769 Analysing the Change – Outcomes and Benefits of Clinic-Based Removal of Renal Transplant Stents Using A Disposable Cystoscope

Introduction

Literature is chock-full of data regarding the “when” of ureteric stent removal after renal transplantation. We have attempted to address the “who”, “where” and “how” components.

Method

The Isiris disposable scope was used to remove renal allograft stents from 383 patients in the Transplant Clinic from June 2018 to April 2020. An advanced nurse practitioner was trained in the procedure. The learning curve, incidence of complications, benefits and cost implications were studied, and compared with the cohort having stent removal with a traditional flexible cystoscope in theatres.

Results

There were 14 failures necessitating theatre removal. The transplant-to-stent-removal interval was significantly lower in the clinic cohort with a mean of 38.80 days (95%CI 37.26–40.34) to 46.55 days in theatres (95%CI 43.47–49.62). 11 patients had urgent bedside stent removal. The service was delivered independently by the nurse for 5.3% of the patients in June 2018 and progressed to over 80% by April 2019. Estimated net gain was £919/patient.

Conclusions

Moving transplant ureteric stent removals from a resource intensive all-day process in theatres to a one-stop event in the clinic is a safe and economical model that can streamline flow in patient pathway and inculcate new skills in other members of the multidisciplinary team.

Historical Context and Recent Advances in Exposure-Response Estimation for Deriving Occupational Exposure Limits

Virtually no occupational exposure standards specify the level of risk for the prescribed exposure, and most occupational exposure limits are not based on quantitative risk assessment (QRA) at all. Wider use of QRA could improve understanding of occupational risks while increasing focus on identifying exposure concentrations conferring acceptably low levels of risk to workers. Exposure-response modeling between a defined hazard and the biological response of interest is necessary to provide a quantitative foundation for risk-based occupational exposure limits; and there has been considerable work devoted to establishing reliable methods quantifying the exposure-response relationship including methods of extrapolation below the observed responses. We review several exposure-response modeling methods available for QRA, and demonstrate their utility with simulated data sets.

Considerations for Using Genetic and Epigenetic Information in Occupational Health Risk Assessment and Standard Setting

Risk assessment forms the basis for both occupational health decision-making and the development of occupational exposure limits (OELs). Although genetic and epigenetic data have not been widely used in risk assessment and ultimately, standard setting, it is possible to envision such uses. A growing body of literature demonstrates that genetic and epigenetic factors condition biological responses to occupational and environmental hazards or serve as targets of them. This presentation addresses the considerations for using genetic and epigenetic information in risk assessments, provides guidance on using this information within the classic risk assessment paradigm, and describes a framework to organize thinking about such uses. The framework is a 4 × 4 matrix involving the risk assessment functions (hazard identification, dose-response modeling, exposure assessment, and risk characterization) on one axis and inherited and acquired genetic and epigenetic data on the other axis. The cells in the matrix identify how genetic and epigenetic data can be used for each risk assessment function. Generally, genetic and epigenetic data might be used as endpoints in hazard identification, as indicators of exposure, as effect modifiers in exposure assessment and dose-response modeling, as descriptors of mode of action, and to characterize toxicity pathways. Vast amounts of genetic and epigenetic data may be generated by high-throughput technologies. These data can be useful for assessing variability and reducing uncertainty in extrapolations, and they may serve as the foundation upon which identification of biological perturbations would lead to a new paradigm of toxicity pathway-based risk assessments.

Considerations for Using Genetic and Epigenetic Information in Occupational Health Risk Assessment and Standard Setting

Risk assessment forms the basis for both occupational health decision-making and the development of occupational exposure limits (OELs). Although genetic and epigenetic data have not been widely used in risk assessment and ultimately, standard setting, it is possible to envision such uses. A growing body of literature demonstrates that genetic and epigenetic factors condition biological responses to occupational and environmental hazards or serve as targets of them. This presentation addresses the considerations for using genetic and epigenetic information in risk assessments, provides guidance on using this information within the classic risk assessment paradigm, and describes a framework to organize thinking about such uses. The framework is a 4 × 4 matrix involving the risk assessment functions (hazard identification, dose-response modeling, exposure assessment, and risk characterization) on one axis and inherited and acquired genetic and epigenetic data on the other axis. The cells in the matrix identify how genetic and epigenetic data can be used for each risk assessment function. Generally, genetic and epigenetic data might be used as endpoints in hazard identification, as indicators of exposure, as effect modifiers in exposure assessment and dose-response modeling, as descriptors of mode of action, and to characterize toxicity pathways. Vast amounts of genetic and epigenetic data may be generated by high-throughput technologies. These data can be useful for assessing variability and reducing uncertainty in extrapolations, and they may serve as the foundation upon which identification of biological perturbations would lead to a new paradigm of toxicity pathway-based risk assessments.

Evaluation of cleaning strategies for removal of biofilms from reverse-osmosis membranes

An evaluation was made of the efficiency of five classes of chemical cleaning agents for removing biofilm from spirally wound cellulose acetate reverse-osmosis membranes receiving influent with high or low levels of combined chlorine. Each cleaning regimen utilized one or more of the following types of chemical: (i) surfactants and detergents, (ii) chaotropic agents, (iii) bactericidal agents, (iv) enzymes, and (v) antiprecipitants. Cleaning efficiency was tested in the laboratory on membrane material removed from operations at various intervals (2 to 74 days). Cleaning effectiveness was evaluated against nontreated control membranes and was scored by scanning electron microscopy and enumeration of surviving bacteria after treatment of the membranes. The combinations of classes which were most effective in biofilm removal were the anionic and chaotropic agent combination and combinations involving enzyme-containing preparations. Membranes receiving influent with high levels of combined chlorine were easier to clean but more susceptible to structural damage from prolonged exposure to combined chlorine. No treatment or combination of treatments was completely effective or effective at all stages of biofilm development.

A survey to determine the blood concentration of cyclosporine 2 hours postdose in stable renal transplant patients

The current method for monitoring cyclosporine measures predose concentrations (C0). A better method has been developed, namely, measurement of the blood cyclosporine concentration at 2 hours postdose (C2). The aim of this survey was to determine the variability of C0 and C2 concentrations among stable renal transplant patients. One hundred two stable renal transplant patients who were at least 6 months posttransplant were recruited from the renal transplant outpatient clinic. The cyclosporine dose was between 100 and 500 mg daily; all patients had been monitored using C0 concentrations. Blood samples for cyclosporine concentration measurements were taken at both C0 and C2 at two consecutive clinic visits. The within- and between-patient variabilities were calculated using nested analysis of variance. The mean age was 50 years (21 to 81); the mean weight was 75 kg. The mean cyclosporine dose was 3.18 mg/kg/d (1.2 to 8.8). The average serum creatinine was 174 micromol/L (77 to 626) and the average cholesterol was 5 micromol/L (3 to 9). The mean (+/-SD) C0 concentration was 150 (47.31) microg/L and C2=895 (239) microg/L. The C0 concentration varied over 16-fold between patients compared to a sevenfold variation in C2. The between-subject coefficient of variation (CV) was 35% for C0 and 30% for C2 and the within subject CV was 23% for C0 and 20% for C2. The results suggest that cyclosporine concentrations at C0 are slightly more variable than those at C2. Whether this modest reduction in variability results in better patient outcomes is the subject of the next phase of this study.

Drop-out rate during living donor selection

This unit carried out 29 live donor transplants over a 3-year period. Many potential donors did not proceed to transplant. For those who had an acceptable tissue type, were blood group compatible and lymphocytotoxic crossmatch negative, we looked at the reasons for cancelling the donor work up. The reasons were impaired renal function (5 potential donors), cardiac/hypertension (4 potential donors), renovascular (1 potential donor), cancer (1 potential donor), cross-match positive at a late stage (3 potential donors), failure to attend at clinic/change of mind (6 potential donors) and hepatitis (2 potential donors). Improvements carried out following the audit include a list of tests which potential donors living away from this unit--especially those abroad--are asked to do before travelling here. An information leaflet has also been produced for potential donors.

Functional annotation of a full-length mouse cDNA collection

The RIKEN Mouse Gene Encyclopaedia Project, a systematic approach to determining the full coding potential of the mouse genome, involves collection and sequencing of full-length complementary DNAs and physical mapping of the corresponding genes to the mouse genome. We organized an international functional annotation meeting (FANTOM) to annotate the first 21,076 cDNAs to be analysed in this project. Here we describe the first RIKEN clone collection, which is one of the largest described for any organism. Analysis of these cDNAs extends known gene families and identifies new ones.

Internet use by patients--a shift in power?

Traditionally, the patient has relied on health care professionals for advice and knowledge. The unprecedented access to information offered by the Internet may challenge this relationship. To investigate this, a questionnaire was sent to 640 transplant patients. 24 responded positively and were interviewed to see if the information they found on the net had been useful, in negotiating a change in treatment or as support. Internet use was associated with younger males who had access to the net at work. 22 had found useful information although only 1 patient had negotiated a change in treatment as a result. As the Internet becomes universally available, patients will be empowered to have a larger role in maintaining their health, and support groups will be better able to help patients. To prepare to deal with this avalanche of information we need to develop a system of accreditation of Internet sites, to create our own sites and to collaborate with patient support groups.

Evaluation of potential transplant recipients and living donors

The transplant waiting list needs to be actively managed by the transplant centre in a systematic way to achieve any degree of efficiency and effectiveness. This paper describes the key role of the transplant nurse in a large centre with over 300 people on the transplant waiting list. It focuses on the way patients are assessed, how the list is updated and the benefit of nurse involvement in the work-up of potential live donors.

Self perception affecting adherence to drug regimen following renal transplantation

The patient, a chronic cannabis user, found it increasingly difficult to tolerate the side effects of the medication on her appearance. Rejection in the early post-transplant period meant that immunosuppression could not be further reduced. We were able to avoid a catastrophic self-initiated cut in immunosuppression, and withdrawal of steroids was carried out according to a schedule supervised by the clinic. Cellular rejection resulted and was treated with i.v. methyl prednisolone and conversion from cyclosporin micro-emulsion (Neoral, Novartis) to tacrolimus (Prograf, Fujisawa) and from azathioprine to mycophenolate mofetil (CellCept, Roche).

Surgery of the cornea

Corneal surgery is a common and essential part of veterinary ophthalmology and ranges from simple linear keratotomy for indolent ulcers to penetrating keratoplasty for restoration of optical clarity. Success in corneal surgery relies on an understanding of corneal anatomy, physiology and wound healing, meticulous attention to detail, microsurgical equipment and techniques, and use of appropriate preoperative, intraoperative, and postoperative medications. Surgical management of corneal disease is indicated for corneal ulceration, excision of a mass lesion, reconstructive procedures, therapeutic indications, optical restoration, and cosmetic purposes.

Visual outcome and ocular survival following iris prolapse in the horse: a review of 32 cases

The medical records of 32 horses treated for iris prolapse (IP) during an 8 year period, at the University of Florida Veterinary Medical Teaching Hospital, were reviewed. Iris prolapse was associated with perforated corneal ulcers in 15 horses (47%), ruptured stromal abscesses in 2 horses (6%), and full thickness corneal lacerations in 15 horses (47%). Initial ophthalmic examinations revealed IP with severe iridocyclitis in all eyes and keratomalacia in 8 eyes with corneal ulcers, one with a stromal abscess and 1 with a corneal laceration. Hyphema was present in 7 eyes with corneal lacerations. Thirty horses were managed with combined medical and surgical therapy. Two horses were only treated medically with topically administered antibiotics. Of the 24 perforations surgically repaired, 21 were closed primarily and 13 were then covered with a conjunctival graft. After combined therapy and a minimum of 4 months of follow-up, vision was retained in 6 of the horses (40%) with perforating corneal disease and 5 of the horses (33%) with perforating corneal lacerations. Post operatively, of the 11 (37%) horses blind at discharge, 6 (55%) subsequently developed phthisis bulbi. Enucleations were performed in 4 cases with extensive keratomalacia and/or endophthalmitis, 2 cases with limbal rupture and total hyphema, and one case with a chronic IP. One horse was subjected to euthanasia after 3 surgical treatments failed to stabilise stromal melting. Horses presented with ulcerative keratitis of fewer than 15 days duration, or horses with corneal lacerations less than 15 mm in length, tended to have a favourable visual outcome. Keratomalacia, hyphema, corneal lacerations longer than 15 mm and lacerations extending to, along, or beyond the limbus, adversely influenced visual outcome. Iridectomy did not appear clinically to exacerbate anterior uveitis or adversely affect visual outcome. Ocular survival following combined therapy was 80% (12/15) in horses with corneal lacerations and 67% (10/15) in horses with ulcerative keratitis.

Corneal stromal abscesses in the horse: a review of 24 cases

The medical records of 24 horses with corneal stromal abscesses were reviewed. Twenty of the horses initially presented with a corneal ulcer, corneal opacity, or evidence of ocular pain. All of the horses were treated with topical antibiotics prior to referral. Most had also been treated with topical atropine sulphate and systemic flunixin meglumine. Ophthalmic examinations revealed focal, yellow-white corneal opacities, corneal vascularisation and evidence of iridocyclitis. Nine of the horses were treated primarily medically as the initial response to topical and systemic medication was rapid. Fifteen horses were treated both medically and surgically. Surgical treatment was undertaken when corneal rupture was imminent, the iridocyclitis was intractable or when there was minimal response to intensive medical therapy. The surgical procedure performed in most cases was a deep keratectomy with a conjunctival pedicle flap. Intraoperative specimens for cytology, culture, and/or histopathology contributed to the aetiological diagnosis in 5 of 8 cases in which preoperative cytology and cultures were nondiagnostic. All horses, excluding one that was enucleated at presentation for iris prolapse, had vision at discharge.

Ocular protection in squash clubs: time for a change?

All squash clubs in the West Midlands were surveyed by postal questionnaire to determine their level of awareness to the risk of ocular injury. Of the 100 clubs surveyed, 51 questionnaires were returned. None of the clubs responding had any information warning of the potential hazards of ocular injury. Thirteen of the clubs had sporting goods shops; of these, three sold protective eye-wear. Significantly, all three stocked the open or lenseless type of eye-guard and only one had the guards with impact-resistant plastic lenses. The majority of clubs (96%) expressed a desire for further information. It is concluded that: (1) players are not warned of the hazards of playing without appropriate eye protection, (2) hazardous eye-guards (open type) continue to be sold, and (3) there is a desire to improve the safety of the sport.

An evaluation of communication strategies during the process of incorporating a college of health studies into a university

This paper reports on an evaluation of communication strategies employed by management during the incorporation of a college of health care studies as a new faculty of a university. Mindful of the stress and anxiety that organizational change can evoke, from the earliest stages of the projected incorporation senior managers at the college and the university employed a wide variety of methods to communicate to staff in the college the changes that were in progress and at the same time to set up mechanisms for evaluating the effectiveness of the communication. The method of inquiry was a questionnaire to all the staff of the college in March and June of the year preceding incorporation. This was supported by interviews with a 10% sample of the college to explore in greater depth issues identified in the questionnaires. The findings indicated that in general communication had been perceived as effective; and that of the various methods used the two most valued by staff were: (a) a regular newsletter; and (b) an advisory and consultative committee of staff drawn from all areas of the work of the college up to and including senior lecturer.