Increasing the options for reducing adverse events: Results from a modified Delphi technique

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background: The aim of this paper is to illustrate a simple method for increasing the range of possible options for reducing adverse events in Australian hospitals, which could have been, but was not, adopted in the wake of the landmark 1995 'Quality in Australian Health Care ' study, and to report the suggestions and the estimated lapse time before they would impact upon mortality and morbidity. Method: The study used a modified Delphi technique that first elicited options for reducing adverse events from an invited panel selected on the basis of their knowledge of the area of adverse events and quality assurance. Initial suggestions were collated and returned to them for reconsideration and comment. Results: Completed responses from both stages were obtained from 20 of those initially approached. Forty-one options for reducing AEs were identified with an average lapse time of 3.5 years. Hospital regulation had the least delay (2.4 years) and out of hospital information the greatest (6.4 years). Conclusion: Following identification of the magnitude of the problem of adverse events in the 'Quality in Australian Health Care ' study a more rapid and broad ranging response was possible than occurred. Apparently viable options for reducing adverse events and associated mortality and morbidity remain unexploited

Influence of adhesive drapes on intraperitoneal volume and pressure during laparoscopy

Background : The influence of adhesive skin drapes on abdominal wall compliance during laparoscopy has not previously been studied. Methods : The effect of removing an adhesive abdominal drape on intraperitoneal volume and pressure was studied in 15 patients undergoing a variety of laparoscopic procedures. The internal consistency of this data was evaluated by comparing the observed response to that which was predicted from analysis based on the theory of elasticity. Results : Removal of an adhesive skin drape after induction of a 15-mmHg pneumoperitoneum was associated with changes in intraperitoneal pressure and volume. These changes were statistically significant, highly predictable and clinically relevant. Conclusions : On the basis of the present observations, we recommend that extensive coverage by adhesive drapes should be avoided for those patients or procedures in which elevated intraperitoneal pressure may be particularly deleterious.Mark Siddins, John Boland, Marcus Riederer, Burapa Kanchanabat, M. Mohan Rao, Peter Hewet

Segmental infarction with graft dysfunction: an emerging syndrome in renal transplantation?

BackgroundSegmental allograft infarction is a poorly characterized complication following renal transplantation. The present study was undertaken with the goal of defining the incidence, clinical characteristics, pathogenesis, and prognosis of this entity.MethodsA retrospective study was performed, reviewing the renal scans performed on all renal transplant recipients at our institution, from January 1997 to January 2000. Segmental infarction was diagnosed on the basis of a significant elevation in lactate dehydrogenase (>500 U/l) together with a photopenic perfusion defect. In these patients, graft characteristics, operative details, clinical course, and long-term outcomes were evaluated.ResultsSegmental infarction was identified in 13 of 277 consecutive renal transplant recipients (4.7%). In nine recipients the onset of infarction occurred within 24 h after transplantation. All received marginal grafts, and in five recipients the transplant operation was complicated by major blood loss. Eight of these recipients exhibited primary non-function, or developed dialysis-dependent renal failure after the onset of infarction. In four patients, the onset of infarction occurred after 24 h (35 h to 10 days). One recipient demonstrated primary non-function, and renal function deteriorated after the onset of infarction in the remaining three. Overall, long-term graft function was impaired. Two allografts never functioned, and six recipients had nadir creatinine clearances below 60 ml/min.ConclusionsThe pathogenesis of segmental infarction appears to be multi-factorial, reflecting the combination of an initiating anatomic lesion and potentiating thrombogenic milieu. Segmental infarction typically occurs in the early postoperative period, and prompt diagnosis is difficult to obtain. In view of this, prophylactic heparin may be warranted for those at highest risk. There was no correlation between the infarct area and the graft function, and the long-term graft function is compromised out of proportion to the extent of parenchymal loss. This finding highlights the role of predisposing factors, particularly marginal graft quality, in determining the functional outcome. Segmental infarction may be more frequently encountered as cadaveric organ shortages encourage greater use of marginal donor kidneys.Burapa Kanchanabat; Mark Siddins; Toby Coates; Mark Tie; Christine H. Russell; Timothy Mathew and Mohan M. Ra

Dendritic cell TH2 cytokine gene therapy in sheep

T. Coates, R. Krishnan, G. Chew, S. Kireta, J. Johnston, B. Kanachanabat, C.H. Russell, M. Siddins, and G.R. Rus