The 30th anniversary of the code of ethics of the Royal Australian and New Zealand College of Psychiatrists–a worthy milestone

Objective To appraise the evolution of the RANZCP’s Code of Ethics on the occasion of its 30th anniversary. Method We scrutinised its five editions, focussing on the revision procedure and changes made, and reviewed relevant literature. Results The procedure of revision has remained constant: incorporating feedback from college members, committees and faculties, and consulting professional medical bodies and mental health advocacy organisations. Seven major themes of change have emerged with respect to patient exploitation, recognition of family and carers, the special place of Indigenous Peoples, confidentiality, engaging patients in decision-making, multidisciplinary collaboration and the well-being of psychiatrists. Conclusions The code has proved to be a dynamic instrument in keeping abreast of changes in psychiatry and society, and promises to maintain a prominent role in promoting high ethical standards in the profession.

Awareness Growth and Belief Revision

The problem of awareness growth, also known as the problem of new hypotheses, is a persistent challenge to Bayesian theories of rational belief and decision making. Cases of awareness growth include coming to consider a completely new possibility (called expansion), or coming to consider finer distinctions through the introduction of a new partition (called refinement). Recent work has centred on Reverse Bayesianism, a proposal for rational awareness growth due to Karni and Vierø. This essay develops a "Reserve Bayesian" position and defends it against two challenges. The first, due to Anna Mahtani, says that Reverse Bayesian approaches yield the wrong result in cases where the growth of awareness constitutes an expansion relative to one partition, but a refinement relative to a different partition. The second, due to Steele and Stefánsson, says that Reverse Bayesian approaches cannot deal with new propositions that are evidentially relevant to old propositions. I argue that these challenges confuse questions of belief revision with questions of awareness change. Mahtani’s cases reveal that the change of awareness itself requires a model which specifies how propositions in the agent’s old algebra are identified with propositions in the new algebra. I introduce a lattice-theoretic model for this purpose, which resolves Mahtani’s problem cases and some of Steele and Stefánsson’s cases. Applying my model of awareness change, then Reverse Bayesianism, and then a generalised belief revision procedure, resolves Steele and Stefánsson’s remaining cases. In demonstrating this, I introduce a simple and general model of belief revision in the face of new information about previously unknown propositions.

Assessment of physical, chemical, and tribochemical properties of biomedical alloys used in explanted modular hip prostheses

During their service life, modular interfaces experience tribological, and corrosion phenomena that lead to deterioration, which in turn can cause a revision procedure to remove the failed prosthesis. To achieve a clearer understanding of the surface performance of those biomedical alloys and the role of the surface properties in the mechanical and chemical performance, samples were taken from retrieval implants made of Ti6Al4V and Co28Cr6Mo alloys. Polarization resistance and pin-on-disk tests were performed on these samples. Physical properties such as contact angle, roughness, microhardness, and Young’s modulus were determined. A correlation between surface energy and evolution of the tribological contact was observed for both biomedical alloys. In tribocorrosion tests, titanium particles seem to remain in the surface, unlike what is observed in CoCr alloys. These metallic or oxidized particles could cause necrosis or adverse tissue reactions.

Cost Utility Analysis of Costal Cartilage Autografts and Human Cadaveric Allografts in Rhinoplasty

Background: Human cadaveric allograft (HCA) and costal cartilage autograft (CCA) have been described for reconstruction during rhinoplasty. Neither are ideal due to infection, resorption, and donor site morbidity. The clear superiority of 1 graft over the other has not yet been demonstrated. This study assesses comparative costs associated with current grafting materials to better explore the cost ceiling for a theoretical tissue engineered implant. Materials and methods: A cost utility analysis was performed. Initial procedure costs include physician fees (CPT 30420), hospital outpatient prospective payments, ambulatory surgical center payments, and fees for the following: rib graft (CPT 20910), hospital observation, and DRG (155) for inpatient admission. Additional costs for revision procedure, included the following fees: physician (CPT 30345), rib graft, hospital outpatient prospective payment, and ambulatory surgical center payments. Total costs under each scenario were calculated with and without the revision procedure. Comparison of total costs for each potential outcome to the estimated health utility value allowed for comparison across rhinoplasty subgroups. Results: The mean cost of primary outpatient rhinoplasty using HCA and CCA were $8075 and $8342 respectively. Revision outpatient rhinoplasty averaged $7447 and increased to $8228 if costal cartilage harvest was required. Hospital admission increased the cost of primary rhinoplasty with CCA to $8609 for observational admission and to $13653 for 1 day inpatient admission. Revision CCA rhinoplasty with an inpatient admission complicated by pneumothorax increased costs to $21 099. Conclusion: Cost of rhinoplasty without hospitalization was similar between HCA and CCA and this cost represents the lower limit of a practical cost for an engineered graft. Considering complications such as need for revision or for admission after CCA due to surgical morbidity, the upper limit of cost for an engineered implant would approximately double.

1040. Knee Explant Analysis (KnEA) Using PLG0206 in Periprosthetic Joint Infection (KnEA Study)

Background PLG0206 is a novel engineered cationic antimicrobial peptide being evaluated for treatment of prosthetic joint infections (PJI). This study evaluated the rapid bactericidal activity of PLG0206 to decrease biofilm and planktonic bacteria on ex vivo infected prosthesis following removal from patients with chronic PJI. Methods De-identified infected prosthetics were removed from nine patients with PJI, despite chronic suppressive oral antibiotics, during a 2-stage revision procedure. Removed prosthetics were then submersed ex vivo to an expected clinical exposure of PLG0206, 1 mg/mL, for ~15 minutes. Upon completion of the 15-minute exposure, the treated explant was placed into buffer and sonicated. The sonication solution was then plated for bacterial analysis including colony forming unit (CFU) enumeration. Remaining explanted implants from the same patient served as a control and was processed similarly but without exposure to PLG0206. Results As shown in the Table, both Gram-positive and Gram-negative bacteria were identified from removed prosthetics during a 2-stage revision procedure of chronic PJI. Eight of ten infected prosthetics treated ex vivo to PLG0206 1 mg/mL were sterilized (No. 1-5, 8-10). Of the two infected prosthetics that were not sterilized (No. 6 and 7), one was polymicrobial (No. 6) and the other was monomicrobial (No. 7). Collectively, infected prosthetics exposed to PLG0206 demonstrated a mean 4log10 reduction (range 2 to 7). Summary of culture and CFU log reduction among infected prosthetics exposed and not exposed to PLG0206 Table: Summary of culture and CFU log reduction among infected prosthetics exposed and not exposed to PLG0206 Conclusion Overall, these findings support the ongoing development of PLG0206 as a local irrigation solution at 1 mg/mL concentration in the wound cavity for 15 minutes in patients undergoing treatment of a PJI occurring after total knee arthroplasty. Disclosures David Huang, MD, PhD, Peptilogics (Employee) Nicholas Pachuda, DPM, Peptilogics (Employee) Despina Dobbins, BS, Peptilogics (Employee) Jonathan Steckbeck, PhD, Peptilogics (Employee) Kenneth Urish, MD, PhD, Peptilogics (Grant/Research Support)

Intergovernmental Conference: Three Case Studies of EC/EU Institution Building

Intergovernmental conference (IGC) within the European integration context is a vehicle for institutional change. Based on the majority decision in the Council, the representatives of member states’ governments convene to debate proposals for amendments to the founding treaties of the European Union (EU) and make decisions on the agreed changes, which are then subject to the ratification process in the member countries according to their constitutional requirements. This procedure was used for almost all treaty revisions until the Treaty of Lisbon in 2007 changed the rules. An ordinary revision procedure was introduced that assumes a role for the Convention to draft changes to the treaties, while keeping the IGC as a next step in the process. A simplified revision procedure was introduced for making adjustments to the internal policies and actions of the EU according to the Treaty on the Functioning of the EU, thus replacing the IGC by a unanimous decision of the European Council. The Merger Treaty of 1965, the Single European Act in 1986, and the Amsterdam Treaty in 1997 represent distinct steps in shaping the perception of the role of the IGC as an institution in the political process within the European Communities and the EU.

Seromadesis following total hip resurfacing by aspiration and injection of doxycycline

Here, we present an interesting case of seroma following hip resurfacing arthroplasty in a 69-year-old man. During the postoperative recovery, the patient made rapid progress and returned to intense activity within the 6-week period. He subsequently developed further right hip pain and swelling. On further examination and on ultrasound scan, a lateral thigh collection was noted. All inflammatory markers were within normal parameters; clinically, there was no evidence of active infection. On initial aspiration and washout, there was a large sterile haemoserous collection. The patient subsequently underwent further aspiration due to persistent collection. After this a revision procedure was performed in two stages with excision of the seroma cavity superficial to fascia lata. Methicillin-sensitive Staphylococcus aureus was grown on extended cultures which was treated successfully with antibiotics. After the second stage revision to total hip replacement, this cavity then recollected. A further trial of aspiration with injection of 200 mg doxycycline, a known sclerosing agent, was performed. The seroma resolved.

The First Endoscopic Sleeve Gastroplasty and Transoral Outlet Reduction in Thailand: Case Report and Literature Review

Obesity is becoming a universal healthcare problem. The role of endoscopic bariatric and metabolic therapies is emerging in the management of obesity and its related conditions. The endoscopic treatment can be used as a primary weight loss procedure and a revision procedure after bariatric surgery. While the prevalence of obesity has been rising over the past two decades in Thailand, the treatment options have been limited to diet and exercise, pharmacological treatment, and bariatric surgery until recently. In 2020, an endoscopic full-thickness suturing device was introduced to Thailand, leading to successful endoscopic bariatric therapy using a suturing device in Thai patients. This article intends to report the first successful endoscopic sleeve gastroplasty and transoral outlet reduction in Thailand with a mini-review focusing on these two procedures' outcomes.