The current role of decompressive craniectomy for severe traumatic brain injury.

There is little doubt that decompressive craniectomy can reduce mortality however, the results of a recent study has provided more evidence to inform the debate regarding clinical and ethical concerns that it merely converts death into survival with severe disability or in a vegetative state. The recently published RESCUEicp trial compared last-tier secondary decompressive craniectomy with continued medical management for refractory intracranial hypertension after severe traumatic brain injury. Patients were randomly assigned to decompressive craniectomy with medical therapy or to receive continued medical therapy with the option of adding barbiturates. The results of the study support the findings of the stroke studies in that the reduction in mortality was almost directly translatable into survival with either severe disability or in a vegetative state. The question remains as to whether there is a subset of patients who obtain benefit from surgical decompression and it is in this regard that the use of observational cohort studies and sophisticated outcome prediction models may be of use. Comparing the percentage prediction with the observed long outcome provides an objective assessment of the most likely outcome can be obtained for patients thought to require surgical intervention. Whilst there will always be limitations when using this type of data they may help prompt appropriate patient-centred discussions regarding realistic outcome expectations. A broader debate is also needed regarding use of a medical intervention that may leave a person in a condition that they may feel to be unacceptable and also places a considerable burden on society.

Reconsidering the role of decompressive craniectomy for neurological emergencies.

OBJECTIVE: There is little doubt that decompressive craniectomy can reduce mortality. However, there is concern that any reduction in mortality comes at an increase in the number of survivors with severe neurological disability. METHOD: Over the past decade there have been several randomised controlled trials comparing surgical decompression with standard medical therapy in the context of ischaemic stroke and severe traumatic brain injury. The results of each trial are evaluated. RESULTS: There is now unequivocal evidence that a decompressive craniectomy reduces mortality in the context of "malignant" middle infarction and following severe traumatic brain injury. However, it has only been possible to demonstrate an improvement in outcome by categorizing a mRS of 4 and upper severe disability as favourable outcome. This is contentious and an alternative interpretation is that surgical decompression reduces mortality but exposes a patient to a greater risk of survival with severe disability. CONCLUSION: It would appear unlikely that further randomised controlled trials will be possible given the significant reduction in mortality achieved by surgical decompression. It may be that observational cohort studies and outcome prediction models may provide data to determine those patients most likely to benefit from surgical decompression.

Intensive care unit research ethics and trials on unconscious patients.

There are widely acknowledged ethical issues in enrolling unconscious patients in research trials, particularly in intensive care unit (ICU) settings. An analysis of those issues shows that, by and large, patients are better served in units where research is actively taking place for several reasons: i) they do not fall prey to therapeutic prejudices without clear evidential support, ii) they get a chance of accessing new and potentially beneficial treatments, iii) a climate of careful monitoring of patients and their clinical progress is necessary for good clinical research and affects the care of all patients and iv) even those not in the treatment arm of a trial of a new intervention must receive best current standard care (according to international evidence-based treatment guidelines). Given that we have discovered a number of 'best practice' regimens of care that do not optimise outcomes in ICU settings, it is of great benefit to all patients (including those participating in research) that we are constantly updating and evaluating what we do. Therefore, the practice of ICU-based clinical research on patients, many of whom cannot give prospective informed consent, ticks all the ethical boxes and ought to be encouraged in our health system. It is very important that the evaluation of protocols for ICU research should not overlook obvious (albeit probabilistic) benefits to patients and the acceptability of responsible clinicians entering patients into well-designed trials, even though the ICU setting does not and cannot conform to typical informed consent procedures and requirements.

Neurotrauma and the rule of rescue.

The rule of rescue describes the powerful human proclivity to rescue identified endangered lives, regardless of cost or risk. Deciding whether or not to perform a decompressive craniectomy as a life-saving or 'rescue' procedure for a young person with a severe traumatic brain injury provides a good example of the ethical tensions that occur in these situations. Unfortunately, there comes a point when the primary brain injury is so severe that if the patient survives they are likely to remain severely disabled and fully dependent. The health resource implications of this outcome are significant. By using a web-based outcome prediction model this study compares the long-term outcome and designation of two groups of patients. One group had a very severe injury as adjudged by the model and the other group a less severe injury. At 18 month follow-up there were significant differences in outcome and healthcare requirements. This raises important ethical issues when considering life-saving but non-restorative surgical intervention. The discussion about realistic outcome cannot be dichotomised into simply life or death so that the outcome for the patient must enter the equation. As in other 'rescue situations', the utility of the procedure cannot be rationalised on a mere cost-benefit analysis. A compromise has to be reached to determine at what point either the likely outcome would be unacceptable to the person on whom the procedure is being performed or the social utility gained from the rule of rescue intervention fails to justify the utilitarian value and justice of equitable resource allocation.

Neurotrauma and the RUB: where tragedy meets ethics and science.

Decompressive craniectomy is a technically straightforward procedure whereby a large section of the cranium is temporarily removed in cases where the intracranial pressure is dangerously high. While its use has been described for a number of conditions, it is increasingly used in the context of severe head injury. As the use of the procedure increases, a significant number of patients may survive a severe head injury who otherwise would have died. Unfortunately some of these patients will be left severely disabled; a condition likened to the RUB, an acronym for the Risk of Unacceptable Badness. Until recently it has been difficult to predict this outcome, however an accurate prediction model has been developed and this has been applied to a large cohort of patients in Western Australia. It is possible to compare the predicted outcome with the observed outcome at 18 months within this cohort. By using predicted and observed outcome data this paper considers the ethical implications in three cases of differing severity of head injury in view of the fact that it is possible to calculate the RUB for each case.

Spinal epidural empyema.

Spinal epidural empyema is a very rare entity occurring with an estimated incidence of 1 per 10,000 hospital admissions. This condition has a reputation for presenting as a diagnostic challenge resulting in late diagnosis and delayed treatment. However, the cornerstones of treatment are prompt diagnosis and early treatment to prevent permanent paralysis and high mortality. We present a cluster of nine cases presenting to the neurosurgery unit over a 3-year period and discuss their relevant features in view of the most recent literature. The diagnosis of spinal epidural empyema was made with gadolinium-enhanced MRI in eight of nine cases. Staphylococcus aureus was isolated as the causative pathogen in all cases. All patients were treated with antibiotics. Eight patients had surgery for debridement and spinal decompression. One patient was treated successfully with antibiotics alone.

An ethics core curriculum for Australasian medical Schools.

Teaching ethics incorporates teaching of knowledge as well as skills and attitudes. Each of these requires different teaching and assessment methods. A core curriculum of ethics knowledge must address both the foundations of ethics and specific ethical topics. Ethical skills teaching focuses on the development of ethical awareness, moral reasoning, communication and collaborative action skills. Attitudes that are important for medical students to develop include honesty, integrity and trustworthiness, empathy and compassion, respect, and responsibility, as well as critical self-appraisal and commitment to lifelong education.

CG-clip expansive open-door laminoplasty: a technical note.

The CG clip is a device designed for use in expansive open-door laminoplasty with both a spacer and means of attachment in a single unit. It provides an effective technique for open-door laminoplasty, which obviates the need for bone grafting or complex internal fixation by providing dynamic stabilization of the open laminae. A number of techniques for expansive open-door laminoplasty have been devised for the decompression of the spinal cord and nerve roots in cervical spondylotic myeloradiculopathy. Each of these techniques requires some degree of internal fixation and/or bone grafting. The CG clip is a single device which is composed of both a spacer and a spring clip for attachment. The spacer ensures a 4-5-mm sagittal expansion of the cervical spinal canal. The spacer is held in place along the lateral cut margin of the laminae by a spring-wound titanium clip, which folds over the central spinous process of the unilaterally elevated laminar block. In all respects except for grafting and internal fixation, the surgery is performed as for a standard expansive open-door laminoplasty. Sixteen of the first 24 patients to undergo this procedure improved at least one point on the Neurosurgical Cervical Spine Scale. Of the remaining eight patients, four remained the same and four deteriorated. The authors have found the CG-clip laminoplasty technique quick and easy to perform, with early results in the treatment of cervical spondylotic myeloradiculopathy consistent with those of other decompressive procedures.

Innovative treatments: ethical requirements for evaluation.

An innovative surgical treatment may arise as a deliberate strategy to solve a clinical problem or as a serendipitous discovery in the course of clinical care. In either case there is a need to evaluate the procedure and there are ethical requirements on such evaluation concerning the reasons for its introduction, patient consent, patient safety and clinical efficacy. Some of these ethical considerations may tell against a randomized controlled trial but the need for monitoring and evaluation along with genuine informed consent remain as absolute requirements. Two cases are introduced and discussed, one of which concerns potentially dangerous surgery and the other a new technology. In each case the ethical requirements are examined and discussed and the possible substitutes for prospective randomized controlled studies in clinical surgery are explored. It is concluded that there are defensible and scientific ways to introduce surgical innovation even where the 'gold standard' of a prospective randomized controlled trial cannot be met.

Ethics and dental research.

Dentistry is a Hippocratic profession and is therefore committed to ongoing research into the causes and treatments of disease. This research embodies ethical standards which place a high value on a respect for persons. Those standards emphasize that we obtain informed consent from individuals selected to participate in research. The relevant information required for informed consent varies from situation to situation but should take into account the need for participants to make a reasoned decision about their involvement. Where community research is involved, there should be consultation with appropriate representatives. In all contemporary medical research, there is an inherent conflict between the ethical requirement that we share information which will help those who are suffering and the need to preserve rights to competitively sensitive information related to product development and academic funding. These various pressures on research emphasize the need for an active and lively appreciation of ethical issues in contemporary biomedical sciences.

Learning to do no harm.

The legalization of euthanasia creates a certain tension when it is compared with those traditional medical principles that seem to embody respect for the sanctity of life. It also creates a real need for us to explore what we mean by harm in relation to dying patients. When we consider that we must train physicians so that they not only understand ethical issues but also show the virtues in their clinical practice, it becomes important for us to strive to train them in virtue rather than mere knowledge. We can only do this by conveying a real sense of the needs of the patient and an ability to relate to patients as people not problems. Such attitudes take shape in a training programme in which practical situations are explored and discussed and the limits of scientific medical responses to those challenges are exposed.

Neuropsychology and meaning in psychiatry.

The relationship between "causal" and "meaningful" (Jaspers) influences on behavior is explored. The nature of meaning essentially involves rules and the human practices in which they are imparted to a person and have a formative influence on that person's thinking. The meanings that come to be discerned in life experience are then important in influencing the shape of that person's conduct. The reasoning and motivational structures that develop on this basis are realized by the shape of the neural processing networks that constitute the mature human brain. This implies that meaning is not only realized by brain micro-structure but, in part, explains its workings. This in turn entails that in psychiatry we must continue to avail ourselves both of neuropsychology/neurobiology and of dynamic/meaningful explanation.