Randomized clinical trial of laparoscopic versus open donor nephrectomy.

BACKGROUND: This randomized controlled trial was designed to determine the safety and efficacy of laparoscopic donor nephrectomy (LDN) in comparison with short-incision open donor nephrectomy (ODN). METHODS: Eighty-four live kidney donors were randomized in a 2 : 1 ratio to LDN (56 patients) or short-incision ODN without rib resection (28). Primary endpoints were pain relief and duration of inpatient stay. RESULTS: There was no donor death or allograft thrombosis in either group. The first warm ischaemic time median (range) 4 (2-7) versus 2 (1-5) min; P = 0.001) and the duration of operation (160 (110-250) versus 150 (90-200); P = 0.004) were longer for LDN. LDN led to a reduction in parenteral morphine requirement 59 (6-136) versus 90 (35-312) mg; P = 0.001) and hospital stay (4 (2-6) versus 6 (2-9) days; P = 0.001), and earlier return to employment (42 (14-84) versus 66.5 (14-112) days; P = 0.004). Postoperative respiratory function was improved after LDN. There were more postoperative complications per donor in the ODN group (0.6(0.7) versus 0.3(0.5); P = 0.033). At a median follow-up of 74 months, there were no differences in renal function or allograft survival between the groups. CONCLUSION: LDN removes some of the disincentives to live donation without compromising the outcome of the recipient transplant.

Introduction of an enhanced recovery protocol into a laparoscopic living donor nephrectomy programme.

INTRODUCTION: Living-donor renal transplantation is the optimal treatment for patients with end-stage renal disease. The rate of living donation in the UK is sub-optimal, and potential donor concerns regarding postoperative recovery may be contributory. Enhanced recovery programmes are well described for a number of surgical procedures, but experience in living-donor surgery is sparse. This study reports the impact of introducing an enhanced recovery protocol into a living-donor renal transplant programme. MATERIALS AND METHODS: All consecutive patients undergoing laparoscopic living-donor nephrectomy over a 25-month period were included. The principles of enhanced recovery were fluid restriction, morphine sparing and expectation management. Outcome measures were postoperative pain scores and complications for donor and recipients. RESULTS: Standard care was provided for 24 (30%) patients and 57 (70%) followed an enhanced recovery pathway. The latter group received significantly less preoperative intravenous fluid (0ml vs 841ml p < 000.1) and opiate medication (14.83mg vs 23.85mg p = 0.001). Pain scores, postoperative complications and recipient transplant outcomes were comparable in both groups. CONCLUSIONS: Enhanced recovery for living-donor nephrectomy is a safe approach for donors and recipients. Application of these techniques and further refinement should be pursued to enhance the experience of living donors.

The epidemiology of serious adverse drug reactions among the elderly.

Although the incidence and prevalence of serious adverse drug reactions (ADRs) in the elderly cannot be accurately stated, published estimates appear to be unchanged since the earliest reports in the 1960s. Whereas heightened awareness of the problem may weigh in favour of a reduction in ADR frequency, the dramatic increase in the number and availability of therapeutic agents has undoubtedly contributed to the observed high proportion of drug-induced morbidity among acute geriatric hospital admissions. No single drug or drug class is of particular concern since none appears to cause serious morbidity out of proportion with its use. Although numerous studies have sought to identify risk factors for ADRs, the only truly independent predictor is the absolute number of concurrently used medications. However, other studies indicate that there is poor doctor-patient agreement regarding a patient's drug regimen, and interventions that aim to reduce the incidence of ADRs have failed to demonstrate a positive effect. Thus at present the most rational approach would appear to be to establish an accurate knowledge of the patients drug regimens: once this is known one can attempt to rationally minimise the number of medications without compromising therapeutic goals.

Urological complications of renal transplantation: the impact of double J ureteric stents.

In a 10 year series of 350 consecutive renal transplant operations, the overall urological complication rate was 7.7%. During this period double J stents were introduced and were used either in the treatment of actual urological complications or as a prophylactic measure to protect ureters which had been damaged at retrieval. A total of 34 double J stents were used in 33 patients. The indications were: ureteric obstruction (n = 13), urinary leak (n = 5), short transplant ureter anastomosed using an extravesical ureteroneocystostomy (n = 10) and ureteric injury at the time of organ retrieval (n = 6). Thirty-two double J stents were inserted at open operation and two were inserted by an antegrade method after percutaneous nephrostomy. Improvement in renal function occurred in 16 out of the 18 cases of urological complications. No kidneys were lost and there were no deaths as a direct result of these complications. In a number of cases the insertion of a double J stent was the only treatment, thus eliminating the need for more complex surgery. All 16 patients who had a ureteric stent inserted as a prophylactic measure at the time of transplantation made uncomplicated postoperative recoveries. Urinary tract infection was relatively common (27%) after double J stent insertion, but other complications were rare. In conclusion, double J stents have proved to be a useful adjunct in the management of renal transplant related urological complications.

Factors predicting outcome after selective ERCP in the laparoscopic era.

This study assessed the outcome of 342 patients with in situ gallbladders undergoing ERCP for suspected choledocholithiasis. The result of ERCP was found to play a significant role (P < 0.0001) in determining whether patients were subsequently managed conservatively (n = 152) or underwent either laparoscopic (n = 110) or open (n = 80) surgery. Those undergoing laparoscopic surgery were noted to be younger (P = 0.0001) and were less likely to be jaundiced (P = 0.0015) or have CBD stones at ERCP (P = 0.0295). In 28 patients with CBD stones remaining after ERCP, pre- rather than postoperative timing of ERCP prevented a potential second operation. The current success rate of 85% in clearing CBD stones at ERCP cannot support a routine policy of intraoperative cholangiography followed by postoperative ERCP.

General practice procedural skills.

In 1988 a self reported competency survey of Queensland interns was undertaken in the final months of their pre-registration year. The survey revealed that 24 of 46 essential procedural skills for general practice had been performed alone by 80 per cent or more of interns. Eleven of the remaining 22 procedures had been performed under supervision by at least 80 per cent of the respondents. There were four procedures that had been performed by fewer than half the respondents.

Competency of medical students in general practice procedural skills.

A self-reported competency survey of 1988 sixth year medical students in Queensland revealed that only 2 of 47 procedural skills considered essential for general practice had been performed alone by 80 per cent or more of students. Six of the essential skills had not been performed by more than 80 per cent of students. Consideration needs to be given to the content and effectiveness of undergraduate general practice procedural skills training.

How do patients identify their drugs?

This survey conducted by FMP trainees in Queensland describes how general practice patients on long term, self administered medications identify their drugs. Trade names are by far the most common means of identification. Generic names and identification by action, colour, and shape and common usage names are less frequently used. Knowledge of alternative trade and generic names is sparse, emphasising the need to inform patients fully of any changes to the brand names of their drugs.

Analysis of the RACGP Fellowship examination results.

The FRACGP examination assesses a candidate's performance in five behavioural attributes--knowledge, interpretation, problem solving, affective behaviour and psychomotor skills. These attributes were used as the basis for comparing the performance of various groups of candidates in the examination.

Improving educational needs assessment for general practitioners.

OBJECTIVE: To improve the quality of educational needs analysis for groups of general practitioners through the development of a range of simple, inexpensive practice based performance measures of general practice. METHOD: Members of one volunteer semi rural division of general practice were allocated randomly to groups that collected or provided data on: local referral patterns; consulting, prescribing and ordering, as collected by the Health Insurance Commission; and age, gender, reasons for encounter and management of a sample of patients. Other information was provided by a recent division community needs analysis, a consumer survey, national health targets and local health professionals. These data were combined to develop a list of educational topics that deserved attention. RESULTS: A total of 56% of GPs agreed to participate, providing Health Insurance Commission data for seven GPs, referral patterns for 11 GPs and BEACH surveys for five GPs. Much of the data collected for other purposes proved to be of little value in determining specific educational needs and the more time consuming methods attracted poor participation rates. The most useful data were those collected locally by the division. CONCLUSION: Educational needs analyses for groups of GPs should consider the perspectives of the profession, funders and patients, in addition to those of individual GPs. Practice based measures of GP performance need to be made more relevant to current practice, while remaining inexpensive and not intruding too much into GPs' time. A range of potential measures is provided.

Recent advances in prophylaxis against deep vein thrombosis.

The major development in DVT prophylaxis in recent years has been the introduction of low molecular weight heparins. Their main improvement compared with unfractionated heparin is in the convenience of a once daily dosage, but they have not yet convincingly been shown to be more effective or safer. A-V impulse boots may have an impact on knee and hip surgery but still face problems with patient acceptability. Probably the best way to ensure that more DVT are prevented is by clinicians maintaining a high level of awareness of the risk, and developing, and adhering to, local guidelines.

Why doctors leave rural practice.

Retention of rural doctors remains difficult because of complex factors that influence decisions of medical families. This study explores the reasons why Queensland rural doctors left their communities during 1995. Semi-structured interviews were conducted with contactable former rural doctors who claimed that they had entered rural practice with the intention to stay for a substantial period of time. The interviews were audiotaped, transcribed and analysed using NUD.IST software. Participants appeared to be subject to a dynamic balance between opposing pressures to stay and pressures to leave. In time, they became susceptible to 'triggers' to leave. These triggers were sometimes locality-specific and could be difficult to address, particularly without early intervention. We believe that it should be possible to develop strategies that address specific concerns of rural doctors, particularly if they are identified early. The optimum period of stay in rural practice should be reconsidered, such that moderate stays should be rewarded in a way that retains the doctors in some form of rural, or near-rural practice.

Work-load generated by the establishment of a non-heart beating kidney transplant programme.

The work-load generated by a non-heart-beating donor (NHBD) kidney transplant programme over a 3-year period is reported. A total of 73 referrals were made, 64 from the Accident department and 9 from the wards. Organ procurement was performed in 24 cases (33%) and resulted in the retrieval of 44 kidneys. Reasons for failure to achieve organ procurement were; refused consent (n = 13; 18%), relatives unavailable to ask for consent (n = 9; 12%), technical problems with catheter insertion or perfusion (n = 10; 14%), transplant staff unavailable (n = 1; 1%), long asystolic period (n = 8; 11%) and donor unsuitable for other reasons (n = 8; 11%). Of the 44 kidneys retrieved, 30 were transplanted locally, 8 were transplanted at other United Kingdom centres and 6 were discarded. Locally transplanted NHBD kidneys represented 21% of the total transplant programme during the time period under study. We conclude that NHBD kidneys are a good source of additional organs for transplantation, but only one-third of referrals result in a successful procurement procedure. Moreover, the setting up of a successful programme is labour-intensive and requires a highly committed staff.