On the ethics of oestrogen treatment for tall girls: an update.

New empirical evidence on the long-term effects of oestrogen treatment for tall adolescent girls has shown that the intended psychosocial benefit of the treatment may not have been realised. This paper describes recent trends in the prevalence of the treatment and the results of a large Australian cohort study evaluating girls assessed between 1959 and 1993 for excessive growth. The paper concludes that oestrogen treatment to prevent extreme tallness should belong to the past, not to the future.

Philosophy meets disability.

The question "what is disability" and its implications are addressed in a new book Arguing about disability: philosophical perspectives, which aims to fill the gap between disability studies and philosophy. The structure of the book has been organised roughly on the basis of three branches of philosophy: metaphysics, political philosophy and ethics. One of the main themes of the book is the characterisation of a third way of thinking about disability, a way between two extremes, the medical and social models of disability.

The ethics of the placebo in clinical practice revisited.

Three recent empirical studies on the use of placebos and two papers arguing for the deliberate use of placebos in clinical practice are analysed. Empirical studies demonstrate that placebos are commonly used. The concept of the placebo is currently understood in different ways, many of which do not refer to inert substances or treatments. The papers arguing for the use of placebos are shown to fail to make their case.

Bone marrow transplantation in the prevention of intellectual disability due to inherited metabolic disease: ethical issues.

Many inherited metabolic diseases may lead to varying degrees of brain damage and thus also to intellectual disability. Bone marrow transplantation (BMT) has been used for over two decades as a form of secondary prevention to stop or reverse the progress of the disease process in some of these conditions. At the population level the impact of BMT on the prevalence of intellectual disability is minute, but at the individual level its impact on the prognosis of the disease and the well-being of the patient can be substantial. The dark side of BMT use is the burden of side effects, complications and transplantation-related mortality in less successful cases. The ethical issues involved in this therapy are discussed in this review.

Rethinking the placebo effect.

There is a rather wide range of meanings for placebo and placebo effect, and some of the controversy has arisen when the proponents of various positions have ignored each other. An attempt is made to clarify some of the conceptual issues related to these concepts. Five uses of placebos as inert substances or treatments are listed. The problem of the placebo effect and the discussion of its existence are examined, and other terms that could cover the phenomenon are suggested. It is suggested that the concept placebo is appropriate only to the research context and that the term care effect be introduced to replace it in clinical contexts.

How tall is too tall? On the ethics of oestrogen treatment for tall girls.

Oestrogen treatment for girls, to prevent psychosocial problems due to extreme tallness, has been available for almost 50 years but uncertainty about its position prevails. The ethical problems of this treatment are focused on in this paper. After a brief overview on historical and medical aspects, ethical issues such as the general justification of oestrogen treatment, evaluation of its success and ethical concerns related to research in this subject are dealt with in detail.

Vitamin C for preventing and treating pneumonia.

BACKGROUND: Pneumonia is one of the most common serious infections, causing two million deaths annually among young children in developing countries. In developed countries pneumonia is most significantly a problem of the elderly. OBJECTIVES: To assess the prophylactic and therapeutic effects of vitamin C on pneumonia. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 1), OLD MEDLINE (1950 TO 1965), MEDLINE (1966 to February Week 2, 2006), EMBASE (1974 to March 2006), Web of Science (1945 to February 2006) and reference lists of reviews and articles. SELECTION CRITERIA: To assess the therapeutic effects of vitamin C, we selected placebo-controlled trials. To assess prophylactic effects, we selected controlled trials with or without a placebo. DATA COLLECTION AND ANALYSIS: Two review authors independently read the trial reports and extracted data. MAIN RESULTS: We identified three prophylactic trials which recorded 37 cases of pneumonia in 2,335 people. Only one was satisfactorily randomised, double-blind and placebo-controlled. Two trials examined military recruits and the third studied boys from "lower wage-earning classes" attending a boarding school in the UK during World War II. Each of these trials found a statistically significant (80% or greater) reduction in pneumonia incidence in the vitamin C group. We identified two therapeutic trials involving 197 pneumonia patients. Only one was satisfactorily randomised, double-blind and placebo-controlled. One studied elderly patients in the UK which found lower mortality and reduced respiratory symptom scores in the vitamin C group; however, the benefit was restricted to the most ill patients. The other studied adults (with a wide age range) in the former Soviet Union and found a dose-dependent reduction in the time to recovery with two vitamin C doses. AUTHORS' CONCLUSIONS: The prophylactic use of vitamin C to prevent pneumonia should be further investigated in populations who have high incidence of pneumonia, especially if dietary vitamin C intake is low. Similarly, the therapeutic effects of vitamin C should be studied especially in patients with low plasma vitamin C levels. The current evidence is too weak to advocate widespread prophylactic use of vitamin C to prevent pneumonia in the general population. However, therapeutic vitamin C supplementation may be reasonable for pneumonia patients who have low vitamin C plasma levels because its cost and risks are low.

Finnish doctors and the realisation of patient autonomy in the context of end of life decision making.

Patient autonomy is a fundamental principle in end of life decision making. However, its realisation may take a variety of forms. Discourse analysis was conducted in a qualitative interview study of 19 physicians. The physicians made use of three different discourses, each of which contained a specific understanding of patient autonomy and a physician's proper activities in the context of end of life decision making.

End of life decisions: attitudes of Finnish physicians.

OBJECTIVES: This study investigated Finnish physicians' experiences of decisions concerning living wills and do not resuscitate (DNR) orders and also their views on the role of patients and family members in these decisions. DESIGN: A questionnaire was sent to 800 physicians representing the following specialties: general practice (n = 400); internal medicine (n = 207); neurology (n = 100), and oncology (n = 93). RESULTS: The response rate was 56%. Most of the respondents had a positive attitude toward (92%), and respect for (86%) living wills, and 72% reported situations in which such a will would have been helpful, although experience with their use was limited. The physicians reported both benefits and problems with living wills. Thirteen per cent had completed a living will of their own. Half did not consider living wills to be reliable if they were several years old. Do not resuscitate orders were interpreted in two ways: resuscitation forbidden (70%) or only palliative (symptom oriented) care required (30%). The respondents also documented DNR orders differently. Seventy two per cent discussed DNR decisions always or often with patients able to communicate, and even 76% discussed DNR orders with the family members of patients unable to communicate. Most respondents were able to approach a dying patient without difficulty. They also felt that education in general was needed. CONCLUSIONS: In general Finnish physicians accept living wills, but find they are accompanied by several problems. Many problems could be avoided if physicians and patients conducted progressive discussions about living wills. The differing interpretations of DNR orders are a matter of concern in that they may affect patient treatment. The promotion of patient autonomy with respect to treatment seems rather good, but the limitations of the study need to be kept in mind.

Boys have more health problems in childhood than girls: follow-up of the 1987 Finnish birth cohort.

The purpose of this study was to describe gender differences in children's health until the age of 7 y. The study cohort consisted of all children born in Finland in 1987 (n = 60254), of whom 99.9% were identified in the follow-up. Childhood health data were received from five national registers (1987-94), from regional registers of intellectual disabilities (1987-96) and from education registers in the largest county (1996). Boys had a 20% higher risk for a low 5-min Apgar score and an 11% higher risk for being preterm. After the perinatal period, boys had a 64% higher cumulative incidence of asthma, a 43% higher cumulative incidence of intellectual disability, a 22% higher incidence of mortality and a higher, but not statistically significant, incidence of epilepsy and vision disorders. No male excess was found for diabetes or hearing disorders. The healthcare-related indicators showed poorer health for boys, who had a 37% higher mean of hospital days, a 28% higher risk for receiving social benefits due to health problems and a 13% higher risk for long-term medication. The differences in the socially defined indicators were greatest, and boys had a two- to three-fold risk of having delayed development, postponed school start or attendance in special education programmes. Gender differences in different social classes were similar. Boys' shorter gestational age at birth did not explain the gender differences in childhood health. Some of boys' poorer health seemed to be biologically based, but the social causes of health problems are amenable to change. In particular, the potential of the school system to reduce ill health among boys should be investigated.

Can children's health be predicted by perinatal health?

BACKGROUND: The purpose of this paper was to investigate how well children's health until age 7 years can be predicted by perinatal outcome using routine health registers. METHODS: Follow-up of one year cohort (N = 60192) was performed by record linkages with personal identification number. The data came from the 1987 Finnish Medical Birth Register, from six other national registers and from education registers of one county. RESULTS: All perinatal health indicators showed a strong correlation with subsequent health, and prediction of good health was satisfactory: 85% of children who were healthy in the perinatal period did not have any reported health problems in early childhood, and 91% of children healthy in early childhood had been healthy in the perinatal period. However, it was not possible to predict poor health outcome: 76% of the children with reported perinatal problems were healthy in early childhood, and 87% of the children with long-term morbidity in childhood did not have any perinatal problems. CONCLUSIONS: Our findings suggest that in assessing risk factors and health care technology, monitoring perinatal health is not enough and long-term follow-ups are needed.

PIP: While perinatal mortality has been widely used as an indicator to measure the standard of health care and to identify risk groups, its value has been questioned because of definition problems and decreasing perinatal mortality rates in industrialized countries. Finnish health register data were used to assess how well children's health until age 7 years can be predicted by perinatal outcome using routine health registers. Specifically, data came from the 1987 Finnish Medical Birth Register, 6 other national registers, and education registers of 1 county. 60,192 children were traced up to age 7 years through record linkages with personal identification numbers. All perinatal health indicators were strongly correlated with subsequent health: 85% of children who were healthy in the perinatal period reported no health problems during early childhood, and 91% of children healthy in early childhood had also been healthy in the perinatal period. However, poor health outcome could not be predicted: 76% of the children with reported perinatal problems were healthy in early childhood, and 87% of the children with long-term morbidity during childhood had no perinatal problems. These findings suggest that when assessing risk factors and health care technology, it is not enough to only monitor perinatal health status. Rather, long-term follow-ups are also needed.

Health registers as a feasible means of measuring health status in childhood--a 7-year follow-up of the 1987 Finnish birth cohort.

Follow-up studies on health have usually been based on ad hoc cohort studies in which detailed information is collected specifically for research purposes on a certain group of people. The increasing collection of routine health data provides an alternative method of gathering follow-up data. In this study, the feasibility of using routinely collected health-register data and data linkages to follow up children's health was investigated. Five nationwide registers, 18 regional registers of intellectually disabled children and school administration data in one county were found to be of use for our follow-up and were combined with the 1987 Finnish Medical Birth Register (n = 60,254 births). In the follow-up, 62 children were untraced (0.1%), 327 were stillborn (0.5%), 440 died after birth (0.7%) and 287 emigrated (0.5%) before the age of 7 years. The cumulative incidences for all diseases (8.9% of all children living in Finland at the age of 7 years), for diabetes (3.0/1000), for epilepsy (6.8/1000) and for asthma (34.2/1000) correspond to the estimates of other studies, but our estimate for intellectual disabilities (18.0/1000, of whom 18% were reported to have an IQ of 70 or less) seems to be an underestimate. Our data collection did not provide reliable information on institutionalised children or children taken into care. Data collection conducted by using health registers is a feasible method, and it saves both time and financial resources compared with cohort studies. Potential problems with data linkage studies are variation in the content of data and in data quality of different registers and data protection issues.

Day-care centers and diarrhea: a public health perspective.

OBJECTIVE: To assess the relation between morbidity from acute diarrhea and the form of day care. STUDY DESIGN: The design was a retrospective cohort study. The setting was the city of Espoo, an urban-suburban municipality in southern Finland with a population of 170,000. The study population comprised 2568 randomly selected children aged 1 to 7 years. The main outcome measure was the occurrence of diarrhea. RESULTS: Children in day-care centers (DCCs) had an increased risk for acute diarrhea compared with children in home care. In the whole group of children in DCCs, the relative risk was 1.20 (95% confidence interval [CI], 1.08 to 1.34). The risk was greatest in 1- and 2-year-old children, for whom the estimated relative risks were 1.76 (95% CI, 1.28 to 2.43) and 1.56 (95% CI, 1.16 to 2.09), respectively. The proportion of diarrhea episodes attributable to DCC care in 1-year-old children was 49% (95% CI, 18% to 91%), in 2-year-old children 37% (95% CI, 11% to 73%), and in the whole group 17% (95% CI, 7% to 29%). The infection risk did not differ between children in home and family care. CONCLUSIONS: The results provide quantitative evidence that the care in DCCs is a major determinant of acute diarrhea in children, whereas family day care does not increase the infection risk.

Nordic Medical Birth Registers in epidemiological research.

This review discusses the use of Nordic Medical Birth Registers (MBRs) in epidemiological studies, paying special attention to the topics that have been investigated and to other data sources that increase the usefulness of MBRs. We divided the reviewed studies into four groups according to the data sources on which they were based: (1) studies using MBR data only; (2) studies combining maternal or paternal background information, obtained from other data sources, with MBR data; (3) studies combining MBR data with subsequent outcome information on newborns; and (4) studies using information about consecutive pregnancies and generations. Our review shows that MBRs are good sources for studying the following topics: maternal biological and obstetric background; interventions and health care during pregnancy and birth; newborns' short-term outcome; and the relations between these factors. In addition, the usefulness of MBRs increases when the data they contain are combined with data from other sources. We found that data from more than twenty different sources have been linked with MBR data in the Nordic counties. As time passes, national MBRs become a useful source of information for studies on consecutive pregnancies or generations. In addition, the associations between pregnancy, delivery, perinatal health and long-term outcome can be studied by using an MBR as the basic data source.