International variations in application of the best-interest standard across the age spectrum.

OBJECTIVE: Ethically and legally, assertions that resuscitation is in a patient's best interest should be inversely correlated with willingness to forego intensive care (and accept comfort care) at the surrogate's request. Previous single country studies have demonstrated a relative devaluation of neonates when compared with other critically ill patients. STUDY DESIGN: In this international study, physicians in Argentina, Australia, Canada, Ireland, The Netherlands, Norway and the United States were presented with eight hypothetical vignettes of incompetent critically ill patients of different ages. They were asked to make assessments about best interest, respect for surrogate autonomy and to rank the patients in a triage scenario. RESULTS: In total, 2237 physicians responded (average response rate 61%). In all countries and scenarios, participants did not accept to withhold resuscitation if they estimated it was in the patient's best interest, except for scenarios involving neonates. Young children (other than neonates) were given high priority for resuscitation, regardless of existing disability. For neonates, surrogate autonomy outweighed assessment of best interest. In all countries, a 2-month-old-infant with meningitis and a multiply disabled 7-year old were resuscitated first in the triage scenario, with more variable ranking of the two neonates, which were ranked below patients with considerably worse prognosis. CONCLUSIONS: The value placed on the life of newborns is less than that expected according to predicted clinical outcomes and current legal and ethical theory relative to best interests. Value assessments on the basis of age, disability and prognosis appear to transcend culture, politics and religion in this domain.

National guidelines for treatment of jaundice in the newborn.

UNLABELLED: Jaundice is the most common reason for instituting treatment in otherwise healthy as well as sick newborn infants. Herein, we describe the process employed in Norway to forge agreement on a set of treatment guidelines that are now used across the country. The Norwegian Pediatric Association was a key resource in this process, which involved contacts with all paediatric departments in Norway. We have also performed an international survey regarding the use of such national guidelines, showing that the majority of those queried confirm having national guidelines. The evidence base for any neonatal jaundice guideline is weak; therefore, it is not surprising that the various guidelines differ both in format and in specifics. In the Norwegian guidelines, treatment indications are based on bilirubin concentrations and related to birth weight. Postnatal age is also factored in because jaundice develops gradually during the first 3-4 days before it levels off. CONCLUSION: Following the introduction of these guidelines, fewer babies in Norway receive phototherapy, and no cases of chronic kernicterus have been reported during this period.

Efficacy of phototherapy for neonatal jaundice is increased by the use of low-cost white reflecting curtains.

OBJECTIVE: To determine whether the addition of low-cost reflecting curtains to a standard phototherapy unit could increase effectiveness of phototherapy for neonatal jaundice. DESIGN: Randomised controlled clinical trial. SETTING: Level-one nursery of the Hospital Universiti Sains Malaysia, Kelantan, Malayasia. PATIENTS: Term newborns with uncomplicated neonatal jaundice presenting in the first week of life. INTERVENTIONS: Phototherapy with white curtains hanging from the sides of the phototherapy unit (study group, n = 50) was compared with single phototherapy without curtains (control group, n = 47). MAIN OUTCOME MEASURES: The primary outcome was the mean difference in total serum bilirubin measured at baseline and after 4 h of phototherapy. The secondary outcome was the duration of phototherapy. RESULTS: The mean (standard deviation) decrease in total serum bilirubin levels after 4 h of phototherapy was significantly (p<0.001) higher in the study group (27.62 (25.24) micromol/l) than in the control group (4.04 (24.27) micromol/l). Cox proportional hazards regression analysis indicated that the median duration of phototherapy was significantly shorter in the study group (12 h) than in the control group (34 h; chi(2) change 45.2; p<0.001; hazards ratio 0.20; 95% confidence interval 0.12 to 0.32). No difference in adverse events was noted in terms of hyperthermia or hypothermia, weight loss, rash, loose stools or feeding intolerance. CONCLUSION: Hanging white curtains around phototherapy units significantly increases efficacy of phototherapy in the treatment of neonatal jaundice without evidence of increased adverse effects.

Neonatal jaundice and scientific fraud in 1804.

In 1785 the University of Paris issued a prize challenge: "Describe neonatal jaundice and distinguish between those circumstances in which jaundice needs professional help and those in which one only needs to await the course of nature." The prize was awarded to Jean Baptiste Timothée Baumes for a paper, published as a pamphlet in 1788, in which he described 10 jaundiced neonates and discussed his theories on the causes and mechanisms. In a revised edition published in 1806 Baumes accused François Bidault of plagiarism in his 1804 thesis submitted for the MD degree at the University of Paris. Herein, Baumes' 1788 original is compared with Bidault's thesis as well as Baumes' 1806 revision. It is clear beyond doubt that the 10 cases discussed by Bidault were the same as those Baumes had published 16 y earlier. Parts of Bidault's descriptions and discussions were verbatim transcripts of Baumes' original. However, Bidault had economized with paper, ink and effort by significantly reducing the overall length of Baumes' original. In his second edition Baumes denounced Bidault in strong terms and suggested that the University of Paris take strong action to punish him for his dishonesty. Unfortunately, university records from that period are incomplete, and it is not clear what, if anything, was done about the matter. Baumes had a very distinguished career and achieved a great reputation as both a teacher and clinician.