Repairing reforms and transforming professional practices

Although much has been written on changing professionalism, only limited attention has been given to the way in which professionals themselves give shape to new requirements in everyday professional practice. This article investigates the understudied reform of postgraduate medical education. The reform takes in a shift from apprenticeship-based training based on “learning-by-doing” and socialization to time-restricted, streamlined, competency-based training programs based on competency-based training and standardized performance assessment. We deploy a mixed-methods study design of surgical training reform in the Netherlands (2011-2012) to examine how surgeons and surgical residents give shape to changes in education as well as in the wider hospital context, and how this impact on surgical training from a micro perspective. Informed by sociological literatures on medical education and changing professionalism, this article reveals how the reform is repaired in everyday training practice. This repair work, as a form of institutional work, goes beyond restoring disrupted institutional arrangements in order to restore the status quo as is often argued. Instead, it involves acting with the reform; seeking feasible solutions that preserve old values and related practices while adopting new requirements that reconfigure institutionalized arrangements in professional training practices

Single-shot, high-dose rabbit ATG for rejection prophylaxis after kidney transplantation

We studied the effects of a single intravenous injection of rabbit ATG (RIVM, Bilthoven, The Netherlands) in a dose of 8 mg/kg body weight administered 6 h after kidney transplantation on graft survival, rejection incidence, T-cell subsets, and cost-effectiveness. A total of 58 (37 male/21 female) consecutive renal allograft recipients were entered in this trial. Treatment results were compared with 56 patients treated with intravenous cyclosporin (CyA). In all patients concomitant medication consisted of steroids and azathioprine, followed by oral CyA. Following rabbit ATG, T cells (WT31) quickly disappeared from the peripheral blood and a return to greater than 100/mm3 was observed at a median of 7 (range 3–21) days. Graft survival was the same in both groups, as was the incidence of primary nonfunction. The rate of acute rejection was significantly lower in the rabbit ATG-treated patients (12 % vs 50%). We conclude that a single shot of rabbit ATG is an attractive, easy, and cost-effective induction scheme with a low incidence of delayed graft function and acute rejection episodes. A relatively high incidence of vascular thrombosis of the graft, however, warrants further study before this treatment regimen can be generally applied

Added value of co-morbidity in predicting health-related quality of life in COPD patients

AbstractThe extent to which a chronic obstructive pulmonary disease (COPD) patient is impaired in health-related quality of life (HRQoL) is only to a small extent reflected in clinical and demographical measures. As the influence of co-morbidity on HRQoL is less clear, we investigated the added value of 23 common diseases in predicting HRQoL in COPD patients with mild to severe airways obstruction.COPD patients from general practice who appeared to have an forced expiratory volume in 1 sec/inspiratory vital capacity (FEV1/IVC) < predicted −1·64 SD, FEV1<80% predicted, FEV1reversibility <12% and a smoking history, were included (n=163). HRQoL was assessed with the short-form-36 (SF-36) and the presence of co-morbidity was determined by a questionnaire, which asked for 23 common diseases.All domains of the SF-36 were best predicted by the presence of three or more co-morbid diseases. FEV1% predicted, dyspnoea and the presence of one or two diseases were second-best predictors. Co-morbidity explained an additional part of the variance in HRQoL, particularly for emotional functioning (ΔR2=0·11). When individual diseases were investigated, only insomnia appeared to be related to HRQoL.As HRQoL is still only partly explained, co-morbidity and other patient characteristics do not clearly distinguish between COPD patients with severe impairments in HRQoL and COPD patients with minor or no impairments in HRQoL. Therefore, it remains important to ask for problems in daily functioning and well-being, rather than to rely on patient characteristics alone

A nationwide assessment of hepatocellular adenoma resection:Indications and pathological discordance

Hepatocellular adenomas (HCAs) are benign liver tumors associated with bleeding or malignant transformation. Data on the indication for surgery are scarce. We analyzed indications and outcome of patients operated for HCAs 50 mm (52%), suspicion of (pre)malignancy (28%), and (previous) bleeding (5.1%). No difference was observed in HCA-subtype distribution between small and large tumors. Ninety-six (43%) patients had a postoperative change in diagnosis. Independent risk factors for change in diagnosis were tumor size <50 mm (adjusted odds ratio [aOR], 3.4; p < 0.01), male sex (aOR, 3.7; p = 0.03), and lack of hepatobiliary contrast-enhanced magnetic resonance imaging (CE-MRI) (aOR, 1.8; p = 0.04). Resection for small (suspected) HCAs was mainly indicated by suspicion of (pre)malignancy, whereas for large (suspected) HCAs, tumor size was the most prevalent indication. Male sex, tumor size <50 mm, and lack of hepatobiliary CE-MRI were independent risk factors for postoperative change in tumor diagnosis

SARS-CoV-2 infects the human kidney and drives fibrosis in kidney organoids

Kidney failure is frequently observed during and after COVID-19, but it remains elusive whether this is a direct effect of the virus. Here, we report that SARS-CoV-2 directly infects kidney cells and is associated with increased tubule-interstitial kidney fibrosis in patient autopsy samples. To study direct effects of the virus on the kidney independent of systemic effects of COVID-19, we infected human-induced pluripotent stem-cell-derived kidney organoids with SARS-CoV-2. Single-cell RNA sequencing indicated injury and dedifferentiation of infected cells with activation of profibrotic signaling pathways. Importantly, SARS-CoV-2 infection also led to increased collagen 1 protein expression in organoids. A SARS-CoV-2 protease inhibitor was able to ameliorate the infection of kidney cells by SARS-CoV-2. Our results suggest that SARS-CoV-2 can directly infect kidney cells and induce cell injury with subsequent fibrosis. These data could explain both acute kidney injury in COVID-19 patients and the development of chronic kidney disease in long COVID

Social epidemics in the aftermath of disasters.

Issue/problem: After disasters, terrorist attacks and wars social epidemics of medically unexplained physical symptoms/syndromes (ups) are often seen. In modern times people feel more vulnerable and especially under pressure of those incidents, everyday symptoms are interpreted as disease and causally attributed to the event(s). How are these symptoms and syndromes linked to each other? What is the role of the media in emerging 'new diseases'? Description: In the aftermath of the Bijlmermeer plane crash (Amsterdam, 1992) we studied, six years later, symptoms attributed to the crash by 850 persons who were invited to present their symptoms to a call center. Then, Symptom Checklist-90 was sent to their homes to measure their distress. The symptoms were compared in the medical files of their general practitioners (GP). On average 4.3 symptoms were presented to the call center and the majority (74%) was presented to the GP. One out of four symptoms were either reported to the GP before the disaster took place, or six or more years after (at the time of immense media attention). There appeared to be a lot of distress more than 2 SDs from normal). Most of the symptoms belong to the ups-group (fatigue, headache, dyspnea). At the moment we monitor all symptoms presented to GPs, company doctors and mental health carers by 11,000 victims of the firework disaster in Enschede, the Netherlands (May, 2000) in an attempt of the Dutch government to prevent or to minimalize social (and psychological) epidemics by means of a proactive public health response. In both studies we carried out a search in literature, especially on ups. Conclusions: Unexplained physical symptoms are a major public health problem, especially in the aftermath of stressfull events. They are closely related to each other and belong to a rather small repertoire of complaints and illness independent of exposure, but the dependent of labeling by physicians and media. (aut. ref.

Comparison between self-reported symptoms and GP records in the aftermath of an airplane disaster.

Background: On October 4th, 1992, an El Al Boeing 747-F cargo crashed on two apartment buildings in Amsterdam. Thirty nine residents on the ground and the four crew members of the plane died. In the years after more and more people, attributed physical signs and symptoms to their presence at the disaster scene. Aim: To investigate the consistency between patient's symptoms attributed to the crash, and GP's diagnoses and perception of the association with the crash. Method: Comparison between self-reported symptoms to a call centre six years after the disaster and GPs' medical records on onset and type of symptoms, diagnoses and GPs' perception of association with the disaster assessed by questionnaire. Results: The 553 respondents reported on average 4.3 complaints to the call centre. The majority of these symptoms (74%) was reported to the GP. Of the top ten of symptoms fatigue, skin complaints, feeling anxious or nervous, dyspnea and backache were in 80% reported to the GP. One out of four symptoms were either reported to the GP before the disaster took place, or six or more years after ('98/'99, at the time of a lot of media attention). Depression (7%), PTSD (5%) and eczema (5%) were most frequently diagnosed by GPs. GPs attributed 6% of all reported symptoms to the disaster. Conclusions: Most of the symptoms attributed to a disaster by patients have been reported to their GP. GP's related only a small proportion of these to the disaster. (aut. ref.

Health impact of the Volendam discotheque fire.

Background: On January 1st, 2001, a fire occurred in an overcrowded pub in the Dutch city of Volendam where young people were celebrating New Year’s Eve. As a result, a total of 14 youngsters died, 250 were injured, and 60 suffer from severe burn injuries. Since Volendam is a small and close-knit community (20.000 inhabitants), we expect adverse health effects not only for the survivors of the disaster, but also for the families and peers of those dead or injured. Aim: The purpose of the study is to evaluate the health impact of the discotheque fire. The study aims to be pro-active in gathering data and material about the health situation and care needs from as many victims and health practitioners as possible, in order to provide optimum aftercare. Methods: Longitudinal data are gathered at GPs practices through a computerized reporting procedure. Since the reporting procedure was already operational one year pre-disaster, baseline information is available. The monitoring provides information about the number of medical consultations and the type of health problems patients present to their GPs. It covers a 3-year period (2000-2002). Health problems are coded according to the International Classification of Primary Care (ICPC) and then summarized into clusters. In general, the following sub-groups are under study: (1) youngsters present during the fire, (2) their parents and (3) their brothers and sisters. Other Volendam patients serve as a reference group. Patients from other Dutch GP-practices are used as control group. Both reference and control groups are stratified for age and sex. Control practices are comparable in respect to income and degree of urbanisation. Results: Youngsters who had been present during the fire, as well as their family members, show a significant increase of health care consumption in the 4-week-period immediately after the fire. Also in the period two-years post-disaster, their health care consumption remains at an elevated level when compared to the pre-disasterperiod. Furthermore, results demonstrate that the parents of youngsters who had been present during the fire, present significantly more health problems to their GP than the Volendam reference group and the control group. Pre- and post-disaster differences are most striking for psychosocial and locomotive problems. Equally, the youngsters themselves present more health problems than their reference and control group. Here, differences are most obvious for problems related to injuries, respiratory and psychosocial complaints. Furthermore, the health problems of the reference group (Volendam patients) differ from the control group (other Dutch GP-patients), in several ways: patients in Volendam report less psychosocial and more respiratory and locomotive problems. These differences are already present one year pre-disaster. Conclusions: As a consequence of the Volendam discotheque fire, the health of the fire victims and their families is worse than in the comparison groups. A continuous monitoring can help to make informed decision in respect to appropriate after-care. (aut. ref.