Development of a core outcome set for trials on induction of labour: an international multistakeholder Delphi study.

OBJECTIVE: To develop a set of core outcomes to be minimally reported in trials on induction of labour. DESIGN: Two-round Delphi survey and consensus meeting. POPULATION: Four stakeholder groups: midwives, obstetricians, neonatologists, and women's representatives. METHODS: Protocol registered with COMET (Registration Number: 695). Stakeholders rated reported outcomes for importance (1-limited to 9-critical). The median rating of each outcome was calculated. The consensus criteria to include outcomes were as follows: ≥70% participants rated outcomes as critical and <15% rated outcomes as limited importance. Outcomes that did not achieve consensus were taken to round two and, if there was still no consensus, to the final consensus meeting. MAIN OUTCOME MEASURES: Outcomes in trials of induction of labour. RESULTS: Of the 159 invited participants, 54% (86/159) completed the first round, and 83% completed the second round (71/86). The core outcome set included 28 core outcomes in four domains: Short-term maternal outcomes (n = 18)-cardiorespiratory arrest, damage to internal organs, death, haemorrhage, hysterectomy, infection, intensive care admission, length of hospital stay, mode of delivery, need for more than one induction agent, oxytocin augmentation, postnatal depression, pulmonary embolus, satisfaction with care, stroke, time from induction to delivery, uterine hyperstimulation, uterine scar dehiscence/rupture; short-term offspring outcomes (n = 8)-admission to the neonatal unit, birth trauma, death, hypoxic ischaemic encephalopathy/need for therapeutic hypothermia, meconium aspiration syndrome, need for respiratory support, infection, and seizures; long-term maternal outcomes (n = 1)-operative pelvic floor repair; long-term offspring outcomes (n = 1)-disability including neurodevelopmental delay. CONCLUSION: Trials on induction of labour should include this core outcome set to standardise reporting. TWEETABLE ABSTRACT: International multistakeholder Delphi study identifies a core outcome set for trials on induction of labour.

A multicenter, randomized trial of flat dosing versus intrapatient dose escalation of single-agent carboplatin as first-line chemotherapy for advanced ovarian cancer: an SGCTG (SCOTROC 4) and ANZGOG study on behalf of GCIG.

BACKGROUND: The aim of the study is to demonstrate that intrapatient dose escalation of carboplatin would improve the outcome in ovarian cancer compared with flat dosing. PATIENTS AND METHODS: Patients with untreated stage IC-IV ovarian cancer received six cycles of carboplatin area under the curve 6 (AUC 6) 3 weekly either with no dose modification except for toxicity (Arm A) or with dose escalations in cycles 2-6 based on nadir neutrophil and platelet counts (Arm B). The primary end-point was progression-free survival (PFS). RESULTS: Nine hundred and sixty-four patients were recruited from 71 centers. Dose escalation was achieved in 77% of patients who had ≥1 cycle. The median AUCs (cycle 2-6) received were 6.0 (Arm A) and 7.2 (Arm B) (P < 0.001). Grade 3/4 non-hematological toxicity was higher in Arm B (31% versus 22% P = 0.001). The median PFS was 12.1 months in Arm A and B [hazard ratio (HR) 0.99; 95% confidence interval (CI) 0.85-1.15; P = 0.93]. The median overall survival (OS) was 34.1 and 30.7 months in Arms A and B, respectively (HR 0.98; 95% CI 0.81-1.18, P = 0.82). In multivariate analysis, baseline neutrophil (P < 0.001), baseline platelet counts (P < 0.001) and the difference between white blood cell (WBC) and neutrophil count (P = 0.009) had a significant adverse prognostic value. CONCLUSIONS: Intrapatient dose escalation of carboplatin based on nadir blood counts is feasible and safe. However, it provided no improvement in PFS or OS compared with flat dosing. Baseline neutrophils over-ride nadir counts in prognostic significance. These data may have wider implications particularly in respect of the management of chemotherapy-induced neutropenia.

Primary and long-term stability of a short-stem hip implant.

The new generation short-stem hip implants are designed to encourage physiological-like loading, to minimize stress-strain shielding and therefore implant loosening in the long term. As yet there are no long-term clinical studies available to prove the benefits of these short-stem implants. Owing to this lack of clinical data, numerical simulation may be used as a predictor of longer term behaviour. This finite element study predicted both the primary stability and long-term stability of a short-stem implant. The primary implant stability was evaluated in terms of interface micromotion. This study found primary stability to fall within the critical threshold for osseointegration to occur. Longer term stability was evaluated using a strain-adaptive bone remodelling algorithm to predict the long-term behaviour of the bone in terms of bone mineral density (BMD) changes. No BMD loss was observed in the classical Gruen zones 1 and 7 and bone remodelling patterns were comparable with hip resurfacing results in the literature.

Robotic Pancreatoduodenectomy: Patient Selection, Volume Criteria, and Training Programs.

INTRODUCTION: There has been a rapid development in minimally invasive pancreas surgery in recent years. The most recent innovation is robotic pancreatoduodenectomy. Several studies have suggested benefits as compared to the open or laparoscopic approach. This review provides an overview of studies concerning patient selection, volume criteria, and training programs for robotic pancreatoduodenectomy and identified knowledge gaps regarding barriers for safe implementation of robotic pancreatoduodenectomy. MATERIALS AND METHODS: A Pubmed search was conducted concerning patient selection, volume criteria, and training programs in robotic pancreatoduodenectomy. RESULTS: A total of 20 studies were included. No contraindications were found in patient selection for robotic pancreatoduodenectomy. The consensus and the Miami guidelines advice is a minimum annual volume of 20 robotic pancreatoduodenectomy procedures per center, per year. One training program was identified which describes superior outcomes after the training program and shortening of the learning curve in robotic pancreatoduodenectomy. CONCLUSION: Robotic pancreatoduodenectomy is safe and feasable for all indications when performed by specifically trained surgeons working in centers who can maintain a minimum volume of 20 robotic pancreatoduodenectomy procedures per year. Large proficiency-based training program for robotic pancreatoduodenectomy seem essential to facilitate a safe implementation and future research on robotic pancreatoduodenectomy.

Genetic variation in RYR1 and malignant hyperthermia phenotypes.

BACKGROUND: Malignant hyperthermia (MH) is associated, in the majority of cases, with mutations in RYR1, the gene encoding the skeletal muscle ryanodine receptor. Our primary aim was to assess whether different RYR1 variants are associated with quantitative differences in MH phenotype. METHODS: The degree of in vitro pharmacological muscle contracture response and the baseline serum creatine kinase (CK) concentration were used to generate a series of quantitative phenotypes for MH. We then undertook the most extensive RYR1 genotype-phenotype correlation in MH to date using 504 individuals from 204 MH families and 23 RYR1 variants. We also determined the association between a clinical phenotype and both the laboratory phenotype and RYR1 genotype. RESULTS: We report a novel correlation between the degree of in vitro pharmacological muscle contracture responses and the onset time of the clinical MH response in index cases (P<0.05). There was also a significant correlation between baseline CK concentration and clinical onset time (P=0.039). The specific RYR1 variant was a significant determinant of the severity of each laboratory phenotype (P<0.0001). CONCLUSIONS: The MH phenotype differs significantly with different RYR1 variants. Variants leading to more severe MH phenotype are distributed throughout the gene and tend to lie at relatively conserved sites in the protein. Differences in phenotype severity between RYR1 variants may explain the variability in clinical penetrance of MH during anaesthesia and why some variants have been associated with exercise-induced rhabdomyolysis and heat stroke. They may also inform a mutation screening strategy in cases of idiopathic hyperCKaemia.

A modified lateral approach to parastomal hernia repair.

AIM: Parastomal hernia commonly occurs following the formation of a stoma. This is a review of parastomal hernia repair using a modified lateral approach to access the defect. PATIENTS/METHODS: A case series of 17 patients, with a median age of 65, who underwent parastomal hernia repair via a lateral approach over a five year period, is presented. RESULTS: Of the 17 repairs, there were four minor complications in the form of a superficial cellulitis and conservatively managed ileus. In total there were four recurrences, though only one recurrence occurred in 11 cases after slight modification of the technique. The period of follow-up ranged from 6 to 60 months. DISCUSSION: The lateral approach is a viable option for repair of parastomal hernia. It does not necessitate a laparotomy or relocation of the stoma.

Oral health and dental morbidity in long-term allogeneic blood and marrow transplant survivors in Australia.

BACKGROUND: Oral and dental disease is a major cause of long-term morbidity following allogeneic blood and marrow transplantation (Allo-BMT). This study aimed to describe the extent and range of oral and dental complications in BMT recipients and to identify gaps in service provision provided to this high-risk group. METHODS: Participants were Allo-BMT recipients, aged >18 years, and received transplants between 2000 and 2012 in NSW. They completed seven surveys, the purpose-designed Sydney Post-BMT Study survey and six other validated instruments. RESULTS: Of 441 respondents, many reported dry mouth (45.1%), dental caries (36.7%), mouth ulcers (35.3%), oral GVHD (35.1%), gingivitis (16.2%), tooth abscess (6.1%) and oral cancer (1.5%). Regular dental visits were reported by 66.2% of survivors. Middle-high income, older age and geographic location showed a positive association with regular dental visits. Of those who did not visit the dentist regularly, 37% stated they did not feel it necessary, 36% reported cost and 20% stated it was not advised by the treating team. CONCLUSION: Despite oral complications commonly occurring after Allo-BMT, many survivors receive inadequate dental care. These results emphasize the need for improved oral health education, the importance of regular dental checks and improvement in the delivery of dental health services for BMT survivors.

Effects of feeding two RRR-α-tocopherol formulations on serum, cerebrospinal fluid and muscle α-tocopherol concentrations in horses with subclinical vitamin E deficiency.

BACKGROUND: Alpha-tocopherol (α-TP) supplementation is recommended for the prevention of various equine neuromuscular disorders. Formulations available include RRR-α-TP acetate powder and a more expensive but rapidly water-dispersible liquid RRR-α-TP (WD RRR-α-TP). No cost-effective means of rapidly increasing serum and cerebrospinal fluid (CSF) α-TP with WD RRR-α-TP and then sustaining concentrations with RRR-α-TP acetate has yet been reported. OBJECTIVES: To evaluate serum, CSF and muscle α-TP concentrations in an 8-week dosing regimen in which horses were transitioned from WD RRR-α-TP to RRR-α-TP acetate. STUDY DESIGN: Non-randomised controlled trial. METHODS: Healthy horses with serum α-TP of <2 µg/mL were divided into three groups and followed for 8 weeks. In the control group (n = 5), no α-TP was administered. In the second group (Group A; n = 7), 5000 IU/day RRR-α-TP acetate was administered. In the third group (Group WD-A; n = 7), doses of 5000 IU/day of WD RRR-α-TP were administered over 3 weeks, followed by a 4-week transition from WD RRR-α-TP to RRR-α-TP acetate, and a final 1 week of treatment with RRR-α-TP acetate. Serum samples were obtained weekly; muscle biopsies were obtained before, at 2.5 weeks and after supplementation. CSF samples were obtained before and after the 8-week period of supplementation. RESULTS: Serum α-TP increased significantly in Group WD-A at week 1 and remained significantly higher than in Group A and the control group throughout the transition, with inter-individual variation in response. Serum α-TP increased significantly by week 7 in Group A. CSF α-TP increased significantly in Group WD-A only. Muscle α-TP concentrations did not differ significantly across groups. Serum and CSF α-TP were closely correlated (r = 0.675), whereas serum and muscle-α-TP concentrations were not correlated. MAIN LIMITATIONS: The study duration was short and data on pre-transition CSF was lacking. CONCLUSIONS: The administration of 5000 IU/day of water-dispersible RRR-α-TP rapidly increases serum α-TP. Serum and CSF α-TP concentrations are sustained with a gradual transition to 5000 IU/day of RRR-α-TP acetate. Periodic evaluation of serum α-TP concentrations is recommended because responses vary among individuals.

The effect of a perioperative ketamine infusion on the incidence of chronic postsurgical pain-a pilot study.

Chronic postsurgical pain (CPSP) is a common and debilitating complication of major surgery. We undertook a pilot study at three hospitals to assess the feasibility of a proposed large multicentre placebo-controlled randomised trial of intravenous perioperative ketamine to reduce the incidence of CPSP. Ketamine, 0.5 mg/kg pre-incision, 0.25 mg/kg/hour intraoperatively and 0.1 mg/kg/hour for 24 hours, or placebo, was administered to 80 patients, recruited over a 15-month period, undergoing abdominal or thoracic surgery under general anaesthesia. The primary endpoint was CPSP in the area of the surgery reported at six-month telephone follow-up using a structured questionnaire. Fourteen patients (17.5%) reported CPSP (relative risk [95% confidence interval] if received ketamine 1.18 [0.70 to 1.98], P=0.56). Four patients in the treatment group and three in the control group reported ongoing analgesic use to treat CPSP and two patients in each group reported their worst pain in the previous 24 hours at ≥3/10 at six months. There were no significant differences in adverse event rates, quality of recovery scores, or cumulative morphine equivalents consumption in the first 72 hours. Numeric Rating Scale pain scores (median [interquartile range, IQR]) for average pain in the previous 24 hours among those patients reporting CPSP were 17.5 [0 to 40] /100 with no difference between treatment groups. A large (n=4,000 to 5,000) adequately powered multicentre trial is feasible using this population and methodology.

The experience of survival following allogeneic haematopoietic stem cell transplantation in New South Wales, Australia.

Allogeneic haematopoietic stem cell transplantation (allo-HSCT) entails long-term morbidities that impair survivors' quality of life through broad physical and psychosocial sequelae. Current data and survival measurements may be inadequate for contemporary Australian allo-HSCT recipients. This study sought to comprehensively describe survivorship in an up-to-date, local setting through validated measurements and a novel questionnaire designed to complement and address limitations of current instruments. All adults who received an allo-HSCT between 2000 and 2012 in New South Wales were eligible and included, if alive, those literate and consenting to the study, which encompassed seven survey instruments. Four hundred and forty-three survivors participated, which is 76% of contactable (n=583) and 66% of eligible survivors (n= 669). Chronic GVHD (cGVHD) and co-morbidity rates were similar to published data. Noteworthy results include prevalent sexual dysfunction (66% females, 52% males), loss of income (low income increased from 21 to 36%, P<0.001) and employment (full-time employment fell from 64 to 33%, P<0.001), suboptimal vaccination (31% complete), and health screening (≈50%). Risk factors for poor vaccination and health screening were cGVHD, younger age, less education, rural/regional residence and transplantation <2 years. This study suggests that improvement in survivorship may necessitate structural changes in the current delivery of health services.

Transforming growth factor-beta induces plasminogen activator inhibitor type-1 in cultured human orbital fibroblasts.

PURPOSE: The level of constitutive plasminogen activator inhibitor type-1 (PAI-1) expression in cultured human orbital fibroblasts is considerably lower than that found in dermal fibroblasts. This divergence in PAI-1 expression implies differences in the pericellular proteolytic environment and, therefore, in the turnover of extracellular matrix. In this article, the authors examine the effect of transforming growth factor-beta (TGF-beta) on PAI-1 expression in orbital fibroblasts. METHODS: Human orbital and dermal fibroblasts were grown in culture. Confluent monolayers were treated with TGF-beta. PAI-1 in the extracellular matrix was quantitated by radiolabeling the cultures and electrophoresing the cellular material on SDS-PAGE. Medium content was determined by immunoprecipitation of [35S]PAI-1 with a rabbit, anti-human, polyclonal antibody. PAI-1 mRNA was determined by Northern hybridization. RESULTS: TGF-beta increased PAI-1 levels in orbital fibroblasts in a dose-dependent manner, up to 35-fold. The induction was maximal after 16 hours of treatment. The increases in extracellular matrix PAI-1 paralleled those observed in the medium. The steady state levels of the mRNA encoding the protein were upregulated by TGF-beta up to 60-fold 8 hours after the addition of TGF-beta. The fractional increase in PAI-1 expression in orbital fibroblasts was consistently greater than that observed in dermal strains. CONCLUSIONS: Exposure to TGF-beta consistently induces PAI-1 expression in orbital fibroblasts, cells that do not express the polypeptide constitutively at high levels. The effects are mediated at the pretranslational level and involve the upregulation of PAI-1 mRNA. These results suggest that TGF-beta may exert a profound regulatory influence on the pericellular proteolytic environment in orbital connective tissue.

Angiogenic and immune parameters during recombinant interferon-alpha2b adjuvant treatment in patients with melanoma.

As an adjuvant therapy for patients with high risk of recurrent melanoma, high-dose interferon (IFN)-alpha2b therapy has been shown to have some efficacy. We examined 22 patients with resected melanoma who were treated with repeated injections of recombinant IFN-alpha2b during the treatment. Both angiogenic and immune parameters were measured. White blood cells (WBCs) and lymphocyte numbers, lymphocyte subpopulations, serum concentrations of IFN-alpha and anti-IFN-alpha antibodies, and the serum vascular endothelial growth factor (VEGF), interleukin (IL)-8, and basis fibroblast growth factor (bFGF) concentrations were determined over time in resected, recurrence-free patients with American Joint Committee on Cancer (AJCC) stage III melanoma with one or less (LN+ < or = 1, n = 7) or more than one (LN+ > 1, n = 8) lymph nodes involved, and AJCC stage IV resected disease (n = 7). Follow-up and recurrence-free intervals were longer in stage III (LN+ < or = 1) patients compared with stage IV patients (P < 0.05). The number of WBCs and lymphocytes decreased during the treatment for all patient groups (P < 0.001). In addition, percentages of CD8 and CD20 were higher in stage IV patients than in stage III (LN+ > 1) and stage III (LN+ < or = 1) patients at the beginning of therapy (P < 0.05). A significant increase in the percentage of CD20+ cells, mostly B lymphocytes, was observed in the stage III (LN+ > 1) and stage III (LN+ < or = 1) patients over time but not in stage IV patients (P < 0.001). Low IL-8 and bFGF concentrations at the beginning of therapy were associated with significantly longer recurrence-free survival (P < 0.05). These results warrant a larger trial to determine if the differences observed in patients before treatment can provide prognostic markers in patients receiving IFN-alpha2b therapy.

Dimensions of subjective uncertainty in social identification and minimal intergroup discrimination.

Social categorization under minimal group conditions reliably produces intergroup discrimination. It is proposed that this might be because the minimal group paradigm engenders high levels of subjective uncertainty among participants, which causes them to use the categorization to define self and thus identify with the minimal group. Uncertainty is generally an aversive state which may be resolved by identification (Hogg, 1996; Hogg & Abrams, 1993). Thus, people may identify with social categories (and express discrimination) when identification resolves uncertainty. To investigate this idea a standard minimal group experiment was conducted, in which the three independent variables of categorizations, task uncertainty and situational uncertainty were manipulated in a 2 x 2 x 2 factorial between-subjects design. Point distribution strategies were measured along with in-group identification, self-esteem, social awareness and, at three occasions, uncertainty about the task and situation. As predicted, under conditions of high task or situational uncertainty, categorized participants identified more with their minimal in-group and exhibited more intergroup discrimination than other participants. There was also some evidence that identification reduced uncertainty. There was only partial support for the mediational role of identification, and similarly, for self-esteem as a derivative motive. These findings are interpreted as supporting an uncertainty reduction model of social identification and group motivation.

Attitude-behaviour relations: the role of in-group norms and mode of behavioural decision-making.

Two experiments provided support for the central hypothesis--derived from social identity/self-categorization theories--that attitudes would be most likely to predict behaviour when they were supported by a congruent in-group norm. In the first experiment, norm congruency and mode of behavioural decision-making (spontaneous or deliberative) were orthogonally manipulated in a between-subjects study of career choice in psychology. Participants exposed to an attitudinally congruent in-group norm towards their preferred career choice were more likely to display attitude-behaviour consistency than those exposed to an attitudinally inconsistent group norm, an effect that was evident under both spontaneous and deliberative decision-making conditions. Using a mock jury paradigm, Expt 2 replicated and extended the first experiment by including a manipulation of in-group salience. As predicted, participants exposed to an incongruent norm displayed greater attitude-behaviour inconsistency than those exposed to a congruent norm. Contrary to predictions, this effect did not vary as a function of group salience, nor did the effects of group norms for high and low salience participants vary as a function of mode of behavioural decision-making. However, there was evidence that perceived identification with the group moderated the influence of norms on attitude-behaviour consistency.

The theory of planned behaviour: self-identity, social identity and group norms.

The aim of the present study was to examine further the role that self-identity plays in the theory of planned behaviour and, more specifically, to: (1) examine the combined effects of self-identity and social identity constructs on intention and behaviour, and (2) examine the effects of self-identity as a function of past experience of performing the behaviour. The study was concerned with the prediction of intention to engage in household recycling and reported recycling behaviour. A sample of 143 community residents participated in the study. It was prospective in design: measures of the predictors and intention were obtained at the first wave of data collection, whereas behaviour was assessed two weeks later. Self-identity significantly predicted behavioural intention, a relationship that was not dependent on the extent to which the behaviour had been performed in the past. As expected, there was also evidence that the perceived norm of a behaviourally relevant reference group was related to behavioural intention, but only for participants who identified strongly with the group, whereas the relationship between perceived behavioural control (a personal factor) and intention was strongest for low identifiers.

Knowing what to think by knowing who you are: self-categorization and the nature of norm formation, conformity and group polarization.

We contrast two theoretical approaches to social influence, one stressing interpersonal dependence, conceptualized as normative and informational influence (Deutsch & Gerard, 1955), and the other stressing group membership, conceptualized as self-categorization and referent informational influence (Turner, Hogg, Oakes, Reicher & Wetherell, 1987). We argue that both social comparisons to reduce uncertainty and the existence of normative pressure to comply depend on perceiving the source of influence as belonging to one's own category. This study tested these two approaches using three influence paradigms. First we demonstrate that, in Sherif's (1936) autokinetic effect paradigm, the impact of confederates on the formation of a norm decreases as their membership of a different category is made more salient to subjects. Second, in the Asch (1956) conformity paradigm, surveillance effectively exerts normative pressure if done by an in-group but not by an out-group. In-group influence decreases and out-group influence increases when subjects respond privately. Self-report data indicate that in-group confederates create more subjective uncertainty than out-group confederates and public responding seems to increase cohesiveness with in-group - but decrease it with out-group - sources of influence. In our third experiment we use the group polarization paradigm (e.g. Burnstein & Vinokur, 1973) to demonstrate that, when categorical differences between two subgroups within a discussion group are made salient, convergence of opinion between the subgroups is inhibited. Taken together the experiments show that self-categorization can be a crucial determining factor in social influence.

The case-based Internet textbook ODITEB for multi-modal diagnosis of tumors--development, features and first experiences.

Internet technologies offer the chance to build high-quality learning media for the education in medicine. In particular, the teaching of diagnostics with medical imaging can be supported by the excellent visualization and interaction capabilities. In cooperation with three radiological departments at German universities in Munich, Erlangen and Würzburg the distributed case-based Internet textbook ODITEB for tumor diagnosis of the GI-tract, liver, pancreas and thorax has been developed. It offers a growing collection of didactically prepared cases located on servers at the provider sites Munich, Erlangen and Würzburg, functionality similar to a real CT console, original DICOM data, X-rays and endoscopic and endosonographic videos, and expert-guided tours through the cases. In a first evaluation in summer 1998, 32 medical students graded the application with 1.9 ('good') on a scale from 1 ('very good') to 5 ('very bad').

Concepts of a Web-based open distributed textbook for the multimodal diagnostics of gastrointestinal tumours with MRI, CT and video-endoscopy addressing students of medicine and students of medical informatics as two different target groups.

Multimodal diagnostics of gastrointestinal tumours with MRI, CT and video-endoscopy is a rapidly changing domain. The education at our universities should overcome the obstacles of traditional learning based on paper media and oral lectures with retention rates of 10-30% only. The paper presents the objectives and the results of the design phase of the project ODITEB1-Open Distributed TExt Book, for Computer-Assisted Instruction in the domain mentioned above. The main objective is to produce an electronic interactive textbook in order to shift education to more efficient learning settings with higher retention rates. The main concepts are 1) three-layer architecture (dynamic case layer, intermediate query layer, static instruction layer) 2) case pool distribution 3) active learners experience (interactive exploration of original image data).

Ethnic identity, self-esteem, and occupational aspirations of Indian and Anglo-Saxon British adolescents.

A questionnaire monitoring occupational aspiration, ethnic identification, adolescent experience, and self-esteem was administered to a large sample of Indian and Anglo-Saxon British male and female adolescents attending school in the West Midlands. The relationship between these variables and differences between the four groups were consistent with predictions derived from the social identity approach to intergroup relations and group behaviour (Tajfel & Turner, 1979). Indian males were found to possess a social mobility belief structure that mediates high occupational aspirations and keeness to marry out of their ethnic group. In contrast, Indian females were found to possess a social change belief structure associated with acceptance of the status quo and lower aspirations. Males and Anglo-Saxons reported higher self-esteem than females or Indians. The adolescent experience findings were less clear, but were consistent with the general interpretation of the data that the differences in intersex relations and gender-related experiences are contingent on ethnicity.

Aspergillus arachnoiditis post intrathecal baclofen pump insertion.

This report describes an unusual fungal infection of an intrathecal baclofen pump which, to our knowledge, has not been reported previously. We describe a 39-year-old man with severe lower limb spasticity due to secondary progressive multiple sclerosis that was managed with insertion of an intrathecal baclofen pump. He subsequently presented with distinct neurological decline secondary to an intrathecal baclofen pump infection with Aspergillus terreus.