Comparison between computer recognition and manual measurement methods for the estimation of leaf area.

BACKGROUND AND AIMS: Leaf area (A) is a crucial indicator of the photosynthetic capacity of plants. The Montgomery equation (ME), which hypothesizes that A is proportional to the product of leaf length (L) and width (W), is a valid tool for non-destructively measuring A for many broadleaved plants. At present, the methods used to compute L and W for the ME can be broadly divided into two kinds: using computer recognition and measuring manually. However, the potential difference in the prediction accuracy using either method has not been thoroughly examined in previous studies. METHODS: In the present study, we measured 540 Alangium chinense leaves, 489 Liquidambar formosana leaves and 215 Liriodendron × sinoamericanum leaves, utilizing computer recognition and manual measurement methods to determine L and W. The ME was used to fit the data determined by the two methods, and the goodness of fits were compared. The prediction errors of A were analysed by examining the correlations with two leaf symmetry indices (areal ratio of the left side to the right side, and standardized index for bilateral asymmetry), as well as the leaf shape complexity index (the leaf dissection index). KEY RESULTS: The results indicate that there is a neglectable difference in the estimation of A between the two methods. This further validates that the ME is an effective method for estimating A in broadleaved tree species, including those with lobes. Additionally, leaf shape complexity significantly influenced the estimation of A. CONCLUSIONS: These results show that the use of computer recognition and manual measurement in the field are both effective and feasible, although the influence of leaf shape complexity should be considered when applying the ME to estimate A in the future.

Using the Montgomery-Koyama-Smith equation to calculate the stomatal area per unit lamina area for 12 Magnoliaceae species.

BACKGROUND AND AIMS: The Montgomery-Koyama-Smith (MKS) equation predicts that total leaf area per shoot is proportional to the product of the sum of individual leaf widths and maximum individual leaf length, which has been validated for some herbaceous and woody plants. The equation is also predicted to be valid in describing the relationship between the total stomatal area per micrograph (AT) and the product of the sum of individual stomatal widths (denoted as LKS) and maximum individual stomatal length (denoted by WKS) in any particular micrograph. METHODS: To test the validity of the MKS equation, 69,931 stomata (from 720 stomatal micrographs from 12 Magnoliaceae species) were examined. The area of each stoma was calculated using empirical measurements of stomatal length and width multiplied by a constant. Six equations describing the relationships among AT, LKS, and WKS were compared. The root-mean-square (RMSE) and the Akaike information criterion (AIC) were used to measure the goodness of fit, and the trade-off between the goodness of fit and the structural complexity of each model, respectively. KEY RESULTS: Analyses supported the validity of the MKS equation and the power-law equation AT ∝ (LKS∙WKS)α, where a is a scaling exponent. The estimated values of α at the species level and for the pooled data were all statistically smaller than unity, which did not support the hypothesis that AT ∝ LTS∙WTS. The power-law equation had smaller RMSE and AIC values than the MKS equation for the data from the 12 individual species and the pooled data. CONCLUSIONS: These results indicate that AT tends to allometrically scale with LKS∙WKS, and that increases in AT do not keep pace with increases in LTS∙WTS. In addition, using the product of LKS and WKS is better than using only one of the two variables.

Modified Montgomery thyroplasty: Customisation of the cartilage window according to laryngeal anatomy.

We described a Montgomery's thyroplasty using a set of measurement devices designed to achieve accurate individualised prosthesis placement. The objective of the present study was to describe the surgical techniques employed via a step-by-step video and show our results. In total, 42 modified thyroplasties were performed during the 10-year study period. The verification of both points: adequate location and size of the prosthesis are the keys to the success of this intervention. The individualisation of the cartilage window location produces optimal functional results in patients post-intervention in terms of the MPT, GRB score, and VHI-30.

Consent for Medical Treatment: What is 'Reasonable'?

The General Medical Council (GMC) instructs doctors to act 'reasonably' in obtaining consent from patients. However, the GMC does not explain what it means to be reasonable: it is left to doctors to figure out the substance of this instruction. The GMC relies on the Supreme Court's judgment in Montgomery v Lanarkshire Health Board; and it can be assumed that the judges' idea of reasonability is adopted. The aim of this paper is to flesh out this idea of reasonability. This idea is commonly personified as the audience that has to be satisfied by the doctor's justification for offering, or withholding, certain treatments and related information. In case law, this audience shifted from a reasonable doctor to a 'reasonable person in the patient's position'; and Montgomery expands the audience to include 'particular' patients, too. Senior judges have clarified that the reasonable person is a normative ideal, and not a sociological construct; but they do not set out the characteristics of this ideal. John Rawls has conceived the reasonable person-ideal as one that pursues fair terms of co-operation with other members of society. An alternative ideal can be inferred from the feminist ethic of care. However, the reasonable patient from Montgomery does not align with either theoretical ideal; but, instead, is an entirely rational being. Such a conception conflicts with both real-life constraints on rationality and the doctor's duty to care for the patient, and it challenges the practice of medicine.

The conundrums of the reasonable patient standard in English medical law.

BACKGROUND: In its 2015 decision in Montgomery v. Lanarkshire Health Board, the Supreme Court of the United Kingdom overruled the long-standing, paternalistic prudent doctor standard of care in favour of a new reasonable patient standard which obligates doctors to make their patients aware of all material risks of the recommended treatment and of any reasonable alternative treatment. This landmark judgment has been of interest to the rest of the common law world. A judicial trend of invoking Montgomery to impose more stringent requirements on doctors is discernible in subsequent decisions since then. MAIN BODY: In this narrative review, without questioning the idea that properly informed patients should play a more active role in procedures affecting their own health in furtherance of their autonomy, safety, and consumer rights, we identify and analyse, with the aid of realistic clinical thought experiments, three practical conundrums that the Montgomery standard may inflict on the daily work of doctors, unfairly exposing them to arbitrary legal risks. CONCLUSIONS: These conundrums pertain to the ascertainment of the risks that must be disclosed to the patient under the test of 'materiality'; the legal uncertainty as to the scope of the exceptions; and the actual ability of doctors to cope with the pressures of time. These conundrums offer ripe opportunities to rethink the proper role of judicially developed medical law in modern health care practice.

Comparing shared decision making using a paper and digital consent process. A multi-site, single centre study in a trauma and orthopaedic department.

INTRODUCTION: The importance of shared decision making (SDM) for informed consent has been emphasised in the updated regulatory guidelines. Errors of completion, legibility and omission have been associated with paper-based consent forms. We introduced a digital consent process and compared it against a paper-based process for quality and patient reported involvement in shared decision making. METHODS: 223 patients were included in this multi-site, single centre study. Patient consent documentation was by either a paper consent form or the Concentric digital consent platform. Consent forms were assessed for errors of legibility, completion and accuracy of content. Core risks for 20 orthopaedic operations were pre-defined by a Delphi round of experts and forms analysed for omission of these risks. SDM was determined via the 'collaboRATE Top Score', a validated measure for gold-standard SDM. RESULTS: 72% (n = 78/109) of paper consent forms contained ≥1 error compared to 0% (n = 0/114) of digital forms (P < 0.0001). Core risks were unintentionally omitted in 63% (n = 68/109) of paper-forms compared to less than 2% (n = 2/114) of digital consent forms (P < 0.0001). 72% (n = 82/114) of patients giving consent digitally reported gold-standard SDM compared to 28% (n = 31/109) with paper consent (P < 0.001). CONCLUSION: Implementation of a digital consent process has been shown to reduce both error rate and the omission of core risks on consent forms whilst increasing the quality of SDM. This novel finding suggests that using digital consent can improve both the quality of informed consent and the patient experience of SDM.

Perioperative visual loss and consent for adult spine surgery: a national survey of the practice amongst spine surgeons and anaesthetists†.

BACKGROUND: Perioperative Visual Loss (POVL) is a devastating complication for patients undergoing spine surgery. Consent process for POVL amongst spine surgeons and anaesthetist remains variable. The aim of this study is to evaluate their practice and views about it. METHODS: Two similar questionnaires were distributed to members of the Society of British Neurological Surgeons (SBNS), British Association of Spine Surgeons (BASS), and Neuroanaesthsia and Critical Care Society (NACCS). RESULTS: A total of 271 responses were received (SBNS/BASS n = 149, NACCS n = 122). Fewer surgeons considered POVL as a material risk for patients compared to the anaesthetists (57.7 versus 79.7%). Outpatient/pre-assessment clinics were considered as the optimal setting for discussing POVL by the majority of the clinicians (81.2 and 93.4%). POVL should be discussed by both specialists according to 75% of the anaesthetists. Estimated incidence of POVL was considered to be higher by the anaesthetists (0.03-0.2% by 63% of the anaesthetist versus 0.0001-0.004% by 57% of the surgeons). Twenty-three surgeons and 10 anaesthetists had a patient who suffered from POVL, which led to a change of practice in most of them. This questionnaire will lead to a change in practice/consent to 18.1% of the surgeons and 23.5% of the anaesthetists. CONCLUSIONS: Most of the surgeons and anaesthetist feel that POVL is a material risk that ideally needs to be firstly discussed before the day of surgery, by both specialties. However, a significant number of clinicians have an opposite view. A national guidance from respective societies should encourage POVL to be discussed routinely.

Association of anhedonia and suicidal ideation in patients with treatment-refractory depression after intravenous ketamine infusions.

OBJECTIVES: Accumulating evidence suggests that the effects of ketamine administered intravenously at subanaesthetic doses on both anhedonic symptoms and suicidal ideation occur independently of depressive symptoms in major depressive disorder (MDD) and bipolar disorder (BD). This study sought to determine the relationship between anhedonia and suicidal ideation after serial ketamine infusions. METHODS: A total of 79 subjects with either treatment-refractory MDD (n = 60) or BD (n = 19) were included in a clinical ketamine study. The Montgomery-Åsberg Depression Rating Scale (MADRS) anhedonia factor and the first five items of the Scale for Suicidal Ideations (SSI-Part I) were used to assess anhedonia symptoms and suicidal ideation, respectively. RESULTS: At baseline, anhedonia, as measured by the MADRS, was not significantly associated with suicidal ideation or specific suicide-related ideation as measured by SSI-Part I (all p's > 0.05). Only the 'wish to die' and 'desire to make a suicide attempt' items were positively associated with anhedonia at two weeks after the sixth ketamine infusion, which was independent of the reductions in depressive symptoms (all p's < 0.05). CONCLUSION: Anhedonia as measured by the MADRS appeared to not be positively related to suicidal ideation after serial ketamine infusions.KEY POINTSSerial ketamine (0.5 mg/kg) infusions have shown quick and dramatic antisuicidal and antianhedonic effects in patients with depression.The association between anhedonia and suicidal ideation after serial ketamine infusions is unclear.Anhedonia appeared to not be positively related to suicidal ideation after serial ketamine infusions.

The frontiers of medical negligence and diagnosis: an interview-based analysis.

While errors in medical diagnosis are common and often litigated, the different dimensions of diagnosis-formation, communication, recording-have received much less legal attention. When the process of diagnosis is differentiated in this way, new and contentious legal questions emerge that challenge the appropriateness of the Bolam/Bolitho standard. To explore these challenges, we interviewed 31 solicitors and barristers and asked them: (i) whether Montgomery should apply to information about alternative diagnoses; and (ii) whether the Bolam/Bolitho standard should be rejected in 'pure diagnosis' cases. Our qualitative analysis of the interviews sheds light not only on the two questions posed, but also on three cross-cutting themes. First, Bolam/Bolitho is criticised on two grounds that are often conflated: its paternalism for patients and its deference to medical professionals. Second, adopting different standards for different aspects of treatment and diagnosis may be justified in principle, but it can sometimes be difficult or not make sense in practice. Third, new conceptions of patients, doctors, and courts are being articulated in terms of rights or responsibilities over risks. In mapping these issues at the frontiers of medical negligence, this empirical study identifies potential pressure points for future legal developments.

Comprehensive geriatric assessment is associated with increased antidepressant treatment in frail older people with unplanned hospital admissions-results from the randomised controlled study CGA-Swed.

BACKGROUND: Frail older people are at higher risk of further deterioration if their needs are not acknowledged when they are acutely ill and admitted to hospital. Mental health comprises one area of needs assessment. AIMS: The aims of this study were threefold: to investigate the prevalence of depression in frail hospital patients, to identify factors associated with depression, and to compare depression management in patients receiving and not receiving Comprehensive Geriatric Assessment (CGA). METHODS: This secondary analysis from the CGA-Swed randomized control trial included 155 frail older people aged 75 years and above. Instruments included Montgomery Åsberg Depression Rating Scale (MADRS), the ICE Capability measure for older people (ICECAP-O) and the Fugl-Meyer Life Satisfaction scale (Fugl-Meyer Lisat). Depression was broadly defined as MADRS score ≥ 7. Regression models were used to identify variables associated with depression and to compare groups with and without the CGA intervention. RESULTS: The prevalence of a MADRS score indicating depression at baseline was 60.7%. The inability to do things that make one feel valued (ICECAP-O) was associated with a fourfold increase in depression (OR 4.37, CI 1.50-12.75, p = 0.007). There was a two-fold increase in odds of receiving antidepressant medication in the CGA intervention group (OR 2.33, CI 1.15-4.71, p = 0.019) compared to patients in the control group who received regular medical care. CONCLUSION: Symptoms of depression were common among frail older people with unplanned hospital admission. Being unable to do things that make one feel valued was associated with depression. People who received CGA intervention had higher odds of receiving antidepressant treatment, suggesting that CGA improves recognition of mental health needs during unplanned hospital admissions in frail older people. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02773914. Retrospectively registered 16 May 2016.

Atomicity and Regularity Principles Do Not Ensure Full Resistance of ECC Designs against Single-Trace Attacks.

Elliptic curve cryptography (ECC) is one of the commonly used standard methods for encrypting and signing messages which is especially applicable to resource-constrained devices such as sensor nodes that are networked in the Internet of Things. The same holds true for wearable sensors. In these fields of application, confidentiality and data integrity are of utmost importance as human lives depend on them. In this paper, we discuss the resistance of our fast dual-field ECDSA accelerator against side-channel analysis attacks. We present our implementation of a design supporting four different NIST elliptic curves to allow the reader to understand the discussion of the resistance aspects. For two different target platforms-ASIC and FPGA-we show that the application of atomic patterns, which is considered to ensure resistance against simple side-channel analysis attacks in the literature, is not sufficient to prevent either simple SCA or horizontal address-bit DPA attacks. We also evaluated an approach which is based on the activity of the field multiplier to increase the inherent resistance of the design against attacks performed.

Differentiating Negligent Standards of Care in Diagnosis.

Diagnosis lies at the heart of the medical encounter, yet it has received much less attention than treatment. It is widely assumed that negligent diagnosis claims should be governed by the Bolam test, but we demonstrate that this is not always the case. First, we disaggregate the diagnostic process into three different acts: forming the diagnosis, communicating it to the patient, and recording it. Second, we consider alternatives to Bolam for defining negligence, including less deferential profession-led standards, patient-led standards, and even a reasonable person standard. Third, bringing together these distinctions-within the diagnostic process, and between standards of care-we reveal the unappreciated complexity of negligent diagnosis. Analysing the standard of care that might apply to the three different acts in the diagnostic process, we identify reasons to think that Montgomery should apply to the communication of a diagnosis. We also argue that even in areas where the law is well-established, such as the application of Bolam to the formation of a diagnosis, challenging questions arise that require further attention. Throughout, the framework and analysis that we develop have significant implications for a set of negligence cases, as well as for medical education, clinical guidelines, and patient care.

Professional Responsibility: Conceptual Rescue and Plea for Reform.

For as long as knowledge asymmetry continues to be deemed the defining characteristic of the lay-professional relationship, the courts' delineation of obligations meant to address lay vulnerability will too frequently end up compounding the layperson's non-epistemic, 'sense of self' vulnerability. The proposed re-conceptualisation of professional responsibility calls for reform on several fronts: among these, an expanded 'duty to consult' (beyond do-not-resuscitate-orders) is uniquely placed as a justiciable criterion capable of addressing such a situational, 'sense of self' vulnerability.

A symptom-based approach in predicting ECT outcome in depressed patients employing MADRS single items.

Establishing symptom-based predictors of electroconvulsive therapy (ECT) outcome seems promising, however, findings concerning the predictive value of distinct depressive symptoms or subtypes are limited; previous factor-analytic approaches based on the Montgomery-Åsberg Depression Rating Scale (MADRS) remained inconclusive, as proposed factors varied across samples. In this naturalistic study, we refrained from these previous factor-analytic approaches and examined the predictive value of MADRS single items and their change during the course of ECT concerning ECT outcome. We used logistic and linear regression models to analyze MADRS data routinely assessed at three time points in 96 depressed psychiatric inpatients over the course of ECT. Mean age was 53 years (SD 14.79), gender ratio was 58:38 (F:M), baseline MADRS score was M = 30.20 (SD 5.42). MADRS single items were strong predictors of ECT response, remission and overall symptom reduction, especially items 1 (apparent sadness), 2 (reported sadness) and 8 (inability to feel), assessing affective symptoms. Strongest effects were found for regression models including item 2 (reported sadness) with up to 80% correct prediction of ECT outcome. ROC analyses were performed to estimate the optimal cut-point for treatment response. MADRS single items during the course of ECT might pose simple, reliable, time- and cost-effective predictors of ECT outcome. More severe affective symptoms of depression at baseline and a stronger reduction of these affective symptoms during the course of ECT seem to be positively associated with ECT outcome. Precise cut-off values for clinical use were proposed. Generally, these findings underline the benefits of a symptom-based approach in depression research and treatment in addition to depression sum-scores and generalized diagnoses.

Consent in pregnancy - an observational study of ante-natal care in the context of Montgomery: all about risk?

BACKGROUND: How to best support pregnant women in making truly autonomous decisions which accord with current consent law is poorly understood and problematic for them and their healthcare professionals. This observational study examined a range of ante-natal consultations where consent for an intervention took place to determine key themes during the encounter. METHODS: Qualitative research in a large urban teaching hospital in London. Sixteen consultations between pregnant women and their healthcare professionals (nine obstetricians and three midwives) where ante-natal interventions were discussed and consent was documented were directly observed. Data were collectively analysed to identify key themes characterising the consent process. RESULTS: Four themes were identified: 1) Clinical framing - by framing the consultation in terms of the clinical decision to be made HCPs miss the opportunity to assess what really matters to a pregnant woman. For many women the opportunity to feel that their previous experiences had been 'heard' was an important but sometimes neglected prelude to the ensuing consultation; 2) Clinical risk dominated narrative - all consultations were dominated by information related to risk; discussion of reasonable alternatives was not always observed and women's understanding of information was seldom verified making compliance with current law questionable; 3) Parallel narrative - woman-centred experience - for pregnant women social factors such as the place of birth and partner influences were as or more important than considerations of clinical risk yet were often missed by HCPs; 4) Cross cutting narrative - genuine dialogue - we observed variably effective interaction between the clinical (2) and patient (3) narratives influenced by trust and empathy and explicit empowering language by HCPs. CONCLUSION: We found that ante-natal consultations that include consent for interventions are dominated by clinical framing and risk, and explore the woman-centred narrative less well. Current UK law requires consent consultations to include explicit effort to gauge a woman's preferences and values, yet consultations seem to fail to achieve such understanding. At the very least, consultations may be improved by the addition of opening questions along the lines of 'what matters to you most?'

Lessons from the vaginal mesh scandal: enhancing the patient-centric approach to informed consent for medical device implantation.

The vaginal mesh scandal, in which thousands of women were irreversibly maimed by polypropylene mesh, revealed multilevel failures in medical device regulation and implantation, demonstrating that patient-centric care has not yet fully transcended from policy into practice. In law, informed consent is considered by a two-stage test: reasonable treatment and patient information disclosure. The standard of reasonable treatment is determined according to what is deemed acceptable in accordance with a body of medical opinion. However, such bodies of medical opinion were vulnerable to external influence from device manufactures. Vaginal mesh manufacturers were found to have had financial links to research, royal colleges, and influential clinicians, which then influenced the basis of the evidence-based practice that often guides such bodies of medical opinion. According to the Independent Medicines and Medical Device Safety Report, patients' mesh complications were also frequently under-reported and patient-based evidence of harm disregarded. Patients were also not sufficiently informed of the material risks or reasonable alternatives to mesh, which is required of the second stage of informed consent pertaining to information disclosure. This paper makes the following recommendations: that conflict of interest disclosure be mandated, that greater value be afforded to patient-based evidence to improve evaluation of treatments, and that information disclosure for informed consent should relate to the risks, benefits, and alternatives to the surgical procedure and medical device. This will ensure that patients can evaluate whether surgeons are offering unbiased treatment options and are also informed of the potential long-term risks associated with device implantation.

High-Speed and Unified ECC Processor for Generic Weierstrass Curves over GF(p) on FPGA.

In this paper, we present a high-speed, unified elliptic curve cryptography (ECC) processor for arbitrary Weierstrass curves over GF(p), which to the best of our knowledge, outperforms other similar works in terms of execution time. Our approach employs the combination of the schoolbook long and Karatsuba multiplication algorithm for the elliptic curve point multiplication (ECPM) to achieve better parallelization while retaining low complexity. In the hardware implementation, the substantial gain in speed is also contributed by our n-bit pipelined Montgomery Modular Multiplier (pMMM), which is constructed from our n-bit pipelined multiplier-accumulators that utilizes digital signal processor (DSP) primitives as digit multipliers. Additionally, we also introduce our unified, pipelined modular adder/subtractor (pMAS) for the underlying field arithmetic, and leverage a more efficient yet compact scheduling of the Montgomery ladder algorithm. The implementation for 256-bit modulus size on the 7-series FPGA: Virtex-7, Kintex-7, and XC7Z020 yields 0.139, 0.138, and 0.206 ms of execution time, respectively. Furthermore, since our pMMM module is generic for any curve in Weierstrass form, we support multi-curve parameters, resulting in a unified ECC architecture. Lastly, our method also works in constant time, making it suitable for applications requiring high speed and SCA-resistant characteristics.

A Medical Tattooing Technique for Enhancing the Three-Dimensional Appearance of the Nipple-Areola Complex After Flap-Based Nipple Reconstruction.

INTRODUCTION: Medical tattooing is a critical reconstructive component in the surgical process for good esthetic outcomes and improved patient satisfaction. There are many nipple reconstruction methods that use a local flap, but reduced post-operative nipple projection is a common problem. Here, we report a modified tattooing method (3D-E tattoo) that enhances the three-dimensional appearance of the nipple-areola complex (NAC), including Montgomery glands, after flap-based nipple reconstruction. METHODS: The subjects were 110 consecutive patients who underwent nipple reconstruction using the C-V flap technique between April 2017 and June 2019. Of these patients, 49 received traditional medical tattooing (Group T) and 61 underwent 3D-E tattoo (Group 3D). A 10-point subjective evaluation of the 3D appearance of the reconstructed NAC was performed, and the scores were compared between the groups. RESULTS: The procedure time for 3D-E tattoo was about 5 minutes longer than that for traditional tattooing. The average score in Group 3D of 7.8/10 was significantly higher than that of 6.4/10 in Group T. CONCLUSION: Application of 3D techniques or "realism" in tattoo artistry has significant potential to improve the esthetic outcomes of reconstructive surgery. Adoption of simple technical skills to produce a more realistic 3D NAC permitted a symmetrical appearance to be reconstructed. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Informed consent in obstetrics - a survey of pregnant women to set a new standard for consent in emergency obstetric interventions.

Informed consent is necessary for all medical, surgical and obstetric interventions. Whilst informed consent can be obtained for elective procedures, it is much more challenging to obtain for emergency interventions. It can be difficult for women to understand the need for emergency intervention when pregnancy has been low risk. This can lead to problems with psychological trauma from the delivery being foremost in their minds in the postnatal period and in future pregnancies. The Montgomery ruling of 2015 encouraged informing women about risks and benefits of interventions and letting the women take responsibility for their own decision-making. Here, a patient-focused survey collected information on pregnant women's knowledge and wishes regarding emergency interventions. The responses were analysed in relation to local and Scottish national delivery data. We have initiated a novel programme to ensure all of our pregnant women are empowered to give informed consent for emergency interventions.IMPACT STATEMENTWhat is already known on this subject? There has been very little published on this subject to date and what has been published has involved focus groups or very small numbers of women.What do the results of this study add? This study adds significantly to our understanding of current Scottish and Highland regional delivery statistics to help foster realistic delivery expectations in our pregnant women. This study is the first to report on pregnant women's understanding of the possibility of requiring emergency intervention in labour and the relevant risks. It also highlights the fact that women prefer to get their information from community midwives, friends and family rather than their obstetricians or GPs. This study is also the first to report women's actual preferences and comments with regard to information provision, labour and delivery experiences and their wishes for the future.What are the implications of these findings for clinical practice and/or further research? The findings from this study have allowed us to develop and implement a novel means of obtaining informed consent in emergency obstetrics and the success of this programme will be reported following future analysis of patient experiences.

Challenging the Comparison in Montgomery Between Patients and 'Consumers Exercising Choices'.

In Montgomery v Lanarkshire Health Board, Lords Kerr and Reed referred to the increasing tendency to treat patients 'as consumers exercising choices'. The question of whether it is helpful to regard patients as consumers is not a new one, but it arises most frequently in discussions about the commercialisation of healthcare. Comparing patients with consumers in relation to informed consent is an interesting development, especially in the light of the growing body of contract and consumer law scholarship which questions the extent to which information disclosures to consumers produce informed choices. If there is evidence that the duties of disclosure which are imposed on retailers, in order to redress the imbalance of knowledge and power in the consumer-retailer relationship, do not always fulfil their intended purpose, might this have any resonance for the duties of disclosure which are imposed upon healthcare professionals?