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A number of studies have shown that decompressive craniectomy can reduce intracranial pressure and may improve outcome for patients with severe head injury. This cohort study assessed the long-term outcome of neurotrauma patients who had a decompressive craniectomy for severe head injury in Western Australia between 2004 and 2008. The web-based outcome prediction model developed by the CRASH trial collaborators was applied to the cohort. Predicted outcome and observed outcome were compared. Characteristics of outcome between those who had had a unilateral and those who had had a bilateral decompressive procedure were compared. All complications were recorded. Among a total of 1,786 adult neurotrauma patients admitted during the study period, 147 patients (8.2%) had a decompressive craniectomy. A significant proportion of patients who required unilateral (37.3%) and bilateral (46.5%) craniectomy were able to return to work or study at 18 months after the injury. The patients who required bilateral craniectomy more likely to be associated with an unfavorable outcome (Glasgow Outcome Scale score >or=3) than those who had unilateral craniectomy (odds ratio 4.42; 95% confidence interval 1.16,16.81; p = 0.029), after adjusting for the timing of surgery, mechanism of injury, and the predicted risk of unfavorable outcome. The functional outcome after either unilateral or bilateral decompressive craniectomy was significantly better than that predicted by the CRASH head injury prediction model when the predicted risk was less than 80%. This study has demonstrated that in Western Australia decompressive craniectomy is a relatively common surgical procedure for the management of neurotrauma. A significant proportion of patients had a better-than-predicted long-term functional outcome.

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.

Severity of TBI had an important effect on cost-effectiveness of decompressive craniectomy. As a lifesaving procedure, decompressive craniectomy was not cost-effective for patients with extremely severe TBI.

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Trust is indispensable not only for interpersonal relationships and social life, but for good quality healthcare. As manifested in the increasing violence and tension in patient-physician relationships, China has been experiencing a widespread and profound crisis of patient-physician trust. And globally, the crisis of trust is an issue that every society, either developing or developed, has to face in one way or another. Yet, in spite of some pioneering works, the subject of patient-physician trust and mistrust --a crucial matter in healthcare especially because there are numerous ethical implications --has largely been marginalized in bioethics as a global discourse. Drawing lessons as well as inspirations from China, this paper demonstrates the necessity of a trust-oriented bioethics and presents some key theoretical, methodological and philosophical elements of such a bioethics. A trust-oriented bioethics moves beyond the current dominant bioethical paradigms through putting the subject of trust and mistrust in the central agenda of the field, learning from the social sciences, and reviving indigenous moral resources.In order for global bioethics to claim its relevance to the things that truly matter in social life and healthcare, trust should be as vital as such central norms like autonomy and justice and can serve as a potent theoretical framework. KEW WORDSChina, trust, patient-physician relationship, healthcare, trust-oriented bioethics, global bioethics 2 The theme of this special issue is "Rebuilding patient-physician trust in China, Developing a trust-oriented bioethics." Utilising a methodology that integrates anthropological and sociological inquiry with ethical analysis, the previous articles have investigated the phenomenon and sources of patient-physician mistrust and the mechanisms required to rebuild a trust in the healthcare system in mainland China. Drawing lessons as well as inspirations from China, in this paper we argue for the necessity of a trust-oriented bioethics and outline the theoretical and methodological foundations of such a bioethics. By so doing, this paper addresses specifically the second main aim of this thematic issue."People cannot stand without trust," as Confucius asserted 2600 years ago in one of his best-known statements, recorded by his disciples in Lunyu (The Analects) (Book XII: 7). Among other things, this means that if trust is absent, neither individual life nor local communities and the wider society can thrive or even survive. The central thesis of this paper (and the entire thematic issue) is that, to paraphrase Confucius, medicine cannot stand without mutual trust between patients and their relatives, on the one side, and health professionals and institutions on the other. And neither can bioethics in China and around the globe stand upright without placing trust in its central agenda. PATIENT-PHYSICIAN MISTRUST IN CHINA: CONSEQUENCES AND CONTEXTChina, the world's most populous country where more than 1.3 billion people live, has been experiencing an e...

This chapter continues from the previous chapter on themes in biopsychosocial conditions of health and disease, picking up some core questions familiar in the theory and philosophy of medicine. We argue that the concepts and boundaries of health and disease are themselves biopsychosocial. Controversies about whether such-and-such a condition is or is not a medical matter, as opposed to difference or lifestyle choice, the consequences of being which involve benefits such as access to healthcare and/or harms such as stigma, and the terms in which such debates are conducted-are all thoroughly biopsychosocial-political. Core defining features of illness-activity limitations, pain and distresslikewise involve our psychology and social life as well as our biology. On the theme of causation, we endorse scientific method as the route to identifying causal mechanisms, note the major role of chronic stress in models of causal mechanisms linking psychosocial factors with biological damage, and spell out that chronic stress is a quintessential biopsychosocial concept. We consider the Research Domain Criteria (RDoC) proposed recently by the N.I.M.H. as a framework for research in mental health as an illustration of a biopsychosocial research framework, potentially extendable to cover physical health and biomedicine. Physical and mental health conditions are brought together in the new biopsychosocial model rather than being axiomatically separate-as they were in the old context of reductionism and dualism.

There is currently a resurgence of interest in the use of decompressive craniectomy. As the procedure is used more frequently, there may be an increasing number of patients surviving a severe traumatic brain injury with severe neurological impairment. The aim of this study was to determine if we could predict those cases that fall into this category. We used the web-based prediction model prepared by the CRASH collaborators and applied it to a cohort of patients who had a decompressive craniectomy in 2006 and 2007 at the two major trauma hospitals in Western Australia. All clinical and radiological data were reviewed and entered into the model, and predicted outcome and actual outcome were compared. Our analysis indicated that a significant cut-off point appeared at which the model predicted a 75% risk of an unfavorable outcome at 6 months; 19 of 27 patients with CRASH scores <75% returned to work, whereas none of the 14 patients with higher scores achieved this degree of rehabilitation at 18 months. Statistical analysis of the outcomes in our cohort confirmed that the CRASH model reliably predicted unfavorable outcome. This study demonstrated that our ability to predict poor outcome has improved.