How do late terminations of pregnancy affect comparisons of stillbirth rates in Europe? Analyses of aggregated routine data from the Euro-Peristat Project.

OBJECTIVE: To describe how terminations of pregnancy at gestational ages at or above the limit for stillbirth registration are recorded in routine statistics and to assess their impact on comparability of stillbirth rates in Europe. DESIGN: Analysis of aggregated data from the Euro-Peristat project. SETTING: Twenty-nine European countries. POPULATION: Births and late terminations in 2010. METHODS: Assessment of terminations as a proportion of stillbirths and derivation of stillbirth rates including and excluding terminations. MAIN OUTCOME MEASURES: Stillbirth rates overall and excluding terminations. RESULTS: In 23 countries, it is possible to assess the contribution of terminations to stillbirth rates either because terminations are rare occurrences or because they can be distinguished from spontaneous stillbirths. Where terminations were reported, they accounted for less than 1.5% of stillbirths at 22+ weeks in Denmark, between 13 and 22% in Germany, Italy, Hungary, Finland and Switzerland, and 39% in France. Proportions were much lower at 24+ weeks, with the exception of Switzerland (7.4%) and France (39.2%). CONCLUSIONS: Terminations represent a substantial proportion of stillbirths at 22+ weeks of gestation in some countries. Countries where terminations occur at 22+ weeks should publish rates with and without terminations in order to improve international comparisons and the policy relevance of stillbirth statistics. TWEETABLE ABSTRACT: For valid comparisons of stillbirth rates, data about late terminations of pregnancy are needed.

Changes in management policies for extremely preterm births and neonatal outcomes from 2003 to 2012: two population-based studies in ten European regions.

OBJECTIVE: To investigate changes in maternity and neonatal unit policies towards extremely preterm infants (EPTIs) between 2003 and 2012, and concurrent trends in their mortality and morbidity in ten European regions. DESIGN: Population-based cohort studies in 2003 (MOSAIC study) and 2011/2012 (EPICE study) and questionnaires from hospitals. SETTING: 70 hospitals in ten European regions. POPULATION: Infants born at <27 weeks of gestational age (GA) in hospitals participating in both the MOSAIC and EPICE studies (1240 in 2003, 1293 in 2011/2012). METHODS: We used McNemar's Chi2 test, paired t-tests and conditional logistic regression for comparisons over time. MAIN OUTCOMES MEASURES: Reported policies, mortality and morbidity of EPTIs. RESULTS: The lowest GA at which maternity units reported performing a caesarean section for acute distress of a singleton non-malformed fetus decreased from an average of 24.7 to 24.1 weeks (P < 0.01) when parents were in favour of active management, and 26.1 to 25.2 weeks (P = 0.01) when parents were against. Units reported that neonatologists were called more often for spontaneous deliveries starting at 22 weeks GA in 2012 and more often made decisions about active resuscitation alone, rather than in multidisciplinary teams. In-hospital mortality after live birth for EPTIs decreased from 50% to 42% (P < 0.01). Units reporting more active management in 2012 than 2003 had higher mortality in 2003 (55% versus 43%; P < 0.01) and experienced larger declines (55 to 44%; P < 0.001) than units where policies stayed the same (43 to 37%; P = 0.1). CONCLUSIONS: European hospitals reporting changes in management policies experienced larger survival gains for EPTIs. TWEETABLE ABSTRACT: Changes in reported policies for management of extremely preterm births were related to mortality declines.

Wide differences in mode of delivery within Europe: risk-stratified analyses of aggregated routine data from the Euro-Peristat study.

OBJECTIVE: To use data from routine sources to compare rates of obstetric intervention in Europe both overall and for subgroups at higher risk of intervention. DESIGN: Retrospective analysis of aggregated routine data. SETTING: Thirty-one European countries or regions contributing data on mode of delivery to the Euro-Peristat project. POPULATION: Births in participating countries in 2010. METHODS: Countries provided aggregated data about overall rates of obstetric intervention and about caesarean section rates for specified subgroups. MAIN OUTCOME MEASURES: Mode of delivery. RESULTS: Rates of caesarean section ranged from 14.8% to 52.2% of all births and rates of instrumental vaginal delivery ranged from 0.5% to 16.4%. Overall, there was no association between rates of instrumental vaginal delivery and rates of caesarean section, but similarities were observed between some countries that are geographically close and may share common traditions of practice. Associations were observed between caesarean section rates for women with breech and vertex births and with singleton and multiple births but patterns of association for women who had and had not had previous caesarean sections were more complex. CONCLUSIONS: The persisting wide variations in caesarean section and instrumental vaginal delivery rates point to a lack of consensus about practice and raise questions for further investigation. Further research is needed to explore the impact of differences in clinical guidelines, healthcare systems and their financing and parents' and professionals' attitudes to care at delivery.

Size at birth by gestational age and hospital mortality in very preterm infants: results of the area-based ACTION project.

BACKGROUND: Size at birth is an important predictor of neonatal outcomes, but there are inconsistencies on the definitions and optimal cut-offs. AIMS: The aim of this study is to compute birth size percentiles for Italian very preterm singleton infants and assess relationship with hospital mortality. STUDY DESIGN: Prospective area-based cohort study. SUBJECTS: All singleton Italian infants with gestational age 22-31 weeks admitted to neonatal care in 6 Italian regions (Friuli Venezia-Giulia, Lombardia, Marche, Tuscany, Lazio and Calabria) (n. 1605). OUTCOME MEASURE: Hospital mortality. METHODS: Anthropometric reference charts were derived, separately for males and females, using the lambda (λ) mu (µ) and sigma (σ) method (LMS). Logistic regression analysis was used to estimate mortality rates by gestational age and birth weight centile class, adjusting for sex, congenital anomalies and region. RESULTS: At any gestational age, mortality decreased as birth weight centile increased, with lowest values observed between the 50th and the 89th centiles interval. Using the 75th-89th centile class as reference, adjusted mortality odds ratios were 7.94 (95% CI 4.18-15.08) below 10th centile; 3.04 (95% CI 1.63-5.65) between the 10th and 24th; 1.96 (95% CI 1.07-3.62) between the 25th and the 49th; 1.25 (95% CI 0.68-2.30) between the 50(h) and the 74th; and 2.07 (95% CI 1.01-4.25) at the 90th and above. CONCLUSIONS: Compared to the reference, we found significantly increasing adjusted risk of death up to the 49th centile, challenging the usual 10th centile criterion as risk indicator. Continuous measures such as the birthweight z-score may be more appropriate to explore the relationship between growth retardation and adverse perinatal outcomes.

Trend of healthcare-associated infections in children: annual prevalence surveys in a research hospital in Italy, 2007-2010.

BACKGROUND: Annual prevalence surveys of healthcare-associated infections (HAIs) between 2007 and 2010 were conducted in the largest tertiary care children's hospital in Italy. During this period, actions to improve HAI prevention were implemented, including strengthened isolation measures; adoption of care bundles for invasive procedures; hand hygiene promotion using the World Health Organization multimodal strategy; and promotion of appropriate antimicrobial use. AIM: To determine the impact of these measures on HAI rates. METHODS: A total of 1506 patients were surveyed. Information on patient demographics, mechanical ventilation, central line and urinary catheterization in the preceding 48 h, and surgery in the previous 30 days were abstracted from medical charts. The type and date of onset of HAIs, and microbiological data were recorded. Univariate and multivariate logistic analysis were used to evaluate changes in HAI rates over time, and the influence of ward type and patient characteristics. FINDINGS: There were significant (P < 0.001) reductions in the prevalence of patients developing HAI (from 7.6% to 4.3%) and in the prevalence of total HAIs (from 8.6 to 4.3 per 100 patients). Factors independently associated with increased HAI risk were hospitalization in intensive care ward, length of stay >30 days, presence of invasive device, and age 6-11 years. CONCLUSION: This HAI prevention strategy was influential in decreasing infections among hospitalized children. Repeated prevalence surveys are an effective tool for monitoring HAI frequency, increasing awareness among the healthcare personnel, and contributing to the establishment of effective infection control.

Multiple forms of hypogonadism of central, peripheral or combined origin in males with Prader-Willi syndrome.

BACKGROUND: Hypogonadism in Prader-Willi syndrome (PWS) is generally attributed to hypothalamic dysfunction or to primary gonadal defect, but pathophysiology is still unclear. OBJECTIVES: To investigate the aetiology of hypothalamic-pituitary-gonadal axis dysfunction in PWS males. METHODS: Clinical examination and blood sampling for luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, inhibin B and sexhormone-binding globulin (SHBG) were performed in 34 PWS patients, age 5·1-42·7 years, and in 125 healthy males of same age range. All participants were divided into two groups : < or ≥13·5 years. RESULTS: Pubertal PWS patients showed an arrest of pubertal development. Patients <13·5 years had normal LH, FSH, testosterone and 7/10 had low inhibin B. Among those ≥13·5 years, 8/24 patients had normal LH and testosterone, high FSH and low inhibin B. 5/24 had low FSH, LH, testosterone and inhibin B; one showed normal LH and FSH despite low testosterone and inhibin B; 4/24 had low testosterone and LH but normal FSH despite low inhibin B; 6/24 showed high FSH, low inhibin B and normal LH despite low testosterone. Compared with controls, patients <13·5 years had lower LH, inhibin B, similar FSH, testosterone, SHBG levels and testicular volume; those ≥13·5 years had smaller testicular volume, near-significantly lower LH, testosterone, SHBG, inhibin B and higher FSH. CONCLUSION: PWS patients display heterogeneity of hypogonadism: (i) hypogonadotropic hypogonadism of central origin for LH and/or FSH; (ii) early primary testicular dysfunction (Sertoli cells damage); and (iii) a combined hypogonadism (testicular origin for FSH-inhibin B axis and central origin for LH-T axis).

Obstetric interventions for babies born before 28 weeks of gestation in Europe: results of the MOSAIC study.

OBJECTIVE: To describe obstetric intervention for extremely preterm births in ten European regions and assess its impact on mortality and short term morbidity. DESIGN: Prospective observational cohort study. SETTING: Ten regions from nine countries participating in the 'Models of Organising Access to Intensive Care for Very Preterm Babies in Europe' (MOSAIC) project. POPULATION: All births from 22 to 29 weeks of gestation (n = 4146) in 2003, excluding terminations of pregnancy. METHODS: Comparison of three obstetric interventions (antenatal corticosteroids, antenatal transfer and caesarean section for fetal indication) rates at 22-23, 24-25 and 26-27 weeks to that at 28-29 weeks and the association of the level of intervention with pregnancy outcome. MAIN OUTCOME MEASURES: Use of antenatal corticosteroids, antenatal transfer and caesarean section by two-week gestational age groups as well as a composite score of these three interventions. Outcomes included stillbirth, in-hospital mortality and intraventricular haemorrhage (IVH) grades III and IV and/or periventricular leucomalacia (PVL) and bronchopulmonary dysplasia (BPD). RESULTS: There were large differences between regions in interventions for births at 22-23 and 24-25 weeks. Differences were most pronounced at 24-25 weeks; in some regions these babies received the same care as babies of 28-29 weeks, whereas elsewhere levels of intervention were distinctly lower. Before 26 weeks and especially at 24-25 weeks, there was an association between the composite intervention score and mortality. No association was observed at 26-27 weeks. For survivors at 24-25 weeks, the intervention score was associated with higher rates of BPD, but not with IVH or PVL. CONCLUSIONS: There are large differences between European regions in obstetric practices at the lower limit of viability and these are related to outcome, especially at 24-25 weeks.

Rates of very preterm birth in Europe and neonatal mortality rates.

OBJECTIVE: To estimate the influence of variation in the rate of very preterm delivery on the reported rate of neonatal death in 10 European regions. DESIGN: Comparison of 10 separate geographically defined European populations, from nine European countries, over a 1-year period (7 months in one region). PARTICIPANTS: All births that occurred between 22(+0) and 31(+6) weeks of gestation in 2003. MAIN OUTCOME MEASURE: Neonatal death rate adjusted for rate of delivery at this gestation. RESULTS: Rate of delivery of all births at 22(+0)-31(+6) weeks of gestation and live births only were calculated for each region. Two regions had significantly higher rates of very preterm delivery per 1000 births: Trent UK (16.8, 95% CI 15.7 to 17.9) and Northern UK (17.1, 95% CI 15.6 to 18.6); group mean 13.2 (95% CI 12.9 to 13.5). Four regions had rates significantly below the group average: Portugal North (10.7, 95% CI 9.6 to 11.8), Eastern and Central Netherlands (10.6, 95% CI 9.7 to 11.6), Eastern Denmark (11.2, 95% CI 10.1 to 12.4) and Lazio in Italy (11.0, 95% CI 10.1 to 11.9). Similar trends were seen in live birth data. Published rates of neonatal death for each region were then adjusted by applying (a) a standardised rate of very preterm delivery and (b) the existing death rate for babies born at this gestation in the individual region. This produced much greater homogeneity in terms of neonatal mortality. CONCLUSIONS: Variation in the rate of very preterm delivery has a major influence on reported neonatal death rates.

BioEnterics intragastric balloon for treatment of morbid obesity in Prader-Willi syndrome: specific risks and benefits.

BACKGROUND: Obesity in Prader-Willi Syndrome (PWS) is progressive, severe, and resistant to dietary, pharmacological, and behavioral treatment. A body weight reduction is mandatory to reduce the risk of cardio-respiratory and metabolic complications. The aim of the study was to assess risks and benefits of BioEnterics Intragastric Balloon (BIB) for treatment of morbid obesity in PWS patients. METHODS: Twenty-one BIB were positioned in 12 PWS patients (4 M, 8 F), aged from 8.1 to 30.1 years, and removed after 8 +/- 1.4 months (range: 5-10 months). Auxological, clinical, and nutritional evaluations were performed every 2 months. Variations in body composition were analysed by dual energy X-ray absorbiometry (DXA). RESULTS: One patient (28.5 years, BMI: 59.3 kg/m(2)) died 22 days after BIB positioning because of gastric perforation. In another case (26.2 years, BMI: 57.6 kg/m(2)), BIB was surgically removed after 25 days because of symptoms suggesting gastric perforation (not confirmed). The remaining ten patients showed a significant decrease of BMI (p = 0.005) and of fat tissue as measured by DXA (p = 0.012). No significant modifications in bone mineral density (BMD) occurred, but a slight loss in lean body mass (p = 0.036) was documented. In five patients, BIB treatment was repeated more than once. CONCLUSION: This study shows that when noninvasive pharmacological therapies fail, BIB may be effective to control body weight in PWS patients with morbid obesity, particularly when treatment is started in early childhood. However, careful clinical follow-up and close collaboration with parents are crucial to avoid severe complications, which can be caused by persisting unrestrained food intake.

Termination of pregnancy among very preterm births and its impact on very preterm mortality: results from ten European population-based cohorts in the MOSAIC study.

OBJECTIVE: To study the impact of terminations of pregnancy (TOP) on very preterm mortality in Europe. DESIGN: European prospective population-based cohort study. SETTING: Ten regions from nine European countries participating in the MOSAIC (Models of OrganiSing Access to Intensive Care for very preterm babies) study. These regions had different policies on screening for congenital anomalies (CAs) and on pregnancy termination. POPULATION OR SAMPLE: Births 22-31 weeks gestational age. METHODS: The analysis compares the proportion of TOP among very preterm births and assesses differences in mortality between the regions. MAIN OUTCOME MEASURES: Pregnancy outcomes (termination, antepartum death, intrapartum death and live birth) and reasons for termination, presence of CAs and causes of death for stillbirths and live births in 2003. RESULTS: Pregnancy terminations constituted between 1 and 21.5% of all very preterm births and between 4 and 53% of stillbirths. Most terminations were for CAs, although some were for obstetric indications (severe pre-eclampsia, growth restriction, premature rupture of membranes). TOP contributed substantially to overall fetal mortality rates in the two regions with late second-trimester screening. There was no clear association between policies governing screening and pregnancy termination and the proportion of CAs among stillbirths and live births, except in Poland, where neonatal deaths associated with CAs were more frequent, reflecting restrictive pregnancy termination policies. CONCLUSION: Proportions of TOP among very preterm births varied widely between European regions. Information on terminations should be reported when very preterm live births and stillbirths are compared internationally since national policies related to screening for CAs and the legality and timing of medical terminations differ.

Doctors' and nurses' attitudes towards neonatal ethical decision making in Ireland.

OBJECTIVE: To explore the clinical staff attitudes towards ethical decision making in neonatal intensive care units (NICUs) in Ireland, to establish differences between doctors and nurses and to compare attitudes in Ireland with those in Europe. DESIGN: Cross-sectional study by means of an anonymous questionnaire. 64 doctors and 228 nurses in seven NICUs participated (response rates 74% and 81%, respectively). Through factor analysis the staff answers to 12 attitude statements were used to build a score whose range varied from 0 (preservation of life in any case) to 10, indicating a more individualised approach according to the patient's best interests. MAIN OUTCOME MEASURE: Staff attitudes to ethical decision making in NICU. RESULTS: Mean values of attitude scores were 5.8 (95% CI 5.3 to 6.2) for doctors, and 6.0 (95% CI 5.5 to 6.5) for nurses. Respondents with experience in follow-up of NICU graduates had significantly higher scores (6.7 vs 5.4, p = 0.018), while the opposite was true among more religious staff (5.8 vs 6.9, p = 0.026) and particularly for minority religions such as Muslim (4.1, 95% CI 3.1 to 5.2). Scores were higher after age 30 for nurses, and after age 40 for doctors, suggesting the adoption of a less vitalistic viewpoint as respondents grow older and more experienced. Among doctors, a relationship was found between the attitude score and their self-reported non-treatment practices. CONCLUSIONS: In Ireland, NICU doctors and nurses hold similar attitudes towards ethical decision making. Personal and professional factors have a statistically significant impact on attitude score. Compared with the rest of Europe, attitudes in Ireland appear more similar to those of southern rather than northern European countries.

[Ethical problems of extreme prematurity: results of a qualitative study with obstetricians and midwives]. / Problèmes éthiques posés par l'extrême prématurité: résultats d'une étude qualitative auprès des obstétriciens et des sages-femmes.

OBJECTIVE: Our objective was to explore the practices, attitudes and feelings of obstetricians and midwives in case of extreme prematurity. POPULATION AND METHODS: A qualitative study was conducted as part of a European Concerted Action (EUROBS) in 1999 and 2000 in three tertiary-care maternity units, located in three cities in the northern, southern and central areas of France respectively. Semi-structured, tape-recorded interviews were conducted and were independently analysed by two different researchers using a content analysis. All full-time obstetricians and half of the full-time midwives were eligible for the study. Overall, 17 obstetricians and 30 midwives participated. RESULTS: Both obstetricians and midwives considered that decision-making in case of very preterm births raised ethical problems concerning the mother and the foetus. Despite some birth weight and gestational age criteria defined in advance, management around delivery appeared to be decided on a case-by-case basis. At birth, the neonatologists made the decisions. They were perceived as more inclined than the obstetrical team to initiate intensive care. If the child was born alive, intensive care was started, knowing that it could be withdrawn later, if appropriate. Parents were sometimes involved in decision-making during pregnancy, less frequently at birth or after birth. DISCUSSION AND CONCLUSION: Compared with obstetricians, midwives tended to have a less favourable perception of the neonatologists' practices, and to deplore the lack of parental information and involvement in decision-making. Decisions about the obstetrical management and resuscitation of extremely preterm infants are essentially always made on a case-by-case basis. Parents are sometimes involved in decision-making. Midwives express serious concerns about the current practices.

Caesarean section on request: a comparison of obstetricians' attitudes in eight European countries.

OBJECTIVE: To explore the attitudes of obstetricians to perform a caesarean section on maternal request in the absence of medical indication. DESIGN: Cluster sampling cross-sectional survey. SETTING: Neonatal Intensive Care Unit (NICU) associated maternity units in eight European countries. POPULATION: Obstetricians with at least 6 months clinical experience. METHODS: NICU-associated maternity units were chosen by census in Luxembourg, Netherlands and Sweden and by geographically stratified random sampling in France, Germany, Italy, Spain and UK. An anonymous, self-administered questionnaire was used for data collection. MAIN OUTCOME MEASURES: Obstetricians' willingness to perform a caesarean section on maternal request. RESULTS: One hundred and five units and 1,530 obstetricians participated in the study (response rates of 70 and 77%, respectively). Compliance with a hypothetical woman's request for elective caesarean section simply because it was 'her choice' was lowest in Spain (15%), France (19%) and Netherlands (22%); highest in Germany (75%) and UK (79%) and intermediate in the remaining countries. Using weighted multivariate logistic regression, country of practice (P<0.001), fear of litigation (P= 0.004) and working in a university-affiliated hospital (P= 0.001) were associated with physicians' likelihood to agree to patient's request. The subset of female doctors with children was less likely to agree (OR 0.29, 95% CI 0.20-0.42). CONCLUSIONS: The differences in obstetricians' attitudes are not founded on concrete medical evidence. Cultural factors, legal liability and variables linked to the specific perinatal care organisation of the various countries play a role. Greater emphasis should be placed on understanding the motivation, values and fears underlying a woman's request for elective caesarean delivery.

Ethical decision-making for extremely preterm deliveries: results of a qualitative survey among obstetricians and midwives.

OBJECTIVE: To explore the practices, attitudes and feelings of obstetricians and midwives in cases of extreme prematurity. METHODS: A qualitative study was conducted as part of a European Concerted Action (EUROBS) in three tertiary-care maternity units, located in three cities in the northern, southern and central areas of France. Semi-structured interviews lasted an average of 60 min and were tape-recorded. They were independently analyzed by two different researchers using a content analysis. All full-time obstetricians and half of the full-time midwives were eligible for the study. Overall, 17 obstetricians and 30 midwives participated. RESULTS: Both obstetricians and midwives considered that decision-making in case of very preterm births raised ethical problems concerning the mother and the fetus. Despite some birth weight and gestational age criteria defined in advance, management around delivery appeared to be decided on a case-by-case basis. At birth, the neonatologists made the decisions. They were perceived as being more inclined than the obstetric team to initiate intensive care. If the child was born alive, intensive care was started, in the knowledge that it could be withdrawn later, if appropriate. Parents were sometimes involved in decision-making during pregnancy, in particular when there was no emergency situation. Compared with obstetricians, midwives tended to have a less favorable perception of the neonatologists' practices, and to report less parental involvement in decision-making. CONCLUSIONS: Decisions about the obstetric management and resuscitation of extremely preterm infants are usually made on a case-by-case basis. Parents are sometimes involved in decision-making. Midwives express serious concerns about the current practices.

Should euthanasia be legal? An international survey of neonatal intensive care units staff.

OBJECTIVE: To present the views of a representative sample of neonatal doctors and nurses in 10 European countries on the moral acceptability of active euthanasia and its legal regulation. DESIGN: A total of 142 neonatal intensive care units were recruited by census (in the Netherlands, Sweden, Hungary, and the Baltic countries) or random sampling (in France, Germany, Italy, Spain, and the United Kingdom); 1391 doctors and 3410 nurses completed an anonymous questionnaire (response rates 89% and 86% respectively). MAIN OUTCOME MEASURE: The staff opinion that the law in their country should be changed to allow active euthanasia "more than now". RESULTS: Active euthanasia appeared to be both acceptable and practiced in the Netherlands, France, and to a lesser extent Lithuania, and less acceptable in Sweden, Hungary, Italy, and Spain. More then half (53%) of the doctors in the Netherlands, but only a quarter (24%) in France felt that the law should be changed to allow active euthanasia "more than now". For 40% of French doctors, end of life issues should not be regulated by law. Being male, regular involvement in research, less than six years professional experience, and having ever participated in a decision of active euthanasia were positively associated with an opinion favouring relaxation of legal constraints. Having had children, religiousness, and believing in the absolute value of human life showed a negative association. Nurses were slightly more likely to consider active euthanasia acceptable in selected circumstances, and to feel that the law should be changed to allow it more than now. CONCLUSIONS: Opinions of health professionals vary widely between countries, and, even where neonatal euthanasia is already practiced, do not uniformly support its legalisation.

Ethical decision-making in prenatal diagnosis and termination of pregnancy: a qualitative survey among physicians and midwives.

OBJECTIVES: This study was aimed at exploring the conflicts and ethical problems experienced by professionals involved in prenatal diagnosis and termination of pregnancy (TOP) in order to improve the understanding of decision-making processes and medical practices in the field of prenatal diagnosis. METHODS: Qualitative study with in-depth tape-recorded interviews conducted in three tertiary care maternity units in France, between May 1999 and March 2000. All full-time obstetricians and half of the full-time midwives were contacted. Seventeen obstetricians and 30 midwives participated (three refusals, five missing). Interviews were transcribed and analysed successively by two different researchers. RESULTS: All respondents stated that prenatal diagnosis and TOP raised important ethical dilemmas, the most frequent being request for abortion in case of minor anomalies. They pointed out the inability of our society to appropriately care for disabled children and the risk of eugenic pressures. The decisions and practices in prenatal diagnosis should be debated throughout society. All respondents reported that their unit did not have protocols for deciding when a TOP was justifiable. The transmission of information to the women appeared to be a problematic area. Moral conflicts and emotional distress were frequently expressed, especially by midwives who mentioned the need for more discussions and support groups in their department. CONCLUSION: Health professionals involved in prenatal diagnosis face complex ethical dilemmas which raise important personal conflicts. A need for more resources for counselling women and for open debate about the consequences of the current practices clearly emerged.

Teaching medical ethics to experienced staff: participants, teachers and method.

Almost all articles on education in medical ethics present proposals for or describe experiences of teaching students in different health professions. Since experienced staff also need such education, the purpose of this paper is to exemplify and discuss educational approaches that may be used after graduation. As an example we describe the experiences with a five-day European residential course on ethics for neonatal intensive care personnel. In this multidisciplinary course, using a case-based approach, the aim was to enhance the participants' understanding of ethical principles and their relevance to clinical and research activities. Our conclusion is that working with realistic cases encourages practising nurses and physicians to apply their previous knowledge and new concepts learnt in the course, thus helping them to bridge the gap between theory and practice.

Glomerular permeability after surgical trauma in children: relationship between microalbuminuria and surgical stress score.

OBJECTIVES: To determine whether there is an increase of urinary albumin during and after surgical trauma and investigate a possible relationship between microalbuminuria and the severity of surgical stress. DESIGN: Prospective study. SETTING: University hospital pediatric intensive care unit. PATIENTS: Forty consecutive children scheduled for elective surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Microalbuminuria/urinary creatinine ratio (MACR) was measured before, during, and after elective moderate or major surgical procedures. The Oxford Surgical Stress Score (SSS) was determined for each patient at the end of the operation, and its relationship with maximum deviation of MACR from baseline values was investigated. MACR showed a progressive increase during surgery and a decrease afterward, reaching preoperative values in most cases within 24 hrs after the end of surgery. There was a significant correlation between the increase in MACR and severity of the surgical trauma as measured by SSS. Two patients showed a rise in MACR after the initial postoperative normalization before clinical appearance of a surgical complication and one patient showed a persistent rise in MACR before clinical appearance of a septic complication. None of the other patients showed any rise in MACR after postoperative normalization, and they all had an uneventful recovery. CONCLUSIONS: MACR rises during and after major or moderate elective surgery in children. There is a significant positive correlation between severity of surgical trauma and capillary permeability in pediatric patients. Microalbuminuria, as an index of capillary permeability, may be an early sign of incipient complications and assist in the identification of those patients whose condition will deteriorate. The test is a cheap, blood-sparing, easy-to-perform bedside procedure that may have a useful role in clinical practice for evaluating the effect of surgical trauma on capillary permeability in children.