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To explore the cortical morphological associations of the psychoses of epilepsy.Psychosis of epilepsy (POE) has two main subtypes - postictal psychosis and interictal psychosis. We used automated surface-based analysis of magnetic resonance images to compare cortical thickness, area, and volume across the whole brain between: (i) all patients with POE (n = 23) relative to epilepsy-without psychosis controls (EC; n = 23), (ii) patients with interictal psychosis (n = 10) or postictal psychosis (n = 13) relative to EC, and (iii) patients with postictal psychosis (n = 13) relative to patients with interictal psychosis (n = 10).POE is characterised by cortical thickening relative to EC, occurring primarily in nodes of the cognitive control network; (rostral anterior cingulate, caudal anterior cingulate, middle frontal gyrus), and the default mode network (posterior cingulate, medial paracentral gyrus, and precuneus). Patients with interictal psychosis displayed cortical thickening in the left hemisphere in occipital and temporal regions relative to EC (lateral occipital cortex, lingual, fusiform, and inferior temporal gyri), which was evident to a lesser extent in postictal psychosis patients. There were no significant differences in cortical thickness, area, or volume between the postictal psychosis and EC groups, or between the postictal psychosis and interictal psychosis groups. However, prior to correction for multiple comparisons, both the interictal psychosis and postictal psychosis groups displayed cortical thickening relative to EC in highly similar regions to those identified in the POE group overall.The results show cortical thickening in POE overall, primarily in nodes of the cognitive control and default mode networks, compared to patients with epilepsy without psychosis. Additional thickening in temporal and occipital neocortex implicated in the dorsal and ventral visual pathways may differentiate interictal psychosis from postictal psychosis. A novel mechanism for cortical thickening in POE is proposed whereby normal synaptic pruning processes are interrupted by seizure onset.

There is international interest for consensus advice for prescribers working in the field of drug resistant epilepsy intending to trial potential therapies that are nonregistered or off-label. Cannabinoids are one such therapy. In 2017, the New South Wales State Government (Australia) set up a cannabinoid prescribing guidance service for a wide variety of indications, based on known pharmacology together with the relevant new literature as it became available. Increasing interest in cannabis medicines use outside this State over the following 5 years together with a paucity of registration-standard clinical trials, lack of information around dosing issues, drug interactions and biological plausibility meant there remained a large unmet need for such advice. To address the unmet need in epilepsy, and until medicines were registered or regulator quality data were available, it was agreed to bring together a working group comprising paediatric and adult epilepsy specialists, clinical pharmacists., clinical pharmacologists and cannabis researchers from across Australia to develop interim consensus advice for prescribers. Although interim, this consensus advice addresses much of the current practice gap by providing an informed overview of the different cannabis medicines currently available for use in the treatment of epilepsy in paediatric and adult settings, with information on dose, drug interactions, toxicity, type of seizure and frequency of symptom relief. As such it supplements the limited evidence currently available from clinical trials with experience from front-line practice. It is expected that this consensus advice will be updated as new evidence emerges and will provide guidance for a subsequent Guideline.

Funder: National Institute for Health Research (NIHR) GOSH BRC, OBJECTIVE: Drug-resistant focal epilepsy is often caused by focal cortical dysplasias (FCDs). The distribution of these lesions across the cerebral cortex and the impact of lesion location on clinical presentation and surgical outcome are largely unknown. We created a neuroimaging cohort of patients with individually mapped FCDs to determine factors associated with lesion location and predictors of postsurgical outcome. METHODS: The MELD (Multi-centre Epilepsy Lesion Detection) project collated a retrospective cohort of 580 patients with epilepsy attributed to FCD from 20 epilepsy centers worldwide. Magnetic resonance imaging-based maps of individual FCDs with accompanying demographic, clinical, and surgical information were collected. We mapped the distribution of FCDs, examined for associations between clinical factors and lesion location, and developed a predictive model of postsurgical seizure freedom. RESULTS: FCDs were nonuniformly distributed, concentrating in the superior frontal sulcus, frontal pole, and temporal pole. Epilepsy onset was typically before the age of 10 years. Earlier epilepsy onset was associated with lesions in primary sensory areas, whereas later epilepsy onset was associated with lesions in association cortices. Lesions in temporal and occipital lobes tended to be larger than frontal lobe lesions. Seizure freedom rates varied with FCD location, from around 30% in visual, motor, and premotor areas to 75% in superior temporal and frontal gyri. The predictive model of postsurgical seizure freedom had a positive predictive value of 70% and negative predictive value of 61%. SIGNIFICANCE: FCD location is an important determinant of its size, the age at epilepsy onset, and the likelihood of seizure freedom postsurgery. Our atlas of lesion locations can be used to guide the radiological search for subtle lesions in individual patients. Our atlas of regional seizure freedom rates and associated predictive model can be used to estimate individual likelihoods of postsurgical seizure freedom. Data-driven atlases and predictive models are essential for evidence-based, precision medicine and risk counseling in epilepsy.

Little is known about psychiatric symptoms among patients with migraine and newly diagnosed focal epilepsy. The investigators compared symptoms of depression, anxiety, and suicidality among people with newly diagnosed focal epilepsy with migraine versus without migraine.The Human Epilepsy Project is a prospective multicenter study of patients with newly diagnosed focal epilepsy. Depression (measured with the Center for Epidemiologic Studies Depression Scale), anxiety (measured with the 7-item Generalized Anxiety Disorder scale), and suicidality scores (measured with the Columbia-Suicide Severity Rating Scale [C-SSRS]) were compared between participants with versus without migraine. Data analysis was performed with the Kolmogorov-Smirnov test for normality assessment, the Mann-Whitney U test, chi-square test, and linear regression.Of 349 patients with new-onset focal epilepsy, 74 (21.2%) had migraine. There were no differences between the patients without migraine versus those with migraine in terms of age, race, and level of education. There were more women in the group with migraine than in the group without migraine (75.7% vs. 55.6%, p=0.0018). The patients with epilepsy and comorbid migraine had more depressive symptoms than the patients with epilepsy without migraine (35.2% vs. 22.7%, p=0.031). Patients with epilepsy with comorbid migraine had more anxiety symptoms than patients with epilepsy without migraine, but this relation was mediated by age in logistic regression, with younger age being associated with anxiety. Comorbid migraine was not associated with C-SSRS ideation or behavior.Among a sample of patients with newly diagnosed focal epilepsy, 21.2% had migraine. Migraine comorbidity was associated with higher incidence of depressive symptoms. Future studies should be performed to better assess these relationships and possible treatment implications.

Almost 10% of people will experience at least one seizure over a lifetime. Although common, first seizures are serious events and warrant careful assessment and management. First seizures may be provoked by acute or remote symptomatic factors including life-threatening metabolic derangements, drug toxicity or structural brain lesions. An unprovoked first seizure may herald the onset of epilepsy and may be accompanied by medical and psychiatric illnesses. Accidents, injuries and death associated with first seizures are likely under-reported. The cognitive and emotional impact of first seizures is often neglected. Evaluation of a patient presenting with a first seizure requires careful history-taking and early specialist assessment, however optimal management strategies have not been extensively investigated. Further, advances in technology and the role of eHealth interventions such as telemedicine may be of value in the care of patients who have experienced a first seizure. This article reviews the impact and implications of first seizures beyond the scope provided in current guidelines which tend to focus on assessment and management. It examines the effect of first seizures on the well-being of patients; assesses morbidity and premature mortality in first seizures and discusses current and future directions to optimise safety and health of people with first seizures, with a focus on adult patients. Recognition of these issues is essential to provide adequate care for people with first seizures.

ObjectivePsychosis of epilepsy (POE) occurs more frequently in temporal lobe epilepsy, raising the question as to whether abnormalities of the hippocampus are aetiologically important. Despite decades of investigation, it is unclear whether hippocampal volume is reduced in POE, perhaps due to small sample sizes and methodological limitations of past research.MethodsIn this study, we examined the volume of the total hippocampus, and the hippocampal head, body and tail, in a large cohort of patients with POE and patients with epilepsy without psychosis (EC). One hundred adults participated: 50 with POE and 50 EC. Total and subregional hippocampal volumes were manually traced and compared between (1) POE and EC; (2) POE with temporal lobe epilepsy, extratemporal lobe epilepsy and generalised epilepsy; and (3) patients with POE with postictal psychosis (PIP) and interictal psychosis (IP).ResultsCompared with EC the POE group had smaller total left hippocampus volume (13.5% decrease, pConclusionPosterior hippocampal volumes are bilaterally reduced in POE. Volume loss was observed on a posteroanterior gradient, with severe decreases in the tail and moderate volume decreases in the body, with no difference in the hippocampal head. Posterior hippocampal atrophy is evident to a similar degree in PIP and IP. Our findings converge with those reported for the paradigmatic psychotic disorder, schizophrenia, and suggest that posterior hippocampal atrophy may serve as a biomarker of the risk for psychosis, including in patients with epilepsy.

Drug-resistant focal epilepsy is often caused by focal cortical dysplasias (FCDs). The distribution of these lesions across the cerebral cortex and the impact of lesion location on clinical presentation and surgical outcome are largely unknown. We created a neuroimaging cohort of patients with individually mapped FCDs to determine factors associated with lesion location and predictors of postsurgical outcome.The Multi-centre Epilepsy Lesion Detection (MELD) project collated a retrospective cohort of 580 patients with epilepsy attributed to FCD from 20 epilepsy centres worldwide. MRI-based maps of individual FCDs with accompanying demographic, clinical and surgical information were collected. We mapped the distribution of FCDs, examined for associations between clinical factors and lesion location, and developed a predictive model of postsurgical seizure freedom.FCDs were non-uniformly distributed, concentrating in the superior frontal sulcus, frontal pole and temporal pole. Epilepsy onset was typically before age 10. Earlier epilepsy onset was associated with lesions in primary sensory areas while later epilepsy onset was associated with lesions in association cortices. Lesions in temporal and occipital lobes tended to be larger than frontal lobe lesions. Seizure freedom rates varied with FCD location, from around 30% in visual, motor and premotor areas to 75% in superior temporal and frontal gyri. The predictive model of postsurgical seizure freedom had a positive predictive value of 70% and negative predictive value of 61%.FCD location is an important determinant of its size, the age of epilepsy onset and the likelihood of seizure freedom post-surgery. Our atlas of lesion locations can be used to guide the radiological search for subtle lesions in individual patients. Our atlas of regional seizure freedom rates and associated predictive model can be used to estimate individual likelihoods of postsurgical seizure freedom. Data-driven atlases and predictive models are essential for evidence-based, precision medicine and risk counselling in neurology.

The purpose of this paper is to quantify, review, and analyze published research output of academic librarians from 21 higher education Institutions in Ireland. A mixed approach using an online survey questionnaire, supplemented by content analysis and extensive literature scoping were used for data collection. Factors inhibiting and predicting the likelihood of research publication are identified. Motivations, barriers, and collaboration are examined. Qualitative perspectives from survey respondents are offered. The survey response was 30%. The main findings are presented and contextualized. There is evidence of moderate research growth and publication rates among the Irish LIS community; Open Access pathways are increasingly accepted. The paper has original value with both exploratory and analytical perspectives. This is the first comprehensive national study of this cohort; it adds value and a new perspective to the existing literature on academic librarians' participation in scholarly endeavou...

The treatment of refractory and super refractory status epilepticus is a "terra incognita" from the point of view of evidence-based medicine. As randomized or controlled studies that are sufficiently powered are not feasible in relation to the many therapies and treatment approaches available, we carried out an online multinational audit (registry) in which neurologists or intensivists caring for patients with status epilepticus may prospectively enter patients who required general anesthesia to control the status epilepticus (SE). To date, 488 cases from 44 different countries have been collected. Most of the patients had no history of epilepsy and had a cryptogenic etiology. First-line treatment was delayed and not in line with current guidelines. The most widely used anesthetic of first choice was midazolam (59%), followed by propofol and barbiturates. Ketamine was used in most severe cases. Other therapies were administered in 35% of the cases, mainly steroids and immunotherapy. Seizure control was achieved in 74% of the patients. Twenty-two percent of patients died during treatment, and four percent had treatment actively withdrawn because of an anticipated poor outcome. The neurological outcome was good in 36% and poor in 39.3% of cases, while 25% died during hospitalization. Factors that positively influenced outcome were younger age, history of epilepsy, and low number of different anesthetics tried. This article is part of a Special Issue entitled "Status Epilepticus".

Understanding the mechanism of psychogenic non-epileptic seizures (PNES) is challenging. A recent review grouped currently hypothesised psychological models into four: (1) traumatic dissociation, (2) hard-wired anxious-arousal responses, (3) conversion defences and (4) conditioned behaviours, but concluded that determining which of these was correct, if any, went far beyond the available evidence.1 Patients’ subjective reports may lend striking support to some models, but are necessarily post-hoc, and susceptible to iatrogenic suggestion.2 Neuroimaging, such as functional MRI, provides more objective evidence, but is typically restricted to the inter-ictal phase because of potential movement during the scan.3 Single photon emission computed tomography (SPECT) would have distinct advantages in imaging of the peri-ictal state as the tracer injection and uptake occur at the time of the seizure while the scanning can be completed later, after the seizure has finished, overcoming the motion issues. The ictal scan could then be compared with an inter-ictal SPECT to determine the ictal contribution to cerebral blood flow. This process is standard for epilepsy surgery workup, and we combined the databases from two epilepsy surgery centres to find opportunistic cases where the ictal scans of potential surgery cases proved to be of PNES—either because the initial epilepsy diagnosis was mistaken or because the scan captured a comorbid non-epileptic …

The accurate measurement of ultraviolet (UV) irradiation, especially within a container or vessel is one of the challenges facing the broad implementation of UV sterilization. Currently, biological indicators are the best method to determine whether an applied UV dose has the necessary efficacy to achieve sterilization. To overcome some of the challenges of using a biological indicator, chemical indicators based upon the degradation of food, drug and cosmetic (FD&C) dyes were developed. In this work, the relationship between UV dose and dye degradation was elucidated and used to create standard curves which could be used as a quantitative measurement system. The use of dye degradation as a measurement of UV dose is especially useful when the levels of UV irradiation within a container cannot be measured directly. Additionally, due to the highly colored nature of the FD&C dyes, the visual changes present upon dye irradiation can be used as a qualitative visual indicator of the UV dose.

All levels of government in Australia (national, state and territory, municipal) are increasingly contracting with charitable and other not-for-profit organisations (and, at times, for-profit businesses) for the delivery of public services. While estimates vary about the extent of such arrangements, recent statistics suggest they are a large and growing phenomena. The shift to ‘purchase of service’ contracting and other forms of ‘managed markets’ has been partly motivated by a desire to improve the efficiency and effectiveness of service delivery. However, there are some criticisms of the approach, arguing that it leads to a range of problems for not-for-profit organisations, including being burdened by excessive regulation, movement away from their core purpose (so-called ‘mission drift’), and a weakening of the connections with the community they serve. This article examines the prevalence of the contracting arrangements and some of the main reasons why they have come about. It also considers the main gains and challenges resulting from such arrangements, in particular for public sector management. The article draws on recent work by the Productivity Commission (‘the Commission’) including the 2010 study of the contribution of the not-for-profit sector (PC 2010); the 2011 inquiry on disability care and support (PC 2011a); and the 2011 inquiry on caring for older Australians (PC 2011b). It also draws more broadly on a range of other Commission work, including recent reports on government services produced for the Council of Australian Governments (SCRGSP 2011a, 2011b). 澳大利亚各级政府（国家级，州和领地级，市级）正越来越多地将公共服务的提供承包予慈善机构和其他非营利组织（有时也包括以营利为目的的企业）。虽然对此种安排所达到的规模估计各不相同，最近有统计数字表明，这是一个庞大且不断增长的现象。政府转向“购买服务”和其他形式的“管理市场”，其部分动因是希望改善服务提供的效率和效益。然而，有一些批评意见认为它会给非营利组织导致一系列问题，其中包括监管过度带来的负担，偏离组织本身的核心目的（所谓的“使命漂移”），与所服务的公民的联系被削弱。本文探讨服务承包这一现象所达到的规模，以及导致其存在的主要原因。本文还讨论了这种安排的主要优点和挑战，尤其是针对公共部门管理。本文基于生产力委员会（“委员会”）近期的研究，它包括2010年对非营利组织贡献的研究（PC 2010）；2011年对残障护理和支持工作的调查（PC 2011a）；和2011年对老年澳大利亚人护理的工作的调查（PC 2011b）。本文还广泛吸收生产力委员会的其他研究，包括近期为澳大利亚政府理事会制作的关于政府服务的报告。

PurposeThis paper describes a comprehensive user survey carried out in an Irish higher education academic library (Waterford Institute of Technology library service) as part of a strategic initiative to engage with library users.Design/methodology/approachTwo major user groups – full‐time undergraduate students and academic staff – were surveyed. The survey instrument was a hardcopy questionnaire. The paper outlines the relative merits of different survey types and the reasoning behind the final choice of survey instrument.FindingsThe main results of the survey are synopsised. The paper also includes selected free‐text comments made by survey respondents and the library's response to the results in terms of how issues highlighted will be addressed.Research limitations/implicationsThe survey focused on two specific user groups, which leaves scope for future research by this institution into how the library is used by other types of users, such as distance learners.Practical implicationsThe survey was a good way of communicating with users. This was the first time such a project has been undertaken at WIT and WIT library service will continue to survey users on a regular basis and to use the results to inform service delivery.Originality/valueAs the first comprehensive survey to be undertaken in the Institute of Technology sector in Ireland, the paper is of potential value to library practitioners in this, or indeed in other sectors, who are considering doing a survey of their users.

This paper explains the endowment effect, whereby sellers generally demand considerably more for a good than buyers are prepared to pay, and related anomalies. Many decisions, including nominating buying or selling prices, involve uncertainty, and we assert that people experience negative psychological reactions to uncertainty. These reactions can affect a person's valuation of the various options, biasing the person's actions towards the status quo, thus producing the endowment effect. Our model also proposes positive or negative reactions to unlikely prospects, which are able to explain commonly observed behaviour in the presence of ambiguity.

Objectives: 1) To describe injuries experienced by the male prisoner population in the Kingston, Ontario area, and to compare them with those observed in the general population; and 2) to compare the incidence and patterns of prisoner injuries seen in emergency departments (EDs) before and after the introduction of a prison injury triage system. Design: A chart review. Setting: The catchment area surrounding 2 hospital-based EDs in Kingston, Ontario, which includes 8 federal and provincial prisons for adult males. Observations: Injuries to male prisoners (ages 18–75 years) who were treated in the ED during 1996–98 were compared with injuries to the general male population of the same age range. An on-site emergency care triage system was introduced to area prisons in 1993. Prisoner injuries seen in the ED during 1996–98 were compared with those seen during a similar period prior to the introduction of the triage system (1981–84). Available comparators included patient demographics, disposition, intent and nature of injury, the need for surgery, and lengths of hospital stay. Results: 148 prisoner injuries were identified for 1996–98. Prisoner injuries seen in the ED were relatively severe when compared with the general male population, as indicated by the higher frequency of fractures (31.8% prisoner vs. 13.4% general, p < 0.001), blunt head injuries (10.1% vs. 2.2%, p < 0.001), hospital admissions (42.6% vs. 4.1%, p < 0.001) and deaths (2.7% vs. 0.6%, p < 0.001). Since the introduction of the triage system there has been a reduction in the rate of prisoner injuries seen in local hospital EDs (6.1/100/yr [before] vs. 1.6/100/yr [after], p < 0.001). There has been an increase in the relative severity of prisoner injuries seen in the EDs as indicated by the increased hospital admission rate (42.6% vs. 22.7%, p < 0.001), increased rate of surgical intervention (27.7% vs. 12.1%, p < 0.001), and increased length of hospital stay (4.0 days vs. 2.1 days, p < 0.05). The mortality rate has remained low and unchanged (0.7% vs. 1.1%, p = 0.99). Conclusions: The introduction of the new triage system appeared to be associated with a decrease in the total number of ED visits by prisoners. The relative acuity of prisoner injuries seen in the EDs appeared to increase following introduction of the triage system.

PurposeThe purpose of this paper is to illustrate that in increasingly financially constrained times, libraries do not require prerequisite specialised marketing expertise to promote their institution and its services successfully by engaging in cost effective marketing initiatives. It also aims to highlight the potential and importance of marketing to enhance services, communicate services and improve library visibility.Design/methodology/approachA case study is undertaken of the marketing experiences of Waterford Institute of Technology (WIT) Libraries, a small to medium‐sized, publicly funded education institute in South‐East Ireland. The paper details a series of low‐cost, practical marketing measures undertaken by WIT Libraries over the period 2007‐2008, and contextualises them for a collective audience.FindingsWIT Libraries are engaged in a wide range of marketing initiatives, adopting traditional means and Web 2.0 technologies where possible to increase the library's exposure and the services it offers. Predominantly these marketing initiatives do not require a significant financial investment and can be implemented utilising existing library resources in terms of staff expertise and facilities. A “one size fits” all approach does not work for all libraries. Specific marketing techniques can be tailored to suit individual libraries and their users' needs. The authors contend that a range of low‐cost initiatives can be used to successfully promote library services amongst users and the wider community. Further mid‐term evaluation may be necessary.Originality/valueThe paper illustrates with concrete examples how a library with no specialised marketing expertise can adapt to the prevailing financial climate, to engage in cost effective initiatives and promote itself and its services successfully. The article will be of value to similar sized and similarly resourced libraries as a basis for engaging in low‐cost effective marketing initiatives.

PurposeThe purpose of this paper is to provide an overview and analysis of current legislation and various schemes and practices that are available to employers and employees in relation to work life balance, family friendly work arrangements, leave entitlements and diverse modes of flexible work in Ireland. Focuses in particular on the Library and Information sector.Design/methodology/approachIntroduces the concept of flexible working, followed by a review of relevant literature. Outlines what flexible work practices are, giving details of various types of flexible working, both statutory and non‐statutory (in Ireland). Then, discusses why flexible work practices have emerged and details background legislation and the issues that the introduction of flexible working raises. Draws conclusions about best practice in relation to the management of flexible work practices.FindingsIt is argued that commitment to work life balance is now firmly in the mainstream and is part of the political agenda in Ireland and the rest of the developed world. Flexibility in work practice is becoming an integral part of employment, particularly in public sector organisations, which are in effect, leading the way on this issue. Flexible work practices have many advantages for both employees and employers. They also create challenges, especially in terms of management. It is important to balance the requirements of the organisation with those of the employees. Key factors in the successful implementation of flexible working are training and communication.Originality/valueThe article provides a firm basis for further investigation and discussion.

Herein, we present the case of a 67-year-old grazier who was bitten by a tiger snake and developed coagulopathy and respiratory distress. The patient required intubation and ventilation in intensive care. There was delayed detection of snake envenomation and administration of antivenom. On extubation several days later, gross external ocular paresis was noted. Clinical testing indicated that the ocular pathology was secondary to neurotoxin-mediated presynaptic blockade. The paresis was partially resolved by the time of discharge one week later. The present case report discusses the possible mechanisms for the delayed development of ophthalmoplegia.

Objective To evaluate, in vitro, a method of measuring cardiac output and shunt fraction during venovenous extracorporeal membrane oxygenation (ECMO). Design Experimental study using an in vitro model. Setting A teaching hospital. Model An ECMO circuit was set up in parallel with a patient circuit consisting of tubing through which saline was circulated from a 50-L reservoir by a pump which was set at 3 L/min to represent cardiac output. A second pump in the ECMO circuit drew saline from the patient circuit and passed it through a membrane oxygenator. The flow from the membrane oxygenator either returned directly to the patient circuit or was diverted, via a third pump, back into the ECMO circuit, thereby producing a shunt. Interventions By adjusting the flow rates of the second (ECMO) and third (shunt) pumps, three shunt fractions of 12%, 25%, and 50% were produced at three different ECMO flow rates. Lithium chloride (0.15 mmol) was injected just downstream of the membrane oxygenator; the lithium ion concentration-time curves were recorded simultaneously in the flow returning to the saline reservoir and in the flow just upstream of the membrane oxygenator using lithium selective electrodes. Measurements and main results Nine pairs of curves were recorded, one pair for each combination of ECMO and shunt flow rates. Analysis of these curves allowed shunt flow and "cardiac output" to be calculated and compared with the flow rates delivered by the pumps. Mean "cardiac output" derived from the lithium dilution curves was 2.98 +/- 0.18 (SD) L/min, compared with a delivered pump flow of 3 L/min. Measured shunt flow = 0.008 + 1.09 x actual shunt flow (R = 0.997). Conclusions This method would allow cardiac output and shunt flow to be measured in patients undergoing venovenous ECMO. It could result in better patient management and improved cannula design.

A new generation of cardiovascular monitor, fed by data from non or minimally invasive sensors, employing algorithms that model the cardiovascular system, combined with user interfaces that facilitate decision support and protocolization of care represent a new era where the costs and risks of applying this form of technology are going to be far outweighed by the clinical, human and financial returns.

The effect of degradable starch microspheres (DSM) on the passage of a low molecular weight marker through the liver of patients with metastases was compared with the passage of an anti-carcinoembryonic antigen monoclonal antibody. In all six patients studied DSM reduced the passage of the marker into the systemic circulation. In three patients who received labelled whole antibody, DSM had no effect. In two of three who received antibody fragments a similar delay to the low molecular weight marker was observed. This delay is likely to be a result of the smaller size of the fragments and may represent accumulation within the extravascular space.