Transplantation in the Context of Migration and Refugees: A Summary of the DICG and TTS Ethics Committee Workshop, Buenos Aires, Argentina, September 2022.

Global conflicts and humanitarian crises have resulted in an unprecedented number of refugees and migrants. This challenges the limited resources of health care systems and jeopardizes the availability of transplant care for these deserving migrants and refugees. This was the basis for a workshop held during the Congress of the Transplantation Society (Buenos Aires, 2022). We elaborate on the proceedings of the workshop entitled "Transplantation in the Context of Migration and Refugees," organized by the Ethics Committee of The Transplantation Society and Declaration of Istanbul Custodian Group. Transplant providers from around the world shared strategies of how each region has responded to providing access to care for refugees and migrants in need of transplant services. The potential exploitation of this vulnerable group leading to illicit organ removal was addressed for each region. The Transplantation Society, Declaration of Istanbul Custodian Group, and global transplant community should continue to focus on the status of refugees and migrants and collaborate on strategies to provide access to transplant care for this deserving population. Global cooperation will be essential to provide vigilant oversight to prevent exploitation of this vulnerable population.

Baseline Ethical Principles and a Framework for Evaluation of Policies: Recommendations From an International Consensus Forum.

To maintain public trust and integrity in organ and tissue donation and transplantation (OTDT), policymakers, governments, clinical leaders, and decision-makers must ensure that policies proposed to increase donation and transplant activity satisfy baseline ethical principles established by international agreement, declaration, and resolution. This article describes the output of the Baseline Ethical Domain group of an international forum designed to guide stakeholders in considering these aspects of their system. Methods: This Forum was initiated by Transplant Québec and co-hosted by the Canadian Donation and Transplantation Program partnered with multiple national and international donation and transplantation organizations. The domain working group members included administrative, clinical, and academic experts in deceased and living donation ethics and 2 Patient, Family, and Donor partners. Identification of internationally accepted baseline ethical principles was done after literature reviews performed by working group members, and a framework for consideration of existing or novel policies was completed over a series of virtual meetings from March to September 2021. Consensus on the framework was achieved by applying the nominal group technique. Recommendations: We used the 30 baseline ethical principles described in World Health Organization Guiding Principles, Declaration of Istanbul, and Barcelona Principles to generate an ethical framework-presented graphically as a spiral series of considerations-designed to assist decision makers in incorporating these ethical principles into practice and policy. We did not seek to determine what is ethical but instead described a method of evaluation for policy decisions. Conclusions: The proposed framework could be applied to new or existing OTDT policy decisions to facilitate the transformation of widely accepted ethical principles into practical evaluations. The framework includes adaptation for local contexts and could be applied broadly internationally.

Study of pre-hospital care, patterns of injury and outcomes of suburban railway accident victims in Mumbai, India.

Background: . India has one of the largest railway networks, with a high incidence of railway-related accidents and fatality rate of 150/million passengers per year. We evaluated the pre-hospitalization period, pattern of injury and outcome of train accident victims in a metropolitan city. Methods: . For this prospective observational study, we included victims of railway accidents presenting to a public hospital of Mumbai (a metropolitan city) from November 2014 to September 2016. We documented a detailed history of the victims and patterns of injury. Injuries were assessed using the revised trauma score, injury severity score (ISS) and trauma score-ISS. The outcome of surviving persons was assessed using the European quality of life questionnaire (EQ-5D-5L) and visual analogue scale (EQ-VAS). Results: . Eighty-one accident victims were admitted during the study period, of which 37 (46%) were seriously injured. The victims were predominantly male (85%), in the age group of 14-45 years (91%), 23 (28%) were in an intoxicated state. Most accidents happened during morning and evening peak hours (60%). The average time for victims to reach hospital was 38.1 minutes and 77 (95%) were transported by an ambulance accompanied by a doctor, while 8 (10%) received first aid at the railway station or in the ambulance. Ten (12%) accident victims died while 71 (88%) were discharged. Conclusions: . We found a high incidence of people in their productive age group losing their lives to railway accidents, which can be prevented with the help of a robust transport system and training the first responder emergency medical care providers.

The Supreme Court of India on euthanasia: Too little, too late.

On Friday, March 9, 2018 the five-judge Constitution Bench (CB) of the Supreme Court of India (SCI) chaired by Dipak Misra, the Chief Justice of India, pronounced its judgment (1) (henceforth CC judgment) granting, for the first time in India, legal recognition to "advanced medical directives" or "living wills", ie, a person's decision communicated in advance on withdrawal of life-saving treatment under certain conditions, which should be respected by the treating doctor/s and the hospital. It also reiterates the legal recognition of the right to "passive euthanasia"; and draws upon Article 21 - the right to life - of the Constitution of India (henceforth Constitution) (2) interpreting robustly that the "right to life" includes the "right to die with dignity". Justices Misra and Khanwilkar disposed of the writ petition filed in 2005 by Common Cause (3) (henceforth CC petition) saying, "The directive and guidelines shall remain in force till the Parliament brings a legislation in the field" (1:p 192).

A Fine doctor.

I met Jonathan Fine for the first time in 2011. He was to travel back to Boston through Mumbai after a stint in Chattisgarh, where he had volunteered with Jan Swasthya Sahayog, the well-known rural hospital near Bilaspur. A friend suggested that since he was a doctor who had done pioneering work by setting up the renowned organisation Physicians for Human Rights, we should arrange a talk by him for medical students. A lecture was thus organised at my alma mater, the GS Medical College and KEM Hospital, where Jonathan spoke on "Why should doctors engage with human rights?" In his characteristic blunt style, rather than talk about his past, he exhorted the audience to visit Chattisgarh and see the severe inequities he had witnessed.

Ways of dying.

How do we die? Is it an event or a process? Does everyone die in the same way or are there different ways of dying? Even with humankind's claims to gigantic strides in knowledge, death still remains one of the great mysteries for the living. And that makes it the subject of profound and perennial philosophical and religious enquiry. Modern medical science, however, had no option but to engage with it in its bodily form and try to define the precise nature of the process of death. Things were rather easy when death was equal to stoppage of the heart. But inevitably, the world of medicine with its keen sense of observation and constant yearning for scientific reasoning, recognised, somewhere in the middle of the last century, that the brains of a set of individuals hooked onto support systems in intensive care units were dying first, inevitably followed by the heart after some time. The tremendous progress in the science of resuscitation, organ support and intensive care while saving many lives resulted in an increasing number of such individuals, who were soon termed "brain dead" but whose hearts were still beating. The damage to the brain was irreversible and complete and inevitably, the heart had to follow within hours, or sometimes days.

Verrucous carcinoma at ileostomy site / Carcinoma verrucoso em local de ileostomia

ABSTRACT We describe of a case, a 50 year old male who was operated for carcinoma of the descending colon and diverting loop ileostomy, developed a fungating lesion in mucocutaneous junction of ileostomy after one year which on histology revealed to be a Verrucous carcinoma.

RESUMO Descrevemos um caso, homem, 50 anos, que foi operado para carcinoma de cólon descendente e ileostomia em alça para desvio. Transcorrido um ano, o paciente desenvolveu uma lesão vegetante na junção mucocutânea da ileostomia; a histologia revelou ser um carcinoma verrucoso.

A study of events between the onset of symptoms and hospital admission in patients with acute abdomen.

BACKGROUND: Acute abdomen is a common surgical emergency. Prompt investigation and treatment, including surgical intervention, is critical in reducing morbidity and mortality. METHODS: We carried out a prospective observational study at a large urban secondary healthcare centre in India. Patients with surgical acute abdomen were consecutively enrolled in the study over a period of 2 years. Data were collected regarding the onset of symptoms, time of presentation to the hospital and events in the intervening period. RESULTS: Analysis showed that misdiagnosis by medical personnel was significantly associated with delay in admission to the hospital. Unfamiliarity with the medical facilities, ignorance, low education and illiteracy and public holiday were the contributing factors for delayed presentation. Even though we detected some trends, the delay was not significantly associated with age, sex, educational level or socioeconomic status of the patient. The delay resulted in an increased mortality and morbidity especially in patients who needed emergency operative management. CONCLUSION: Delayed presentation of acute abdomen is often not due to a single reason. The causes are distributed over various levels starting from the patient, family, medical personnel, administrative deficiencies, socioeconomic and sociocultural status of the country.

Castleman's disease in carcinoma gall bladder.

Castleman's disease (CD) also known as angiofollicular lymph node hyperplasia represents a group of uncommon non-clonal lymphoproliferation. We herein report a case of CD associated with carcinoma of the gall bladder. To the best of our knowledge, it is the first of its kind and has not been reported in the past. The hypothesis regarding the aetiopathogenesis of CD is that it is associated with interleukin-6 surges. This may be explained by the overproduction of IL-6 by tumour cells or IL-6 production due to a long-standing/smouldering localised inflammatory response. An important question raised by this observation is whether the finding of CD has any effect on the outcome of this patient of carcinoma of the gall bladder. Further research is required in this matter.

Why have we embraced minimally invasive surgery and ignored enhanced recovery after surgery?

There has been a lot of enthusiasm about minimally invasive surgery (MIS) in the surgical community in recent times. Some of the main reasons for this are an unmatched appeal to patients, doctors and healthcare systems alike. Push from the industry also serves as an important reason for its popularity. 'Enhanced recovery after surgery' (ERAS) is a programme of implementing multimodal interventions in the perioperative period to promote faster recovery. Even though MIS is an important component of ERAS protocols, the latter has not seen the reception the former has received. In this article, the authors present their personal viewpoint on the matter. The authors intend to highlight issues surrounding an increasing emphasis on MIS and to caution against the MIS operative technique superseding comprehensive perioperative care.