Transplant tourism or international transplant medicine? A case for making the distinction.

Transplant tourism is routinely denounced by influential voices such as the World Health Organization, the Declaration of Istanbul and the Madrid Resolution as an unethical solution to worldwide organ shortages. Instead, it is suggested that national deceased donor schemes and multinational organ-sharing programs are the only acceptable avenues for addressing the organ shortage crisis. The present demand for self-sufficiency in organ supply responds to risks such as poor clinical outcomes, and exploitation of the poor through the various commercial practices of transplant tourism. However, opponents of transplant tourism say little about what governments should do to ensure that their citizens have real and comprehensive access to all forms of transplantation. To address this complex question, we describe a current practice of international transplant medicine in Singapore. It addresses salient concerns with transplant tourism and supports the principle of national self-sufficiency in organ supply, even as its health care system thrives and expands comprehensive transplant services to its citizens by catering to international patients. We offer a critical appraisal of the Singaporean system, and some suggestions to minimize the risk of abuse by international patients or operatives of illegal organ markets.

Antimicrobial resistance and virulence gene profiles in multi-drug resistant enterotoxigenic Escherichia coli isolated from pigs with post-weaning diarrhoea.

This study aimed to characterize antimicrobial resistance and virulence genes in multi-drug resistant enterotoxigenic Escherichia coli (ETEC) isolates (n=117) collected from porcine post-weaning diarrhoea cases in Australia (1999-2005). Isolates were serotyped, antibiogram-phenotyped for 12 antimicrobial agents and genotyped by PCR for 30 plasmid-mediated antimicrobial resistance genes (ARGs), 22 intestinal and 38 extraintestinal E. coli virulence genes (VGs). Nine serogroups were identified, the most prevalent being O149 (46.2%), O141 (11.2%) and Ont (31.6%). None of the isolates showed resistance to ceftiofur or enrofloxacin and 9.4% were resistant to florfenicol. No corresponding extended-spectrum/AmpC ß-lactamase, fluoroquinolone or floR ARGs were detected. An antimicrobial resistance index (ARI) was calculated from the combined data with a weighting for each antimicrobial agent dependent upon its significance to human health. Serogroup O141 isolates had a significantly higher ARI due to an elevated prevalence of aminoglycoside ARGs and possession of more virulence genes (VGs), including ExPEC or EHEC adhesins (bmaE, sfa/focDE, fimH, ihA) in toxin-producing strains that lacked the normally associated F4 and F18 fimbriae. Few associations between ARGs and VGs were apparent, apart from tetC, sfa/focDE and ompT which, for a sub-set of O141 isolates, suggest possible plasmid acquisition from ExPEC. The multi-drug resistant ETEC ARG/VG profiles indicate a high probability of considerable strain and plasmid diversity, reflecting various selection pressures at the individual farm level rather than emergence and lateral spread of MDR resistant/virulent clones.

Antimicrobial use in the Australian pig industry: results of a national survey.

OBJECTIVE: To describe how various antimicrobials are used in commercial pig herds in Australia and for what disease conditions. PROCEDURE: Managers of large pig herds (> 200 sows) across Australia and their veterinarians participated in an internet-based survey in 2006. Questions were asked about herd management, the occurrence of bacterial diseases and the type and frequency of antimicrobial use. An antimicrobial usage index for each herd was derived as a summary of the risk of selection for antimicrobial resistance. Relationships between responses were explored with univariate and multivariate analysis. RESULTS: Responses were received for 197 herds estimated to represent at least 51% of all large pig herds in Australia. Most piggeries relied on drugs of low importance in human medicine (e.g. tetracyclines, penicillins and sulfonamides). For the two drugs of high importance in human medicine that can be legally prescribed to pigs in Australia, ceftiofur use was reported in 25% of herds and virginiamycin in none. Infections attributed to Lawsonia, Mycoplasma and Escherichia coli motivated the most use of antimicrobials. No useful association was found between management factors and the antimicrobial use index. CONCLUSION: Most antimicrobial use in the Australian pig industry is based on drugs of low importance to public health. Enhanced control of E. coli infections without reliance on antimicrobials would further reduce the risk of selecting for antimicrobial resistance relevant to public health. The amount of variation in the usage index between herds suggests that antimicrobial use should be constantly reviewed on a herd by herd basis.

Prevalence of Parkinson disease in Singapore: Chinese vs Malays vs Indians.

OBJECTIVE: To investigate the prevalence of Parkinson disease (PD) in Singapore and compare the rates between Singaporean Chinese, Malays, and Indians. METHODS: A three-phase community-based survey among a disproportionate random sample of 15,000 individuals (9,000 Chinese, 3,000 Malays, 3,000 Indians) aged 50 years and above who live in central Singapore was conducted. In phase 1, trained interviewers conducted a door-to-door survey using a validated 10-question questionnaire. In phase 2, medical specialists examined participants who screened positive to any of the questions. Participants suspected to have PD had their diagnosis confirmed in phase 3 by a movement disorders specialist. RESULTS: The participation rate was 67% among 22,279 eligible individuals. Forty-six participants with PD were identified of which 16 were newly diagnosed cases. The prevalence rate of PD for those aged 50 and above in Singapore was 0.30% (95% CI: 0.22 to 0.41), age-adjusted to US 1970 census. The prevalence rates increased significantly with age. The age-adjusted prevalence rates among Chinese (0.33%, 95% CI: 0.22 to 0.48), Malays (0.29%, 95% CI: 0.13 to 0.67), and Indians (0.28%, 95% CI: 0.12 to 0.67) were the same (p = 1.0). CONCLUSIONS: The prevalence of PD in Singapore was comparable to that of Western countries. Race-specific rates were also similar to previously reported rates and similar among the three races. Environmental factors may be more important than racially determined genetic factors in the development of PD.

Screening for hearing impairment in a cohort of elderly patients attending a hospital geriatric medicine service.

INTRODUCTION: This study sets out to determine the usefulness of a questionnaire to screen for hearing impairment, assess the psychosocial impact of hearing handicap and survey older persons' attitudes towards hearing aid usage. METHODS: Subjects were recruited from a Geriatric Medicine unit over a six-month period. A questionnaire was administered, followed by an otoscopic examination and audiometric testing. RESULTS: Sixty-three patients were included in the study. Fifty-two (83%) patients had hearing impairment, of which 34 were moderately severe and 18 were mild. Of the six questions used in hearing screening, the question on self-perception was the most specific (91%). Administering the remaining five questions on activities of daily living improved the questionnaire's sensitivity from 58% to 73%, although the specificity was reduced from 91% to 64%. Of the 30 patients with self-perceived and audiometrically-confirmed hearing impairment, about 40% reported negative psychosocial impact as a result of the handicap. 66.7% were not keen to consider using hearing aid, even if recommended. The willingness to use hearing aids was correlated to patients' functional status (p=0.002) but not to the severity of hearing impairment (p=0.157). CONCLUSION: Self-perception of hearing problems in the elderly is a strong indicator of hearing impairment. Introducing additional culturally-relevant questions based on activities of daily living improves the detection rate of hearing impairment. Although hearing loss impacts negatively on psychosocial well-being, most elderly subjects are unwilling to consider the use of hearing aids. There is a need to educate the elderly on the importance of intervention in order to reduce their handicap and improve their quality of life.

Ethical issues in stem cell research.

Like most cutting edge medical technology, human stem cell research raises a number of difficult and important ethical issues and concerns, requiring potential benefits to be balanced against the need to protect the rights and welfare of citizens. Much of the debate involves research using embryonic stem (ES) cells, which in turns revolves around the moral status of the human embryo, and the level of respect and protection that should be accorded. This is an especially sensitive issue in pluralistic societies where different, if not conflicting, cultural and religious perspectives exist. Another contentious issue as far as the derivation of ES cells is concerned is the intent involved in producing the embryos, specifically whether it is ethically permissible to allowing embryos to be made solely for the purpose of research. These and several other relevant ethical issues will be discussed, including a comparison of guidelines and positions adopted in different countries.

The use of information technology in medicine: defining its role and limitations.

Information Technology (IT) has transformed the ways modern healthcare systems acquire, store, access and communicate medical information. These developments offer significant benefits to patients and healthcare providers, but they give rise to ethical and legal challenges in the protection of patient privacy and confidentiality. The traditional and humanistic concept of doctor-patient relationship is also under threat as IT is used to bypass the need for personal consultations. One effective approach to continue the use of IT in medicine while minimising its potential hazards is through legal reforms and setting public standards for accessibility and expression of patient autonomy. Ultimately, the role and limitations of IT as a tool to pursue the goals of medicine has to be carefully deliberated, clearly defined and judiciously delineated to ensure its effectiveness and safety.

Assessing decision-making capacity in dementia patients: a semi-structured approach.

One of the consequences of the rapidly increasing numbers of dementia patients in Singapore will be the need for all clinicians (including non-psychiatrists) to be familiar with the fundamentals of how decision-making capacity should be assessed. The clinical settings when the need for such evaluations arise, often involve cognitively or emotionally impaired patients who are required to make treatment, placement, financial or testamentary decisions. The clinician must first diagnose the patient's psychopathology and then go onto testing the functional abilities involved in decision-making. These comprise (1) making and expressing a choice, (2) understanding the relevant information, (3) appreciating the relevance of the information to oneself and (4) reasoning with the given information. The eventual judgement of the patient's decision-making capacity involves the weighing of impairment noted in any of the four decisional abilities against the potential adverse consequences of abiding by the patient's decision. The ethical impulse underlying this manner of judgement balances the respecting of patient's autonomy with protecting the patient from harm. Given the relative complexity of the assessment process, there is merit in developing a semi-structured approach to the evaluation of patients' decision-making capabilities; such an approach can guide a wider group of clinicians and psychologists through the essential steps of the process and thus enable the assessment to be more thorough, as well as fairer, to the patient.

Neurofibrillary and ethico-legal tangles: in search of surrogates for dementia patients lacking decision-making capacity and relatives.

Singapore's greying population has led to an alarming increase in the prevalence of dementia, and inevitably to a rising number of dementia patients who lack competence and relatives. Although legislative provisions exist in the current Mental Disorders and Treatment Act (MDTA) for the appointment of committees of person and estate for incompetent patients, healthcare professionals continue to face challenging obstacles in their attempts to search for appropriate surrogate decision-makers for such patients. We illustrate, with 2 cases from our clinical experience, the ethical, legal and administrative tangles faced in our search for appropriate surrogate decision-makers. Specific problems, such as administrative ambiguities in applying the MDTA and the impracticalities of a rigorous judicial process in appointing surrogates, are discussed. We propose possible solutions how these obstacles can be effectively tackled, in particular adopting a radical shift from the present judiciary model to a clinical-based model of appointing surrogates for healthcare decisions. This clinical model is based on best interests considerations and emphasies peer review and a multidisciplinary consultative approach in determining the clinical merits of proposed treatment and its impact on quality of life. The ultimate aim of such a change is to facilitate timely medical care while ensuring ethical practices that respect the patient's dignity.

Doctor-patient relationship: from medical paternalism to enhanced autonomy.

For centuries, physicians have been allowed to interfere and overrule patient's preferences with the aim of securing patient benefit or preventing harm. With the radical rise in emphasis on individual control and freedom, medical paternalism no longer receives unquestioned acceptance by society as the dominant mode for decision-making in health care. But neither is a decision-making approach based on absolute patient autonomy a satisfactory one. A more ethical and effective approach is to enhance a patient's autonomy by advocating a medical beneficence that incorporates patients' values and perspectives. This can be achieved through a model for shared decision making, acknowledging that though the final choices reside ultimately in patients, only through physician beneficence can the patient be empowered to make meaningful decisions that serve them best. For such a model to function effectively, the restoration of trust in doctor-patient relationship and the adoption of patient-centred communication are both crucial.