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Background Leg muscle weakness is a major impairment for individuals with cerebral palsy (CP) and is related to reduced functional capacity. Evidence is limited regarding the translation of strength improvements following conventional resistance training to improved gait outcomes. Research Question Does a combined functional anaerobic and lower limb strength training intervention improve gait kinematics and kinetics in individuals with CP aged 15–30 years? 17 young adults (21 ± 4 years, 9 males, GMFCS I = 11, II = 6) were randomized to 12 weeks, 3 sessions per week, of high intensity functional anaerobic and progressive resistance training of the lower limbs (n = 8), or a waitlist control group (n = 9). Pre- and post-training outcomes included maximum ankle dorsiflexion angle at foot contact and during stance, gait profile score, ankle and hip power generation during late stance, and the ratio of ankle to hip power generation. Results There were no between-group differences after the intervention for any kinematic or kinetic gait outcome variable. Within-group analysis revealed an increase in peak ankle power during late stance (0.31 ± 0.28 W·kg−1, p = 0.043) and ankle to hip power ratio (0.43 ± 0.37, p = 0.034) following training in the intervention group. Significance We have previously reported increased overground walking capacity, agility and sprint power, in the training group compared to the control group at 12-weeks. These changes in overground measures of functional capacity occurred in the absence of changes in treadmill gait kinematics and kinetics reported here. ANZCTR: 12614001217695.

Aim The aim of this study was to systematically review the current literature to determine the impact of strength training on skeletal muscle morphology and architecture in individuals aged 4–20 years with spastic type cerebral palsy. Methods A comprehensive search for randomised and non-randomised controlled trials, cohort studies and cross-comparison trials was performed on five electronic databases. Included studies were graded according to level of evidence and assessed for methodological quality using the Downs and Black scale. Quantitative data was analysed using effect sizes. Results Six of 304 articles met the inclusion criteria. Methodological quality of the included papers ranged from 14 to 19 (out of 32). A large effect was found on muscle cross-sectional area following strength training, with small to moderate effects on muscle volume and thickness. Conclusion and implications There is preliminary evidence that strength training leads to hypertrophy in children and adolescents with CP. A paucity of studies exist measuring morphological and architectural parameters following strength training in these individuals. Overall low study methodological quality along with heterogeneous study design, dissimilar outcome measures, and lack of adequate control groups, indicated that care is needed when interpreting the results of these studies in isolation.

Cerebral palsy (CP) is the largest single cause of childhood physical disability. While the brain lesion responsible for CP is static, there is a cascade of secondary musculoskeletal adaptations including reduced muscle size, reduced joint range of motion, increased joint stiffness, and muscle weakness. These secondary alterations progress with age and contribute to a gradual loss of functional capacity into adulthood. Strength training has been used to increase muscle strength in individuals with CP, however it may not be an effective intervention for improving gross mobility-related measures, such as walking performance. It is also unknown whether skeletal muscle in young adults with CP can undergo hypertrophy or architectural adaptations in response to different exercise modes. The general aim of this thesis was to examine the effect of combined functional anaerobic and strength training (FAST) on muscle properties, functional capacity, and gait in adolescents and young adults with CP.A systematic review was undertaken (Chapter 2) to determine the effects of muscle strengthening interventions on skeletal muscle morphology and architecture in children and adolescents with CP. The analysis revealed preliminary evidence that strength training leads to increased muscle size in children and adolescents with CP, accompanied by an increase in muscle strength. Muscle hypertrophy findings may, however, be confounded by factors such as natural growth and concurrent therapies. The findings of this review informed the design of the FAST program and outcome measures used in the following studies to better understand the muscular responses to exercise training in this population.The full study protocol for the FAST intervention is described in Chapter 3. There have been no previous exercise trials conducted in young adults with CP using training parameters that meet established guidelines, that have measured muscle morphology and architecture outcomes. Details of the functional anaerobic and resistance training parameters and progressions according to established guidelines are set out, as well as establishing a-priori outcome measures and the data analysis plan for implementation of the intervention.A cross-sectional study was undertaken (Chapter 4) to investigate the relationships between muscle strength, stiffness, and functional capacity in a larger sample of adults with CP. The results of this study demonstrated that maximum isometric plantar flexion strength independently explained 50 – 61% of variance in functional capacity outcome measures. Passive medial gastrocnemius muscle fascicle stiffness and ankle joint stiffness were not related to functional capacity measures. These findings suggest lower isometric muscle strength of the plantar flexor muscles contributes to the decline in functional capacity in adults with CP.Chapter 5 investigated the impact of the FAST intervention on lower limb muscle volumes, joint and muscle stiffness, muscle strength, and functional capacity in a sample of 17 young adults with CP. Participants were randomised to 12 weeks, 3 sessions per week, of high intensity functional anaerobic and progressive resistance training of the lower limbs (n=8), or a waitlist control group (n=9). Pre- and post-training plantar flexor and tibialis anterior muscle volumes and composition, passive and active plantar flexor muscle properties, and functional capacity outcomes were assessed. The training group had higher values compared to the control group (adjusted mean difference) at 12-weeks for: more- and less-impaired total plantar flexor and tibialis anterior muscle volumes; maximum isometric plantar flexion strength; muscle power sprint test peak power; agility shuttle time; composite functional strength score; and six-minute walk test distance. The addition of anaerobic training to progressive resistance exercise likely contributed to the improved functional capacity.The final experimental study (Chapter 6) reports on the gait outcomes following the FAST intervention. Participants walked at a preferred walking speed on a force instrumented, tandem treadmill, while three-dimensional kinematics, kinetics were simultaneously acquired. There were no changes between the training group and control group for maximum ankle DF angle at foot contact or during stance; gait profile score; and peak ankle power during late stance. Within-group analysis revealed an increase in ankle power generation during late stance after training in the intervention group, in part due to a compensatory reduction in hip power generation, indicating a potential trade-off between the two joints post-training. Overground functional capacity improvements reported in Chapter 5 occurred in the absence of treadmill gait kinematic changes. The collection of studies in this thesis provides new information on the relationships between muscle structure and function in adults with CP, and the influence of a combined FAST intervention on muscle properties, functional capacity, and gait. Skeletal muscle in high functioning young adults appears to be capable of undergoing a hypertrophic response to FAST. Undertaking specific anaerobic exercises in addition to resistance exercise may be important for improving functional capacity in these individuals. Taken together, these findings have important implications for the prescription of exercise in high functioning young adults with CP as a means of addressing the muscle and functional deficits that progress with age in this population.

The purpose of this paper was to systematically assess the effect of Oxford Foot Model (OFM) marker misplacement on hindfoot relative to tibia, and forefoot relative to hindfoot kinematic calculations during the stance phase of gait. Marker trajectories were recorded with an 8-camera motion analysis system (Vicon Motion Systems Ltd., UK) and ground reaction forces were recorded from three force platforms (AMTI, USA). A custom built marker cluster consisting of 4 markers in a square arrangement (diagonal distance 2 cm) was used to assess the effect of marker misplacement in the superior, inferior, anterior and posterior direction for the sustentaculum tali (STL), the proximal 1st metatarsal (P1M), distal 5th metatarsal (D5M), proximal 5th metatarsal (P5M) and lateral calcaneus (LCA) markers. In addition manual movement of the heel complex 1 cm superiorly, inferiorly, medially and laterally, and also an alignment error of 10° inversion and 10° eversion was assessed. Clinically meaningful effects of marker misplacement were determined using a threshold indicating the minimal clinically important difference. Misplacement of the heel-wand complex had the most pronounced effect on mean kinematic profiles during the stance phase across all degrees-of-freedom with respect to hindfoot-tibia and forefoot-hindfoot angles. Vertical marker misplacement of the D5M and P5M markers affected the sagittal plane, and to a lesser extent frontal plane, forefoot-hindfoot kinematics. In conclusion, the OFM is highly sensitive to misplacement of the heel-wand complex in all directions and the P5M marker in the vertical direction.

This study aimed to investigate the efficacy of a 12-wk combined functional anaerobic and strength training program on neuromuscular properties and functional capacity in young adults with spastic-type cerebral palsy.A total of 17 young adults (21 ± 4 yr, 9 males, Gross Motor Function Classification System I = 11 and II = 6) were randomized to 12 wk, 3 sessions per week, of high-intensity functional anaerobic and progressive resistance training of the lower limbs (n = 8), or a waitlist control group (n = 9). Pre- and posttraining plantarflexor and tibialis anterior muscle volumes and composition, passive and active plantarflexor muscle properties, and functional capacity outcomes were assessed.The training group had higher values compared with the control group (adjusted mean difference) at 12 wk for the following: more- and less-impaired total plantarflexor and tibialis anterior muscle volumes, maximum isometric plantarflexion strength, muscle power sprint test peak power, agility shuttle time, composite functional strength score, and 6-min walk test distance. The change in total plantarflexor muscle volume was associated with the change in plantarflexor muscle strength. There were relationships between the change in plantarflexor muscle strength and the change in functional capacity outcomes (functional strength; 6-min walk test).Combined functional anaerobic and strength training increased muscle size, strength, and functional capacity in young adults with cerebral palsy. The addition of anaerobic training to progressive resistance training programs assists in the transfer to improved functional capacity.

Objective To investigate the relation between lower limb muscle strength, passive muscle properties, and functional capacity outcomes in adults with cerebral palsy (CP). Design Cross-sectional study. Setting Tertiary institution biomechanics laboratory. Participants Adults with spastic-type CP (N=33; mean age, 25y; range, 15–51y; mean body mass, 70.15±21.35kg) who were either Gross Motor Function Classification System (GMFCS) level I (n=20) or level II (n=13). Interventions Not applicable. Main Outcome Measures Six-minute walk test (6MWT) distance (m), lateral step-up (LSU) test performance (total repetitions), timed up-stairs (TUS) performance (s), maximum voluntary isometric strength of plantar flexors (PF) and dorsiflexors (DF) (Nm.kg −1 ), and passive ankle joint and muscle stiffness. Results Maximum isometric PF strength independently explained 61% of variance in 6MWT performance, 57% of variance in LSU test performance, and 50% of variance in TUS test performance. GMFCS level was significantly and independently related to all 3 functional capacity outcomes, and age was retained as a significant independent predictor of LSU and TUS test performance. Passive medial gastrocnemius muscle fascicle stiffness and ankle joint stiffness were not significantly related to functional capacity measures in any of the multiple regression models. Conclusions Low isometric PF strength was the most important independent variable related to distance walked on the 6MWT, fewer repetitions on the LSU test, and slower TUS test performance. These findings suggest lower isometric muscle strength contributes to the decline in functional capacity in adults with CP.

The purpose of this study was to systematically review the current literature to determine the effect of a femoral derotation osteotomy (FDRO) on hip and pelvic rotation kinematics during gait compared to no intervention in children with spastic cerebral palsy (CP). We performed a systematic search for prospective and retrospective cohort studies of children with CP, who were treated with a FDRO, and were assessed with pre and post surgery three-dimensional gait analysis. Medline, CINAHL, EMBASE, the Cochrane Library and Web of Science were searched up to December 2013. Data sources were prospective and retrospective studies. Mean differences were calculated on pooled data for both pelvic and hip rotation kinematics. Thirteen of 196 articles met the inclusion criteria (5 prospective, 8 retrospective). All included studies were of sufficient quality for meta-analysis as assessed using a customised version of the STROBE checklist. Meta-analysis showed that FDRO significantly reduced pelvic retraction by 9.0 degrees and hip internal rotation by 17.6 degrees in participants with unilateral CP involvement and hip internal rotation by 14.3 degrees in participants with bilateral CP involvement. Pelvic symmetry in children with unilateral spastic CP is significantly improved by FDRO. Patients with bilateral involvement do not improve their transverse plane pelvic rotation profiles during gait as a result to FDRO, although this result should be interpreted with caution due to the heterogeneous nature of these participants and of the methods used in the studies assessed.

The aim of this study was to compare voluntary and involuntary force generating capacity of the triceps surae muscles in healthy young and older adult participants during isometric and isokinetic contractions. Ultrasound was used to measure medial gastrocnemius (MG) fascicle length during maximal voluntary isometric contractions and supra-maximal isometric twitch contractions at five ankle angles throughout the available range of motion, as well as isokinetic concentric and eccentric contractions at four ankle velocities. Maximum voluntary activation of the plantar flexors was assessed using the twitch interpolation technique. Peak plantar flexor torque was significantly lower in older adults compared to young participants by 42%, 28% and 43% during maximal voluntary isometric contractions, supra-maximal isometric twitch and concentric contractions respectively. No age-related differences in eccentric torque production were detected. When age-related differences in triceps surae muscle volume determined from MRI were taken into account, the age-related peak plantar flexor torque deficits for maximum voluntary isometric, supra-maximal twitch, and concentric contractions were 24%, 19% and 24% respectively. These age-related differences in torque were not explained by torque-length-velocity behaviour of the MG muscle fascicles, passive plantar flexor torque-angle properties, decreased neural drive of the plantar flexor muscles or antagonistic co-activation of the tibialis anterior muscle. The residual deficit in isometric and concentric plantar flexor torques in healthy older adults may involve reduced muscle quality. A significant reduction in supra-maximal twitch torque at longer MG fascicle lengths as well as a lower MG fascicle velocity during eccentric contractions in older adults was detected, which could possibly be a function of the reported increased Achilles tendon compliance in older adults.

Manual tracking of muscle fascicle length changes from ultrasound images is a subjective and time-consuming process. The purpose of this study was to assess the repeatability and accuracy of an automated algorithm for tracking fascicle length changes in the medial gastrocnemius (MG) muscle during passive length changes and active contractions (isometric, concentric and eccentric) performed on a dynamometer. The freely available, automated tracking algorithm was based on the Lucas-Kanade optical flow algorithm with an affine optic flow extension, which accounts for image translation, dilation, rotation and shear between consecutive frames of an image sequence. Automated tracking was performed by three experienced assessors, and within- and between-examiner repeatability was computed using the coefficient of multiple determination (CMD). Fascicle tracking data were also compared with manual digitisation of the same image sequences, and the level of agreement between the two methods was calculated using the coefficient of multiple correlation (CMC). The CMDs across all test conditions ranged from 0.50 to 0.93 and were all above 0.98 when recomputed after the systematic error due to the estimate of the initial fascicle length on the first ultrasound frame was removed from the individual fascicle length waveforms. The automated and manual tracking approaches produced similar fascicle length waveforms, with an overall CMC of 0.88, which improved to 0.94 when the initial length offset was removed. Overall results indicate that the automated fascicle tracking algorithm was a repeatable, accurate and time-efficient method for estimating fascicle length changes of the MG muscle in controlled passive and active conditions.

A method for deriving Site-Specific Assessment Criteria (SSAC) for use when considering risk to human health from chronic exposure to heavy metals (except lead), metalloids, and organic substances in soil, with application to the United Kingdom (UK), is described. The SSAC represents the soil concentration above which an unacceptable risk to human health may be indicated. The method considers the UK standard land uses (residential with and without plant uptake, allotment gardens, and commercial/industrial) by applying the default exposure factors and algorithms provided. Non-standard land uses can be also considered. Site-specific determinations of contaminant bioaccessibility or of plant-to-soil concentration factors may be used if available. The method adopts the risk-based source-pathway-receptor pollutant linkage framework and a deterministic methodology. Exposure pathways considered are direct ingestion of soil and dust, consumption of home grown or allotment vegetables, ingestion of soil at...

A recently developed semi-mechanistic temporal model is used to predict food product radiocaesium activity concentrations using soil characteristics available from spatial soil databases (exchangeable K, pH, percentage clay and percentage organic matter content). A raster database of soil characteristics, radiocaesium deposition, and crop production data has been developed for England and Wales and used to predict the spatial and temporal pattern of food product radiocaesium activity concentrations (Bq/kg). By combining these predictions with spatial data for agricultural production, an area's output of radiocaesium can also be estimated, we term this flux (Bq/year per unit area). Model predictions have been compared to observed data for radiocaesium contamination of cow milk in regions of England and Wales which received relatively high levels of fallout from the 1986 Chernobyl accident (Gwynedd and Cumbria). The model accounts for 56% and 80% of the observed variation in cow milk activity concentration for Gwynedd and Cumbria, respectively. Illustrative spatial results are presented and suggest that in terms of food product contamination areas in the North and West of England and Wales are those most vulnerable to radiocaesium deposition. When vulnerability is assessed using flux the spatial pattern is more complex and depends upon food product.

Six sites of variable soil type and environments in England and Scotland were sown with winter wheat (Triticum aestivum L. cv. Mercia) in the autumns of 1992 and 1993 with optimum inputs for growth. Crop monitoring between February and grain maturity provided data to investigate environmental and physiological factors important in controlling biomass accumulation.With increasing use of crop modelling as a tool for interpreting experiments and as crop management decision support systems, it is important that all influences on crop productivity are understood. The ‘radiation use efficiency’ or radiation conversion coefficient provides a convenient basis to study these influences.Significant differences in seasonal radiation conversion coefficients were observed between sites (P < 0·001), ranging from 2·82 to 3·87 g total dry matter/MJ absorbed photosynthetically active radiation. A series of simple dry matter models were developed to help explain biomass accumulation in relation to a number of environmental variables (using the measured green area index as an input) with correlation coefficients [ges ] 0·98 obtained across all sites. Apart from sunlight, differences in the canopy's ability to accumulate nitrogen and maintenance respiration costs were the most significant factors (P < 0·001). The nitrogen effect suggests changes in the conversion of assimilates with nitrogen availability, despite relatively high nutrition levels ([ges ] 180 kg N/ha).Over all sites the canopy extinction coefficient could be described as a linear function of the site spring time plant population (P < 0·01). A more detailed model considered canopy light attenuation to vary between sites according to sowing date and autumn/winter plant establishment and environment.

Within the RESTORE project (‘restoration strategies for radioactive contaminated ecosystems’) funded by the European Commission Nuclear Fission Safety Programme, environmental models are being developed to identify regions that are vulnerable to increased radionuclide transfer as a consequence of the Chernobyl nuclear power plant accident and nuclear weapons testing at the Semipalatinsk test site in Kazakhstan. Since radionuclide transfer varies in space and time depending on deposition processes, soil type, land use, and resulting contamination in food products, the radionuclide transfer through food chains derived from a variety of ecosystems is analysed by the use of models embedded in a Geographical Information System. The Chernigov region in northern Ukraine was affected by the Chernobyl fallout resulting in deposition levels ranging from 15 to 300 kBq m −2 . GIS-based steady state and dynamic transfer models within an environmental decision support system (EDSS) were run for this region to model radiocaesium transfer from soil to various agricultural products on a collective farm level and on a district level within this region using spatial data sets of soil attributes, soil contamination and land use. Observed agricultural product contamination was available for comparison with model predictions. This paper presents examples of radiocaesium transfer from soil to fodder grass and potatoes to make an initial assessment of the radioecological situation in the Chernigov region to identify critical gaps in the model structure and data required for model input and validation. It highlights the feasibility of applying spatial and temporal data sets to make predictions of the present radioecological situation, as an alternative to approaches commonly used which categorise such data sets, thereby losing valuable information.

A simple model of canopy expansion and senescence with accumulated thermal time from sowing was used to describe differences in canopy development and potential size across a range of sites in the UK between 1992 and 1995. The principal model inputs were nitrogen, temperature and sowing date. The model was calibrated across six sites within the major wheat growing areas using canopy data collected during the 1992/93 and 1993/94 growing seasons and was validated using data collected in the 1994/95 season. The model was able to predict the time course of green area index (GAI) over a season with an r2[ges ]0·87 for the five English sites, and an r2=0·68 for the single Scottish site. This model may prove to be a useful approach to forecasting the potential canopy size, based upon an estimate or measure of the total nitrogen available to the crop (both from applied fertilizer and the soil).

Functions which predict rate of leaf emergence and final number of leaves, used in a model to predict the date at which growth stages occur, were tested in an experiment on winter wheat cv. Mercia grown with standardized husbandry at six sites in 1992/93, 1993/94 and 1994/95. A study of the number of detectable nodes on the culm and leaf length was also made.The predicted rate of leaf emergence was mostly within 5% of the observed value. The difference between observed and predicted final number of leaves was mostly less than half a leaf but suspected errors in leaf counts resulted in some differences of more than two leaves.Variable extension of the basal internode impaired confidence in the detection of nodes. The mean number of detectable nodes differed significantly among sites and between seasons from 3·7 to 4·8 but could not be related to sowing date or final number of leaves. Further information on factors affecting extension of the basal internode is desirable to standardize node detection and improve prediction of culm leaf appearance.Culm leaves showed successively longer laminae up to the penultimate leaf. There was a significant relationship between length of the flag leaf and the final number of leaves, but it was positive in 1993/94 and negative in 1994/95. This may have been due to greater water stress in 1994/95.

This article describes the history of prostaglandins and the current status of research into their applications in gynecology. Studies of their use in inducing menstruation, labor and abortion are described.

In this paper we argue that the human form should be seen to exist, in a longitudinal way, throughout the continuum of human growth and development. This entails that the moral value of that form, which we link analytically to the adult, interacting, social and rational being, attaches to all phases of human life to some extent. Having established this we discuss the consequences it has for the moral status of the human embryo. We then apply this argument, and the resulting moral status, to the area of reproductive technology. In doing this we show that there are certain regulations and controls which ought to apply to the use of these infertility treatments.The human form exists in a longitudinal way in a continuum of human growth and development. The moral value of this form, which is intrinsic, links the embryo with the rationally, social and morally active adult. The argument has certain consequences for human embryos. The relative sanctity of human life is thus established. Therefore to do harm to human life does harm a basic moral principle. This sanctity is attached to the whole human form, including embryos. The result is that when dealing with embryos, one must realize one is dealing with human life. And often this life must be balanced against the value of another human life. This argument provides excellent defense from moral arguments that attempt to label embryo research as immoral. Researchers must understand that they are dealing with human life and once this is admitted it is simply a matter of valuing the life accordingly.

Countermeasures have been effectively employed within intensive agricultural systems in areas of the Former Soviet Union (FSU) affected by the Chernobyl accident. However, ingestion doses continue to be elevated in some areas as a result of few foodstuffs which are collected from the wild or produced by the household. Forest fungi and berries, and milk from privately owned cattle are the most notable contributors to 137Cs intakes amongst these foodstuffs. In this paper we consider advice which would help affected populations to both understand the importance of these exposure routes and to reduce their exposure. In addition to the potential radiological benefits, self-help schemes are highly cost-effective and likely to have a positive psychological influence on populations living within contaminated areas of the FSU. Evidence to suggest that the transfer of radiocaesium to cow milk is considerably higher in the FSU than within western Europe and North America is discussed.

Since the Chernobyl accident it has been recognised that agriculturally produced foods are not the only important food types which contribute to the radiation dose received by man. The transfer of radiocaesium to ‘wild food’ products (e.g. edible fungi, freshwater fish, game animals) is often much greater than that to agriculturally produced foodstuffs. The accumulation of radiocaesium by certain species of edible fungi for instance, results in radiocaesium levels that are far in excess of most other foods consumed by man.

Medea killed her children to take away the smile from her husband9s face, according to Euripides, an offence against nature and morality. What if Medea had still been carrying her two children, perhaps due to give birth within a week or so, and had done the same? If this would also have been morally reprehensible, would that be a judgment based on her motives or on her action? We argue that the act has multiple and holistic moral features and that, in fact, there is no absolute principle, such as the right of the fetus to life, which governs our moral judgments about fetal-maternal conflicts. We suggest that they illustrate a pervasive feature of human moral discourse and can only be addressed by attending to a range of negotiable moral considerations which depend on particular features of each situation.

Currently the management of adult victims of violence by general practitioners and accident and emergency departments is reactive, concerned almost exclusively with the management of physical injuries. Professor Jonathan Shepherd outlines some ideas for a more proactive approach on the part of doctors to improve the protection and support of vulnerable people; to deal with psychological sequelae; to take the responsibility of making an official complaint to the police away from seriously injured people, who are unable to give or withhold consent to disclosure; and to prevent assailants inflicting further injuries. We asked a sociologist, a psychiatrist, a moral philosopher, and a police surgeon for their comments.

Doctors in accident and emergency departments are sometimes presented with patients with potentially life threatening conditions who refuse to consent to treatment. The doctors then face a dilemma: to withhold necessary treatment or to act against a patient's express wishes. Two such cases are presented, and we asked a lawyer, two medical ethicists, a psychiatrist, and an accident and emergency physician to comment on the implications.

The hospice believes in the concept of a gentle and harmonious death. In most hospice settings there is also a rejection of active euthanasia. This set of two apparently conflicting principles can be defended on the basis of two arguments. The first is that doctors should not foster the intent to kill as part of their moral and clinical character. This allows proper sensitivity to the complex and difficult situation that arises in many of the most difficult terminal care situations. The second argument turns on the seduction of technological solutions to human problems and the slippery slope that may arise in the presence of a quick and convenient way of dealing with problems of death and dying.

A 55-year-oldwoman with pancytopenia following chemotherapy for non-Hodgkin's lymphoma had blood taken for routine biochemical analyses shortly after being given intravenous azlocillin. The serum sample yielded several surprising results which bore no relation to previous and subsequent measurements (Table 1). The main changes observed in the azlocillin associated sample were a rise in sodium and fall in chloride concentration accompanied by an increase in the anion gap, rises in creatinine and total protein and a fall in urea. Azlocillin as a sodium salt is reconstituted for injection to yield a concentration of 100 giL and administered intravenously as a bolus in amounts of up to 5 g in 50 mL. The measured azlocillin concentration in the sample taken shortly after intravenous administration was 25 g/L, suggesting a 1 in 4 dilution of azIoci1lin solution in plasma. Sincethe concentration of sodium in the antibiotic solution as prepared for infusion is 217 mmollL, a 1 in 4 dilution in the patient's serum would produce a mixture with a sodium level of 155 mmol/L.

Laboratory findings were compared with lung scans in a prospective study of 260 patients undergoing ventilation-perfusion (V/Q) lung scanning for suspected pulmonary thromboembolism. The best discrimination between different lung scan results was obtained from the level of plasma cross-linked fibrin degradation products, every patient with a scan indicating a high probability of thromboembolism having detectable levels. An acute phase response was demonstrated in patients with pulmonary thromboembolism by a raised neutrophil count and elevated levels of plasma fibrinogen and serum C-reactive protein. A normal level of serum C-reactive protein and/or plasma cross-linked fibrin degradation productions in blood taken within 4 days of onset of symptoms virtually excluded the diagnosis of pulmonary thromboembolism. Detection of free plasma DNA was not helpful in discriminating between groups with different lung scan results. Discriminant analysis was used to assess the variables examined and to derive diagnostic models. An accuracy of 78 per cent was obtained with one model for classifying test patients according to the three lung scan classes of low, intermediate and high probability. A second model, for distinguishing patients with a low and a high probability of pulmonary thromboembolism on the basis of lung scans, and a third for predicting those with a low probability on lung scan, were accurate in 94.6 per cent and 83.5 per cent of patients respectively. Discriminant models could be used in the diagnosis of pulmonary thromboembolism, especially when diagnostic imaging is not available.

Laboratory findings were compared with lung scans in a prospective study of 260 patients undergoing ventilation-perfusion (V/Q) lung scanning for suspected pulmonary thromboembolism. The best discrimination between different lung scan results was obtained from the level of plasma cross-linked fibrin degradation products, every patient with a scan indicating a high probability of thromboembolism having detectable levels. An acute phase response was demonstrated in patients with pulmonary thromboembolism by a raised neutrophil count and elevated levels of plasma fibrinogen and serum C-reactive protein. A normal level of serum C-reactive protein and/or plasma cross-linked fibrin degradation productions in blood taken within 4 days of onset of symptoms virtually excluded the diagnosis of pulmonary thromboembolism. Detection of free plasma DNA was not helpful in discriminating between groups with different lung scan results. Discriminant analysis was used to assess the variables examined and to derive diagnostic models. An accuracy of 78 per cent was obtained with one model for classifying test patients according to the three lung scan classes of low, intermediate and high probability. A second model, for distinguishing patients with a low and a high probability of pulmonary thromboembolism on the basis of lung scans, and a third for predicting those with a low probability on lung scan, were accurate in 94.6 per cent and 83.5 per cent of patients respectively. Discriminant models could be used in the diagnosis of pulmonary thromboembolism, especially when diagnostic imaging is not available.

Our impulse in medicine is to furnish help and comfort to the human beings who come to us, and to do so by using whatever technology is appropriate. This intuitive feeling is challenged by certain medical ethicists. Their principles, however, must be combined.

Currently the management of adult victims of violence by general practitioners and accident and emergency departments is reactive, concerned almost exclusively with the management of physical injuries. Professor Jonathan Shepherd outlines some ideas for a more proactive approach on the part of doctors to improve the protection and support of vulnerable people; to deal with psychological sequelae; to take the responsibility of making an official complaint to the police away from seriously injured people, who are unable to give or withhold consent to disclosure; and to prevent assailants inflicting further injuries. We asked a sociologist, a psychiatrist, a moral philosopher, and a police surgeon for their comments.

Doctors in accident and emergency departments are sometimes presented with patients with potentially life threatening conditions who refuse to consent to treatment. The doctors then face a dilemma: to withhold necessary treatment or to act against a patient's express wishes. Two such cases are presented, and we asked a lawyer, two medical ethicists, a psychiatrist, and an accident and emergency physician to comment on the implications.