End-of-life decisions in neonatal intensive care: physicians' self-reported practices in seven European countries. EURONIC Study Group

BACKGROUND

The ethical issue of foregoing life-sustaining treatment for newborn infants at high risk of death or severe disability is extensively debated, but there is little information on how physicians in different countries actually confront this issue to reach end-of-life decisions. The EURONIC project aimed to investigate practices as reported by physicians themselves.

METHODS

The study recruited a large, representative sample of 122 neonatal intensive-care units (NICUs) by census (in Luxembourg, the Netherlands, and Sweden) or stratified random sampling (in France, Germany, the UK, Italy, and Spain) with an overall response rate of 86%. Physicians' practices of end-of-life decision-making were investigated through an anonymous, self-administered questionnaire. 1235 completed questionnaires were returned (response rate 89%).

FINDINGS

In all countries, most physicians reported having been involved at least once in setting limits to intensive care because of incurable conditions (61-96%); smaller proportions reported such involvement because of a baby's poor neurological prognosis (46-90%). Practices such as continuation of current treatment without intensification and withholding of emergency manoeuvres were widespread, but withdrawal of mechanical ventilation was reported by variable proportions (28-90%). Only in France (73%) and the Netherlands (47%) was the administration of drugs with the aim of ending life reported with substantial frequency. Age, length of professional experience, and the importance of religion in the physician's life affected the likelihood of reporting of non-treatment decisions.

INTERPRETATION

A vast majority of neonatologists in European NICUs have been involved in end-of-life limitation of treatments, but type of decision-making varies among countries. Culture-related and other country-specific factors are more relevant than characteristics of individual physicians or units in explaining such variability.

[Plastic surgery of the anorectal area. Indications, technique and outcome]

Anal canal stenosis with alteration of the sensoric continence or mucosal ectropion may occur after anorectal operations. Island flaps with perianal skin or the VY-anoplasty are simple plastic methods to reconstruct the anorectal region and cure patients--who often have suffered for a long time--from anal strictures or mucosal ectropion. In the period from 1994-1998 we reconstructed the anodermal region of seven patients using one of the above mentioned anorectal plastic procedures. Three patients complained of an anal stenosis and one patient suffered from an ectropion of the rectal mucosa after an improperly performed Whitehead hemorrhoidectomy. Three patients had a sensomotoric incontinence twice due to a congenital anal atresia and in one case caused by an accident. All patients were highly pleased after the operation--no complication occurred.

Analysis of the underestimation of induced abortions in a survey of the general population in France

INTRODUCTION

A pilot study has been conducted in France to estimate the extent of underreporting of induced abortion and the factors linked to underreporting.

METHODS

A representative random sample of 300 women aged between 18 and 44 years of age who had been pregnant during the previous 2 years and 100 women who had not was selected from the telephone directory. Interviews were conducted by telephone.

RESULTS

The annual incidence of induced abortion for the 18-44-year-old age group was 6.9 per 1000 (95% confidence interval 2.2-11.6), while the rate derived from national statistics was 15 per 1000. Five women who reported a therapeutic abortion in their lifetime had confused induced abortion and therapeutic abortion. There was no significant difference in the proportion of women reporting induced abortion in their lifetime between those answering with another adult present and those who were alone when answering (13.1% versus 11.1%, p = 0.8). There was also no significant difference according to the sex of the interviewer (10.0% for men versus 12.2% for women, p = 0.6).

CONCLUSION

The results suggest that the context in which the questions were asked does not affect the validity of the answers and that there is a problem in the comprehension of the terminology used. Extensive rewriting and reformulation of the questions is required to minimize the underreporting of induced abortion.

[Idiopathic entrapment neuropathy of the ilio-inguinalis nerve--a differential diagnosis in inguinal pain]

We report the case of a 41-year old man, who developed leftsided and later rightsided inguinal pain radiating to the scrotum within three months. There was also sensory disturbance in the supply area of the left ilioinguinal nerve. No surgical procedures in the inguinal region had been done, so that we supposed an idiopathic entrapment neuropathy of the ilioinguinal nerve. Infiltration with local anesthetics resolved the complaints on the left side completely. On the right side neurolysis was necessary, to ablate symptoms. The entrapment neuropathy of the ilioinguinal nerve--often called ilioinguinal-syndrome--is a relevant differential diagnosis of inguinal pain. Anatomy, pathology, clinical presentation and therapy of this syndrome are discussed in the article. Knowledge of this syndrome prevents unnecessary investigation.

[The parathyrotoxic crisis - a surgical emergency]

INTRODUCTION

The extremely rare but life-threatening hypercalcemic crisis is caused by an exacerbation of a chronic hyperparathyroidism. The etiologic reasons for this exacerbation are conditions which increase the serum calcium level in addition to the hyperparathyroidism with a complete breakdown of the calcium homeostasis, e. g. malignant tumors, primary and tertiary hyperparathyroidism, vitamin D poisoning or overdoses of calcium, vitamin D and calcium-containing ionizer in patients with renal insufficiency.

METHODS

We present the clinical course of five patients with an acute hypercalcemic crisis and discuss the diagnostic procedure and the principles of surgical treatment with regard to the current literature.

RESULTS

A hypercalcemic crisis develops if the total serum calcium concentration is over 4 mmol/l and parathormone over 90 pmol/l. The resulting syndrome is manifested by nausea and vomiting, polyuria and consecutive dehydration and hypotonia culminating in lethargy, hallucinations and coma. Hypercalcemia is the single most important diagnostic finding.

CONCLUSION

The emergency therapy predominantly consists on the one hand in rehydration and parallel stimulation of diuresis. Urgent surgery is required if conservative therapy is not successful.

Birth outcomes of immigrant women in the United States, France, and Belgium

OBJECTIVES

To compare maternal characteristics and birth outcomes of Mexico-born and native-born mothers in the United States and those of North African mothers living in France and Belgium to French and Belgian nationals.

METHODS

We examined information from single live birth certificates for 285,371 Mexico-born and 3,131,632 U.S.-born mothers (including 2,537,264 U.S.-born White mothers) in the United States, 4,623 North African and 103,345 Belgian mothers in Belgium, and a French national random sample consisting of 632 North African and 11,185 French mothers. The outcomes were mean birthweight, low birthweight, and preterm births. Differences between native/nationals and foreign-born mothers in each country were assessed in bivariate and multivariate analyses controlling for maternal risk factors.

RESULTS

The adjusted odds for low birthweight were lower for immigrants than native/nationals by 32% in the United States, by 32% in Belgium, and by 30% in France. The adjusted odds for preterm births were lower for immigrants compared with native/nationals by 11% in the United States and by 23% in Belgium. In France, the odds for preterm births were comparable for immigrants and naturalized mothers. Infants of immigrant mothers also had higher mean birthweights in all three countries.

CONCLUSION

Despite their disadvantaged status, Mexico-born and North African-born women residing in the United States, France, and Belgium show good birth outcomes. These cannot be explained solely by traditional risk factors. Protective factors and selective migration may offer further clues.

[Experiences in surgery of proctologic diseases in patients with HIV infection]

Individuals who are seropositive for the human immunodeficiency virus (HIV) often suffer from disorders affecting the anorectum, but unfortunately the best kind of treatment frequently seems questionable. In a retrospective investigation we reviewed 29 HIV-positive patients with anorectal lesions who had experienced a proctologic operation. Our impression correlates with other findings according to which HIV-positive patients in advanced stages have a poorer post-operative outcome in terms of morbidity and survival than patients in an early CDC disease stage. This implies that the indication for a proctologic operation in an immunocompromised state has to be considered carefully.

Antenatal glucocorticoid treatment and cystic periventricular leukomalacia in very premature infants

BACKGROUND

Antenatal glucocorticoid therapy decreases the incidence of several complications among very premature infants. However, its effect on the occurrence of cystic periventricular leukomalacia, a major cause of cerebral palsy, remains unknown.

METHODS

We retrospectively analyzed a cohort of 883 live-born infants, with gestational ages ranging from 24 to 31 weeks, who were born between January 1993 and December 1996 at three perinatal centers in the Paris area. The mothers of 361 infants had received betamethasone before delivery, the mothers of 165 infants had received dexamethasone before delivery, and the mothers of 357 infants did not receive glucocorticoids. We compared the rates of cystic periventricular leukomalacia among the three groups of infants in bivariate and multivariate analyses after adjustment for confounding factors.

RESULTS

The rate of cystic periventricular leukomalacia was 4.4 percent among the infants whose mothers had received betamethasone, 11.0 percent among the infants whose mothers had received dexamethasone, and 8.4 percent among the infants whose mothers had not received a glucocorticoid. After adjustment for gestational age, the mode of delivery, and the presence or absence of chorioamnionitis, prolonged interval between the rupture of membranes and delivery (>24 hours), preeclampsia, and the use of tocolytic drugs, antenatal exposure to betamethasone was associated with a lower risk of cystic periventricular leukomalacia than was either the absence of glucocorticoid therapy (adjusted odds ratio, 0.5; 95 percent confidence interval, 0.2 to 0.9) or exposure to dexamethasone (adjusted odds ratio, 0.3; 95 percent confidence interval, 0.1 to 0.7). The adjusted odds ratio for the group of infants whose mothers had received dexamethasone as compared with the group of infants whose mothers had not received a glucocorticoid was 1.5 (95 percent confidence interval, 0.8 to 2.9).

CONCLUSIONS

Antenatal exposure to betamethasone but not dexamethasone is associated with a decreased risk of cystic periventricular leukomalacia among very premature infants.

Novel inhibitors of Erm methyltransferases from NMR and parallel synthesis

The Erm family of methyltransferases confers resistance to the macrolide-lincosamide-streptogramin type B (MLS) antibiotics through the methylation of 23S ribosomal RNA. Upon the methylation of RNA, the MLS antibiotics lose their ability to bind to the ribosome and exhibit their antibiotic activity. Using an NMR-based screen, we identified a series of triazine-containing compounds that bind weakly to ErmAM. These initial lead compounds were optimized by the parallel synthesis of a large number of analogues, resulting in compounds which inhibit the Erm-mediated methylation of rRNA in the low micromolar range. NMR and X-ray structures of enzyme/inhibitor complexes reveal that the inhibitors bind to the S-adenosylmethionine binding site on the Erm protein. These compounds represent novel methyltransferase inhibitors that serve as new leads for the reversal of Erm-mediated MLS antibiotic resistance.

Experimental hyperlipidemia prevents the protective effect of ischemic preconditioning on the contractility and responsiveness to phenylephrine of rat-isolated stunned papillary muscle

This study was designed to establish a hyperlipidemic diet (significant increase in the cholesterol and triglycerides blood levels, but without atherogenic changes in heart muscle and coronary vessels) and to investigate the influence of experimental hyperlipidemia on the effects of ischemic preconditioning (PC) of rat-isolated papillary muscle on the time course of contractility during simulated ischemia and reperfusion and responsiveness to phenylephrine under such a condition. The animals were divided in four experimental groups: standard diet-fed control group (SD), SD underwent ischemic preconditioning (SD-PC), hyperlipidemic diet-fed group (HLD) and HLD underOFFt PC (HLD-PC). Force of contraction (Fc), velocity of contraction (+dF/dt), and velocity of relaxation (-dF/dt) were measured. HLD preparations were more sensitive to ischemia then SD ones. PC, performed by 5-min perfusion with no-substrate solution gassing with 95% N2/5% CO2 in the presence of fast electrical stimulation, and 10 min of reperfusion with normal solution and rate of stimulation, significantly increased the resistance of isolated cardiac tissues to simulated ischemia in SD-PC group, but not in HLD-PC group. Negative inotropic action of phenylephrine occured in SD group of preparations after simulated-ischemia/reperfusion period was also prevented by PC. Therefore, we conclude that experimental hyperlipidemia significantly influenced the function of rat heart muscle including the higher sensitivity to ischemia and different reaction to the same PC procedure.

Parental visiting, communication, and participation in ethical decisions: a comparison of neonatal unit policies in Europe

AIM

To compare neonatal intensive care unit policies towards parents' visiting, information, and participation in ethical decisions across eight European countries.

METHODS

One hundred and twenty three units, selected by random or exhaustive sampling, were recruited, with an overall response rate of 87%.

RESULTS

Proportions of units allowing unrestricted parental visiting ranged from 11% in Spain to 100% in Great Britain, Luxembourg and Sweden, and those explicitly involving parents in decisions from 19% in Italy to 89% in Great Britain. Policies concerning information also varied.

CONCLUSIONS

These variations cannot be explained by differences in unit characteristics, such as level, size, and availability of resources. As the importance of parental participation in the care of their babies is increasingly being recognised, these findings have implications for neonatal intensive care organisation and policy.

[Littré's hernia--clinical aspects and review of the history]

In 1700, the French surgeon Alexandre de Littré described for the first time a new form of inguinal hernia. This hernia varied from the known forms of hernias in its clinical course and in the postmortem examination results performed by Littrè himself. The characteristic feature of this hernia was the fact that the entire circumference of the bowel wall was not part of the hernial sac, but only the antimesenteric part of the intestinal wall. The underlying pathomechanism was explained 100 years later by Meckel. In a scientific paper about hernias some years earlier, Richter described the intestinal wall hernia, and this initiated the confusing use of the clinical entity known as the Richter-Littré hernia in Germany. In this case report we describe the historic development of this entity.

[Infant temperament at 6-9 months old: validation of the French version of the Infant Characteristics Questionnaire and factors associated with measurement]

BACKGROUND

The aim of the study was to assess the validity of the French version of the Infant Characteristics Questionnaire (ICQ), which was developed by Bates in 1979 to investigate the parental perceptions of infant temperament at 6 months of age.

METHODS

The French version was established after translation/back-translation, and tested on a sample of 794 mothers, who gave birth in 1995 in four French Departments and who returned the questionnaire which was mailed 6 months after the birth.

RESULTS

The non-response rate of each item was very low (< 2%). Factor analysis resulted in the same four factors as in the American data: fussy/difficult, unadaptable, unpredictable, dull. However, some of the items did not have similar factor loadings. Thus new factor scores were defined for the French version of the ICQ. Internal consistency, as measured by the Cronbach coefficient, was satisfactory (> 0.7) for the factors fussy/difficult and unadaptable. It was lower, but acceptable (> 0.6) for the two other factors. The infant's temperament was not related to birth parameters. In contrast, some factor scores were significantly associated with parity, mother's education, as well as her health and the infant's health after leaving the maternity ward.

CONCLUSIONS

The French version of the ICQ is well accepted and has a good validity. This scale provides a useful instrument for research, especially for epidemiological studies on infant health and development, as well as their determinants.

Participation in a mail survey: role of repeated mailings and characteristics of nonrespondents among recent mothers

This study analysed the characteristics of respondent and nonrespondent mothers at each stage of a survey procedure, from a initial questionnaire to a reminder letter and two repeated mailings. Of 938 mothers of liveborn children who, while maternity inpatients, received a questionnaire and information about a mail survey to follow 2 months later, 828 completed and returned the initial questionnaire, 708 agreed to participate in the mail survey and were sent the mail questionnaire, and 612 finally completed and returned the questionnaire at 2 months. There were differences between respondents and non-respondents for socio-demographic factors at each stage of the process. The final response rate to the mail questionnaire was higher among mothers who were younger, were breast feeding, and had more education, an occupation and fewer children. The characteristics of late respondents were intermediate between those of early to middle respondents and nonrespondents for age, educational level, breast feeding and occupation. Maternal and infant health varied only slightly according to response status. Repeated mailings increased response and diminished selection. A mail questionnaire after contact in a maternity ward is a cost-effective means of gathering data about a large sample of recent mothers and their children.

Lead and copper contamination of soil from industrial activities and firing ranges

Lead still remains one of the most thoroughly investigated heavy metals in the environment. Although the identification of lead in soil is a routine matter, its environmental consequence is still much debated because of its potential mobility. We have investigated lead- and copper-contaminated soil from two different areas. One was in an urban area, which formerly had a lead smelter within the city. The other a firing range, in which hundreds of thousands of rounds were fired into a very large mound known as a berm. Homogeneity tests, depth profiles, and Pb-Cu correlations are discussed.

Electrochemical therapy in palliative treatment of malignant dysphagia: a pilot study

BACKGROUND/AIMS

Electrochemical therapy (ECT), a method based on the application of a low-level direct current, was employed in this study to relieve severe dysphagia. In addition, we aimed to assess the efficacy, safety and requirements for follow-up re-interventions.

METHODOLOGY

Sixteen patients with inoperable and circumferential malignant stenosis of the esophagus were palliated by ECT at presentation and then repeatedly whenever tumor growth and dysphagia recurred. The electrode was inserted and placed at the level of stenosis under fluoroscopic guidance, and an electric quantity of 300-560 coulombs (5-6.5 V; 60-90 mA) was given. When total luminal occlusion was found, prior balloon dilatation enabled insertion of the electrode. Patients with squamous cell carcinoma also received external beam radiotherapy of 20-30 Gy in 10 daily fractions. Dysphagia was graded on a scale of O to 4 (O = normal; 4 = complete dysphagia), and follow-up esophagograms were obtained for response evaluation.

RESULTS

The severity of dysphagia decreased by 1-4 (median: 2) grades with an improvement in 6 patients with totally obstructing lesions. Dysphagia recurred in all but 1 patient after a median interval of 10 weeks, but was easily treated with repeat ECT sessions. However, 2 patients became unresponsive to ECT after 7 and 3 months of therapy, respectively. There were no ECT-related complications.

CONCLUSIONS

In conclusion, this pilot study suggests that electrochemical therapy may provide safe and effective palliation of narrowing and circumferential esophageal carcinoma. It requires repeat interventions and dilatation expertise is necessary for insertion of the electrode through the totally obstructing lesion.

[Gastric teratoma]

Gastric teratomas are rare and mostly benign. They frequently become evident as a palpable abdominal mass. A malignant, aggressive solid tumor must be excluded. We present a 6-month-old male infant with a history of bleeding of the upper gastrointestinal tract. After in toto excision the histopathology was that of a benign gastric teratoma. Our method of reading the diagnosis and the subsequent therapy are described.

[Breast feeding at maternity hospitals in France in 1995. National perinatal survey]

The objectives of the study were to estimate the current level of breast-feeding at hospital discharge in France, and to identify maternal factors and characteristics of the pregnancy and delivery associated with breast-feeding.

DATA AND METHODS

The sample included all births during 1 week in France in 1995 (n = 12,179 babies). The data were collected during the postnatal stay in hospital. Factors associated with breast-feeding were identified, using bivariate analysis and multiple logistic regression. As the relations between the studied factors and breast-feeding differed between French women and women of foreign nationality, multivariate analysis was carried out separately in the two groups.

RESULTS

In 1995, 52% of babies were breastfed at hospital discharge, including 10% of babies partially breastfed. Breastfeeding was more common among women of foreign nationality than among French women, 76 vs 49%. In both groups, breastfeeding was more common among older women, women with a high level of education or a qualified occupation; breastfeeding was also more frequent among non smokers during pregnancy and among women who attended antenatal classes. On the contrary, among French women, induction of labour and delivery in a small hospital were associated with a low level of breastfeeding; among women of foreign nationality, a low level of breastfeeding was observed for unmarried women, women who had an induction or a caesarean section, and those who delivered in a private hospital.

CONCLUSION

France was at the lowest level among Western countries for which national data on breastfeeding were available. Efforts to promote breastfeeding are needed, both towards sub-groups of pregnant women and towards health professionals. Maternity hospitals should provide support to breastfeeding mothers, and avoid practices which may affect breastfeeding.

Prenatal alcohol exposure and development at preschool age: main results of a French study

Very high levels of alcohol consumption during pregnancy are harmful for the central nervous system of the child and affect morphogenesis and growth. The aim of this study was to investigate the effects of moderate prenatal alcohol exposure on development at preschool age in a longitudinal study. Pregnant women were interviewed on their alcohol consumption during pregnancy at their first visit to the maternity hospital of Roubaix, France. The development of their 160 children was assessed at the age of 4 1/2. Multiple regression analyses indicated that consumption of 1.5 oz of absolute alcohol (approximately 3 drinks) or more during pregnancy was significantly related to a decrease of 7 points on the general cognitive index of the McCarthy scales, after controlling for confounders. This level of consumption was also related to a higher score on minor neurological anomalies, a lower height of the child, and a higher score on facial features. This level of 1.5 oz of absolute alcohol/day should not be interpreted as a biological threshold, because the study does not allow conclusions to be drawn regarding the effects of lower levels of alcohol consumption. Alcohol consumption during pregnancy can affect the development of the child, at levels well below those associated with fetal alcohol syndrome.

Sex as a variable can be a surrogate for some working conditions: factors associated with sickness absence

More than twice as many workdays are lost to illness than for personal or family reasons. We examine possible workplace determinants of sickness absence among French workers in the food processing industry. These workers are exposed to a variety of environmental and organizational constraints: cold, uncomfortable postures, assembly-line work, and irregular schedules. In 1987-1988, a medical examination and questionnaire were administered to 558 men and 790 women as part of a study of 17 poultry slaughterhouses and 6 canning factories. Women's and men's working conditions were very different, and their sickness absences for musculoskeletal and respiratory illnesses were related to some of their specific working conditions: cold exposure, ill-adapted work stations, and problems with their supervisors and co-workers. If male and female workers were combined into a single analysis that adjusted for sex, many of the associations operant for a single sex could no longer be seen.

AIDS wasting syndrome as an enterometabolic disorder: the gut hypothesis

There is an interesting relationship between the HIV virus, the health of the gastrointestinal tract, and AIDS wasting syndrome, involving Tumor Necrosis Factor alpha (TNF alpha), specific and non-specific immunity in the gut, gut permeability, and oxidative stress. It is hypothesized that the progression of HIV to full-blown AIDS may be impacted by maintaining a healthy gut. A therapeutic protocol which decreases oxidative stress, inhibits TNF alpha, enhances phase I and II liver detoxification, and improves specific and non-specific immunity in the gut should be part of a therapeutic protocol for HIV-infected individuals. Through a better understanding of the pathophysiology of HIV advancing to AIDS, the practitioner can develop a treatment strategy of nutritional and lifestyle changes which could theoretically prevent an HIV infection from advancing to full-blown AIDS.