PREDICT-GTN 1: Can we improve the FIGO scoring system in gestational trophoblastic neoplasia?

Gestational trophoblastic neoplasia (GTN) patients are treated according to the eight-variable International Federation of Gynaecology and Obstetrics (FIGO) scoring system, that aims to predict first-line single-agent chemotherapy resistance. FIGO is imperfect with one-third of low-risk patients developing disease resistance to first-line single-agent chemotherapy. We aimed to generate simplified models that improve upon FIGO. Logistic regression (LR) and multilayer perceptron (MLP) modelling (n = 4191) generated six models (M1-6). M1, all eight FIGO variables (scored data); M2, all eight FIGO variables (scored and raw data); M3, nonimaging variables (scored data); M4, nonimaging variables (scored and raw data); M5, imaging variables (scored data); and M6, pretreatment hCG (raw data) + imaging variables (scored data). Performance was compared to FIGO using true and false positive rates, positive and negative predictive values, diagnostic odds ratio, receiver operating characteristic (ROC) curves, Bland-Altman calibration plots, decision curve analysis and contingency tables. M1-6 were calibrated and outperformed FIGO on true positive rate and positive predictive value. Using LR and MLP, M1, M2 and M4 generated small improvements to the ROC curve and decision curve analysis. M3, M5 and M6 matched FIGO or performed less well. Compared to FIGO, most (excluding LR M4 and MLP M5) had significant discordance in patient classification (McNemar's test P < .05); 55-112 undertreated, 46-206 overtreated. Statistical modelling yielded only small gains over FIGO performance, arising through recategorisation of treatment-resistant patients, with a significant proportion of under/overtreatment as the available data have been used a priori to allocate primary chemotherapy. Streamlining FIGO should now be the focus.     

Neonates as intrinsically worthy recipients of pain management in neonatal intensive care

One barrier to optimal pain management in the neonatal intensive care unit (NICU) is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are (1) vulnerable to pain and harm, and (2) completely dependent on others for pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate’s family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers.

     

Sperm speed is associated with sex bias of siblings in a human population

Recent studies investigating possible causes of male subfertility have largely focused on how lifestyle or environmental factors impact on the process of spermatogenesis. Markedly, fewer studies have investigated those risk factors that result in reduced sperm quality, such as poor sperm motility. The speed at which sperm swim is a major predictor of fertility and is extremely variable in human populations. It has been hypothesized that offspring sex may be adaptively manipulated to maximize the offspring''s reproductive fitness (e.g., parents with genes for good male fertility traits, such as high sperm speed, would produce primarily sons and fewer daughters because the offspring will inherit advantageous male fertility genes). Conversely, parents with poor male fertility genes would produce primarily daughters. We tested whether there was an association between how fast a man''s sperm swam and the sex bias of his siblings in a sample of men attending clinic for fertility investigations with their partner and with a wide range of semen characteristics, including sperm speed. We found that the sex bias of a man''s siblings is associated with his sperm speed; men with female-biased siblings had significantly slower sperm (judged using computer-assisted sperm analysis (CASA)) than men from male-biased sibships. This observation suggests family composition is an important factor that needs to be considered in future epidemiological and clinical studies of human fertility.     

Practical aspects of sperm banking for cancer patients

Semen storage is now routinely offered to men of reproductive age who are diagnosed with malignant disease and who require surgical or chemotherapeutic treatments that have a significant risk of leaving them sterile or subfertile. There is a perception by the public at large and professionals in the field that this is a routine and simple process. Yet, semen storage for such men requires a number of unique skills from a multidisciplinary team of oncologists, nurses, counsellors and scientists (andrologists or embryologists) in order to provide a quality service to the patient. All too often it is seen as 'just another branch' of assisted conception treatment but there are sufficient unique issues for it to be considered a specialty in its own right. In the absence of professional guidelines to outline 'best practice', the British Andrology Society invited interested parties to attend a one-day workshop. This was designed as an interactive workshop for all those involved in the process of semen storage, be they clinicians, nurses, counsellors and scientific staff from either the disciplines of reproductive medicine or oncology. It was intended to examine the process of semen storage for such patients from the point of initial diagnosis, through the process of banking semen samples, to the point at which they are either used in treatment or are discarded. The programme was designed to promote maximum interaction between the speakers and the audience and between those from different specialties and disciplines so that they may learn from each other, developing and improving the service that is provided to these men.