Julie M Bridson’s research while affiliated with University of Liverpool and other places

Even a mention of formal assessment of senior clinicians can be a contentious issue, to say least, when revalidation is said to be firmly in place in NHS-UK for almost half a decade. Since revalidation is accepted as a standard modality of assessment of performance, some colleagues in NHS wonder 'stir up a hornets' nest,' when the authors allude to limitations of revalidation because poorly performing senior NHS clinicians may 'slip through the net.' NHS consultants have clinical as well as training roles. Fundamentally, this assessment (revalidation) is meant to ensure the safety of the public and mitigates the risk of disciplinary action by the GMC. Unfortunately, a disciplinary action is often the first sign of underperformance. In fact, the Bristol and Shipman inquiries have underscored the importance of the non-clinical and behavioural skills like communication, team-working, personal organization and leadership are as important as clinical skills. Rather than considered an assessment tool, an annual appraisal is aimed to facilitate and improve the way NHS consultants work and provide services. The authors have to wait for five years, to assess the efficacy of the system that was introduced with much 'fanfare' since it was projected as a panacea for poor performance by 'bad doctors.' The objectives of this article are to contextualize the issue of the underperformance among senior clinicians in the current NHS environment and to conceptualize the idea that their performance as trainers is directly related to their performance as clinicians. It is worth identifying the underlying factors of that are related to, or even better, can predict underperformance and will help evolve a strategy to help those consultants who are underperforming.

p> Background: While variations in medical practice are a norm and each patient poses a multitude of challenges, many clinicians are not comfortable in dealing with unexpected complex issues even though they may have enough knowledge as demonstrated by passing a number of tricky certifying (or exit) examinations. One reason for the lack of self-efficacy, even if being endowed with good knowledge, is that we are not good in learning from errors. A regular reflective practice offers superb learning opportunities when a clinician is “ stuck in a mire ” . Difficult clinical situations warrant a flexible and, at the same time, an evidence-based approach to ensure that crucial decision-making process is correct and efficient. Each clinical case offers a great opportunity to reinforce these “ threshold concepts ” , however , not everyone of us is “blessed” with these crucial not-so-difficult-to-acquire skills so necessary to be a life-long learner. The faculty of this course (a totally on-line MSc in Transplant Sciences) aims for unceasing engagement with students in order to facilitate them to negotiate through “ stuck places ” and “ tricky bends ” in their own work place. This course, not just meant for knowledge transfer, provides a platform that allows participants (the students and faculty) to learn from each other’s experience by using “ e-blackboard ” . The mainstay of this course are twofold: (a) Emphasis on achieving critical decision-making skills , (b) Regular feedback to allow reflective practice and, thereby, constantly learning from errors and reinforcing good practices. The aim of this article is to assess the performance of educators and how well the “ ethos of critical threshold ” has been accepted from the perspective of students. Methods: The critical thresholds of each chapter in 4 modules of this totally on-line course were defined to a razor-sharp precision. Learning objectives of learning activity were defined to achieve constructive alignment with critical threshold. We employed level 1, 2, 4 and 5 of Kirkpatrick pyramid , (a) for the evaluation of performance of educators of program, and (b) to evaluate the acceptance of this non-traditional format in clinical medicine education by postgraduate 80 students in 22 countries. Results: Students’ survey (Kirkpatrick level 1) was done only for module 1 of cohort 1 reported students’ satisfaction rate of 93%. Excluding a total of 12 drop-outs in 2 modules (n=10 in first cohort’s module 1, and n=2 in module 2), as many as 93% of students of first cohort passed module. Nine out of 60 registrants of module 1 in 2nd cohort took recess for one year requesting to join back as a part of 3rd cohort commencing one year later, all 51 who continued passed though 3 of them had to resit. All those who passed module 1 (both cohorts) and 2 (1st cohort) registered for their respective next module (return on investment Kirkpatrick level 5). Conclusion: For a successful model in distance learning in clinical transplantation it is imperative for the students to accomplish well defined “critical-decision making” skills. In order to learn critical thresholds, a regular feedback is integral to learning from reflective practice. This course equips the students to develop skills of negotiating “sticky mire”, as obvious from perceived high return of investment.</em

Transplant renal vein thrombosis usually occurs early after surgery with a reported prevalence of 0.1% to 4.2%. It is a devastating event that ultimately leads to graft loss in almost all cases. There are many predisposing factors related to donor, recipient, surgery, and immunosuppression, with mechanical factors being considered the most common causes of transplant renal vein thrombosis. The clinical manifestations of acute renal vein thrombosis are nonspecific and are not dissimilar to the features of urine leak, urinary obstruction, or severe acute rejection. The diagnosis of transplant renal vein thrombosis depends on a high index of clinical suspicion and duplex ultrasonographic scans. Although venography remains the criterion standard, this procedure is invasive and nephrotoxic, due to use of ionizing contrast agents and also due to exposure to ionizing radiation. There are 2 therapies that have been described in the literature for salvaging a renal allograft with transplant renal vein thrombosis: thrombolytic therapy and surgical thrombectomy. The usual end result is renal allograft nephrectomy because the diagnosis is almost always too late. © Başkent University 2017 Printed in Turkey. All Rights ReserveD.

Background: While variations in medical practice are a norm and each patient poses a multitude of challenges, many clinicians are not comfortable in dealing with unexpected complex issues even though they may have enough knowledge as demonstrated by passing a number of tricky certifying (or exit) examinations. One reason for the lack of self-efficacy, even if being endowed with good knowledge, is that we are not good in learning from errors. A regular reflective practice offers superb learning opportunities when a clinician is " stuck in a mire ". Difficult clinical situations warrant a flexible and, at the same time, an evidence-based approach to ensure that crucial decision-making process is correct and efficient. Each clinical case offers a great opportunity to reinforce these " threshold concepts " , however, not everyone of us is " blessed " with these crucial not-so-difficult-to-acquire skills so necessary to be a lifelong learner. The faculty of this course (a totally on-line MSc in Transplant Sciences) aims for unceasing engagement with students in order to facilitate them to negotiate through " stuck places " and " tricky bends " in their own work place. This course, not just meant for knowledge transfer, provides a platform that allows participants (the students and faculty) to learn from each other's experience by using " e-blackboard ". The mainstay of this course are twofold: (a) Emphasis on achieving critical decision-making skills, (b) Regular feedback to allow reflective practice and, thereby, constantly learning from errors and reinforcing good practices. The aim of this article is to assess the performance of educators and how well the " ethos of critical threshold " has been accepted from the perspective of students. Methods: The critical thresholds of each chapter in 4 modules of this totally on-line course were defined to a razor-sharp precision. Learning objectives of learning activity were defined to achieve 302 Published by SCHOLINK INC. constructive alignment with critical threshold. We employed level 1, 2, 4 and 5 of Kirkpatrick pyramid, (a) for the evaluation of performance of educators of program, and (b) to evaluate the acceptance of this non-traditional format in clinical medicine education by postgraduate 80 students in 22 countries. Results: Students' survey (Kirkpatrick level 1) was done only for module 1 of cohort 1 reported students' satisfaction rate of 93%. Excluding a total of 12 drop-outs in 2 modules (n=10 in first cohort's module 1, and n=2 in module 2), as many as 93% of students of first cohort passed module. Nine out of 60 registrants of module 1 in 2nd cohort took recess for one year requesting to join back as a part of 3rd cohort commencing one year later, all 51 who continued passed though 3 of them had to resit. All those who passed module 1 (both cohorts) and 2 (1st cohort) registered for their respective next module (return on investment Kirkpatrick level 5). Conclusion: For a successful model in distance learning in clinical transplantation it is imperative for the students to accomplish well defined " critical-decision making " skills. In order to learn critical thresholds, a regular feedback is integral to learning from reflective practice. This course equips the students to develop skills of negotiating " sticky mire " , as obvious from perceived high return of investment.

Introduction: Distance education is not yet popular in clinical medicine due to the strongly ingrained belief among medical professionals that face-to-face and bedside teaching is a prerequisite to learning clinical medicine. Transplantation Science is a challenging subspecialty to teach and we demonstrate how our educational approach can be effective in improving the attainment of the postgraduate students. Methods: This online course was designed in the UK by an international board of academic and clinical experts and attracted international students (n=28) from 12 countries. The diversity of the student demographics presents inherent challenges mainly due to a fundamental disparity between perception and implementation of the knowledge. We employed multidisciplinary coursework as the main strategy to improve the attainment of these students to overcome these challenges. Results: The significant attainment changes noted by implementing multidisciplinary coursework-based pedagogy is exemplified by qualitative and quantitative improvement in performance in the final assessment marks when compared to the first assignment (66% ± 3.2 vs 56% ± 5.1, P <0.05). This improvement is reflected in 'habitual use' of critically reflective practice and implementation of evidence-based medicine. Conclusions: Well-designed, multidisciplinary formative coursework is a valuable tool to develop the attainment of postgraduate sub-specialty trainees perusing a career in clinical medicine.

AIM To explore the benefits and harms of corticosteroid (CS) minimization following renal transplantation. METHODS CS minimization attempts to improve cardiovascular risk factors (hypertension, diabetes, dyslipidemia), to enhance growth in children, to ameliorate bone disease and to lead to better compliance with immunosuppressive agents. Nevertheless, any benefit must be carefully weighed against the reduction in net immunosuppression and the potential harm to renal allograft function and survival. RESULTS Complete CS avoidance or very early withdrawal (i.e., no CS after post-transplant day 7) seems to be associated with better outcomes in comparison with later withdrawal. However, an increased incidence of CS-sensitive acute rejection has been observed with all CS minimization strategies. Among the prerequisites for the safe application of CS minimization protocols are the administration of induction immunosuppression and the inclusion of calcineurin inhibitors in maintenance immunosuppression regimens. CONCLUSION Transplant recipients at low immunological risk (primary transplant, low panel reactive antibodies) are thought as optimal candidates for CS minimization. CS avoidance may also be undesirable in patients at risk for glomerulonephritis recurrence or with severe delayed graft function and prolonged cold ischemia time. Thus, CS minimization is not yet ready for implementation in the majority of transplant recipients.

In organ transplantation, a wide variety of injurious events such as ischaemia-reperfusion injury, endothelial damage and the traumatic exposure of tissues during surgery occur intra-operatively. The barrage of multiple antigens presented to the recipient cause very intense immunological reaction to occur at the time of transplantation. Thus, an induction immunosuppressive protocol aimed at maximal immunosuppression in the peri-operative period when immunological stimulation is maximal is justified. Organ transplant recipients of African descent are generally considered as high immunological-risk patients in view of the intense immunological response to transplanted organs seen in these patients compared with their Caucasian counterparts. However, due to the huge additional cost of induction antibody medications, most centers in resource-poor economies in Africa base their induction protocol on high doses of calcineurin based triple-drug therapy. Outcomes from the centers have been considerably poorer in terms of allograft rejection, graft loss and patient survival, compared with other parts of the world where high-risk patients received antibody induction therapy. Basiliximab induction protocols may offer cost–benefit advantages in resource constrained centers compared with currently used calcineurin based triple-drug therapy. The clinical and financial benefits of reduced acute allograft rejection rates, graft loss and the excellent side effect profile Basiliximab in renal transplant recipients, potentially outweighs the additional costs incurred in the management of higher acute rejection rates, and graft loss in calcineurin based triple-drug therapy. This reflective review article, examines the possible role of Basiliximab induction protocol as a means of improving clinical outcomes of renal transplantation, in African transplant centres operating in financial constraint economies.

Obesity is associated with worse short-term outcomes after kidney transplantation but the effect on long-term outcomes is unknown. Although some studies have reported worse outcomes for obese recipients when compared to recipients with a BMI in the normal range, obese recipients who receive a transplant have better outcomes than those who remain wait-listed. Whether transplant candidates should be advised to lose weight before or after transplant has been debated and this is mainly due to the gap in the literature linking pre-transplant weight loss with better outcomes post-transplantation. The issue is further complicated by the use of BMI as a metric of body fat, the obesity paradox in dialysis patients and the different ethical viewpoints of utility versus equity. Measures used to reduce weight loss, including orlistat and bariatric surgery (in particular those with a malabsorptive component), have been associated with enteric hyperoxaluria with consequent risk of nephrolithiasis and oxalate nephropathy. In this review, we discuss the evidence regarding the use of weight loss measures in the kidney transplant candidate and recipient with a view to recommending whether weight loss should be pursued before or after kidney transplantation.

The introduction of the calcineurin inhibitors cyclosporine and tacrolimus in the immunosuppressive regimens for kidney transplant has been associated with substantial reductions in the incidence of acute rejection, with a subsequent improvement in 1-year graft survival. However, this has not directly correlated with improvements in long-term allograft survival. Immunosuppressive medications are associated with toxicities related directly to immunosuppressive effects, and these are similar among different agents. In addition, there are other toxicities that are unique for each drug. Immunosuppressive minimization strategies have attempted to address both of these toxicities. Calcineurin inhibitors have been associated with chronic nephrotoxicity, and various calcineurin inhibitor-sparing strategies have been used to address this issue with the aim of improving long-term outcomes. However, there has been a paradigm shift over the past 10 to 15 years, with the appreciation that calcineurin inhibitor nephrotoxicity is not the major cause of late graft failure. Studies have now shown that chronic immune injury mediated by donor-specific antibodies may account for most late graft losses. Although some patients do benefit from calcineurin inhibitor-sparing approaches, others may have late allograft loss from chronic and subacute immune-mediated injury. Unfortunately, the vast majority of calcineurin inhibitor-sparing studies have short-term follow-up and have not explored the change in the donor-specific antibody profile. One of the biggest challenges that we face is being able to distinguish among patients who will benefit from this strategy and those who will not. In this study, we review the various strategies used to limit or avoid the use of calcineurin inhibitors and address the benefits and pitfalls associated in pursuing such strategies.

There is a misconception among transplant clinicians that contraception after a successful renal transplant is challenging. This is partly due to the complex nature of transplant patients, where immunosuppression and graft dysfunction create major concerns. In addition, good evidence regarding contraception and transplant is scarce, with most of the evidence extrapolated from observational and case-controlled studies, thus adding to the dilemma of treating these patients. In this review, we closely analyzed the different methods of contraception and critically evaluated the efficacy of the different options for contraception after kidney transplant. We conclude that contraception after renal transplant is successful with acceptable risk. A multidisciplinary team approach involving obstetricians and transplant clinicians to decide the appropriate timing for conception is recommended. Early counseling on contraception is important to reduce the risk of unplanned pregnancies, improve pregnancy outcomes, and reduce maternal complications in patients after kidney transplant. To ascertain appropriate advice on the method of contraception, individualizing the method of contraception according to a patient's individual risks and expectations is essential.