Introducing Incentives and Reducing Disincentives in Enhancing Deceased Organ Donation and Transplantation.

Despite the effectiveness of solid organ transplantation, progress to close the gap between donor organs and demand remains slow. An organ shortage increases the waiting time for transplant and involves significant costs including patient morbidity and mortality. Against the background of a low deceased organ donation rate, this article discusses the option of introducing incentives and removing disincentives to deceased organ donation. Perspectives from ethics, general public opinion, and the health care profession are examined to ensure a comprehensive appraisal and illustrate different facets of opinion on this complex area. Special cultural and psychosocial considerations in Asia, including the family based consent model, are discussed.

Detecting Facet Joint and Lateral Mass Injuries of the Subaxial Cervical Spine in Major Trauma Patients.

STUDY DESIGN: Radiologic imaging measurement study. PURPOSE: To assess the accuracy of detecting lateral mass and facet joint injuries of the subaxial cervical spine on plain radiographs using computed tomography (CT) scan images as a reference standard; and the integrity of morphological landmarks of the lateral mass and facet joints of the subaxial cervical spine. OVERVIEW OF LITERATURE: Injuries of lateral mass and facet joints potentially lead to an unstable subaxial cervical spine and concomitant neurological sequelae. However, no study has evaluated the accuracy of detecting specific facet joint injuries. METHODS: Eight spinal surgeons scored four sets of the same, randomly re-ordered, 30 cases with and without facet joint injuries of the subaxial cervical spine. Two surveys included conventional plain radiographs series (test) and another two surveys included CT scan images (reference). Facet joint injury characteristics were assessed for accuracy and reliability. Raw agreement, Fleiss kappa, Cohen's kappa and intraclass correlation coefficient statistics were used for reliability analysis. Majority rules were used for accuracy analysis. RESULTS: Of the 21 facet joint injuries discerned on CT scan images, 10 were detected in both plain radiograph surveys (sensitivity, 0.48; 95% confidence interval [CI], 0.26-0.70). There were no false positive facet joint injuries in either of the first two X-ray surveys (specificity, 1.0; 95% CI, 0.63-1.0). Five of the 11 cases with missed injuries had an injury below the lowest visible articulating level on radiographs. CT scan images resulted in superior inter- and intra-rater agreement values for assessing morphologic injury characteristics of facet joint injuries. CONCLUSIONS: Plain radiographs are not accurate, nor reliable for the assessment of facet joint injuries of the subaxial cervical spine. CT scans offer reliable diagnostic information required for the detection and treatment planning of facet joint injuries.

Hydroxychloroquine overdose: case report and recommendations for management.

Hydroxychloroquine poisoning has rarely been reported in the literature, with only 18 cases being found on searching the literature. In this paper, we report a case that occurred in Hong Kong, and we make recommendations for emergency management of hydroxychloroquine overdose based on our and other's experience.

Mycobacterium fortuitum infection following total knee arthroplasty: a case report and literature review.

Although Mycobacterium fortuitum is ubiquitous in our environment, infection of total knee arthroplasties with this organism is uncommon. This particular mycobacterium belongs to a group of organisms known as rapidly growing mycobacteria that distinguishes itself from the more typical Mycobacterium tuberculosis by their lower virulence and lack of human-to-human transmission. Another distinguishing feature is their resistance to almost all traditional anti-tuberculous medications and many antibiotics. Because such infections are encountered so infrequently, delays in reaching a microbiological diagnosis are not unusual. This inevitably compromises patient care. At present, there is no universally accepted treatment protocol. Management tends to be individualized, but cure may be possible with a prolonged course of appropriate anti-microbial therapy, removal of the implant, biopsy to confirm eradication of the organism, and finally, reimplantation of a new prosthesis. This paper presents the successful treatment of such an infection. Use of the combination of meropenem and moxifloxacin has not been previously reported in this setting. This case suggests that their in vivo activity is clinically effective against M. fortuitum peri-prosthetic infections when combined with surgical therapy.

Arthroplasty tourism.

The practice of "medical tourism" is gaining popularity. Lower costs and shorter waiting times are compelling motivating factors. There are also increasing commercial interests promoting medical tourism. There are very limited clinical data to support or refute this practice. However, medical tourism breaks important elements in the traditional health care model, including patient selection, continuity of care, and practice auditing. When complications arise, challenges specific to medical tourism patients may be encountered.

Comparison of oral prednisolone/paracetamol and oral indomethacin/paracetamol combination therapy in the treatment of acute goutlike arthritis: a double-blind, randomized, controlled trial.

STUDY OBJECTIVE: We compare the analgesic efficacy and adverse effects of oral prednisolone/acetaminophen and oral indomethacin/acetaminophen combination therapy in the treatment of acute goutlike arthritis in patients presenting to an emergency department (ED). METHODS: This is a double-blind, randomized, controlled study in a university hospital emergency department (ED) in the New Territories of Hong Kong. Patients older than 17 years and presenting between February 1, 2003, and June 30, 2004, with a clinical diagnosis of goutlike arthritis were randomized to receive either oral prednisolone/acetaminophen or oral indomethacin/acetaminophen combination therapy. Primary outcome measures were pain scores, time to resolution of symptoms and signs, and adverse effects. Secondary outcome measures were the need for additional acetaminophen and relapse rate. RESULTS: There were 90 patients randomized: 46 patients to the indomethacin group and 44 patients to the prednisolone group. Baseline characteristics, including pain scores, were similar in the 2 groups. Both treatment groups had a similar decrease in pain score in the ED. The mean rate of decrease in pain score with activity for indomethacin was -1.7+/-1.6 (SD) mm per day and for prednisolone was -2.9+/-2.0 (SD) mm per day (mean difference 1.2 mm/day; 95% confidence interval 0.4 to 2.0 mm/day; P=.0026). Although these differences were statistically significant, at no time was the difference in mean pain score greater than 13 mm. Therefore, it is unclear whether these differences are clinically significant. The mean total dose of acetaminophen consumed by the prednisolone group was significantly more than in the indomethacin group (mean 10.3 g, range 1 to 21 g versus mean 6.4 g, range 1 to 21 g). Twenty-nine patients in the indomethacin group and 12 patients in the prednisolone group experienced adverse effects (P<.05). The commonest adverse effects in the indomethacin group were nausea, indigestion, epigastric pain, dizziness, and gastrointestinal bleeding (N=5; 11%). None of the patients in the prednisolone group developed gastrointestinal bleeding. The relapse rate for both groups was similar. CONCLUSION: In the treatment of acute goutlike arthritis, oral prednisolone/acetaminophen combination is as effective as oral indomethacin/acetaminophen combination in relieving pain but is associated with fewer adverse effects.

Total glossectomy: is it justified?

BACKGROUND: The treatment of advanced malignancies of the tongue with total glossectomy is controversial. METHODS: The present study retrospectively reviews 20 patients that had total glossectomy with or without laryngectomy performed at the Princess Alexandra Hospital (Woolloongabba, QLD, Australia) over the past 10 years. The clinicopathologic parameters, perioperative morbidity and mortality were assessed. RESULTS: The 5 years disease free and disease specific survival rates were 34% and 38%, respectively. Ninety per cent of patients acquired independent oral feeding prior to discharge, while 57% of patients that had laryngeal preservation performed achieved satisfactory vocal rehabilitation. CONCLUSION: Total glossectomy is an oncologically sound surgical procedure that should only be performed in carefully selected patients with advanced malignancies affecting the tongue.