Donor selection for renal transplantation : a study on mixed lymphocyte reactions and kidney allograft survival in unimmunosuppressed dogs

The prime cause of failure of a transplanted kidney is immunological rejection of the graft. Graft rejection will not occur, when the transplanted organ is obtained from a donor which is genetically identical to the recipient (isogenic transplant). Graft rejection can always occur, when donor and recipient are genetically different (allogenic transplant). Unrelated people are always genetically different. Only when donor and recipient are monozygotic twins, complete genetic identity exists. Thus a transplanted organ will be antigenic, when donor and recipient are not monozygotic twins. The immune reaction, evoked by the antigens of such an allograft, consists of two components. In the first place, antibodies will be produced, which are specifically directed against the transplanted antigens (the so called humoral immune response). Secondly, immune reactive cells are generated, which specifically can attack the transplanted organ (the cellular immune response). The mechanism of the destruction of the allograft is complicated and only partly known. Both different types of antibodies and different types of cells are involved. Microscopically, arteritis and a cellular infiltrate can be seen (Busch et al., 1977). Progressive damaging of the glomeruli and tubuli results in a increasing loss of function of the transplanted kidney. Two factors determine the strength of the immune reaction of the recipient against the allograft. These factors are the immune response potential of the recipient and the strength of the antigenic stimulus (Lengerova, 1969). The strength of the antigenic stimulus is dependent on the immunogenetic difference between donor and recipient. Consequently, two methods are available to prevent allograft rejection, namely modification of the immune response and selection of compatible donor-recipient pairs

Incidence of osteonecrosis after renal transplantation

The incidence of osteonecrosis was 24% in 248 patients who had received 262 kidney transplants 1971-1982. However, based only on patients at risk, i.e. alive with functioning transplants, the incidence at 1, 3 and 6 years was found to be 13, 27 and 36%; after six years no new cases were found. the relative increase in body-weight at 180 days was predictive as regards risk for osteonecrosis, while the cumulative dose of steroids was not. This suggests that individual sensitivity to steroids rather than the absolute cumulative dose is involved in the development of osteonecrosis

Surgical residents’ perceptions of patient safety climate in Dutch teaching hospitals.

Rationale, Aims and objectives: Explicit attention to patient safety during surgical training is needed to improve patient safety. A positive safety climate is associated with greater patient safety and is a requisite for safety teaching at the workplace. The Safety Climate Survey (SCS) measures perceptions of safety climate. This study aims to take a first step in validating the SCS for use among surgical residents in the Netherlands and to highlight opportunities for safety climate improvement through changes in surgical training in the Netherlands. It therefore assesses (1) if the SCS can be used to assess surgical residents' perceptions of the safety climate in Dutch teaching hospitals; and (2) how, according to SCS results, these residents perceive the safety climate in Dutch teaching hospitals. Methods: In a cross-sectional study conducted in February 2011, a Dutch translation of the SCS was administered to all general surgical residents in the Netherlands. Face validity and internal consistency were assessed, as were overall mean, means per item and significant differences in means between different groups of respondents. Results; In total, 306 of 390 (78%) residents completed the questionnaire. The SCS showed good face validity and internal consistency (Cronbach's alpha = 0.87). Residents reported an overall mean of 3.95 (standard deviation 0.51) out of a maximum score of 5.00, and 52% reported an overall mean of 4.00 or higher. Women and residents working in university hospitals gave significantly lower scores. Significant differences were also found among hospitals and among regions. Majority of the items scored less than 4.00. Conclusions: The SCS is potentially useful to measure surgical residents' perceptions of the patient safety climate in Dutch teaching hospitals. There is considerable room for improvement of the patient safety climate. Surgical training should include better feedback, formal patient safety teaching sessions at the workplace and specific attention to patient safety during the introduction in a new hospital, and supervisors should encourage surgical residents to report any patient safety concern they may have. (aut.ref.

A patient safety curriculum for medical residents based on the perspectives of residents and supervisors.

Objectives: To develop a patient safety course for medical residents based on the views of medical residents and their supervisors. Methods: In 2007, questionnaires were distributed to investigate residents' and supervisors' perspectives on the current patient safety performance and educational needs of residents. These perspectives were categorized according to the factors that influence daily practice as described in the London Protocol. Selection of course content and corresponding learning goals was made by an expert panel and based on the questionnaires' outcomes. Results: One hundred sixteen (64%) respondents filled out the questionnaire. Residents rated health care as significantly safer than supervisors. Close links were found between described risks and expressed educational needs. Both were found to be predominantly related to team factors, work environmental factors, and individual factors. The principal course themes that were selected are as follows: (1) principles of patient safety, (2) human factors, (3) effective teamwork, (4) contribution to safer care, and (5) medicolegal aspects of patient safety. Conclusions: Residents are not fully aware of all potential risks of their work and of their own role in patient safety. This underlines the need for an explicit focus on patient safety issues during their training. A needs assessment among involved parties engages respondents in the process and can provide valuable input for developing patient safety education for residents. (aut.ref.

Effects on incident reporting after educating residents in patient safety: a controlled trial.

Background: Medical residents are key figures in delivering health care and an important target group for patient safety education. Reporting incidents is an important patient safety domain, as awareness of vulnerabilities could be a starting point for improvements. This study examined effects of patient safety education for residents on knowledge, skills, attitudes, intentions and behavior concerning incident reporting.Methods: A controlled study with follow-up measurements was conducted. In 2007 and 2008 two patient safety courses for residents were organized. Residents from a comparable hospital acted as external controls. Data were collected in three ways: 1] questionnaires distributed before, immediately after and three months after the course, 2] incident reporting cards filled out by course participants during the course, and 3] residents' reporting data gathered from hospital incident reporting systems. Results: Forty-four residents attended the course and 32 were external controls. Positive changes in knowledge, skills and attitudes were found after the course. Residents' intentions to report incidents were positive at all measurements. Participants filled out 165 incident reporting cards, demonstrating the skills to notice incidents. Residents who had reported incidents before, reported more incidents after the course. However, the number of residents reporting incidents did not increase. An increase in reported incidents was registered by the reporting system of the intervention hospital. Conclusions: Patient safety education can have immediate and long-term positive effects on knowledge, skills and attitudes, and modestly influence the reporting behavior of residents. (aut. ref.

Prioritising patients on surgical waiting lists: A conjoint analysis study on the priority judgements of patients, surgeons, occupational physicians, and general practitioners

The prioritisation of patients on waiting lists is ascribed high potential for diminishing the consequences of waiting times for elective surgery. However, consistent evidence is lacking about which factors determine patient priority and it is unclear whether different stakeholders have different opinions on this issue. This study, conducted in the Netherlands, investigates the judgements of patients, laypersons (i.e. patients on other waiting lists), and physicians on the priority of patients on waiting lists. Participants were former patients with varicose veins (N=82), inguinal hernia (N=86), and gallstones (N=89), 101 surgeons, 95 occupational physicians, and 65 general practitioners. Each participant judged the priority of paper vignettes of patients with varicose veins, inguinal hernia, and gallstones. The vignettes were designed according to conjoint analysis methodology and described the physical symptoms, the psychological distress, the social limitations, and impairments in work of patients. Multilevel regression analysis of the responses showed that all groups made significant distinctions in patient priority depending on the severity of each characteristic in the vignettes. The physical symptoms and impairments in work had on average the highest impact on priority, but the summed impact of non-physical factors exceeded that of the physical symptoms. The different groups of participants appraised only the importance of the physical symptoms differently, but opinions on priority varied widely within each group. Whereas the high level of agreement between the different groups would facilitate the acceptance and the implementation of explicit prioritisation of patients on the waiting list, the high inter-individual variation signifies that consensus criteria for prioritisation are needed to warrant equity and transparency in care provision.The Netherlands Access to care Waiting lists Prioritisation Surgery