Termination for fetal anomaly: are women in England given a choice of method?

Choice of a medical or surgical method of termination for fetal anomaly (TFA) is advocated in national guidelines based on a similar risk profile. We investigated whether women are offered a choice of method, by surveying members of a UK parent support organisation. An online questionnaire was designed to examine respondents' experience of TFA. A total of 351 responses were included in the final analysis. TFAs after 24 weeks' gestation and selective reductions were excluded. Mean gestational age at TFA was 17 weeks; 14% (n = 50) were offered a choice of method, falling to 8% (n = 19) after 14 weeks' gestation. Overall, 78% (n = 275) underwent medical TFA with 88% stating they chose it because it was the only method offered; 60% (n = 30) of those offered a choice had a surgical TFA. Our survey suggests that women having TFA are not offered a choice of method. Service delivery should be improved to meet national guidance and women's needs.

Influence of the structure of cornstarch dispersions on kinetics of aroma release.

This study deals with the impact of food structure and texture on aroma release. This was done with cornstarch dispersions with constant concentrations in starch but differing in their structures. The structure parameters of the cornstarch dispersions were varied by changing the shearing conditions during the pasting process. Linalool and isoamyl acetate were chosen as reference aroma compounds. Linalool is known to form complexes with amylose while isoamyl acetate does not. The release of aroma compounds from starch dispersions under stirring was studied at 2 temperatures by discrete sampling of the headspace. Aroma release curves were modeled and the kinetic and thermodynamic parameters were extracted. The release of linalool seemed to be governed mainly by the interactions (complexation) with starch. In contrast, the interactions between starch and isoamyl acetate were feebler, and the release of this aroma compound was governed by the structure of the starch dispersion. The observed interactions were better established at 20 degrees C than at 32 degrees C.

A simple system for nutritional studies with chronic consumption of liquid diet in rats.

A feeding system allowing liquid diet distribution to rats without any loss by evaporation is described. A liquid diet stirred continuously is offered to rats in water bottles. The diet is made available to the animals without any clotting throughout the 24-h period. Such a system could be applied to alcohol administration.

Behavior of [185W]thiotungstates injected into sheep and the influence of copper: their fate and the effect of the compounds upon plasma copper.

[185W]trithio- and tetrathiotungstates (0.5 mg W) were injected intravenously into sheep. The compounds circulated in plasma bound reversibly to plasma proteins, particularly to albumin. After the first few minutes, levels declined exponentially with a T 1/2 of 12-14 hr. The initial movement of [185W]trithiotungstate from the plasma compartment was delayed transiently by the immediate injection of copper (2-6 mg); the longer-term metabolism was unaffected. The final fate of the compounds appeared to be hydrolysis and excretion in urine as [185W]tungstate. 185W from [185W]trithiotungstate appeared more rapidly than from [185W]tetrathiotungstate, but in both the rate was unaffected by copper injections. Since the appearance in urine did not correspond to the disappearance from plasma, it was suggested that the hydrolysis occurred in extravascular tissues and that the liver might be the site. A control experiment showed that [185W]tungstate in plasma was very rapidly cleared (and appeared in urine). At higher W levels (25-50 mg W per sheep per day), systematic copper metabolism was perturbed since plasma copper levels rose. The experiments demonstrated that in sheep the behavior and the effects of thiotungstates and thiomolybdates are sufficiently similar for 185W to be used as a more convenient alternative to 99Mo for longer-term studies on the interaction of the compounds with copper metabolism in animals.

[A mutation in the mechanisms of social control: the case of abortion]. / Une mutation dans les dispositifs de controle social: le cas de l'avortement.

PIP: This article examines the process by which the control and suppression of abortion shifted from the judicial domain to become an object of medical control in France. Abortion was a crime under the Napoleonic Code of 1810 and remained severely punishable for a century, but the law was regarded as too severe and prosecution was lax. The prescribed punishments became less stringent in 1923 but were later toughened again. Laws against abortion did not seem fair to much of the population concerned or to many of those charged with enforcing the laws, and they did not seem to uphold any inviolable moral principle. Increasing discontent with existing abortion laws, which were felt no longer to reflect the needs or mores of the society, and moreover to penalize poor women, who could not afford medically safe abortions abroad, and a belief that the law was doing nothing to reduce the numbers of abortions were among the stimuli that prompted the search for improved legislation. The public debate about the revised abortion law and the proper role of physicians and magistrates in determing access to abortion are traced though an exposition of opinions and quotations of the major participants in the controversy. The law of 1975 removed abortion from the control of magistrates and thereby liberalized access to it, but by entrusting access to abortion to the medical profession, the law embodied a bias toward preventing abortion. New social forces were behind the 1975 law, including pressure from women's groups which were developing a new consciousness of their rights and place in society, and a new role of medical practitioners, who occupy a privileged position in a social system based on knowledge rather than property. The new law still regards abortion as an evil and attempts to discourage it by imposing numerous constraints concerning when, where, and by whom it can be performed, by not requiring health personnel or facilities to make abortion available and by limiting the number that can be performed in any 1 establishment, and by obliging the abortion seeker to complete a maze of preliminary requirements. The law, by its own inner contradictions in authorizing and at the same time condemning and attempting to suppress abortion, and by granting control of access to the medical system despite the fact that abortion is not an illness, carries the seeds of its own ultimate failure.^ieng

An appraisal of blood trauma and blood-prosthetic interface during left ventricular bypass in the calf and humans.

Mechanical circulatory support was accomplished in 20 calves (mean, 140 days) and in 5 patients following operation for acquired heart disease (range, 1 hour to 8 days) employing a pneumatically actuated xenograft-valved assist pump interposed between the left ventricular apex and aorta. Following pump implantation in calves, hematocrit and platelets decreased transiently and returned to normal within 14 days. Plasma hemoglobin and erythrocyte mechanical fragility values were elevated for 48 hours. Platelet survival was slightly reduced, but erythrocyte survival values were similar to controls. In patients who received assist pumps, plasma hemoglobin and erythrocyte mechanical fragility were transiently elevated, but rapidly decreased to normal. Thrombocytopenia occurred only in the presence of bleeding and renal failure requiring hemodialysis. Pump flow of the left ventricular assist device was maintained above 2.0 L/min/m2 despite serious arrhythmias. Postmortem examination revealed no evidence of thromboemboli in the clinical patients although anticoagulant agents were not administered.

Quantitative radionuclide angiocardiography. Determination of left ventricular ejection fraction in children.

A method is described for measuring left ventricular ejection fraction which uses high frequency computer recording of gamma scintillation camera data and peripheral venous injectinon of technetium-99m as sodium pertechnetate. Data from mechanical model experiments are used to show feasibility of this method. A phantom experiment is described which was used to develop a technique for accurate delineation of the ventricular outline in the presence of background. The left ventricular ejection was measured in 12 patients by radionuclide angiocardiography and biplane cineangiography. Comparison of these two methods gave a correlation coefficient of 0-91. In addition, left ventricular ejection fraction was measured in 34 patients (aged 7 weeks to 18 years) without evidence of cardiac disease using the radionuclide method alone. Average ejection fractions of 0-66 and 0-70 were found for children over 2 years of age and children 2 years of age or younger, respectively. In addition, an interobseerver comparison study was performed with the data from 10 patients, and only small differences were noted (SD 0-025).

The surgical management of discrete and diffuse supravalvar aortic stenosis.

Between 1956 and 1976, 18 patients underwent surgery for supravar aortic stenosis at the The Children's Hospital Medical Center, Boston. Discrete obstruction, present in 11, was treated by insertion of a prosthetic gusset placed across the area of narrowing and extending into the noncoronary sinus of Valsalva. There was one operative death. Residual gradients (measured in five patients) ranged from 4-55 mm Hg, one of which was supravalvar in location. Significant aortic regurgitation was not common preoperatively. The diffuse form of supravalvar obstruction, a more difficult surgical problem, was present in seven patients. There were three operative deaths. Complete relief of the pressure gradient was achieved only in one instance by insertion of a left ventricular-aortic bypass shunt diverting the majority of the cardiac output into the descending thoracic aorta. This patient is now asymptomatic 20 months following operation. On the basis of this experience, it is suggested that patients with the diffuse form of supravalvar obstruction, and perhaps even those with a hypoplastic annulus alone, would benefit from a left ventricular-aortic bypass shunt.

Quantitative radionuclide angiocardiography: detection and quantitation of left to right shunts.

In 105 patients defection and quantitation of left to right shunts was performed using quantitative radionuclide angiocardiography. The radionuclide angiocardiograms were acquired and analyzed by a gamma camera interfaced to a digital computer system. Pulmonary to systemic flow (Qp/As) ratios were calculated by analysis of pulmonary time-activity histograms using a gamma variate model. All patients were studied with cardiac catheterization, left ventricular angiocardiography and radionuclide angiocardiography. The radionuclide method allowed precise detection and quantitation of left to right shunts with a Qp/Qs ratio of 1.2 to 3.0. There was good agreement between the Ap/As ratio calculated by oximetry at cardiac catheterization and radionuclide angiocardiography (r = 0.94). The information gathered with this nontraumatic method appears sufficiently reliable to be used in the management of patients.

A new method for temporary left ventricular bypass. Preclinical appraisal.

Surgical patients who cannot be weaned from cardiopulmonary bypass during operation or who develop balloon-dependent left ventricular failure postoperatively are now considered unsavable. However, in those with potentially reversible ventricular dysfunction, recovery might be possible if an improved means of temporary circulatory support were available. Towards this end, a pneumatically actuated, left ventricular assist pump was developed and evaluated in 20 consecutive calf experiments. The device, containing a flexible polyurethane pumping chamber, was positioned on the chest wall and connected to the left ventricular apex and descending thoracic aorta by two Dacron valved conduits (xenograft valves). All animals survived a 14 to 30 day pumping interval, and 7 underwent successful removal of the device by division of the Dacron conduits below skin level. As a prelude to human investigation, pumps were implanted during a series of routine autopsies through midline sternotomy incison. The device was positioned on the right anterolateral chest wall, with two valved conduits traversing the mediastinum to connect the pump to the left ventricular apex and ascending aorta.

Relief of congenital obstruction to left ventricular outflow with a ventricular-arotic prosthesis.

Hypoplasia of the aortic valve annulus and ascending aorta is a rare form of congenital aortic stenosis, with a poor prognosis. Replacement of the aortic valve and ascending aorta with a suitable prosthesis is feasible, but the hypoplastic valve annulus must also be enlarged if an adult-sized aortic valve is to be placed in the subcornary position. In an effort to develop a new method of surgical treatment for this congenital abnormality, we fabricated a prosthesis which can be interposed between the left ventricular apex and descending thoracic aorta. This prosthesis is coupled to a 25 mm. Dacron graft and xenograft valve and is lined with flocked Dacron fibrils to encourage formation of a stable biologic lining and prevent thrombus buildup. The prosthesis was implanted in a 22 year old male patient of the Children's Hospital Medical Center without difficulty. Postoperative cardiac catheterization idicated that all of the contrast material was ejected from the left ventricle through the prosthesis. The patient was discharged from the hospital taking sodium warfarin and remains entirely asymptomatic.

Transmural coronary venous O2 saturations in normal and isolated hearts.

Blood O2 saturations were measured by microscopic oximetry in the small coronary veins of wither open-chest or isolated and blood-perfused dog hearts. Subendocardial saturations (average 34%) were significantly lower than subepicardial (average 52%) in isolated hearts contracting isovolumically at systolic and coronary perfusion pressures of 100 mmHg. Saturations of botb regions fell and were not significantly different from each other (both averaged 16%) with partial coronary occlusion. When MVo2 was increased by calcium infusion, subendocardial saturations fell sharply to about 2% and were significantly, lower than subepicardial (average 10%). Conversely, when MVo2 was decreased by ventricular decompression, saturations rose equally in subendocardium (average 40%) and subepicardium (average 45%) (not significant). These data illustrate the efficacy of cascular autoregulation in isolated hearts. In open-chest dogs, as in isolated hearts with partial coronary occlusion, subendocardial (average 20%) saturations were not significantly diffenent from each other and ranged from 0 to 70%, suggesting the possibility of significant differences either in regional coronary flow or MVo2, or both, in closely adjacent areas throughout the myocardium.

The Anrep effect reconsidered.

Evidence is presented supporting the hypothesis that the positive inotropic effect after an abrupt increase in systolic pressure (Anrep effect) is the recovery from subendocardial ischemia induced by the increase and subsequently corrected by vascular autoregulation of the coronary bed. Major evidence consists of data obtained from an isolated heart preparation showing that the Anrep effect can be abolished with coronary vasodilation, and that with an abrupt increase in systolic pressure there is a significant reduction in the distribution of coronary flow to subendocardial layers of the ventricle. Furthermore, the intracardiac electrocardiogram shows S-T segment and T wave changes after an abrupt increase in ventricular pressure similar to that noted after coronary constriction. Major implications are that normally there may be ischemia of the subendocardial layers tending to reduce myocardial contractility which may account, in part, for the positive inotropic effect of various coronary vasodilators; that with an abrupt increase in ventricular pressure the subendocardium is rendered temporarily ischemic, placing the heart in jeopardy from arrhythmias until this is corrected; and that end-diastolic pressure and the intracardiac electrocardiogram may provide a means of evaluating the adequacy of circulation to subendocardial layers in diseased ventricles when systolic pressure is abruptly increased.