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Representatives from eight European countries compared the legal, ethical and professional settings within which decision making for neonates takes place. When it comes to limiting treatment there is general agreement across all countries that overly aggressive treatment is to be discouraged. Nevertheless, strong emphasis has been placed on the need for compassionate care even where cure is not possible. Where a child will die irrespective of medical intervention, there is widespread acceptance of the practice of limiting aggressive treatment or alleviating suffering even if death may be hastened as a result. Where the infant could be saved but the future outlook is bleak there is more debate, but only two countries have tested the courts with such cases. When it comes to the active intentional ending of life, the legal position is standard across Europe; it is prohibited. However, recognising those intractable situations where death may be lingering and unpleasant, Dutch paediatricians have reported that they do sometimes assist babies to die with parental consent. Two cases have been tried through the courts and recent official recommendations have set out standards by which such actions may be assessed. [ABSTRACT FROM AUTHOR]

Objectives To develop and test an MRI cartilage scoring system for use at the wrist in rheumatoid arthritis (RA). Methods MRI scans were obtained using a 3T MRI scanner with dedicated wrist coil in 22 early and 16 established RA patients plus 22 controls. Axial and coronal T1-weighted (precontrast and postcontrast) and T2-weighted turbo spin echo sequences were obtained. Eight wrist joints were scored for cartilage narrowing: distal radioulnar, radiolunate, radioscaphoid, triquetrum-hamate, capitate-lunate, scaphotrapezoid, second metacarpal base-trapezoid and third metacarpal base-capitate, using a system based on the Sharp van der Heijde x-ray joint space narrowing (JSN) score by three radiologists. Fifteen sites at the wrist were also scored for synovitis, bone oedema and erosion using the RA MRI score. Results Interobserver (three-reader) and intraobserver reliability (readers 1 and 2) for the cartilage score were excellent: intraclass correlations (ICC (95% CI)) 0.91, (0.86 to 0.94), 0.98 (0.96 to 1.00) and 0.94 (0.87 to 1.00), respectively. Cartilage scores (median, range) were higher in the established RA group (11.9, 2.3–27.3) than the early RA group (2.15, 0–6) (p≤0.001) but early RA scores did not differ from healthy controls (2.3, 1–8.7). Cartilage scores correlated with synovitis (R=0.52), bone oedema (R=0.63) and erosion scores (R=0.66), p<0.001 for all, and with x-ray JSN scores (R=0.68 to 0.78). Conclusion This MRI cartilage score demonstrated excellent reliability when tested in a three-reader system. However, cartilage loss in early RA could not be distinguished from that seen in healthy controls. [ABSTRACT FROM PUBLISHER]

Objectives-To determine parents' views on autopsy after treatment withdrawal. Design-Face to face interviews with 59 sets of bereaved parents (108 individual parents) for whose 62 babies there had been discussion of treatment withdrawal. Results-All except one couple were asked for permission for postmortem examination; 38% refused. The main reasons for declining were concerns about disfigurement, a wish to have the child left in peace, and a feeling that an autopsy was unnecessary because the parents had no unanswered questions. The diagnosis, the age of the child, and the approach of the consultant appeared to influence consent rates, Of those who agreed to autopsies, 92% were given the results by the neonatologist concerned. Whether or not they had agreed to the procedure, at 13 months no parent expressed regrets about their decision. Conclusions-Autopsy rates in the East of Scotland stand at 62%. Parents' perceptions are an important element in consent to postmortem examination. [ABSTRACT FROM AUTHOR]

Objective-To explore parents' perceptions of treatment withdrawal and the dying process. Design-Face to face interviews with 59 sets of parents of 62 babies in the East of Scotland three months and 13 months after death. Results-22% of the parents expressed reservations about the length of the dying process, which they reported in these instances had taken from three to 36 hours. Deaths that medical teams had predicted would be quick had, according to the parents' recollections, taken from 1.5 to 31 hours. When a baby died swiftly, this seemed to confirm the wisdom of the decision to stop. When babies lingered, doubts were raised. Conclusions-Parents need to be adequately prepared for what may happen after treatment withdrawal. The debate should be reopened about the best way to manage protracted deaths in line with parental need. [ABSTRACT FROM AUTHOR]

The ethical issues around decision making on behalf of infants have been illuminated by two empirical research studies carried out in Scotland. In-depth interviews with 176 medical and nursing staff and with 108 parents of babies for whom there was discussion of treatment withholding/withdrawal, generated a wealth of data on both the decision making process and the management of cases. Both staff and parents believe that parents should be involved in treatment limitation decisions on behalf of their babies. However, whilst many doctors and nurses consider the ultimate responsibility too great for families to carry, the majority of parents wish to be the final arbiters. We offer explanations for the differences in perception found in the two groups. The results of these empirical studies provide both aids to ethical reflection and guidance for clinicians dealing with these vulnerable families. They demonstrate the value of empirical data in the philosophical debate. [ABSTRACT FROM AUTHOR]

Objective-To explore parents' experiences of bereavement care after withdrawal of newborn intensive care. Design-Face to face interviews with 108 parents of 62 babies born over two calendar years in the East of Scotland. Results-only 22% were seen by six weeks after the death, 10% were not recalled before 6-11 months, and 8% were not seen at all in the first year. All except one couple saw the neonatologist who had cared for their baby. Only 33% remembered a neonatal nurse being present. Most (88%) were seen in the study hospital. Parents highlighted a number of specific needs. Appointments should be: (a) scheduled soon after the death of the baby and certainly within two months of the death irrespective of whether or not autopsy results are available; (b) with the named neonatologist; (c) in a setting away from the hospital if possible. Parents value: (a) efforts to find out how they are coping; (b) full frank information given sensitively to enable them to build up a cohesive picture of what happened and assess their future risks; (c) reassurance where possible, but half truths, false reassurances, and broken promises are unacceptable. Conclusions-Follow up care is a crucial part of the management of families from whose babies treatment has been with- drawn. Resources devoted to it should be re-examined to provide a service more in tune with parental need. In choosing the place, timing, and conduct of the meeting, staff should be sensitive to the expressed wishes of the parents themselves. [ABSTRACT FROM AUTHOR]

Focuses on the impact of neonatal care-related technological advances on dilemmas about resuscitation and life-prolonging treatment for severely compromised infants. Final decision as a responsibility of the doctor in clinical charge of the infant; Support for team approach to decision-making; Support for families who bear the consequences of their decision.

OBJECTIVE--To evaluate the clinical and echocardiographic results of mitral valve repair done within an 11 year period. DESIGN--Retrospective review of case notes and clinical and echocardiographic examination of survivors. Analysis was made according to the intention to treat principle. PATIENTS--A consecutive series of 94 patients with mitral valve disease who had mitral reconstruction between 1980 and 1991. INTERVENTIONS--Mitral repair according to the techniques of Carpentier or Duran. MAIN OUTCOME MEASURES--Operative mortality, actuarial survival, rates of freedom from reoperation, thromboembolism, infective endocarditis, clinical state, and echocardiographic findings. RESULTS--There were equal numbers of males and females (mean (range) age 49 (4-74) years). The aetiology of mitral disease was degenerative in 59% and rheumatic in 30% of the patients. Operative mortality was 3%. The 10 year actuarial and valve related survival rates were 67% and 75%. At 10 years, 84% of the patients were free from thromboembolism, 94% free from haemorrhage related to anticoagulation, 88% free from infective endocarditis, and 73% free from reoperation. Of 75 survivors with completed follow up, 96% were in New York Heart Association functional class I or II and 64% were in sinus rhythm. Of 55 survivors who had an echocardiogram at follow up, normal left ventricular end diastolic dimension was shown in 76% and normal left ventricular shortening fraction in 89%. Doppler studies showed no mitral regurgitation in 36%, trivial or mild in 42%, moderate in 14%, and severe in 7% of patients. In stepwise logistic analysis previous myocardial infarction was associated with poor outcome (odds ratio: 13.7, p < 0.05). CONCLUSION--The results are comparable with similar studies and support the value of mitral valve repair. There is reservation about the use of repair for patients with previous myocardial infarction. [ABSTRACT FROM PUBLISHER]

Twenty-four patients with subacute massive pulmonary embolism were studied both during their initial illness and up to nine years after it. The most common mode of presentation was progressive dyspnoea over a two to 12 week period, which in some, but not all, patients was accompanied by pleuritic chest pain and haemoptysis. Physical signs at diagnosis usually suggested right heart strain and ventilation/perfusion mismatch and in the five patients with the highest pulmonary artery pressures the pulmonary component of the second sound was accentuated. The chest x-ray and electrocardiogram provided useful diagnostic information in most patients though occasionally they were normal. Early response to thrombolytic treatment was poor when compared with patients with acute pulmonary embolism but was occasionally dramatically successful, and heparin alone provided satisfactory treatment in the eight patients receiving it. Pulmonary embolectomy provided poor results and four of the five patients undergoing this form of treatment died. Nine patients died during the initial illness and in seven death was directly related to embolic disease. One patient died from neoplastic disease during follow-up. Though the prolonged illness, poor initial response to treatment, and absence of predisposing factors suggest that recurrent embolic disease and late pulmonary hypertension might occur three was no evidence of this during a follow-up period of one to nine years (median five years). [ABSTRACT FROM PUBLISHER]

Background: The reason for the association of increased risk of death with fenoterol in patients with asthma in New Zealand is unknown but may relate to its cardiovascular effects. Most deaths from asthma occur outside hospital, where hypoxaemia is likely to be a complicating factor. The cardiovascular effects of fenoterol have been investigated therefore under conditions of normoxaemia and hypoxaemia.Method: Eight healthy men were studied on two occasions. Measurements of heart rate, blood pressure, total electromechanical systole (QS2I), electrocardiographic QTc interval, cardiac index, stroke volume, and ejection fraction were made under conditions of normoxaemia and hypoxaemia (arterial oxygen saturation 90%) before and after administration of 800 micrograms of fenoterol by a metered dose inhaler. The order in which treatments were applied was according to a Latin square design.Results: Before inhalation of fenoterol hypoxaemia was associated with a significant increase in heart rate (8 beats/min) and QTc interval (15.6 ms). Under conditions of normoxaemia fenoterol caused a significant increase in heart rate (14.3 beats/min), systolic blood pressure (7.7 mm Hg), stroke volume (27.7 ml), cardiac index (1.6 1/min/m2), ejection fraction (11.48), and QTc interval (32.9 ms) and a fall in QS2I (-23.2 ms) and diastolic blood pressure (-8.4 mm Hg). Under conditions of hypoxaemia the changes after inhalation of fenoterol were similar to those recorded during normoxaemia; thus the effects of hypoxaemia and fenoterol were additive (heart rate 21.9 beats/min, QTc 43.5 ms with fenoterol and hypoxaemia).Conclusion: The chronotropic and electrophysiological effects of fenoterol were enhanced by conditions of hypoxaemia. [ABSTRACT FROM AUTHOR]

Presents the 10th article in a series of 12 on the ABC of preterm birth. The support of parents with babies in the neonatal unit; Sources of stress on the parents; Various coping mechanisms; Ideas on how to limit parental stress; Dealing with death and decision making; Help for bereaved parents; Suggestion of a formal approach to discharge planning to ease anxiety over taking a child home.

Examines the effect of different serum digoxin concentrations on the ventricular rate at rest and during increasing workloads in patients with atrial fibrillation. Performance of a double blind study; Reduction in heart rate; Debate over the use of digoxin in the treatment of heart failure.

Comments on an article about the anomalies in clinical practice concerning the moral status of fetuses. Legal aspects of prenatal diagnosis of fetal abnormalities; Ethical issues associated with medical-related decision making; Right of parents to limit treatment or terminate pregnancy.