Can Anti-Müllerian Hormone levels predict future pregnancy outcomes in recurrent pregnancy loss?

OBJECTIVE

Serum Anti-Müllerian Hormone (AMH) levels have been shown to be lower among women who have experienced recurrent pregnancy loss (RPL) compared with the general population. However, it is unclear whether it can predict livebirth. This study aims to determine whether AMH can predict the likelihood of a livebirth in women with RPL.

STUDY DESIGN

Prospective analysis of a consecutive cohort of women undergoing investigation for RPL in a tertiary referral centre over a seven year period (August 2014 -December 2021). Analysis was performed using descriptive statistics, chi-square models and logistic regression models adjusting for maternal age and previous livebirth. Exclusion criteria for the regression analysis included abnormal parental karyotype and abnormal pelvic ultrasound scan. Pregnancy outcome was defined as livebirth or further pregnancy loss.

RESULTS

There were 488 women who underwent investigation of RPL during the study period. Of these, 65.2% (n = 318) conceived following attendance at the clinic. The majority of these women (69.4%, n = 221) proceeded to have a livebirth. There were no differences in median AMH levels between the livebirth group and the further pregnancy loss group (11 pmol/L vs 9 pmol/L respectively (p = 0.083). AMH did not affect clinical pregnancy rates (p = 0.77, 95% CI = 0.99 [0.98, 1.01]) or pregnancy outcome (p = 0.30, 95% CI = 1.01 [0.99, 1.04]). Abnormal pelvic ultrasonography (p = 0.04) and an abnormal parental karyotype (p = 0.04) were associated with an increased likelihood of a subsequent pregnancy loss.

CONCLUSION

Although AMH levels may have some utility in counselling of some couples with RPL, these contemporaneous data indicate that low AMH does not negatively influence subsequent pregnancy outcome in women with recurrent pregnancy loss.

Implementation of the Vinehealth application, a digital health tool, into the care of patients living with brain cancer

e13582

Background: Cancers of the brain lead to significant neurocognitive, physical and psychological morbidities. Digital technologies provide a novel platform to capture and evaluate these needs. Mobile health (mHealth) applications typically focus on one aspect of care rather than addressing the multimodal needs of the demographic of these patients. The Vinehealth application aims to address this by tracking symptoms, delivering machine learning-based personalised educational content, and facilitating reminders for medications and appointments. Where mHealth interventions traditionally lack the evidence-based approach of pharmaceuticals, this study acts as an initial step in the rigorous assessment of a new digital health tool. Methods: A mixed methodology approach was applied to evaluate the Vinehealth application as a care delivery adjunct. Patients with brain cancer were recruited from the day of their procedure ± 7 days. Over a 12-week period, we collected real-world and ePRO data via the application. We assessed qualitative feedback from mixed-methodology surveys and semi-structured interviews at onboarding and after two weeks of application use. Results: Six participants enrolled of whom four downloaded the application; four completed all interviews. One patient set up their device incorrectly and so couldn't receive the questionnaires; excluding this patient, the EQ-5D-5L and EORTC QLQ-BN20 completion rates were 100% and 83% respectively. Average scores (±SD) at onboarding and offboarding were EQ-5D-5L: 2.07±1.28 and 1.73±1.22, and QLQ-BN20: 13.33 and 22.5. In total: 212 symptoms, 174 activity, and 47 medication data points were captured, and 113 educational articles were read. Participants were generally optimistic about application use. All users stated they would recommend Vinehealth and expressed subjective improvements in care. Accessibility issues in the ePRO delivery system which impacted completion rate were identified and have subsequently been fully addressed. Conclusions: This feasibility study showed acceptable patient use, led to a subjective improvement in care, and demonstrated effective collection of real-world and validated ePRO data. This provides a strong basis to further explore the integration of the Vinehealth application into brain cancer care. This study will inform the design of a larger, more comprehensive trial continuing to evaluate improvements in care delivery through data collection, educational support and patient empowerment.

Stopping targeted therapy for complete responders in advanced BRAF mutant melanoma

BRAF inhibitors revolutionised the management of melanoma patients and although resistance occurs, there is a subgroup of patients who maintain durable disease control. For those cases with durable complete response (CR) it is not clear whether it is safe to cease therapy. Here we identified 13 patients treated with BRAF +/- MEK inhibitors, who cease therapy after prolonged CR (median = 34 months, range 20-74). Recurrence was observed in 3/13 (23%) patients. In the remaining 10 patients with sustained CR off therapy, the median follow up after discontinuation was 19 months (range 8-36). We retrospectively measured ctDNA levels using droplet digital PCR (ddPCR) in longitudinal plasma samples. CtDNA levels were undetectable in 11/13 cases after cessation and remained undetectable in patients in CR (10/13). CtDNA eventually became detectable in 2/3 cases with disease recurrence, but remained undetectable in 1 patient with brain only progression. Our study suggests that consideration could be given to ceasing targeted therapy in the context of prolonged treatment, durable response and no evidence of residual disease as measured by ctDNA.

Improved calibration of the OMEGA gas Cherenkov detector

Inertial fusion implosions are diagnosed using γ rays to characterize the implosion physics or measure basic nuclear properties, including cross sections. For the latter, previously reported measurements at laser facilities using gas Cherenkov detectors are limited by a large systematic uncertainty in the detector response. We present a novel in situ calibration technique using neutron inelastic scattering, which we apply to the new GCD-3 detector. The calibration accuracy is improved by ∼3× over the previous method.

Decision making in surveillance of high-grade gliomas using perfusion MRI as adjunct to conventional MRI and artificial intelligence

2054

Background: Surveillance of High-Grade Gliomas (HGGs) remains a major challenge in clinical neurooncology. Histopathological validation is not an option during the course of disease and imaging surveillance suffers from ambiguous features of both disease progression and treatment related changes. This study aimed to differentiate between Pseudoprogression (PsP) and Progressive Disease (PD) using an artificial intelligence (support vector machine - SVM) classification algorithm. Methods: Two groups of patients with histologically proven HGGs were analysed, a group with a single time point DSC perfusion MRI (45 patients) and a group with multiple time point DSC perfusion MRI (19 patients). Both groups included conventional MRI studies prior and after each perfusion MRI. This study design aimed to replicate decision making in clinical practice including multiple previous studies for each patient. SVM training was performed with all available MRI studies for each group and classification was based on different feature datasets from a single or multiple (subtracted features) time points. Classification accuracy comparisons were performed by calculating prediction error rates for different feature datasets and different time point analyses. Results: Our results indicate that the addition of multiple time point perfusion MRI combined with structural (conventional with gadolinium-enhanced sequences) MRI features results in optimal classification performance (median error rate: 0.016, lowest value dispersion). Subtracted feature datasets improved classification performance, more prominently when the final and first perfusion studies were included in the analysis. On the contrary, in the single time point group analysis, structural feature-based classification performed best (median error rate: 0.012). Conclusions: Validation of our results with a larger patient cohort may have significant clinical importance in optimising imaging surveillance and clinical decision making for patients with HGG.

TP3-4 Changes in whole brain connectomes with simulated laser interstitial thermal therapy (LITT) using seizure free and non-seizure free ablation cavities in mesial temporal sclerosis: a graph theory approach

Objectives

LITT is a novel means of focal lesioning. Improved seizure free outcome has been associated with the extent to which the mesial hippocampal head is ablated, but not overall ablation volume. We question whether specific changes in structural network connectivity exist in patients that achieve seizure freedom.

Design

Retrospective

Subjects

25 MTS patients after LITT with 2 year outcome.

Methods

Ablation cavities from 11 seizure free and 14 non-seizure free patients were combined to generate group masks. In 12 separate pre-operative patients with MTS (6 right), weighted normalized connectomes were generated with 1 × 10^7 streamlines. To simulate ablations the group cavity masks were excluded from the connectomes prior to normalization. Differences in connectomes were assessed by graph theory metrics.

Results

Greater node strength (str) in non-seizure free patients were present in the ipsilateral basal temporo-occipital cortices in both right and left MTS. Str and local efficiency were relatively maintained in the ipsilateral thalamus of seizure free cavities. Betweenness centrality in non-seizure free cavities were greater in ipsilateral temporal poles in right and left MTS.

Conclusions

Differences in network connectivity are present following simulated LITT for MTS between seizure free and non-seizure free ablation cavities. LiTT ablation cavities may be pre-operatively modelled to ensure the ablation cavity includes important structures and non-essential or inhibitory connectivity is spared. Prospective validation is required.

P35 Ability to quantify stereoelectroencephalography (SEEG) electrode trajectory proximity to vessels across imaging protocols

Objectives

Automated planning of stereoelectroencephalography (SEEG) electrode trajectories is dependent on vessel segmentation.1 We quantify imaging protocols ability to measure trajectory-to-vessel distance.

Design

Retrospective analysis.

Subjects

Ten consecutive patients were selected whom had SEEG implantation (95 electrodes) and Digital Catheter Subtraction Angiography (DSA) with catheterization of carotid or vertebral arteries, post-gadolinium T1-weighted (GAD), phase-contrast MR angiography and MR venography (MR) acquired.

Methods

SEEG trajectories were planned manually with DSA. Minimum distance to vessels and risk1 were computed for each trajectory using vessel segmentation from GAD, MR, or DSA. Vessel size was considered by including DSA vessels diameters above 1, 2, 3, or 4 mm.

Results

Minimum distance to a vessel was 6.2±3.9 mm (GAD), 2.5±1.6 mm (MR), and 1.5±1.2 mm (DSA). Based on DSA vessel size minimum distances were 2.0±1.5 mm (DSA >1 mm), 3.4±2.6 (DSA >2 mm), 6.6±4.6 mm (DSA >3 mm), and 11.8±7.9 mm (DSA >4 mm). Risk was 0.4±0.4 (GAD), 0.8±0.4 (MR), and 1.1±0.2 (all DSA), 1.0±0.2 (DSA >1 mm), 0.7±0.4 (DSA >2 mm), 0.4±0.5 (DSA >3 mm), and 0.2±0.3 (DSA >4 mm).

Conclusions

DSA is best able to segment vessels. MR has metrics similar to DSA vessels above 2 mm. GAD has metrics similar to DSA vessels above 3 mm.

WP1-15 Computer-assisted versus manual planning for stereotactic brain biopsy: retrospective comparative pilot study

Objectives

Stereotactic brain biopsy is among the most common neurosurgical procedures. Planning a safe surgical trajectory requires careful attention to a number of features including:

traversing the skull perpendicularly;

avoiding critical neurovascular structures; and

minimising trajectory length.

The aim of this study was to develop a platform, SurgiNav, for automated trajectory planning in stereotactic brain biopsy.

Methods

A prospectively maintained database was searched between February and August 2017 to identify all adult patients that underwent stereotactic brain biopsy in whom post-operative imaging was available. In each case, the standard pre-operative T1-weighted gadolinium-enhanced MRI was used to generate models of the cortex and vasculature. A surgical trajectory was then generated using automated computer-assisted planning (CAP) and metrics compared to the trajectory of the implemented manual plan (MP) using the paired T-test.

Results

15 consecutive patients were identified; who had a diagnostic biopsy and there were no immediate complications. Feasible trajectories were generated using CAP in 12 patients, and in these the mean trajectory length using CAP was comparable to MP (31.7 mm vs. 37.1 mm; p=0.3), and mean angle was similarly perpendicular from orthogonal (9.3° vs. 15.3° p=0.1), but the risk-metric was significantly lower (0.16 vs. 0.48; p=0.03).

Conclusions

Computer-assisted planning for stereotactic brain biopsy appears feasible in most cases and may be safer in selected cases.

P31 Optimising trajectories in computer assisted planning for cranial laser interstitial thermal therapy: a machine learning approach

Objectives

Optimal trajectory planning for cranial laser interstitial thermal therapy (cLITT) in drug resistant focal mesial temporal lobe epilepsy (MTLE).

Design

A composite ablation score of ablated AHC minus ablated PHG volumes were calculated and normalised. Random forest and linear regression were implemented to predict composite ablation scores and determine the optimal entry and target point combinations to maximize this.

Subjects

Ten patients with hippocampal sclerosis were included.

Methods

Computer Assisted Planning (CAP) cLITT trajectories were generated using entry regions that include the inferior occipital gyri (IOG), middle occipital gyri (MOG), inferior temporal gyri (ITG) and middle temporal gyri (MTG). Target points were varied by sequential erosions and transformations of the centroid of the amygdala. In total 760 trajectory combinations were generated per patient and ablation volumes were calculated based on a conservative 15 mm maximum ablation diameter.

Results

Linear regression was superior to random forest predictions. Linear regression indicated that maximal composite ablation scores were associated with entry points that clustered around the junction of the IOG, MOG and MTG. The optimal target point was a translation of the centroid of the amygdala anteriorly and medially.

Conclusions

Machine learning techniques accurately predict composite ablation scores with linear regression outperforming the random forest approach. Optimal CAP entry points for cLITT maximize ablation of the AHC and spare the PHG.

Imaging fast electrical activity in the brain with electrical impedance tomography

Imaging of neuronal depolarization in the brain is a major goal in neuroscience, but no technique currently exists that could image neural activity over milliseconds throughout the whole brain. Electrical impedance tomography (EIT) is an emerging medical imaging technique which can produce tomographic images of impedance changes with non-invasive surface electrodes. We report EIT imaging of impedance changes in rat somatosensory cerebral cortex with a resolution of 2ms and <200μm during evoked potentials using epicortical arrays with 30 electrodes. Images were validated with local field potential recordings and current source-sink density analysis. Our results demonstrate that EIT can image neural activity in a volume 7×5×2mm in somatosensory cerebral cortex with reduced invasiveness, greater resolution and imaging volume than other methods. Modeling indicates similar resolutions are feasible throughout the entire brain so this technique, uniquely, has the potential to image functional connectivity of cortical and subcortical structures.

Monte Carlo validation experiments for the gas Cherenkov detectors at the National Ignition Facility and Omega

The gas Cherenkov detectors at NIF and Omega measure several ICF burn characteristics by detecting multi-MeV nuclear γ emissions from the implosion. Of primary interest are γ bang-time (GBT) and burn width defined as the time between initial laser-plasma interaction and peak in the fusion reaction history and the FWHM of the reaction history respectively. To accurately calculate such parameters the collaboration relies on Monte Carlo codes, such as GEANT4 and ACCEPT, for diagnostic properties that cannot be measured directly. This paper describes a series of experiments performed at the High Intensity γ Source (HIγS) facility at Duke University to validate the geometries and material data used in the Monte Carlo simulations. Results published here show that model-driven parameters such as intensity and temporal response can be used with less than 50% uncertainty for all diagnostics and facilities.

Diagnosing inertial confinement fusion gamma ray physics (invited)

The gamma reaction history (GRH) diagnostic is a multichannel, time-resolved, energy-thresholded γ-ray spectrometer that provides a high-bandwidth, direct-measurement of fusion reaction history in inertial confinement fusion implosion experiments. 16.75 MeV deuterium+tritium (DT) fusion γ-rays, with a branching ratio of the order of 10(-5)γ/(14 MeV n), are detected to determine fundamental burn parameters, such as nuclear bang time and burn width, critical to achieving ignition at the National Ignition Facility. During the tritium/hydrogen/deuterium ignition tuning campaign, an additional γ-ray line at 19.8 MeV, produced by hydrogen+tritium fusion with a branching ratio of unity, will increase the available γ-ray signal and may allow measurement of reacting fuel composition or ion temperature. Ablator areal density measurements with the GRH are also made possible by detection of 4.43 MeV γ-rays produced by inelastic scatter of DT fusion neutrons on (12)C nuclei in the ablating plastic capsule material.

GEANT4 simulations of Cherenkov reaction history diagnostics

This paper compares the results from a GEANT4 simulation of the gas Cherenkov detector 1 (GCD1) with previous simulations and experimental data from the Omega laser facility. The GCD1 collects gammas emitted during a deuterium-tritium capsule implosion and converts them, through several processes, to Cherenkov light. Photon signals are recorded using subnanosecond photomultiplier tubes, producing burn reaction histories. The GEANT4 GCD1 simulation is first benchmarked against ACCEPT, an integrated tiger series code, with good agreement. The simulation is subsequently compared with data from the Omega laser facility, where experiments have been performed to measure the effects of Hohlraum materials on reaction history signals, in preparation for experiments at the National Ignition Facility.

Development and characterization of sub-100 ps photomultiplier tubes

We describe the evaluation of a microchannel plate (MCP) photomultiplier tube (PMT), incorporating a 3 μm pore MCP and constant voltage anode and cathode gaps. The use of the small pore size results in PMTs with response functions of the order of 85 ps full-width-half-maximum, while the constant electric field across the anode and cathode gaps produces a uniform response function over the entire operating range of the device. The PMT was characterized on a number of facilities and employed on gas Cherenkov detectors fielded on various deuterium tritium fuel (DT) implosions on the Omega Laser Facility at the University of Rochester. The Cherenkov detectors are part of diagnostic development to measure Gamma ray reaction history for DT implosions on the National Ignition Facility.

Acute osteomyelitis and septic arthritis in children

OBJECTIVE

To review the clinical presentation, clinical management and organisms responsible for acute haematogenous osteomyelitis (AHO) and septic arthritis (SA) in the post Haemophilus influenzae type B (Hib) vaccine era and to evaluate current Australian antibiotic guidelines for these conditions.

METHODS

A retrospective chart review of children less than 16 years of age presenting to The Children's Hospital at Westmead in the period from January 1998 to July 2002 with an ICD discharge code consistent with AHO or SA.

RESULTS

During the 4 1/2-year period 120,511 children were admitted to The Children's Hospital at Westmead. There were 102 cases of AHO and 47 cases of SA during this time. An organism was identified either by blood culture or tissue biopsy in 45% of children with AHO and 38% with SA. Staphylococcus aureus was the most common identifiable causative organism accounting for 76% of isolated organisms in AHO and 39% of isolated organisms in SA. Methicillin-resistant S. aureus (MRSA) was responsible for 9% of AHO and 6% of SA cases. There were no cases due to Haemophilus influenzae or Kingella kingae during the study period. The majority (66%) of children with AHO were managed non-operatively with intravenous and then oral antibiotics. Thirty-five (34%) children had operative treatment to drain pus. In contrast, 74% of the patients with SA had one or more surgical procedures performed to drain pus from involved joints.

CONCLUSIONS

Staphylococcus aureus remains the most common organism causing AO and SA; however, community-acquired methicillin-resistant strains are now occurring. Haemophilus influenzae is no longer a common cause of SA. Our study supports the current Australian antibiotic guidelines that recommend flucloxacillin alone as the empiric treatment of choice of both AHO and SA in children fully immunised against Hib. However the possibility of community-acquired MRSA should be considered, particularly in high risk groups such as indigenous Australian children or children from regional areas with a high rate of community-acquired MRSA.

Synergistic effect of particles and cyclic pressure on cytokine production in human monocyte/macrophages: proposed role in periprosthetic osteolysis

Macrophages, activated by particulate wear debris, are important in the process of osteolysis, which occurs during joint implant loosening. We previously found increased levels of interleukin-1beta (IL-1beta), IL-6, and tumor necrosis factor-alpha in cultured macrophages subjected to cyclical pressure of 0.138 MPa, suggesting that cyclic pressure may be another relevant cause of macrophage activation. The current study first investigated the effects of a range of cyclic pressures on cultured macrophages, including an investigation of the time course of cytokine expression. At 0.138 MPa, supernatant levels of TNF-alpha were maximal at 12 h, whereas IL-6 and IL-1beta were maximal at 24 h. All four cyclic pressure levels tested (without particles) resulted in increased production of all three cytokines relative to control. These increases were most marked at 0.069 and 0.035 MPa, and the increase in cytokine production at 0.017 MPa was not statistically significant. Further studies demonstrated that conditioned media from cyclically pressurized macrophages stimulated bone resorption in a neonatal mouse calvarial assay system. There were increased levels of calcium released from calvaria cultured in conditioned media from pressurised monocytes, and an increase in tartate-resistant acid phosphatase-positive osteoclasts was observed microscopically. As particulate wear debris is important in implant loosening, ultra high molecular weight polyethylene particles were also added to the pressurized cell cultures. The experiments compared the effect of atmospheric pressure, cyclic pressure alone, particles alone, and particles and cyclic pressure combined. A combination of ultra high molecular weight polyethylene particles and cyclic pressure at 0.017 MPa resulted in a dramatic synergistic elevation of levels of all three cytokines compared with the levels found with either pressure or particles alone. We propose that monocyte/macrophage activation by cyclic pressure plays a major role in the osteolysis seen in aseptic loosening of implants. The synergistic effect observed between particles and pressure could accelerate implant loosening, and implies that reduction in either cyclic pressure (by improving implant fixation) or wear debris load would reduce osteolysis.

Involvement of the nuclear orphan receptor NURR1 in the regulation of corticotropin-releasing hormone expression and actions in human inflammatory arthritis

OBJECTIVE

To examine the regulation and mode of action of peripheral corticotropin-releasing hormone (CRH) in human inflammatory arthritis.

METHODS

CRH messenger RNA (mRNA) levels were measured in normal and inflamed synovial tissue and in primary synoviocytes prior to and following cytokine stimulation. Primary synoviocytes were transiently transfected with CRH promoter/reporter constructs, and promoter activity in response to cytokines was assessed. Immunohistochemical staining established CRH receptor expression, and Northern blot analysis confirmed that the nuclear transcription factors NUR77 and NURR1 contributed to synovial CRH receptor-mediated signaling. Primary synoviocytes were treated with pro- and antiinflammatory mediators, and the time course of NURR1 and NUR77 modulation was examined. Nuclear extracts were analyzed by electrophoretic mobility shift assay to determine NURR1 binding to the CRH promoter/enhancer.

RESULTS

CRH mRNA was up-regulated in the synovial tissue in rheumatoid arthritis (RA), psoriatic arthritis (PsA), and sarcoid arthritis, but not in normal synovium. Inflammatory cytokines, such as interleukin-1beta and tumor necrosis factor alpha, enhanced the transcriptional activity of the human CRH promoter and increased levels of CRH mRNA in primary synoviocytes. Synovial CRH functioned in a paracrine manner to induce NURR1 and NUR77. NURR1 was abundantly expressed in the inflammatory cells of both RA and PsA synovium. NURR1 and NUR77 were differentially regulated, and NURR1 was the major cytokine-regulated member of the NURR subfamily as well as the mediator of cytokine- and CRH-dependent inflammatory responses in synovium. Furthermore, glucocorticoids dramatically suppressed cytokine- and CRH-induced synovial NURR1 mRNA.

CONCLUSION

These data demonstrate the involvement of the transcription factor NURR1 in the regulation of CRH expression and activity in human inflammatory arthritis.

The effect of cyclic pressure on human monocyte-derived macrophages in vitro

Aseptic loosening and osteolysis around prosthetic joints are the principal causes of failure and consequent revision. During this process activated macrophages produce cytokines which are thought to promote osteolysis by osteoclasts. Changes in pressure within the space around implants have been proposed as a cause of loosening and osteolysis. We therefore studied the effect of two different regimes of cyclic pressure on the production of interleukin-1beta (IL-1beta), IL-6 and tumour necrosis factor-alpha (TNF-alpha) by cultured human monocyte-derived (M-D) macrophages. There was a wide variation in the expression of cytokines in non-stimulated M-D macrophages from different donors and therefore cells from the same donor were compared under control and pressurised conditions. Both regimes of cyclic pressure were found to increase expression of IL-6 and TNF-alpha. Expression of IL-1beta was increased by a higher-frequency regime only. Our findings suggest that M-D macrophages are activated by cyclic pressure. Further work will be required to understand the relative roles of frequency, amplitude and duration of applied pressure in the cellular effects of cyclic pressure in this system.

The effect of cyclic pressure on human monocyte-derived macrophages in vitro

Aseptic loosening and osteolysis around prosthetic joints are the principal causes of failure and consequent revision. During this process activated macrophages produce cytokines which are thought to promote osteolysis by osteoclasts. Changes in pressure within the space around implants have been proposed as a cause of loosening and osteolysis. We therefore studied the effect of two different regimes of cyclic pressure on the production of interleukin-1β (IL-1β), IL-6 and tumour necrosis factor-α (TNF-α) by cultured human monocyte-derived (M-D) macrophages. There was a wide variation in the expression of cytokines in non-stimulated M-D macrophages from different donors and therefore cells from the same donor were compared under control and pressurised conditions.

Both regimes of cyclic pressure were found to increase expression of IL-6 and TNF-α. Expression of IL-1β was increased by a higher-frequency regime only. Our findings suggest that M-D macrophages are activated by cyclic pressure. Further work will be required to understand the relative roles of frequency, amplitude and duration of applied pressure in the cellular effects of cyclic pressure in this system.

Patenting medical and surgical techniques: an ethical-legal analysis

Considerable controversy has recently arisen regarding the patenting of medical and surgical processes in the United States. One such patent, viz. for a "chevron" incision used in ophthalmologic surgery, has especially occasioned heated response including a major, condemnatory ethics policy statement from the American Medical Association as well as federal legislation denying patent protection for most uses of a patented medical or surgical procedure. This article identifies and discusses the major legal, ethical and public policy considerations offered by proponents and opponents of such patents. The existing literature divides up into those who favor such patents essentially without qualification, and those who condemn and wish to outlaw them. We advance a compromise position where administrative and legislative action is called for to provide more specific guidelines regarding the patentability of such processes by the Patent and Trademark Office. Our position, in sum, will be that too much is at stake in this complicated area for either the blanket prohibition, or wholesale, uncritical acceptance, of the patenting of medical and surgical processes or techniques.

Ultrasound compared with radiographic assessment in developmental dysplasia of the hip

Two hundred and seventy-two patients 'at risk' for hip dislocation underwent ultrasound examination. From this group 60 patients had ultrasound evidence of DDH (developmental dysplasia of the hip). Thirty-eight of these were also assessed radiographically. The diagnosis of dislocation was more accurate with sonography, where there was only one scan showing an equivocal dislocation (not dislocated on arthrography). On radiographic evaluation there were six cases of equivocal dislocation, and one case which was wrongly diagnosed as dislocation (dysplastic on sonography and arthrogram). A high level of agreement was found between the two methods in the diagnosis of dysplastic and normal hips (88 and 86% respectively). In view of the advantages of sonographic evaluation of the dislocated and dysplastic hip: safe (no ionizing radiation), dynamic and static assessment, accurate (prior to femoral epiphysis ossification) and non-invasive (compared with arthrogram), radiographic and arthrographic assessment of the hip has been largely abandoned in our practice.

Comparison of diclofenac sodium and morphine sulphate for postoperative analgesia after day case inguinal hernia surgery

Postoperative pain may be a significant reason for delayed discharge from hospital, increased morbidity and reduced patient satisfaction with ambulatory hernia surgery. This study compared two postoperative oral analgesic protocols after day case inguinal hernia repair; 30 mg morphine sulphate (MST) and 10 mg metoclopramide every 8 h for 48 h or 75 mg diclofenac twice daily for 48 h. The pain reported in the MST group was significantly greater on both the day of operation and the first postoperative day (P < 0.05, Mann-Whitney U test). A significantly higher proportion of patients taking MST complained of nausea on the day of operation and on the 1st postoperative day (P < 0.05, chi 2). The time taken to walk, dress and leave home alone were achieved in a significantly shorter duration in patients taking diclofenac. We conclude that diclofenac provides effective analgesia, has a more acceptable side-effect profile than morphine sulphate and is the treatment of choice after ambulatory hernia surgery.

Subjective perception of additional support requirements of elderly patients discharged from accident and emergency departments

Fifty per cent of elderly patients discharged from accident and emergency (A&E) departments experience functional deterioration and increased dependence; 5.6% require readmission within 14 days. Discharge is often to inadequate community support. Functional assessment by A&E department staff may identify patients at greatest risk. The predictive ability of 25 patients aged 75 years or over to identify their additional support requirements following discharge from the A&E department was evaluated retrospectively using interview questionnaires 10-20 days after discharge. A total of 23 patients, of mean age 79.3 years, were interviewed. Six patients expressed concern both about coping at home and about needing extra support; four of the nine patients who recruited additional help were in this group (P = 0.239; n.s.). There was no correlation between additional support needed and patients living alone (P = 0.302; n.s.), dependent relative (P = 0.325; n.s.) or existing domiciliary support (P = 0.197; n.s.). All patients were satisfied with their management, and of the six who expressed concern about being able to cope at home, none informed A&E staff. Patients' perception is an unreliable indicator of their need for additional help and their ability to manage at home after discharge from A&E departments. Additional support requirements appear to be unrelated to domestic circumstances.

Influence of local sensory afference in the calibration of human balance responses

Peripheral sensory modulation of balance behavior may require a "calibrated" mechanism which would maintain upright standing by a feedback control of torque at the ankle joint. The calibration of human balance was studied using a systematic presentation of perturbation excursions and velocities in normal freely standing subjects. All perturbations (posterior movements of a force platform) induced a forward body sway and were presented by first increasing and then decreasing the magnitude of perturbation. In preselected conditions the stability of the ankle and hence the accuracy of surface orientation inputs was altered using a foam base placed under the subjects feet. Each subject pressed a hand held response key at the moment a postural disturbance was detected. The automatic neuromuscular response (ANR) was recorded from the gastrocnemius muscles bilaterally and the perturbation detection time (DT) was obtained from the onset of thenar muscle discharge. The major findings in this study were: (1) Conscious DT changed as a function of step variations in perturbation excursion and was disassociated from the ANR latency. The ANR latency remained essentially constant in all conditions and did not have any influence on the kinematics of body sway. (2) Normalized peak body sway decreased during unstable ankle conditions and the reduction of body sway could be attributed to an increase in the gain of the ANR across a 200 ms integration period. The ANR 200 ms amplitude also showed higher correlations with perturbation magnitude during unstable (versus stable) ankle conditions. (3) The 200 ms gastrocnemius amplitude was modulated by excursion and velocity of platform displacement but the amplitude integrated over 100 ms was dependent on only the velocity of perturbation. Our results indicate that balance is controlled by a centrally initiated postural response but regulated in amplitude by local sensory information. These results establish that the gain of the ANR is functional, peripherally driven, and occurs subconsciously to alter the kinematics of body sway.

Kinematic properties of voluntary postural sway in patients with unilateral primary hemispheric lesions

The temporal and spatial characteristics of rapid voluntary body sway following unilateral cerebrovascular accident were assessed in single and combined planes of motion during a visually cued non-choice reaction time movement. Three distinct directions of intentional body sway were assessed: forward, toward the paretic, and toward the non-paretic lower extremity. Fluctuations in the center of foot pressure served as the basis for calculating body displacement and velocity by combining frontal and sagittal movement in an X-Y coordinate system (a bi-planar analysis). A linear regression analysis was used on individual force output channels to reduce the sway motion into separate component parts. The velocity profile in each direction of intended sway was calculated from the slope of the regression line (a single-plane analysis). Bi-planar velocity analysis showed that hemiplegics swayed as fast as normal subjects in any sway direction. In contrast, single plane analysis revealed a decrease in the velocity of hemiplegic sway when weight shifts were directed toward the paretic extremity. Response velocity in the non-paretic direction was similar to a comparison group of normal individuals. The apparent contradiction between single and bi-planar analyses was attributed to hemiplegic sway in extraneous planes of motion surrounding the intended sway path. During the course of body sway, hemiplegics showed a statistically larger range of extraneous movement away from the plane of intended movement. The directional deficits in sway velocity and excursion are compared to previously reported sway pathology associated with lesions of the human central nervous system.

Severe steroid responsive pneumonitis associated with pyoderma gangrenosum and ulcerative colitis

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Bacterial contamination of the small intestine is an important cause of occult malabsorption in the elderly

A study was conducted to examine the contribution that occult malabsorption makes to malnutrition among elderly patients admitted to an acute geriatric ward. Malnutrition was defined by anthropometric, haematological, and biochemical measurements. Out of 490 patients, 55--many of whom had presented with non-gastrointestinal symptoms--were found to be malnourished. In 31 poor diet alone was probably the cause, but in the remaining 24 patients previously unrecognised malabsorption was detected. Of these patients, 17 were found to have bacterial contamination of the small bowel (nine with duodenojejunal diverticula, four after gastric surgery, and four diagnosed as contamination with "no sump"). In 10 patients contamination was confirmed by culture of intestinal juice: Escherichia coli was predominant in nine cases, and anaerobic organisms in one. Small bowel bacterial overgrowth without a "blind loop" or obvious underlying cause has not previously been fully proved in the elderly. Coeliac disease was detected in two patients, and chronic pancreatitis in two. Occult malabsorption is an important cause of malnutrition in the elderly. Such malnutrition not infrequently occurs in geriatric patients presenting to hospital with non-specific symptoms of physical deterioration.