 63 (71%) had clinical stage III disease at baseline. Out of the 72 patients included in the efficacy population, 38 patients (52.7% [95% CI, 41.4 to 63.9]) achieved a pCR. The exploratory post hoc analysis showed a pCR rate increased from 46% (23/50) after one cycle to 68.2% (15/22) after two cycles of neoadjuvant pembrolizumab (P = .0125). With a median follow-up of 24.5 (95% CI, 23.3 to 25.6) months, three disease recurrences occurred. Grade ≥3 immune-related toxicities were reported in 14 (15.7%) patients including one grade 5 (myasthenia). CONCLUSION:The IMHOTEP trial showed promising results, with pCR achieved after one or two cycles of neoadjuvant pembrolizumab in 53% of patients with dMMR/MSI CRC. To our knowledge, this prospective study is the first to demonstrate the feasibility and the safety of perioperative pembrolizumab.
