52
in the belief that they have cyanotic heart disease. Whether suitable children genuinely do better with ECMO or whether difficulties in transfer and speed of deterioration make the use of ECMO impossible, can all be answered by a controlled trial. In setting up such a trial, great care must be taken in defining entry criteria, "conventional therapy", and "successful outcome"; these points lie at the heart of the ECMO controversy world wide.z It is our impression that in the UK, ECMO is little more expensive than conventional intensive care. Even in the United States, ECMO is felt to be cost effective. This too needs formal prospective evaluation. We do not wish to see the piecemeal introduction of ECMO. A trial with close attention to entry criteria and to morbidity and mortality is the correct way to establish whether ECMO has a place. Department of Child Health, Leicester Royal Infirmary
D.
J. FIELD
Regional Cardiothoracic Unit, Groby Road Hospital,
R. K. FIRMIN
Leicester LE3 9QE, UK 1. Sosnowski
AW, Bonser SJ, Field DJ, Graham TR, Firmin RK. Extra corporeal membrane oxygenation. Br Med J 1990; 301: 303-04. 2. Lantos JD, Frader J. Extra corporeal membrane oxygenation and the ethics of clinical research m pediatrics. N Engl JMed 1990; 323: 409-13.
US military medical school SIR,—Iam surprised to see The Lancet stoop to such a low level of journalism as Mr Greenberg’s piece (Nov 24, p 1306) on the Uniformed Services University of the Health Sciences (USUHS). One does not need to know the facts to discern the tone of bias and ridicule ("superfluous", "extravagant", "costly relic", "pampered lord", "reprieves from oblivion"). However, those familiar with the facts know that USUHS provides more than 10% of US military physician acquisitions each year. These doctors, besides an excellent medical education, receive extensive military experience which sets them apart from their civilian-trained counterparts. This training is not accomplished at a cost "4-5 times more expensive than civilian medical education". USUHS operates more economically than civilian medical schools (comparisons can be made from data in the Aug 15, 1990, issue of JAMA). Those who are willing to investigate the facts and evaluate the quality of the institution and its graduates will see that USUHS does not need a newspaper columnist as its saviour. The appeal to Ann Landers was to address the publicity issue mentioned in the opening sentence of Greenberg’s article. 700 Fordham St,
Rockville, Maryland 20850, USA
Altered
JOHN W. GARDNER
grounds for abortion?
SIR,-The Human Fertilisation and Embryology Act 1990 amends the Abortion Act 1967 by substituting the following grounds for termination of pregnancy:
"(a) that the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk greater than if the pregnancy were terminated, of injury to the physical and mental health of the pregnant woman or any existing children of her family; or (b) that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman;
or
(c) that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were
terminated; or
(d) that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped." Termination of pregnancy under (a) which is similar to the 1967 Act, can take place up to 24 weeks only, but sections (b), (c), and (d) apply without regard to gestational age.
It had hitherto always been lawful for a doctor to bring a to an end if the woman’s life or health were threatened, the commonest reason for this being fulminant toxaemia, an example quoted several times in the Parliamentary debate. Previously it was the case that if the infant was capable of being bom alive, then, after affording priority to the woman’s own health, every effort to perserve the life and wellbeing of the infant was required. However, very-low-birthweight infants delivered under adverse conditions are at "considerable risk of long-term morbidity". Such babies will be close to or at the limit of viability and at such risk of disability that there could be grounds for destructive delivery under pregnancy
(d). It appears therefore that in the UK
a
doctor
now
needs the
explicit consent of the woman to save her baby during delivery if there is a risk of serious handicap. If she withholds it or cannot give it then the Human Fertilisation and Embryology Act permits the doctor to destroy the child-indeed if the doctor does not, it is conceivable that the parent(s) could bring an action for negligence, using the doctors refusal to apply the criterion in (d). Furthermore (d) bears an interpretation which would apply to any of the common complications of pregnancy which can result in cerebral palsy. The consequences for obstetric management could be very grave involving the destruction of many thousands of at-risk infants. Will it be necessary to take those destructive instruments from the age of obstructed labour from the museum shelves? This Act makes it more expedient to kill than to strive to save where the wellbeing of the child is in doubt. Worcester Royal Infirmary, Worcester WR1 3AS, UK
A. P. COLE J. G. DUDDINGTON
Tolerance and the fetal
graft
(p 538) suggests the expression of a form of the major-histocompatibility-complex non-immunogenic (MHC) class I molecule at the fetomaternal interface as the main reason for maternal tolerance towards the fetal graft. However, in a response to this editorial Dr Innes and colleagues (Nov 3, p 1133) suggest that these molecules are indeed immunogenic. If this is so, why do maternally derived T lymphocytes migrating into the decidua (which is in direct contact with cytotrophoblast) not respond to these MHC molecules? We have demonstrated the lack of expression of the two variants of the T-cell antigen receptor (TCR) by mature intradecidual T lymphocytes during early normal pregnancy.l Our data clearly show that CD3T lymphocytes in first trimester decidua do not express immunohistochemically detectable amounts of &agr;/&bgr; or r/8 TCR molecules. It therefore seems probable that most intradecidual T lymphocytes will not be activated by the antigen and thus will be functionally anergic towards paternally derived fetal antigens. In addition we found that T lymphocytes isolated from the decidua can be induced to express normal amounts of the &agr;/&b(3gr; TCR heterodimer by in-vitro stimulation with phytohaemagglutinin-P and exogenous interleukin-2, which suggests that TCR expression can be restored in this T lymphocyte subset. This supports the notion that the absence of detectable TCR molecules on intradecidual T lymphocytes in situ results from specific down-regulation or modulation rather than from intrinsic deficiency of TCR expression. These findings provide an additional structural basis to explain local matemal tolerance towards the semiallogeneic fetus. SIR,—Your Sept
1 editorial
Departments of Obstetrics and Gynaecology and Pathology, University of Tubingen, 7400 Tubingen, Germany
KLAUS MARZUSCH JOHANNES DIETL HANS-PETER HORNY PETER RUCK EDWIN KAISERLING
Department of Pathology, University of Kiel
HENRIK GRIESSER
Department of Immunology, University of Heidelberg
DIETER KABELITZ
J, Homy H-P, Ruck P, et al. Intradecidual T lymphocytes lack immunohistochemically detectable T-cell receptors. Am J Reprod Immunol (in press)
1. Dietl
in the belief that they have cyanotic heart disease. Whether suitable children genuinely do better with ECMO or whether difficulties in transfer and speed of deterioration make the use of ECMO impossible, can all be answered by a controlled trial. In setting up such a trial, great care must be taken in defining entry criteria, "conventional therapy", and "successful outcome"; these points lie at the heart of the ECMO controversy world wide.z It is our impression that in the UK, ECMO is little more expensive than conventional intensive care. Even in the United States, ECMO is felt to be cost effective. This too needs formal prospective evaluation. We do not wish to see the piecemeal introduction of ECMO. A trial with close attention to entry criteria and to morbidity and mortality is the correct way to establish whether ECMO has a place. Department of Child Health, Leicester Royal Infirmary
D.
J. FIELD
Regional Cardiothoracic Unit, Groby Road Hospital,
R. K. FIRMIN
Leicester LE3 9QE, UK 1. Sosnowski
AW, Bonser SJ, Field DJ, Graham TR, Firmin RK. Extra corporeal membrane oxygenation. Br Med J 1990; 301: 303-04. 2. Lantos JD, Frader J. Extra corporeal membrane oxygenation and the ethics of clinical research m pediatrics. N Engl JMed 1990; 323: 409-13.
US military medical school SIR,—Iam surprised to see The Lancet stoop to such a low level of journalism as Mr Greenberg’s piece (Nov 24, p 1306) on the Uniformed Services University of the Health Sciences (USUHS). One does not need to know the facts to discern the tone of bias and ridicule ("superfluous", "extravagant", "costly relic", "pampered lord", "reprieves from oblivion"). However, those familiar with the facts know that USUHS provides more than 10% of US military physician acquisitions each year. These doctors, besides an excellent medical education, receive extensive military experience which sets them apart from their civilian-trained counterparts. This training is not accomplished at a cost "4-5 times more expensive than civilian medical education". USUHS operates more economically than civilian medical schools (comparisons can be made from data in the Aug 15, 1990, issue of JAMA). Those who are willing to investigate the facts and evaluate the quality of the institution and its graduates will see that USUHS does not need a newspaper columnist as its saviour. The appeal to Ann Landers was to address the publicity issue mentioned in the opening sentence of Greenberg’s article. 700 Fordham St,
Rockville, Maryland 20850, USA
Altered
JOHN W. GARDNER
grounds for abortion?
SIR,-The Human Fertilisation and Embryology Act 1990 amends the Abortion Act 1967 by substituting the following grounds for termination of pregnancy:
"(a) that the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk greater than if the pregnancy were terminated, of injury to the physical and mental health of the pregnant woman or any existing children of her family; or (b) that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman;
or
(c) that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were
terminated; or
(d) that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped." Termination of pregnancy under (a) which is similar to the 1967 Act, can take place up to 24 weeks only, but sections (b), (c), and (d) apply without regard to gestational age.
It had hitherto always been lawful for a doctor to bring a to an end if the woman’s life or health were threatened, the commonest reason for this being fulminant toxaemia, an example quoted several times in the Parliamentary debate. Previously it was the case that if the infant was capable of being bom alive, then, after affording priority to the woman’s own health, every effort to perserve the life and wellbeing of the infant was required. However, very-low-birthweight infants delivered under adverse conditions are at "considerable risk of long-term morbidity". Such babies will be close to or at the limit of viability and at such risk of disability that there could be grounds for destructive delivery under pregnancy
(d). It appears therefore that in the UK
a
doctor
now
needs the
explicit consent of the woman to save her baby during delivery if there is a risk of serious handicap. If she withholds it or cannot give it then the Human Fertilisation and Embryology Act permits the doctor to destroy the child-indeed if the doctor does not, it is conceivable that the parent(s) could bring an action for negligence, using the doctors refusal to apply the criterion in (d). Furthermore (d) bears an interpretation which would apply to any of the common complications of pregnancy which can result in cerebral palsy. The consequences for obstetric management could be very grave involving the destruction of many thousands of at-risk infants. Will it be necessary to take those destructive instruments from the age of obstructed labour from the museum shelves? This Act makes it more expedient to kill than to strive to save where the wellbeing of the child is in doubt. Worcester Royal Infirmary, Worcester WR1 3AS, UK
A. P. COLE J. G. DUDDINGTON
Tolerance and the fetal
graft
(p 538) suggests the expression of a form of the major-histocompatibility-complex non-immunogenic (MHC) class I molecule at the fetomaternal interface as the main reason for maternal tolerance towards the fetal graft. However, in a response to this editorial Dr Innes and colleagues (Nov 3, p 1133) suggest that these molecules are indeed immunogenic. If this is so, why do maternally derived T lymphocytes migrating into the decidua (which is in direct contact with cytotrophoblast) not respond to these MHC molecules? We have demonstrated the lack of expression of the two variants of the T-cell antigen receptor (TCR) by mature intradecidual T lymphocytes during early normal pregnancy.l Our data clearly show that CD3T lymphocytes in first trimester decidua do not express immunohistochemically detectable amounts of &agr;/&bgr; or r/8 TCR molecules. It therefore seems probable that most intradecidual T lymphocytes will not be activated by the antigen and thus will be functionally anergic towards paternally derived fetal antigens. In addition we found that T lymphocytes isolated from the decidua can be induced to express normal amounts of the &agr;/&b(3gr; TCR heterodimer by in-vitro stimulation with phytohaemagglutinin-P and exogenous interleukin-2, which suggests that TCR expression can be restored in this T lymphocyte subset. This supports the notion that the absence of detectable TCR molecules on intradecidual T lymphocytes in situ results from specific down-regulation or modulation rather than from intrinsic deficiency of TCR expression. These findings provide an additional structural basis to explain local matemal tolerance towards the semiallogeneic fetus. SIR,—Your Sept
1 editorial
Departments of Obstetrics and Gynaecology and Pathology, University of Tubingen, 7400 Tubingen, Germany
KLAUS MARZUSCH JOHANNES DIETL HANS-PETER HORNY PETER RUCK EDWIN KAISERLING
Department of Pathology, University of Kiel
HENRIK GRIESSER
Department of Immunology, University of Heidelberg
DIETER KABELITZ
J, Homy H-P, Ruck P, et al. Intradecidual T lymphocytes lack immunohistochemically detectable T-cell receptors. Am J Reprod Immunol (in press)
1. Dietl
