Informed choice requires information about both benefits and harms.

A study found that women participating in mammography screening were content with the programme and the paternalistic invitations that directly encourage participation and include a pre-specified time of appointment. We argue that this merely reflects that the information presented to the invited women is seriously biased in favour of participation. Women are not informed about the major harms of screening, and the decision to attend has already been made for them by a public authority. This short-circuits informed decision-making and the legislation on informed consent, and violates the autonomy of the women. Screening invitations must present both benefits and harms in a balanced fashion, and should offer, not encourage, participation. It should be stated clearly that the choice not to participate is as sensible as the choice to do so. To allow this to happen, the responsibility for the screening programmes must be separated from the responsibility for the information material.

Anonymity in connection with sperm donation.

Since Sweden abolished anonymity in connection with sperm donation in 1985, a number of other countries have followed suit. A legal provision still exists in Denmark to the effect that the donor must be anonymous. Arguments given in a Danish context against retaining the present scheme involving anonymous sperm donation will be discussed. The biggest problem with sperm donation seems to be non-disclosure. Current and important arguments in favour ofabolishing anonymity are that it sends out a clear signal that non-disclosure is unacceptable and that, in principle, all citizens should have access to the information available about themselves. However, the arguments can be criticised both from theoretical (legal) and several practical (medical) points of view. A substantive alternative to abolishing anonymity might be to inform parents about avoiding non-disclosure--and to design information material for the children, to support the parents.

Euthanasia--he illusion of autonomy.

The paper deals with some of the more common arguments used for the legalisation of voluntary euthanasia. It looks at these arguments from an ethical and philosophical point of view. First, the argument that to offer a person the possibility of euthanasia is to respect that person's autonomy is questionable. Can a person's decision on euthanasia be really autonomous? If euthanasia were legal everybody would be conscious of this option: the patient, the doctor, the family and the nursing staff. Thus, there could be indirect pressure on the patient to make a decision. The choice is meant to be free but the patient is not free not to make the choice. Secondly, a choice that seeks to alleviate suffering and thus improve life by annihilating it is irrational. Thirdly, autonomy as to one's own death is hardly exercised freely. Even an otherwise competent person may not be competent in deciding on his own death on account of despair, hopelessness, fear or maybe a feeling of being weak, superfluous and unwanted. This is a very uncertain base for decision-making, especially in the irrevocable decision of euthanasia. Finally, a competent person usually makes any choice in a responsible way and after due consideration; a 'good' decision should consider and respect the wishes and feelings of others. This will be no less the case in making a decision on the so-called free choice of euthanasia. Thus 'normal' behaviour in decision making will only add to the tendency of the already depressed person to feel a burden on his family, the staff and even on society.

Human rights violations in Burma/Myanmar. A two year follow-up examination.

INTRODUCTION: The aim was to describe recent exposure to human rights violations among refugees from Burma/Myanmar. The study includes the Mon people, an ethnic group whose human rights situation hitherto has not been documented thoroughly. Moreover, the aim was to compare the refugees that fled recently with refugees who fled two to three years ago, with respect to exposure to human rights violations in order to evaluate whether the situation of Burmese ethnic minority groups has changed during the last few years. METHODOLOGY: Systematic interviews and clinical examinations of 129 Burmese refugees, including Mons, who had fled Burma within 12 months were carried out in December 1999. A score was used to quantify the exposure. RESULTS: The interviewees reported forced labour (88%), porter service (77%), forced relocation from their villages (54%), looting (88%), and/or loss of at least one relative (46%) through killing, disappearances or landmine accidents. Twenty per cent reported that they themselves or family members had been tortured. Rape of women was reported by 46%. CONCLUSION: All groups examined reported exposure to massive violations of human rights. The Mons had been exposed to the same extent as the others. There was no sign of improvement of the human rights situation during the past two years. Apart from a few cases of arbitrary arrests and landmine operations, the Burmese army was held responsible for all the reported violations of human rights. A cease-fire agreement with the Burmese army seems to influence the risk of an ethnic group of being forcibly relocated, but not the overall exposure to human rights violations.

Uptake index and stimulated salivary gland response in 99Tcm-pertechnetate salivary gland scintigraphy in normal subjects.

With a view to improve the diagnosis of salivary gland diseases (in particular, Sjögrén's syndrome) associated with decreased salivary gland function and decreased stimulated salivary gland response, the normal range of radionuclide uptake function and the stimulated salivary gland response were established in 27 subjects without any known salivary gland disease. Following injection of 99Tcm-pertechnetate, sequential images were recorded for 40 min with oral administration of citric acid at 30 min. The total uptake index (TUI) was calculated as the sum of the background corrected count rates over the parotid and submandibular glands at 3 min divided by the injected dose. The TUI, expressed as a percentage of dose, was 0.55 +/- 0.12 (mean +/- S.D.). The stimulated salivary gland response (SSGR) was calculated as the difference between the rate constants (min-1) of monoexponential fits to the time-activity curves over the four salivary glands immediately after and before the administration of citric acid. The lower significance limit (P < 0.05) of the SSGR was a 2.4% decrease per min. The parameters TUI and SSGR can be used as a diagnostic tool in, for example, early Sjögren's syndrome.

A comparison of three diuretic regimens in heart failure.

Eight patients with mild heart failure were treated in random order for 1 week with 2 mg bumethanide at 0800 and 1200 (treatment 1) h, 1 mg bumethanide at 0800, 1200, 1800, 2200 (treatment 2) and 5 mg bendroflumethiazide at 0800 and 1800 (treatment 3) h. The 'quality of life' did not differ significantly between the three treatment periods. At the presumed trough of the diuretic effect the circulating blood volume was largest during treatment 1; it was 6.3% smaller during treatment 2 (P < 0.02) and 6.7% lower during treatment 3 (P < 0.05). In comparison with treatment 1, the maximal increase in rate-pressure product during physical exercise was 24.6% higher in treatment 3. Compared with treatment 1 the area under the curve (AUC) for plasma lactate during physical exercise was 14% lower during treatment 2 (P < 0.05) and 18% lower during treatment 3 (P < 0.01). These findings suggest that the type of program for diuretic therapy influences the magnitude of inevitable diurnal fluctuations in body fluids, the ability of the heart to work and the ability of the body to adjust to the oxygen demand.

Doctors' requirements for reproducibility of diagnostic information.

Two radiologists independently assessed 100 leg vein phlebograms for the presence or absence of deep venous thrombosis. In a subsequent questionnaire, 66 physicians were asked to state the level of agreement they would require to use conventional phlebography in their diagnostic decisions, and whether they would reduce their requirements if the phlebographic technique were made less painful and less expensive. The responses indicated physicians' requirements for reproducibility of a well-known routine diagnostic method may be unrealistic, and that physicians do not consider the inconvenience of an examination to the patient or its cost in setting their requirements for diagnostic precision.

Plasma concentrations of adrenaline, noradrenaline and dopamine during forearm dynamic exercise.

In six healthy volunteers plasma concentrations of adrenaline, noradrenaline and dopamine were measured at rest and during dynamic forearm exercise at submaximal and maximal intensities. Arterial and venous concentrations of adrenaline and noradrenaline increased with forearm exercise at all workloads. Dopamine concentrations did not change. The increases in adrenaline and noradrenaline were almost linearly related to the increase in heart rate with no levelling off at maximal exercise intensities. It is concluded that dynamic exercise with the forearm muscle group causes a small but significant activation of the sympatho-adrenal system as reflected by increases in plasma concentrations of adrenaline and noradrenaline.

Forearm oxygen uptake during maximal forearm dynamic exercise.

This study was undertaken in an attempt to determine the maximal oxygen uptake in a small muscle group by measuring directly the oxygen expenditure of the forearm. Five healthy medical students volunteered. The subjects' maximal forearm work capacity was determined on a spring-loaded hand ergometer. Exercise was continued until exhaustion by pain or fatigue. Two weeks later intra-arterial and intravenous catheters were placed in the dominant arm. Blood samples for measurement of oxygen concentration were collected via the catheters. Forearm blood flow was measured by means of the indicator dilution technique. Oxygen uptake was determined according to the Fick principle. The forearm oxygen uptake attained at maximal work loads was a mean of 201 (SD +/- 56) mumol.min-1.100 ml-1. It was impossible at maximal exercise to discern a plateau of the oxygen uptake curve in relation to work output. It is suggested that a plateau in the oxygen uptake curve is not a useful criterion for maximal oxygen uptake in a small muscle group. Skeletal muscle may have an unused capacity for oxygen consumption even at maximal exercise intensity where muscle work cannot be continued due to muscle pain and fatigue.

Microvascular circulatory changes in the lower extremities after reconstructive vascular surgery for intermittent claudication.

We have studied the circulatory changes in the lower extremities after reconstructive vascular surgery in ten patients with intermittent claudication. The following examinations were carried out 3 days before, 3 days, and 28 days after the operation: measurement of ankle systolic blood pressure, calf plethysmography, resting calf muscle blood flow and resting subcutaneous foot blood flow. The vasoconstrictor response (veno-arteriolar reflex) was also assessed. On the night before the operation and on the 28th night after aorto-bifemoral bypass surgery, subcutaneous adipose tissue blood flow in the forefoot was measured during sleep. The ankle systolic blood pressure and the ankle index rose significantly. The former increased from 57 +/- 16.4 mmHg to 93 +/- 24.0 mmHg (mean +/- S.E.M.) and was still elevated on the 28th postoperative day. The total limb blood flow, the muscle blood flow and the blood flow in the subcutaneous tissue of the forefoot during daytime were unchanged. In contrast, the blood flow in the forefoot during sleep increased significantly from 3.5 +/- 1.63 ml x (min x 100 g)-1 to 5.2 +/- 2.14 ml x (min x 100 g)-1 (mean +/- S.E.M.) on the 28th night. The vasoconstrictor response was potentiated, and increased from 27% before the operation to 45% on the third postoperative day. This change was maintained 28 days postoperatively. In conclusion the increase in arterial blood pressure was only reflected in the vasoconstrictor response which had returned to normal by the third postoperative day and nocturnal blood flow in the subcutaneous adipose tissue which did likewise.

Cardiac function at rest and during exercise in early and late alcohol intoxication.

Seven healthy men, aged 21 to 30 years, were investigated by radionuclide cardiography at rest and during submaximal exercise at heavy (early) and during declining (late) alcohol intoxication. Control studies, in which alcohol was substituted by an isocaloric, isovolumic drink, were performed on a different day. The left ventricular ejection fraction at rest decreased from 59 to 56% during early intoxication (serum ethanol 35 +/- 6 mmol/l), whereas no change was observed in the ejection fraction during exercise. No significant change was recorded in stroke volume after alcohol consumption as opposed to a small increase after ingestion of the caloric drink. Plasma noradrenaline concentrations were elevated during exercise and early intoxication. During late intoxication (serum ethanol 21 +/- 5 mmol/l) the left ventricular ejection fraction at rest was increased by 7% compared with the baseline value. At rest the heart rate was increased from 68 +/- 7 to 84 +/- 15 beats/min, whereas cardiac output had reverted to the baseline value. Plasma noradrenaline at late intoxication was increased both at rest and during exercise compared with the baseline values. Apart from tachycardia and a reduction in left ventricular volumes during late intoxication no alcohol induced hemodynamic changes occurred during exercise.

Diagnostic strategy in suspected duodenal ulcer disease. A questionnaire study.

In a questionnaire study of 89 Danish gastroenterologists the current diagnostic strategy in patients suspected of having duodenal ulcer disease was elucidated. A case summary concerning a patient with upper abdominal pain was presented. It was assumed that the patient had had a double-contrast barium meal examination or an upper gastrointestinal endoscopy performed. If the X-ray had revealed a deformity of the duodenal bulb, 30% of the gastroenterologists would offer the patient specific medical treatment (H2-blocking agent etc.), but a significantly higher number of gastroenterologists, 45%, (p less than 0.05) would offer specific medical treatment if a deformity was revealed at endoscopy. There was also a significant difference (p less than 0.01) between those who would offer specific treatment if X-ray (84%) or if endoscopy (100%) had revealed an ulcer. Considerable variation was found among experts in their decisions on the basis of X-ray and endoscopy in patients with suspected duodenal ulcer disease. Gastroenterologists generally rely more on endoscopic than on radiographic findings.

Scintigraphic control of pulmonary embolism.

Pulmonary embolism was diagnosed by combined perfusion and ventilation scintigraphy in 30 patients. A control examination 6 months later revealed pulmonary embolism or infarction in 8, in spite of conventional treatment. Therefore, patients treated for pulmonary embolism should be reexamined 3 to 6 months after diagnosis.

Central and peripheral haemodynamic changes after alcohol ingestion.

Central and peripheral haemodynamic changes 1 and 8 hours after alcohol ingestion were studied in seven healthy men, aged 21-30 years, by radionuclide cardiography and strain gauge plethysmography. Heart rate (HR) increased by 12% and cardiac output (CO) by 24% 1 hour after alcohol ingestion (mean serum ethanol 35 mmol/l). Left ventricular (LV) ejection fraction (EF) decreased by 5% because of endsystolic dilation and the forearm blood flow increased by 140%. Eight hours after alcohol ingestion (serum ethanol 21 mmol/l.) hangover symptoms were present in all subjects. HR and CO remained increased by 19% and 23%, respectively. A 4% increase was recorded in LVEF. The total peripheral resistance was reduced by 25%, while the forearm blood flow had returned to baseline values. No significant changes in plasma catecholamines were recorded. Apart from a slight increase in CO at 1 hour no haemodynamic changes were recorded after ingestion of an isovolumic, isocaloric drink. The present findings suggest that acute alcohol intoxication causes impairment of LV contractility, but that tachycardia results in an increase in cardiac output accompanied by an increased blood flow in the forearm. In the early hangover phase, when the serum ethanol is still elevated, cardiac output remains enhanced because of tachycardia, although the sympathetic nervous activity as measured by the plasma norepinephrine level is not influenced. A reduced total peripheral resistance may contribute to the increase in LV contractility in spite of sustained alcohol intoxication.

Effects of autonomic blockade on cardiac function at rest and during upright exercise in humans.

The cardiac function was studied by radionuclide cardiography in eight healthy subjects at rest and during submaximal upright exercise before and after autonomic blockade with metoprolol and atropine. At rest the median stroke volume was reduced by 21% during autonomic blockade (P less than 0.01), but cardiac output was maintained by a concomitant increase in heart rate. The systolic blood pressure was reduced from 120 to 105 mmHg (P less than 0.01), and left ventricular ejection fraction was reduced from 61 to 56% (P less than 0.05). After autonomic blockade the heart rate reached during exercise was the same. Stroke volume and cardiac output were maintained through cardiac dilation. The increase in left ventricular end-diastolic volume was 31 vs. 10% during control conditions (P less than 0.01). The systolic blood pressure was reduced from 174 to 135 mmHg (P less than 0.01). Left ventricular ejection fraction was reduced from 75 to 67% (P less than 0.05), but the increase from rest to exercise was preserved. Total peripheral resistance was reduced by 17% (P less than 0.05). These findings suggest that the heart possesses intrinsic mechanisms to maintain cardiac output during submaximal upright exercise. End-diastolic dilation results in a preserved stroke volume despite a reduced contractility.

First-pass radionuclide determination of cardiac output: an improved gamma camera method.

A technique for noninvasive determination of cardiac output by aid of first-pass radionuclide cardiography is described. After intravenous injection of 10-15 mCi technetium-99m-(99mTc) labeled red blood cells the method requires acquisition of a first passage time-activity curve recorded with a gamma camera over the left ventricle, the background corrected left ventricular count rate recorded after complete mixing of the tracer in the circulation, and determination of the distribution volume of the tracer. The method was applied in 14 patients with heart disease of various origins and evaluated against the conventional tracer dilution technique with arterial sampling of blood activity. Cardiac output determinations by external counting ranged from 2.30 to 8.56 l/min, mean +/- s.d. 4.50 +/- 1.66 l/min and by arterial blood sampling from 1.88 to 8.96 l/min, mean +/- s.d. 4.52 +/- 1.71 l/min. An excellent correlation was demonstrated between the two techniques, r = 0.978 (p less than 0.001). When no background subtraction was applied to the left ventricular counts at equilibrium, radionuclide cardiac output values were approximately 40% higher than those obtained by arterial sampling. The new first-pass radionuclide cardiographic technique may prove a useful tool in the noninvasive evaluation of cardiac function, especially in patients with arrhythmias and/or valvular incompetence.