Celebrated for disproving the traditional view that lack of oxygen at birth (perinatal asphyxia) contributes significantly to cerebral palsy, a 1986 New England Journal of Medicine article by Karin Nelson and Jonas Ellenberg engineered a new consensus in the medical community: that lack of oxygen at birth rarely causes cerebral palsy. We demonstrate that the article's central argument relies on straightforwardly fallacious statistical reasoning, and we discuss significant implications -- e.g. how carefully fetuses are monitored during labor and delivery, (...) expert testimony in malpractice cases, and public policy decisions. (shrink)

Beginning in the mid-1930s the comparative physiologists Laurence Irving and Per Fredrik Scholander pioneered the study of diving mammals, particularly harbor seals. Although resting on earlier work dating back to the late nineteenth century, their research was distinctive in several ways. In contrast to medically oriented physiology, the approaches of Irving and Scholander were strongly influenced by natural history, zoology, ecology, and evolutionary biology. Diving mammals, they argued, shared the cardiopulmonary physiology of terrestrial mammals, but evolution had modified these basic (...) adaptive processes in extreme ways. In particular, seals’ remarkable ability to hold breath, lower metabolism, produce energy anaerobically, and resist asphyxiation, provided a sharp contrast with terrestrial mammals, including humans. This diving physiology was an extreme elaboration of a general regulatory mechanism that allowed seals and other diving mammals to remain active underwater for extended periods. The decrease in heart rate referred to as bradycardia or the “diving reflex” was highly developed in diving mammals, but also found in less developed form in many other organisms faced by asphyxia. It therefore served as a kind of “master switch” for lowering metabolism in diving, hibernation, parturition, drowning, and other physiological responses involving lack of oxygen. Studying bradycardia unified a wide diversity of physiological phenomena, while also providing a context for contrasting the physiological responses of various species, including humans. Conducted in the laboratory and the field, this research served as a bridge between a comparative physiological ecology focused on non-human species and a human-centered general physiology. (shrink)

Birth asphyxia is the most common single cause of death in term newborn infants. The majority of deaths in developed countries follow decisions to withdraw intensive care. Recent technological advances, particularly the use of magnetic resonance imaging (MRI) of the brain, may affect the process of prognostication and decision-making. There is little existing evidence about how prognosis is determined in newborn infants and how this relates to treatment withdrawal decisions.An exploratory qualitative study was performed using in-depth semi-structured interviews with (...) a sample of ten neonatologists from tertiary intensive care units in the UK. Participants were purposively selected to ensure a range of experience and type of unit. They were asked about the process of prognostication for infants with birth asphyxia and decisions about treatment withdrawal. Interviews were transcribed and thematically analysed.MRI played a significant role in decision-making about life-sustaining treatment for a number of clinicians. Clinicians did not identify particular ethical concerns related to MRI, though wider discussion revealed issues relating to uncertainty around predictions, the timing of prognostication and decision-making, and difficulty in predicting quality of life. (shrink)

This article addresses the problem of the place of philosophy in higher education today through the analysis of a single issue: the standardization of academic writing and its effects on the practice of philosophy and teaching. From the formal analysis of the academic “paper”, as the unique pattern of production and evaluation of current research, this article evaluates its impact on the relationship between thinking, writing and education. It concludes that standardization of writing in the globally homologated university, leads to (...) a stifling of thought not only in philosophy but in all areas of knowledge. At the same time gives us the key to diagnose and locate, in each of these areas, what are the spaces of the non-negotiable from which we must rethink our relationship with education and thinking inside and outside the university. (shrink)

Morbidity of birth asphyxia has been estimated to be 42 million disability-adjusted life years. The study sought to assess the impact of the use and completion of partograph during labour on reducing birth asphyxia at the St Anthony’s Hospital, Dzodze, in the Volta Region of Ghana. A retrospective study design using a quantitative approach was adopted for the study. A simple random sampling technique was used to select a total of 200 folders of labouring women who were admitted (...) and delivered at St Anthony’s Hospital, Dzodze, between 1st May 2015 and 30th April 2016. A structured checklist, which was developed by using labour and foetal monitoring parameters based on the standards of the World Health Organization partograph usage, was used to review all the 200 existing maternal records. The findings revealed that partographs were used by midwives at St Anthony’s Hospital with the majority of the maternal folders fully completed. The use and completion of partograph were found to be associated with less non-asphyxiated birth outcomes. Labours which were monitored with partograph were 4.29 times less likely to result in birth asphyxia [AOR 4.29 ], and those that were monitored with a completed partograph were 5.3 times less likely to result in birth asphyxia [AOR 5.31 ]. Midwives used partographs during labour at St Anthony’s Hospital. The use and completion of partograph were significantly associated with a reduced incidence of birth asphyxia at the hospital. Birth asphyxia could be reduced if partographs are used and completed by midwives during labour in all cases. (shrink)

Objective: To assess whether continuous consent, a process in which information is given to research participants at different stages in a trial, and clinician training in that process were effective when used by clinicians while gaining consent to the Total Body Hypothermia (TOBY) trial. The TOBY trial is a randomised controlled trial (RCT) investigating the use of whole-body cooling for neonates with evidence of perinatal asphyxia. Obtaining valid informed consent for the TOBY trial is difficult, but is a good (...) test of the effectiveness of continuous consent. Methods: Semistructured interviews were conducted with 30 sets of parents who consented to the TOBY trial and with 10 clinicians who sought it by the continuous consent process. Analysis was focused on the validity of parental consent based on the consent components of competence, information, understanding and voluntariness. Results: No marked problems with consent validity at the point of signature were observed in 19 of 27 (70%) couples. Problems were found mainly to lie with the competence and understanding of the parents: mothers, particularly, had problems with competence in the early stages of consent. Problems in understanding were primarily to do with side effects. Problems in both competence and understanding were observed to reduce markedly, particularly for mothers, in the post-signature phase, when further discussion took place. Randomisation was generally understood but unpopular. Information was not always given by clinicians in stages during the short period available before parents gave consent. Most clinicians, however, were able to give follow-up information. Discussion: Consent validity was found to compare favourably with similar trials examined in the Euricon study. Conclusion: Adopting the elements of the continuous consent process and clinician training in RCTs should be considered by researchers, particularly when they have concerns about the quality of consent they are likely to obtain by using a conventional process. (shrink)

A half century ago electronic fetal monitoring was rushed into clinical use with the promise that the secrets of fetal heart rate decelerations had been discovered and that the newly discovered knowledge would prevent cerebral palsy with just in time cesarean sections preventing babies from experiencing asphyxia, which was thought to be the primary cause of cerebral palsy. In the years since electronic fetal monitoring’s debut, it has been discovered that asphyxia is a rare cause of cerebral palsy. (...) At the same time electronic fetal monitoring use increased to 85% of all labors, the C-section rate increased to 33% without an attributable decrease in the rate of cerebral palsy. What went wrong with electronic fetal monitoring? The answer lies in a new analysis of the physiologic theories concerning fetal heart rate decelerations, demonstrating that the earlier electronic fetal monitoring theories were wrong. This revelation is only the latest evidence that electronic fetal monitoring use today... (shrink)

Background: Lay persons’ judgements of the acceptability of the not uncommon practice of ending the life of a damaged neonate have not been studied. Methods: A convenience sample of 1635 lay people in France rated how acceptable it would be for a physician to end a neonate’s life—by withholding care, withdrawing care, or active euthanasia—in 54 scenarios in which the neonate was diagnosed either with perinatal asphyxia or a genetic abnormality. The scenarios were all combinations of four factors: three (...) levels of maturity or immaturity, three levels of severity of the health problem, three levels of parents’ preference concerning prolonging care and two levels of decision-making (with or without consulting the other caregivers). Analyses: Analyses of variance of the participants’ responses were performed to determine the importance of each factor; the interactions among factors, with methods of ending life and with other patient characteristics; and the differences between asphyxia and genetic abnormality. A cluster analysis was performed to look for groups with different patterns of responses. Results: Lay people assigned most importance to the parents’ request and to the severity of the problem. Except for a small group (12%) always opposed to ending life, they used a simple additive-type rule in integrating the information. Implications: Most of this sample of French lay people are not categorically for or against ending the life of a damaged neonate, but judge its degree of acceptability by adding up those factors that seem most salient to them. (shrink)

Neonatal mortality during the first week of life, corresponding to the years 19750·023 per year. This decline cannot be explained by an increase in the mean birth weight (MBW=23440·835−10·107 g per year). From the most frequent of the causes of death to the least were: congenital anomalies, preterm born or low birth weight, respiratory problems, pregnancy difficulties, hypoxaemia/asphyxia, delivery difficulties and infectious diseases. This sequence changed when the specific age at death was considered. The NMR descended evenly for both (...) sexes for the causes indicated above, except for preterm born or low birth weight, in which the male mortality decrease was greater since its rate was more elevated at the beginning of the period studied. For all the causes listed, NMR was more elevated both in urban areas and for males. Early neonatal mortality (first 24 hours) was higher for pregnancy difficulties, preterm born or low birth weight, congenital anomalies and hypoxaemia/asphyxia. (shrink)

You have not opened the wrong journal!The police have a duty to protect the public and to investigate any, and all, serious crimes. The article by Lynøe and Leijonhufvud raises important issues about the interaction between hospital staff and police in cases in which suggested medical negligence crosses into the arena of serious legal offences, which range from murder and homicide to serious assault.1Although arising in Sweden, the issues raised in this case are generalisable. While our understanding is limited to (...) the journal article there seem several uncontested facts: a children's intensive care doctor was arrested, charged and acquitted of the mercy killing of an infant in a Swedish hospital. The baby had sustained severe brain injury prior to this clinician's involvement, either due to birth asphyxia or to an accidental overdose of salt. The baby died after withdrawal of life-sustaining treatment with parental agreement. At a later stage, the family asked the police to investigate the initial salt incident. Despite the team attending the baby after WLST stating that only a morphine infusion was administered, a 25-day postmortem femoral artery sample showed ‘an extremely high level of thiopentone’ , although no control sample was analysed.Healthcare staff are subject to the laws of their country. However, Lynøe and Leijonhufvud raise the issue of a conflict between what they term ‘soft law’—the rules, regulations and ethics of healthcare practice and the law of the land. …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Pairing breaths:Rabah Ameur-Zaïmech's Terminal Sud (2019)Marion Froger (bio)Translated by David F. BellAsphyxiaNever had I felt such a sense of suffocation watching a film by Rabah Ameur-Zaïmeche.1 The poisoned atmosphere of Terminal Sud (2019) recalls the atmosphere of the Algerian War (1955-1962) and that of the decade of darkness (1991-2002) in that country. The filmmaker chose not to make a historical film, however, but rather a dystopia that fuses together (...) periods and places. The story appears to be contemporary, in a country bathed in the colors of southern France, apparently in the grip of all the violence that French and Algerian memories are nowhere near forgetting.2 Bandits wearing combat uniforms, policemen wearing outfits sporting an acronym that strangely resembles one used by Islamist Algerian groups,3 and generals evoking the French putschists of 1961 all fight against each other—ransoming, threatening, kidnapping, killing, and torturing the local population. Meanwhile, out in the countryside, guerrillas (maquisards4) try to care for their dying leader, like North African freedom fighters (fellagas) were doing before them, and this in turn evokes French Resistance fighters in the 1940s. The film's work on confused memories, which, according to Thierry Kuntzel, is related to the condensation, overdetermination, and displacement of dreamwork, transforms being out of breath into a symptom that hounds the doctor, played by Ramzy Bédia ("Inhale…Exhale…Inhale again…Hold your breath…Exhale"), a state of the world in the form of a trap that threatens to suffocate him—and launches the quest for a filmic poetics of calm through the pairing of breaths.Peeling façades with tightly closed doors, lowered metal shop shutters, narrow and tense streets: the doctor, his wife Hazia, and their family slip outside in fear of kidnapping and gunfire, climb up stairs breathing heavily, anxiously await by the window, their bodies obscured in starkly contrasting shadows cast by glaring light, hug each other with endless sighs. As they share their grief, they have barely enough breath left to sing to the memory of someone who has disappeared,5 as if after an argument, [End Page 244] when everything has been said and all that remains is a strangled sob serving as last farewell.The film opens with an attack on a minivan used for public transportation: bandits, who could be soldiers, steal everything from the passengers and driver. The doctor sees his patients in a rundown hospital, treats a woman whose breathing is raucous, her voice taut with anxiety, and who speaks about the disappearance of her husband. Back home, he finds anonymous letters containing death threats and, to calm down, he searches for his breath by taking a deep drag from a cigarette and a swig of whiskey. "I can't take it any longer, I can't even stand up, I can't do anything, I'm at the end of my rope, I'm tired […] Is that what our country has become?" he confides to a friend several hours before losing, in the emergency room, his wife's brother, a journalist assassinated in front of his house. "Stay with me," he says as he runs beside the stretcher calling for help, "Breathe, breathe."The spasmodic breathing of Ramzy Bédia, provoked by the fear, effort, and pain that define his character, intensifies as the film progresses. He barely breathes in the car taking him to treat the rebel leader; he is running out of breath beside the leader's bed as we hear the death rattle and as Bédia shouts to the leader's comrades, "Give him some air, everyone get out!" Later, one of the policemen standing guard at the entrance to the hospital will be mortally wounded by a kamikaze attack and will die on the operating table despite the doctor's exhausting reparatory manipulations. Asphyxia will ultimately directly threaten the doctor after his arrest. Tied to an old bedspring, he will be tortured by electroshock,6 will attempt one last time to justify himself to a soldier who wants to know everything about the rebel leader the doctor has treated, and will nearly suffocate in his... (shrink)

BackgroundEuthanasia is performed on occasion, even on newborns, but is highly controversial, and it is prohibited by law and condemned by medical ethics in most countries.AimTo characterise and compare the judgments of lay persons, nurses, and physicians of the acceptability of actively ending the life of a damaged newborn.MethodsConvenience samples of 237 lay persons, 214 nurses, and 76 physicians in the south of France rated the acceptability on a scale of 0–10 of giving a lethal injection in 54 scenarios composed (...) of all combinations of 4 within-subject factors: gestational age of 6,7, or 9 months; 3 levels of severity of either perinatal asphyxia or of genetic disease; attitude of the parents about prolonging care unknown, favourable, or unfavourable; and decision made individually by the physician or collectively by the medical team. Overall ratings were subjected to cluster analysis and each cluster to analysis of variance and graphic representation.ResultsLay persons (mean acceptability rating 4.29) were significantly more favourable to euthanasia than nurses (2.84), p<.005, or physicians (2.12), p<.005. Five clusters were found with different judgment rules, i.e., how the information was integrated. More physicians (30 per cent) than nurses (14 per cent), p<.01, or lay persons (11 percent), p<.01, rated euthanasia as never, under any condition, acceptable. Most, however, asserted that it was increasingly acceptable as the factors combined to favour it, especially when the parents desired to stop treatment. More physicians (45 per cent) and nurses (46 per cent) than lay persons (21 per cent), p<.01, used a complex conjunctive rule (level of parent’s attitude x level of severity of damage x consultation with team or not) rather than a simple additive rule.ConclusionsUnlike lawand medical ethics, most of the lay persons. nurses, and physicians judged the acceptability of euthanasia as a function of the circumstances. Most health professionals combined the factors in a conjunctive (multiplicative), rather than additive, fashion in accordance with legislation for adults in the Netherlands and elsewhere that requires a set of criteria to be fulfilled before it is legitimate to end apatient’s life. (shrink)

Neonatal brain monitoring in the neonatal intensive care units (NICU) requires a continuous review of the spontaneous cortical activity, i.e., the electroencephalograph (EEG) background activity. This needs development of bedside methods for an automated assessment of the EEG background activity. In this paper, we present development of the key components of a neonatal EEG background classifier, starting from the visual background scoring to classifier design, and finally to possible bedside visualization of the classifier results. A dataset with 13,200 5-minute EEG (...) epochs (8–16 channels) from 27 infants with birth asphyxia was used for classifier training after scoring by two independent experts. We tested three classifier designs based on 98 computational features, and their performance was assessed with respect to scoring system, pre- and post-processing of labels and outputs, choice of channels, and visualization in monitor displays. The optimal solution achieved an overall classification accuracy of 97% with a range across subjects of 81–100%. We identified a set of 23 features that make the classifier highly robust to the choice of channels and missing data due to artefact rejection. Our results showed that an automated bedside classifier of EEG background is achievable, and we publish the full classifier algorithm to allow further clinical replication and validation studies. (shrink)

This study identified the influences of maternal socio-demographic and antenatal factors on stillbirths and neonatal deaths in New South Wales, Australia. Bivariate and multivariate analyses were used to explore the association of selected antenatal and maternal characteristics with stillbirths and neonatal deaths. The findings of this study showed that stillbirths and neonatal deaths significantly varied by infant sex, maternal age, Aboriginality, maternal country of birth, socioeconomic status, parity, maternal smoking behaviour during pregnancy, maternal diabetes mellitus, maternal hypertension, antenatal care, plurality (...) of birth, low birth weight, place of birth, delivery type, maternal deaths and small gestational age. First-born infants, twins and infants born to teenage mothers, Aboriginal mothers, those who smoked during the pregnancy and those of lower socioeconomic status were at increased risk of stillbirths and neonatal deaths. The most common causes of stillbirths were conditions originating in the perinatal period: intrauterine hypoxia and asphyxia. Congenital malformations, including deformities and chromosomal abnormalities, and disorders related to slow fetal growth, short gestation and low birth weight were the most common causes of neonatal deaths. The findings indicate that very low birth weight (less than 2000 g) contributed 75·6% of the population-attributable risks to stillbirths and 59·4% to neonatal deaths. Low gestational age (less than 32 weeks) accounted for 77·7% of stillbirths and 87·9% of neonatal deaths. The findings of this study suggest that in order to reduce stillbirths and neonatal deaths, it is essential to include strategies to predict and prevent prematurity and low birth weight, and that there is a need to focus on anti-smoking campaigns during pregnancy, optimizing antenatal care and other healthcare programmes targeted at the socially disadvantaged populations identified in this study. (shrink)

L'extrême barbarie de la seconde guerre mondiale, et l'espoir d'une vie différente pour l'humanité, ont amené M. Merleau-Ponty à réfléchir sur le marxisme - théorique d'une part, stalinien d'autre part. Notre projet consiste à suivre son cheminement intellectuel à cet égard depuis ses premiers écrits politiques de '45 jusqu'en I960, quelques mois à peine avant sa mort subite survenue il y a exactement trente ans, en mai 1961. Mais en quoi est-il pertinent, à l'heure où un vent d'Histoire plane sur (...) l'Est, de revenir sur des textes dont certains atteindront bientôt le demi-siècle ? C'est que l'auteur a vu clair avant presque tout le monde, de telle sorte qu'il réussit à identifier, inscrite dès l'origine dans son propre système, l'asphyxie inévitable du régime soviétique. Aussi, lire le Merleau-Ponty de ces années pas si lointaines, c'est lire à notre avis l'URSS de Gorbatchev et voir également s'épanouir la nouvelle Europe depuis Prague jusqu'à Sofia. C'est comprendre du même souffle - ce que n'eût point désavoué Marx - qu'on ne saurait bâillonner indéfiniment, enracinée dans le tissu de l'homme, la Volonté-de-liberté des peuples et des nations.The extreme barbarity of the Second World War, and the hope for a different life for Humanity, lead Merleau-Ponty to reflect on marxism, theoretical as well as Stalinian. Our aim is to follow his intellectual progress on this subject since his first political writing, from 1945 until I960, that is, just a few months before his sudden death in may 1961. However, where is the relevance to come back to these fifty years old texts when History blows on eastern countries? Simply because Merleau-Ponty has foreseen the present situation almost before any other analyst, in such a way that he identified successfully the unavoidable asphyxia of the soviet regimen, as inscribed at the very outset of this political system. To read the Merleau-Ponty of these years, it is, do we think, to read the USSR of Gorbatchev, and to see also the new Euro pa to expand, from Prague to Sofia. It is also to understand, by the same occasion - and Marx would not have disavowed it -, that one cannot silence indefinitely the Will of liberty of people and nations which is routed in the nature of man. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Vice and ViciousnessGwen Adshead (bio)Keywordspsychiatric diagnosis, antisocial behaviorI am Grateful to Professor Sadler for such a clear and helpful account of how human misconduct (or vice) has been confounded diagnostically with human disease (as defined by the Diagnostic and Statistical Manual of Mental Disorders [DSM] classificatory system); and even more grateful for the chance to offer comment. Professor Sadler’s paper raises questions about the DSM enterprise as a whole; (...) and this is a field in which I have no particular experience to offer for additional discussion. But his other main point is that psychiatrists are constantly invited to distinguish between vice and disease, and he gives three examples, one of which is a clinical case from my own research. I entirely agree with him that this is a good example, and in this commentary, I will explain why.The argument is about how to distinguish between human behaviors that reflect chosen deviance from prosocial norms and behaviors that reflect a diseased state of mind. Arguments are both legal and political: Aristotle, in the Nichomachean Ethics sets out conditions in which a man should not be blamed for his behaviors, and to some extent these conditions still hold good in the criminal court; ignorance of the meaning of one’s actions, or being forced to act under duress, are good legal defenses. Politically, as Professor Sadler makes clear, the arguments were set out first by Foucault and then Szasz; it is possible for the state to use medical discourse to turn what might be a legitimate social grievance into individual pathology—the ultimate ad hominem argument.These arguments have not gone away, despite the best efforts of a materialist wing of neuropsychiatry, aided and abetted by pharmaceutical companies, who have a great interest in reductionist arguments in the biosciences. This is particularly so in relation to antisocial behaviors, especially crime. I want to focus on one particular type of antisocial behaviors, namely, the wish to hurt another person. I focus on this because it is my clinical bread and butter: My work as a forensic psychiatrist and psychotherapist requires me to try and understand how and why people want to hurt others. But I think it also makes sense to focus on this because it is the most problematic wish socially and demands understanding. All three of Professor Sadler’s examples involve hurt and harm to others, and it is noteworthy that neuroreductionist or medicalized explanations are rarely sought for theft or tax evasion. This must be in part because socially we think it is normal to try and profit yourself, even illegally, if you can get away with it. (I actually think that such behavior is not all that normal, but that is an argument for another day).Let us take the clinical example from my own work, cited by Professor Sadler. It is an example of what is called in the DSM “Factitious Disorder by Proxy” (FDP), although it also has an unhelpful eponym of “Munchausen’s Syndrome by Proxy.” As a practicing forensic psychiatrist, it is one of the best examples I know of what has been crudely dichotomized as a “mad or bad?” debate. A [End Page 23] mother quite deliberately makes her child ill, and then presents the child to medical services as in need of hospital treatment. In the case I described with Dr. Bluglass, the mother smothered her baby girl and then presented her as having “breathing difficulties” (which was, of course, quite true in one sense). There are two examples of vice here: deliberately hurting your child and lying to others about it; the lies also have the indirect result of potentially causing more harm to the baby. Harming your child, and then lying about it, in a not-for-profit way, are criteria for FDP.Quite how these actions ever made it into the DSM is puzzling, when they are quite straightforwardly antisocial. If a man in the street were to smother another man to the point of asphyxia, and then lie about it, we might well ask many questions about why he had done it, but we would not say that no offence had occurred. We... (shrink)

OBJECTIVE: We studied and compared the attitudes of pregnant women v new mothers in an attempt to confirm changing patterns of maternal response towards medical ethical decision making in critically ill or malformed neonates. DESIGN: Data were obtained by questionnaires divided into three sections: 1. sociodemographic; 2. Theoretical principles which might be utilised in the decision-making process; 3. Hypothetical case scenarios, each followed by possible treatment options. RESULTS: Pregnant women (n = 545) consistently requested less aggressive medical intervention for the (...) hypothetical cases than did new mothers (n = 250) [Trisomy 18: 57% v 42%; p = 0.0004; Asphyxia: 75% v 63%; p = 0.0017; Down's syndrome 81% v 62%; p = 0.0001; LBW 85% v 75%; p = 0.004]. Significant differences were also observed in the responses to the theoretical principles, with pregnant women attributing less importance to preserving life at all cost, while being more concerned with physical and emotional pain and suffering, with financial cost, and with the infant's potential for future productivity. (shrink)