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Yoshitada5 1 Introduction/Background: To summarize the clinical features and Kobe University Hospital purchase tinidazole visa, Department of Rehabilitation Medi- the genetic factors of Sotos syndrome and to look for an effective cine discount tinidazole 300mg, Kobe order tinidazole master card, Japan cheap tinidazole 1000 mg free shipping, 2Kobe University Graduate School of Medicine, method to rehabilitate. Material and Methods: Report the clinical Department of Orthopaedic Surgery, Kobe, Japan, 3Kobe Univer- manifestation, genetic testing results and other relevant factors of sity Graduate School of Medicine, Department of Pediatrics, Kobe, a patient with Sotos syndrome and review the literatures. Results: Japan, 4Kobe University Graduate School of Medicine, Depart- Sotos syndrome is a overgrowth syndrome, which features mainly ment of Neurology/Molecular Brain Science, Kobe, Japan, 5Kobe overgrowth in childhood, craniofacial abnormalities, developmen- University Graduate School of Medicine, Division of Rehabilita- tal delay and learning diffculties, meanwhile with some different tion Medicine, Kobe, Japan characteristics. Orthopaedic management of the club foot in The Prof Dr R 1University Malaysia Sabah, Faculty of Medicine and Health Sci- Soeharso Ortopaedic Hospital using the Ponseti method. Manage- ence, Kota Kinabalu, Malaysia, 2University Kebangsaan Malaysia, ment of Rehabilitation Medicine for the club foot is maintained Rehabilitation Unit- Department of Orthopaedics and Traumatol- the corrected club foot after the period of conservative treatment ogy- Faculty of Medicine, Kuala Lumpur, Malaysia, 3University of with Ponseti serial cast by Orthopedic Surgeon. Material and Methods: This study used cross sectional de- Introduction/Background: In the early childhood years, children sign with data collected from the medical records from Jan at 2013 begin to learn fundamental motor skills which is not maturation- until Dec at 2014. Flexibility assessment of the foot by measuring ally driven but requires environmental support and multiple op- of cavus, adductus, varus and equinus degrees pre Ponseti cast, pre portunities to acquire and hone these skills. These samples included 18 children, or has been linked to other areas of development such as language 27 feet, due to not all the children had bilateral club foot. Results: and social skills, working memory and verbal fuency, children’s the number of baby boy is more dominant for 11 children (61. Results: Twenty three autism, 8 treatment to maintained the correction of the club foot. All the children had normal ability 724 with audition, limb (left) and overall health. Left eye and right eye abilities were lack- 1Bundang Jesaeng General Hospital, Department of Rehabilitation ing in 5. Lacking in right limb abilities Medicine, Seong-nam si- Gyounggi-do, Republic of Korea was in 2. The data 1University of Padjadjaran, Physical Medicine & Rehabilitation, were analyzed using frequency analysis. Results: At the domain Bandung, Indonesia level, the activities and participation domain was highly checked in the all age groups. Items related with activities of daily lives were Introduction/Background: Most children with arthrogryposis have frequently mentioned. In the body functions domain, mental functions of lan- their potential functional. Rehabilitation programs aim to achieve guage, mobility of joint functions, and gait pattern functions were their fullest potential to facilitate and promote maximal independ- J Rehabil Med Suppl 55 Poster Abstracts 211 ent function in mobilization, activities of daily life and so improve 728 quality of life. X ray of upper and lower extremi- tion Department, Kunming, China ties revealed arthrogryposis of these joints. Serial casting Introduction/Background: To discuss the common causes of in- was undertaken at the age of 5 days to 3 months once a week in fants’ emeses in the course of hyperbaric oxygen therapy and fnd Orthopaedics Department. Cock up splint was un- The top four reasons of infants vomiting in the course of hyperbaric dertaken at the age of 7 months to present. Researchers took appropriate measures depend- Results: Range of motion of contracted joints has been increased ing on the situations. Mobilization function including sit- advance, the rest all had a normal and safe therapy and no asphyxia ting independently from prone position, standing and side to side happened. Conclusion: Not following the before entering cabin di- walking with support has been achieved. However, hand dexterity etary guidance combining crying in the cabin is the main cause is poor and no improvement in fne motor skill. Taking appropriate eral services in rehabilitation can improve functional performance measures according to the different situations, end the therapy in in arthrogryposis. Further follow up and evaluation of interventions advance if necessary, is the effective measure to make sure infants is still be needed to achieve optimal function in mobilization and will not be chocked on vomits. At 24 h, we can see obvious edema and method to promote children’s recovery and reduce the abnormal rate. At 7 day, the ligated side was atrophy; Compared with control group, the intervention group has light changes. Results: In our population of 121 post-menopausal women, ing Research Center, Taoyuan, Taiwan 77 women (63. Many studies have shown its benefcial conditions limiting mobility, including dysmobility syndrome, in effects of physical and cognitive function in older adults without patients with a history of fragility fractures might be useful to iden- cognitive impairment, but evidence in those whom with cogni- tify those who have a higher risk of new fractures. There are growing applications of the interactive game-Kinect in health promotion and rehabilitation to enhance motivation and participation of the clients. Results: There tion in comparisons with other existing equations in patients with were no signifcant differences of basic characteristic data between cerebral infarct during acute care. The Owen and Japanese sim- tion did not reach signifcance, but with the Tai-chi group revealed plifed equations use sex and weight as explanatory variables, the relative maintenance and the control signifcantly decline after 6 Harris-Benedict and Miffin equations include sex, weight, age and month. Actual resting in improving balance, endurance and behavior problems, reducing energy expenditure values were assessed by indirect calorimetry on care burdens, and at least maintaining cognitive function. The absolute values of the differences between the actual resting energy expenditure and the predicted values derived from the equations were used in analyses. Material and Methods: In this retrospective case-control study we examined data from the medi- P. Cases were represented by 1Surabaya, Indonesia, 2Widya Mandala University, Medical School, women who had had a fragility fracture at least a year before the Surabaya, Indonesia evaluation and controls were women without any fragility fracture. They tend to restrict their activity which J Rehabil Med Suppl 55 Poster Abstracts 213 could lead to a decrease in their functional mobility capability and 735 their balance. Material and Methods: It was a cross-sectional study to a Introduction/Background: The aim of the study was to review the 128 elderly healthy subjects from the catholic church community- various causes which may lead to inpatient falls in the rehabilita- dwelling, 93 females and 38 males, 68. Results: There was no signifcant differences Medical Center, Israel between the years 2008–2012. Conclusion: The experience have infuenced the occurrence of the fall, action which caused the of falling has no effect in older Adults’ Fear of Falling and their fall, location in the hospital where the fall occurred, and the injury functional mobility. Results: The patients who fell once were falling is related to the balance ability. More subjects have to be hospitalized in the rehabilitation department for various reasons, examined to understand the relationship of mobility limitation and for example: cerebral injury of vascular, or traumatic origin, after fear of falling. Elderly with mild cognitive disorders are considered at higher risk for developing dementia. Results: 15 participants, diagnosed with very mild to mild cognitive Introduction/Background: Stationary geriatric early rehabilitation is impairments, were recruited form neuro-psychiatrists. Demograph- very well implemented and suffciently standardized in many coun- ic data was showed as followed: male: 12; age: 79. Fall incidence is the patients from 2008 to 2014 which our department of Geriatrics 3/15. Fall has a moderate correlation orthopaedic and internal/cardiological departments. It does not as well as 286 cardiological/internal patients with an average age disturb the movement of the larynx. Each subject was fxed to the stable posture of the head and is possible to obtain a suffcient functional progress for all patients asked to swallow a spoonful of jelly and 3mL of water. Displacement of the bright spot matrix was analyzed and 737 calculated laryngeal elevation time. Lan2 measured laryngeal elevation time using a newly-developed optical 1China Medical University, Department of Physical Therapy, Tai- laryngeal organ motion analysis system. Positive correlation was chung, Taiwan, 2China Medical University, Department of Health found between age and the laryngeal elevation time in water swal- Risk Management, Taichung, Taiwan, 3China Medical University, lowing, whereas no signifcant correlation in jelly swallow. Katsuki1 has been little available evidence about the barriers and facilita- tors of people’s health in the community caring centers in Taiwan. Par- formula and that can be directly connected to feeding tubes with an ticipants were also invited to wear a wrist-band physical activity re- adapter. Results: Overall, 127 participants id enteral formula and an adapter reduced the time of nursing work completed the questionnaires (age: 74. Material and of those, 5 also agreed to wear the physical activity record- and Methods: Five trained nurses were recruited for the evaluation. With the good validity of wearable health tion, and cleaning were measured with a stopwatch.

Children of psychiatric patients are often adversely affected across a wide range of functions; they are often ignored in routine anamnesis; parents may fear being blamed and having their offspring removed from their care; and a significant minority of childhood psychiatric problems persist into adulthood purchase 500mg tinidazole with mastercard. Also discount tinidazole online american express, while reminiscence may be enjoyed many by senior citizens buy discount tinidazole 300 mg on-line, it may be irritating for others cheap 1000mg tinidazole otc. Leaving home may be resisted tenaciously, and change of any type may be traumatic. Stress hormones, neurotransmitters and cytokines are among several mediators that are essential for maintaining stability (or homeostasis) through change, a process known as allostasis. If release is not switched off following cessation of stress, if they are excessively employed in response to numerous stressors, or if they are 502 inadequately turned on, then the body experiences damage. Social institutions are given overt roles that may be markedly different from their latent roles. In some countries the army is meant to protect the inhabitants from external aggression but in fact it is employed to enforce conformity on the internal citizenry. Goffman’s (1961) ‘total institution’, an attack on badly run asylums, described regimes where everything is done in the one place and in a regulated fashion, where 506 patients have no social roles and progressively lost autonomy , and where patients and staff are kept socially apart. Nurses, the ‘culture carriers’ of the hospital, decided who should see a psychiatrist. Nevertheless, not all research points the finger at institutional environments, and patients with schizophrenia may still have negative symptoms or a ‘clinical poverty syndrome almost a decade after discharge. Among the great array of functions attributed to cytokines are cell multiplication/repair/migration (including embryogenesis/organogenesis), angiogenesis, and immunity/inflammation/fibrosis. Interferons are divided into alpha and beta (type-1, antiviral) and gamma (type-2, immunostimulation, from cells such as natural killer cells and some helper T cells). Haematopoietins include granulocyte- and granulocyte monocyte- colony stimulating factors. The term ‘illness behaviour’ refers to the various ways in which a symptom(s) may be perceived, evaluated and acted upon, i. Divorcees die earlier and have more psychiatric (depression, anxiety, alcohol abuse) and physical illness than married people. The exact direction of causality is probably complex and variable between couples. McWhinnie’s (1967) retrospective analysis found that 10 of 58 adopted adults had suffered from mental illness. Wieder (1977) found a 15-30% incidence of adoptees in the psychiatric population compared with 2% of the general population. Illegitimacy, along with new genetic mutations and low penetrance, complicate counselling. Intercountry adoption in Sweden may be associated with an excess of suicide and attempted suicide, psychiatric admission, drug/alcohol abuse, and criminality. According to 508 Term dating from The Social System of 1951 by Harvard sociologist Talcott Parsons (1902-79). Using a modified Edinburgh Postnatal Depression Scale Payne ea (2010) looked at adoptive mothers during the first post-adoption year and found that the mothers may become depressed as a result of stress and problems of adjustment. China’s 1995 Law on Maternal and Infant Heath Care ordered compulsory premarital examination for serious genetic diseases, some infectious diseases, and ‘relevant’ mental disorders. Options for those with ‘positive’ testing were long-term contraception or tubal ligation. The Irish 513 Supreme Court defined ‘unborn’ as applying to embryos only following implantation in the womb. There might be 70,000 deaths among women from unsafe abortions, and perhaps 5 million women were temporarily or permanently disabled. According to Anonymous (2007c) each year there are 210 million pregnancies world-wide, one in five end in abortion, ¾ such women live in developing countries, 97% of the 20 million annual unsafe abortions occur in developing countries, ¼ of the women are aged 15-19 years, 68,000 women die from unsafe procedures, and 5. Sedgh ea (2007) estimated 46 and 42 million induced abortions worldwide in 1995 and 2003 respectively; there were 31 abortions for every 100 livebirths in 2003; and 48% of abortions were unsafe and 97% of these were in developing countries. Also, when abortion became legal in South Africa there was a huge reduction in maternal mortality. The rate for British 521 women having abortions is much higher than for Irish women. Single women outnumber other categories in abortion statistics, although Clare (2000, p. Pushing a pregnant young female to marry the child’s father cures nothing and may make matters worse. The Irish Medical Council approved (December, 2001) an amendment to it’s A Guide to Ethical Conduct and Behaviour, Fifth Edition 1998, recognising ‘that termination of pregnancy can occur when there is real 522 and substantial risk to the life of the mother’. In 2009 the Irish Medical Council added a ‘clear and substantial’ risk of maternal suicide. Since 1967, the law in England and Wales allows abortion act on grounds of likely damage to the health of the mother or her children. An English analysis of 1994-2000 showed that teenage pregnancies peaked in 1998, declining thereafter; this was associated with less conceptions and births and a 7. Satisfaction with abortion and negative emotions may decrease and increase respectively with the passage of time. Gissler ea (1996) in Finland found a suicide rate in the year after abortion to be thrice that of the population rate. The first problem here is weeding out whether abortion leads to suicide or whether a common cause operates for both abortion and suicide, and the second difficulty is that the same authors report a doubling of suicide after miscarriage. There is evidence that if the mother of an unwanted pregnancy is forced to proceed to term, both she and her offspring will experience later psychosocial difficulties. One might speculate that unwanted pregnancy might correlate with psychosocial difficulties in the first place. Because some women do experience psychological problems following abortion it is important that appropriate follow-up care be available. In January 2002 the French Parliament adopted a bill which overturned a court ruling that had compensated 528 a boy disabled by rubella contracted in utero. The court had held that because doctors had failed to diagnose rubella (because of laboratory error) that an abortion had not been recommended! Lack of social competence, an inability to attain and perform certain social roles, and a lack of self- confidence characterises a group of people who show increased vulnerability to mental breakdown. Social variables (status, roles, home circumstances) may be as important as severity of symptoms in determining who receives treatment and in what setting, as well as the type of label (e. Social factors are also important in relation to readmission and relapse rates: lack of social supports, high levels of expressed emotion. Unemployment appears to have a real but complicated relationship with depression (Gavin ea, 2010) and suicide in both sexes,(Kreitman, 1993; Stuckler ea, 2009) completed and attempted. Unemployment rates are a very powerful indicator of the serious mental illness requiring inpatient treatment in the working-age population. The best chance for the severely mentally ill, including first-episode psychosis cases (Killackey ea, 2008), getting a job is to offer supported employment (placement in competitive work while offering on the job support) rather than offering prevocational 530 training. Organisational downsizing (reduction in personnel numbers) may increase sickness absence and the risk of death from cardiovascular disease in those who are left in the job. The role of propaganda in spreading racism can hardly be 533 disputed given the many examples of history. Obviously, many factors potentially interact in an individual to promote violence (Anonymous, 2008a) and research has been poor at weighting them, even at the population level. Relatives of patients may conceal their association with the mentally ill (Murphy, 1999) or may experience stigma by association, especially if experiencing mental health problems of their own. Luty ea (2007) found that didactic factsheets largely failed to alter stigma for schizophrenia and alcoholism. According to some authors,(Murphy ea, 1993; Wolff ea, 1996a) older age, low educational level, and low socio-economic status predict negative attitudes towards the mentally ill, whilst greater knowledge about the subject is associated with more sympathy and less fear. However, Crisp ea (2005) found that 16-19 year 531 Under the former the employer had to make accommodations for disabled employees up to a nominal cost, whereas under the latter the employer is obliged to do so unless such accommodation would constitute an undue burden or hardship for the employer. Negative discrimination was common and centred around making or keeping friends, the family, finding and keeping employment, and intimate and personal relationships.

Demonstrations of specimens discount tinidazole 500mg visa, photographs discount 500mg tinidazole otc, and slides of both dead bodies and living people generic 300 mg tinidazole amex. Demonstrations of specimens buy tinidazole 500 mg overnight delivery, photographs, and slides of both dead bodies and living people. Types of mechanical asphyxia- hanging, ligature strangulation and manual strangulation – general and type characteristics, manner of death. Other types of mechanical asphyxia - drowning, airway obstruction, postural asphyxia, asphyxia due to exhaustion or displacement of environmental oxygen. Medicolegal autopsy in cases of traumatic injuries, postmortem changes, diagnosis of death. Introduction and preparing a specific Forensic Medical Expert Examination for a particular case. Practical introduction of the methods of chemical examination of biological materials. Basics of legal proceedings in Forensic Medicine in the Republic of Bulgaria (Penal Procedure Code and Code of Civil Practice). Blunt force trauma – definition, types, mechanism of causation, morphological characteristics of the injuries. Abrasions – definition, mechanism of causation, morphological characteristics, medicolegal importance. Bruises – definition, mechanism of causation, morphological characteristics, medicolegal importance. Lacerations - definition, mechanism of causation, morphological characteristics, medicolegal importance. Motor vehicle trauma – definition, classification, major issues concerning Forensic Medical Expert Examinations. Common morphological characteristics in cases of death caused by mechanical asphyxia-postmortem appearances. Airway obstruction, postural asphyxia, asphyxia due to exhaustion or displacement of environmental oxygen. Major issues of Forensic Medical Expert Examination in cases of mechanical asphyxias. Major issues concerning Forensic Medical Expert Examination in cases of electrical injuries and lightning stroke. The impairment of health and death caused by the effect of chemical agents (Forensic Toxicology). Medium bodily injury - legal and medical criteria (article 129 from Criminal Code) 31. Severe bodily injury - legal and medical criteria (article 128 from Criminal Code) 32. Fornication (act for the purpose of arousing or satisfying sexual desire, without copulation - articles 149 and 150 from Criminal Code). Homosexual acts (sexual intercourse or acts of sexual satisfaction with a person of the same sex - article 157 from Criminal Code). Rape (sexual intercourse with a person of the female sex - 329 article 152 from Criminal Code). Short summary for different types of examination- genetic and serological methods. Forensic Medical Expert Examination of dead body in cases of sudden natural death. Early postmortem changes –changes in the skin, changes in the eye, livor mortis, algor mortis and rigor mortis. Application of medical methods for diagnosis and treatment leading to a temporary change in consciousness. Score assessment Participation in seminars, weekly tests, essay preparation and presentation Semester exam: Yes / written and oral examination State Exam Yes Lecturer Full Professor from the Department of Epidemiology Department: Epidemiology and medicine of disastrous events. Methodology and methods of epidemiology of infectious diseases and their application in the study of massive, socially significant diseases. Epidemiologic characteristics, prevention, surveillance and control of infectious diseases. Teoretical and practical training in the field of epidemiology as a essential medical discipline. Knowledge about the mode of transmition and distribution of infectious diseases and the system of measures for prevention and control them. Knowledge of basic epidemiological characteristics of chronic mass non communicable diseases and their prevention and control. Knowledge of basic epidemiologic characteristics of non communicable diseases with massive infectious etiology and their prevention and control. Skills such as physicians to participate in solving practical problems limiting, reducing economic and social losses, elimination and eradication of infectious diseases. Theoretical knowledge about the epidemiologic features characteristic of mass non communicable diseases with such infectious etiology. Technical means and methods - autoclave, desinfection chamber - evaluation effienciency of prevention and control. Practical skills: - To make the epidemiologic history of different infectious diseases. Subject, theory and methods of epidemiology of infectious diseases and epidemiology of mass non-infectious diseases. Definition, the aim, the main tasks of epidemiology of infectious diseases and epidemiology of mass non-infectious diseases. Theory of epidemiology of infectious diseases: theory of epidemic process, epidemiologic aspects of infectious process, epidemiologic aspects of epizootic process, socio – ecosystemic dependency of diseases, molecular-genetic processes in microbial populations. Methods of epidemiology: descriptive-evalutional, observation, experimental, analysis and synthesis, molecular-genetic, molecular-biologic. Source of infection: definition of source of infection and a reservoir, a animal reservoirs, non animal reservoirs. Transmission of infectious diseases: direct and indirect contact, air born, fecal oral, blood, vector-borne transmission, derma, factors for transmition. Human behavior among family members among family members, school, work, different groups etc. Natural factors of epidemic process : geographic-climatic-meteorological and cosmic influences depending the place and time. Non infectious diseases: environmental factors, social factors, life-style related factors, iatrogenic factors. Criteria for elimination and eradication: economic considerations , social and political. Epidemiology of air born infections: Diphtheria, Scarlet fever, Meningococcial infection, Pertussis. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mode of transmission, Immunity after disease,Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease, Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease,Characteristics of epidemiological process: Lethality, Season, Age, Morbidity. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, 340 Immunity after disease,Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease,Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease,Characteristics of epidemiologic process: Lethality, Seasonal features Age, Morbidity. Epidemiology of tick borne infections: Congo-Crimean fever, Q – rickettsiosis, Mediterranean Spotted fever, Lyme disease. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease,Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease,Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity.

Fetal screening will also aVect the view of pregnancy as being unreal until the quality of the fetus is guaranteed (‘tentative pregnancy’ as formulated by Rothman buy 300 mg tinidazole, 1987) and attachment to the fetus may be weakened order generic tinidazole on-line. Although it may not aVect existing children with disabilities purchase 500 mg tinidazole visa, this value judgement may in the long run create a more negative view about people with disabilities order tinidazole once a day. Ethical and social aspects of evaluating fetal screening 185 worry about one’s worthiness nature of reproduction fetus position Existence attachment to the fetus views of disabled people veiws on reproduction eugenics worry Doing the test attachment to the fetus physical harm worry relationship with child False positives subsequent children diagnostics adverse effects False negatives disappointment relationship with child disability abortion attitudes True positives no abortion guilt responsibility health other services Resources costs place of care personnel structure Figure 12. Hemminki positives are false positives) and because the diagnosis, usually by amniocent- esis, takes weeks, there is a great deal of well-documented stress for the pregnant woman and her partner (Santalahti et al. This worry may make the couple’s lives miserable and may negatively aVect the pregnancy experience, with ongoing ramiWcations for family relationships and subse- quent pregnancies. False negatives (when the fetus has the condition but it is not detected by the screening test) may lead to disappointment – the mother/parents falsely assume the child to be normal, and they may be totally unprepared at the birth. In the case of true positives (when the condition is deWnitely conWrmed from the screening test or in a diagnostic test) the option of termination, often at late gestation, has to be faced. Because screening tests may require special skills and technology, they may have a notable impact on the place of antenatal care and type of personnel needed (Hemminki et al. Measuring of maternal blood pressure and weight, and doing various laboratory tests with the aim of identifying deviations or pathological Wndings are core elements. It is true that abortion is not the sole purpose of fetal screening, as knowledge of a handicapped fetus may be important in planning for delivery and newborn care. Other special features diVerentiating fetal screening from other antenatal Ethical and social aspects of evaluating fetal screening 187 screening include its target, the involvement of other people and its relation to eugenic ideology. Fetal screening has an impact not only on the mother and her fetus, but also on the father and siblings of the child, especially in cases of genetic screening. On a societal level this question may bother handicapped people in general – if the birth of people like themselves is not wanted, they may think that they are not wanted either. The fourth special feature of fetal screening, diVerentiating it from other antenatal screening procedures, is its possible relation to eugenic ideology. Eugenics was prominent in the western world early in the twentieth century, but is a source of shame today because of its connection to fascist politics and nationalistic and racist movements (Hemminki et al. Before the technology for fetal screening was available, the reproduction of people assumed to have unwanted hereditary characteristics was regulated either through isolation in institutions, marriage prohibitions, sterilizations and other pregnancy prevention methods, or through unselective abortions if an aVected woman got pregnant. A Wfth of the physicians agreed that it was so, in whole or in part; about half said it was not; and most of the other respondents either could not say or chose the option, ‘I do not know what eugenics is and cannot make a comparison’ (Hemminki et al. Those physicians who agreed that fetal screening was not linked to eugenics based their opinion on the intention and voluntariness of screening, focusing on improvement of a race versus de- creasing suVering among individuals. Fetal screening is based on certain values and beliefs, such as the import- ance of health, the feeling that a handicapped child is worse than none at all (particularly if there is an option of having a chance to try again) and the perception that handicaps cause suVering to the child itself, the parents 188 E. Through the organization of screening programmes and concomitant research, medicine and health care have been given the author- ity to deWne which diseases and characteristics qualify for these beliefs. In Finland, the oYcal time limit between a miscar- riage and birth is 22 gestation weeks, meaning that products of pregnancies spontaneously ending after 22 weeks will be recorded as children. In the following I compare, as examples, the ethical debates on fetal screening to those on abortion, in vitro fertilization and the intensive care of preterm infants (Hemminki et al. In fetal screening (and consequent selective abortions) ethical discussion has focused on the rights of parents to have healthy children, on the rights of disabled persons, on unintended eVects of screening procedures and on the general threat of eugenics as an ideology. Although the balance between additional surviving healthy infants and additional disabled infants saved is highly positive, with far more healthy than disabled survivors, the absolute numbers of children with disabilities may have increased as a result of neonatal intensive care (Hagberg et al. For example, although selective termination of pregnancy after screening is sometimes only possible after the twentieth week of gesta- tion, little of the ethical literature on screening has concerned the start of life and its ending, issues so central in the abortion discussion. In many countries the oYcial statistical limit for abortion and birth is 22 weeks of gestation, and newborns born spontaneously at that age often receive treat- ment to keep them alive, sometimes even successfully. Finally, when fetuses are screened using chorionic villus biopsy or amniocentesis, some pregnancies with healthy fetuses will be unintentionally terminated as a result of such screening itself. Hemminki pregnancies, the practice has emerged of terminating some of the fetuses to reduce the number of infants to be born and thus the risk of prematurity (see Chapter 16). As I have argued in the preceding section, there is a great deal of inconsistency in what ethical factors are thought crucial in diVerent interventions. Perhaps this is explained by the general marginality of ethics in medicine until comparatively recently, by increasing specialization in health care provision, by each intervention’s unique history and rationale, and by the diVerent main purposes of the activities (Hemminki et al. But it would be useful to think of common principles that apply to diVerent interventions, to classify the interventions by the ethical principle on which they are based and to acknowledge the ethical principles with which they are in conXict. It would require a lot of theoretical and methodological thinking and research to be able to compare, for example health and ethical consequences jointly in the way one currently compares health and economic consequences. Furthermore, indi- vidualistic thinking emphasizes autonomous choices as the answer to various ethical problems, forgetting the societal perspective of consequences and control. The myth of the objectivity of research is strong among health and economic researchers, and they may Wnd the explicit value requirements of ethics diYcult. It is easier to Wnd examples of techniques that Ethical and social aspects of evaluating fetal screening 191 are eVective but ethically unacceptable, than to Wnd an example of an ineVective technique which for ethical reasons should be used. Even though public health people think in terms of groups and societies, the units of measurement are usually on an individual level, which are then summed up to form a group eVect. The current state of aVairs where the value of a health technology is judged only on the basis of some of its consequences, and the use of the technology is promoted on the basis of such deWcient information (in addition to commer- cial and other interests), is not satisfactory. Other counter- arguments include the claim that such considerations result in censorship and harm all innovative basic research, and the possibility that someone somewhere will do such research anyhow. When we have the technology ready, arrangements similar to those currently in place for drugs could be introduced – drugs are not allowed to be marketed before assessment. This is relatively artiWcial even in regard to health eVects, and when social and ethical dimen- sions are introduced, the need to inspect a technology within a context becomes very evident and necessary. Most new technologies are produced by proWt-making companies, or their products are needed in producing the technology, and commercial pressures are clear. But professionals may also have proWt motives – their own income may be inXuenced by the use of a technology, and above all, their professional image and esteem, both per- sonally and as a disciplinary group, may depend on it. Because evaluations currently are narrowly done and the crucial ethical and social elements are usually not there, the strong commercial and professional pressures are likely to lead to unnecessary, premature or too widespread use of health technol- ogy. These questions include not only personal, mother–child rela- tionships, but also the way that parenting generally, like pregnancy, may be becoming tentative and provisional, instead of the unconditional acceptance of the child as ‘a gift of God’ common in traditional rhetoric, at least, if not in practice. Prenatal counselling Prenatal testing and counselling have expanded since prenatal diagnosis of Down’s syndrome, thalassaemia and sickle cell anaemia began through am- niocentesis in the late 1960s. Chorionic villus sampling (cvs), another diag- nostic test which also draws fetal material from within the maternal abdo- men, has since been developed. There are now two further and less invasive methods: examination of serum from maternal blood tests; or, from about 12–15 weeks gestation, nuchal translucency (swelling in the fetal neck) by ultrasound scanning. In Britain, in areas where there are many members of ethnic minority groups aVected by sickle cell anaemia or thalassaemia, universal prenatal screening for these conditions has been implemented or proposed. Alderson cystic Wbrosis – is not yet routinely screened for, but, as with other mono- genetic conditions, prenatal tests are often oVered to families known to be aVected. The tests may be preceded or followed by counselling, which ranges from giving medical results to detailed discussion about the nature and meaning of the tests, the results and the possible choices they oVer (Green and Statham, 1996; Marteau et al. There is a crucial diVerence in knowledge of the condition being tested for between people with an aVected close relative who have personal experience and who opt-in to have prenatal tests, and the ‘healthy’ unaVected majority of pregnant women who are routinely screened unless they opt-out. Yet because personal opt-in testing involves far fewer people and tends to be done by clinical geneticists, whereas mass screening involves far more people and is done by generalist prenatal staV, the latter group usually receive less counselling (Clarke, 1994, 1997). Prenatal counselling can begin before conception, when people in a ‘high risk’ group or family are tested for their carrier status of single gene condi- tions. So a positive result leads on to decisions about whether or not to have the more invasive deWnitive tests of amniocentesis or cvs, and whether or not to continue with the pregnancy. Advantages of prenatal counselling Advocates of universal prenatal screening and counselling say that the servi- ces oVer every woman information and opportunities to choose. With fetal tests, parents may be more accepting of an impaired child if they are able to prepare emotionally before the birth, and are also able to feel that they chose to have the child rather than feeling imposed upon. Termination of aVected pregnancies obviates the emotional, practical and Wnancial costs of supporting disabled children, and also pre- vents the suVering which the child and family would otherwise endure. Decades of preconceptual and prenatal screening in Cyprus have contained the costs of treating thalas- saemia, which would otherwise have overwhelmed the national budget (Modell and Kuliev, 1993).