QUALITY IMPROVEMENT: Supporting a hospital in difficulty: -experience of a '-buddying' agreement to implement a new medical pathway.

Increased NHS regulation has identified many healthcare organisations with operational and/or financial difficulties. Although the causes are often complex, most cases are effectively managed internally with limited input from external agencies. How best to support the few organisations needing additional support has not been established. 'Buddying', in which senior clinical and managerial teams from a well performing organisation work with colleagues from an organisation in difficulty has been proposed as a potential solution. Previous reports suggest that these partnerships are generally valued by the organisation in difficulty but there is a paucity of measured operational benefit. In this article we present our experience of a 'buddying agreement' and its impact on the introduction of a new 'whole system' medical pathway (ie rotas, staffing, process) at an organisation in difficulty. We describe the process, problems, effect on operational performance, staff survey feedback six months post-implementation and the lessons learned. Factors critical to success were good communication; clear responsibilities, common values and strong governance; incorporation into an effective local improvement programme; targeting of specific issues; ability to influence people and foster relationships; adequate 'manpower' and gradual transition to local 'ownership'.

The power of digital communications: improving outpatient attendances in south London.

Missed appointments represent a significant burden to healthcare budgets. The average 'did not attend' (DNA) rate across the NHS is 6.7%; however, significant variation can be observed. In 2015, Guy's and St Thomas' NHS Foundation Trust observed a DNA rate of 13.5% and partnered with DrDoctor to reduce this by implementing their innovative outpatient scheduling and booking platform. The overall rate has reduced by 17.2%; Guy's and St Thomas' NHS Foundation Trust has estimated a £2.6 million financial benefit in the first year and 91% of patients would recommend the service. This case study describes the onboarding process for DrDoctor's platform across Guy's and St Thomas' NHS Foundation Trust, the benefits delivered and next steps for the partnership.

Association of thrombotic microangiopathy and intimal hyperplasia with bleeding post-renal biopsy in antiphospholipid antibody-positive patients.

OBJECTIVE: Renal biopsy remains the gold standard investigation for both diagnostic and prognostic purposes in the clinical management of lupus nephritis. However, it is not without potentially significant complications. The objectives of this study were to determine the rate of significant bleeding post-renal biopsy in patients with lupus nephritis and to identify risk factors associated with hemorrhagic complications. METHODS: Clinical data were retrospectively collected on 215 renal biopsies performed over a 13-year period (1999-2012). Patients were categorized into 3 groups: a diagnosis of systemic lupus erythematosus (SLE) alone, SLE with coexisting antiphospholipid syndrome (APS), or a diagnosis of SLE with either positive anticardiolipin antibodies and/or lupus anticoagulant (LAC) without clinical APS manifestations. RESULTS: Major bleeding complications were significantly more common in those with coexisting APS and/or antiphospholipid antibodies (aPL). LAC, presence of thrombotic microangiopathy (TMA) on renal biopsy, older age at the time of the biopsy (age >40 years), and elevated serum creatinine (>400 µmoles/liter) were independent risk factors for increased risk of bleeding. TMA and severe fibrous intimal hyperplasia on renal biopsy were significantly more prevalent in those who developed severe bleeding complications. CONCLUSION: Based on these findings, lupus nephritis patients with coexisting APS, positive LAC, and histologic evidence of TMA and/or fibrous intimal hyperplasia are at increased risk of bleeding post-renal biopsy. aPL should be checked in all lupus nephritis patients before undergoing renal biopsy, as this subset of patients warrants particular caution pre- and postprocedure.

Mycophenolate mofetil in systemic lupus erythematosus: efficacy and tolerability in 86 patients.

OBJECTIVE: To assess the indications, efficacy, and tolerability of mycophenolate mofetil (MMF) in patients with systemic lupus erythematosus (SLE) resistant to other immunosuppressive therapy. METHODS: Records of 93 patients with SLE were retrospectively reviewed. Seven patients were excluded. The remaining 86 patients received other immunosuppressive drugs before MMF. Efficacy was measured by changes in daily oral prednisolone dose, European Consensus Lupus Activity Measurement Index (ECLAM), erythrocyte sedimentation rate (ESR), C-reactive protein, and dsDNA antibody titer. In renal patients, changes in serum creatinine, creatinine clearance, chromium-51 EDTA glomerular filtration rate (EDTA-GFR), and 24 hour urine protein excretion were also evaluated. RESULTS: Indications for MMF were mainly renal involvement (59% of patients), uncontrolled disease activity (14%), and other SLE related manifestations (13%). Overall, we found a significant reduction in the steroid dosage, ECLAM, ESR, and anti-dsDNA antibody titer. Renal patients (n = 35) showed a significant reduction in urinary 24 hour protein excretion. Levels of serum creatinine, creatinine clearance, and EDTA-GFR showed no significant change during treatment. Thirty-seven patients (42.8%) developed adverse events. Gastrointestinal intolerance in 25 (29%) and infections in 20 (23.2%) were the most frequent. The drug was discontinued in 14 (16.3%) patients due to side effects and 6 patients discontinued MMF because they achieved disease remission and were trying to conceive. MMF was stopped due to lack of efficacy in 12 patients. CONCLUSION: Our data suggest that MMF is a good therapeutic alternative for patients with SLE and renal involvement or refractory disease activity.

Measuring blood pressure in stable renal transplant recipients: what you measure depends on what you use.

BACKGROUND: Blood pressure levels have a major impact on cardiovascular and renal transplant outcomes after renal transplantation. But there are significant challenges to accurately measure blood pressure levels in stable healthy renal transplant outpatients. We aimed to test whether there are differences in BP measurements taken using either automated oscillometric machines or a random zero sphygmomanometer. METHODS: Blood pressure was recorded twice in a random order with each of three BP measuring devices (DINAMAP BP8800; OMRON HEM 713 and a Random-Zero Hawskley sphygmomanometer). Results were analysed to determine observer bias, cardiovascular artefacts, and intra- and inter-machine BP variation. RESULTS AND CONCLUSIONS: There was no significant observer bias or cardiovascular artefacts. Intra-machine variability was small. BP measurement using DINAMAP and OMRON could lead to a difference of up to 30 mm Hg higher or 15 mm Hg lower than Hawskley random zero BP readings. Though widely used for 'convenience', oscillometric measures of BP in the renal transplant clinic are not optimal.

Thrombotic micro-angiopathy with sirolimus-based immunosuppression: potentiation of calcineurin-inhibitor-induced endothelial damage?

Thrombotic microangiopathy is a rare but important finding in the context of organ transplantation. Acute renal insufficiency in the setting of hemolysis and thrombocytopenia, a triad that constitutes 'hemolytic uremic syndrome', can be associated with, or triggered by, conditions such as verocytotoxin-producing Escherichia coli, viral infections, malignant hypertension, scleroderma, allograft rejection, lupus erythematosus, pregnancy, and medications including mitomycin C, calcineurin inhibitors, and oral contraceptives. After renal transplantation, it can occur, as either a de novo episode, or recurrent disease. Calcineurin inhibitors have long been associated with post-transplantation thrombotic microangiopathy. Sirolimus has been used as a primary immunosuppressant in patients transplanted with a history of earlier hemolytic-uremic syndrome, and also as rescue therapy in patients with calcineurin-inhibitor-associated thrombotic microangiopathy. We describe four cases where there was significant thrombotic microangiopathy in the context of contemporaneous or contiguous calcineurin inhibitor and sirolimus usage. As the intrarenal cyclosporin concentration is thought to be significantly elevated when cyclosporin and sirolimus are used together, this may explain these findings, and mandates caution in their co-administration.

Recurrence of hemolytic uremic syndrome after live related renal transplantation associated with subsequent de novo disease in the donor.

There is a significant risk of disease recurrence in patients with nondiarrheal (D-) hemolytic uremic syndrome (HUS) undergoing renal transplantation. Recent studies have found that approximately 20% of sporadic cases of HUS have mutations in the gene for the complement regulatory protein factor H. The authors report on 2 families, in each of which a family member initially presented with sporadic HUS and subsequently received a live-related renal transplant, one from a sibling and the other from the father. Subsequently, both recipients suffered recurrent HUS in the allograft, and both donors had HUS within a year of the transplant. Neither family has a factor H mutation. This report underlines the risk of disease recurrence in recipients associated with live-related renal transplantation in HUS and also suggests that the donors may be at risk.

The comprehensiveness care of sickle cell disease.

Millions of people across the world have sickle cell disease (SCD). Although the true prevalence of SCD in Europe is not certain, London (UK) alone had an estimated 9000 people with the disorder in 1997. People affected by SCD are best managed by a multidisciplinary team of professionals who deliver comprehensive care: a model of healthcare based on interaction of medical and non-medical services with the affected persons. The components of comprehensive care include patient/parent information, genetic counselling, social services, prevention of infections, dietary advice and supplementation, psychotherapy, renal and other specialist medical care, maternal and child health, orthopaedic and general surgery, pain control, physiotherapy, dental and eye care, drug dependency services and specialist sickle cell nursing. The traditional role of haematologists remains to co-ordinate overall management and liase with other specialities as necessary. Co-operation from the affected persons is indispensable to the delivery of comprehensive care. Working in partnership with the hospital or community health service administration and voluntary agencies enhances the success of the multidisciplinary team. Holistic care improves the quality of life of people affected by SCD, and reduces the number as well as length of hospital admissions. Disease-related morbidity is reduced by early detection and treatment of chronic complications. Comprehensive care promotes awareness of SCD among affected persons who are encouraged to take greater control of their own lives, and achieves better patient management than the solo efforts of any single group of professionals. This cost-effective model of care is an option for taking haemoglobinopathy services forward in the new millennium.