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.

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.

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.

Implementing the National Institute of Clinical Excellence improving outcome guidelines for head and neck cancer: developing a business plan with reorganisation of head and neck cancer services.

The implementation of the National Institute of Clinical Excellence improving outcome guidelines (NICE-IOG) manual for head and neck cancer may have a huge potential cost implication. Head and neck cancer is a rare disease which utilises large quantities of resources which can only be provided in a tertiary centre. Head and neck cancer services should be centralised into a single site for each cancer network.

Late low-dose steroid withdrawal in renal transplant recipients increases bone formation and bone mineral density.

Corticosteroids have been the most widely used immunosuppressive agents since the first clinical transplantation in the 1950s. There are few studies of late steroid withdrawal in renal transplantation and none have prospectively assessed bone mineral density (BMD). The study aim was to assess the impact of corticosteroid withdrawal, in stable renal transplant recipients, on BMD and bone turnover.

Reduction of proteinuria with mycophenolate mofetil in predominantly membranous lupus nephropathy.

Introduction: Lupus membranous nephropathy (LMN) presents a difficult clinical problem as no particular treatment has been proven to be effective. Studies have shown good results with mycophenolate mofetil (MMF) in proliferative lupus nephropathy (LN) (WHO class III and IV disease).

Objectives: To study whether MMF treatment was effective in membranous predominant LN in patients resistant to or intolerant of other immunosuppressive agents.

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.

Mycophenolate mofetil in nonlupus glomerulonephropathy.

Mycophenolate mofetil (MMF) initially found widespread use in the immunoprophylaxis of rejection in organ transplantation. It has subsequently been used in lupus glomerulonephritis, where early studies have shown it to be effective in induction and maintenance therapy. The randomized studies have mostly studied small groups of patients and their conclusions do need to be confirmed in larger studies.

Renal artery stenosis in hypertensive patients with antiphospholipid (Hughes) syndrome: outcome following anticoagulation.

Objective: We have demonstrated a point prevalence of 26% renal artery stenosis in patients with antiphospholipid syndrome (APS) and uncontrolled hypertension. We describe the effect of anticoagulation on blood pressure control and renal function.

Methods: We studied 23 patients retrospectively with renal artery stenosis (RAS).

Symptomatic cytomegalovirus infection complicating treatment of acute systemic vasculitis.

Cytomegalovirus (CMV) is usually a complication of renal/solid organ or bone marrow transplantation. We describe three cases of severe CMV in the context of vasculitis immunosuppression.

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.

Adult onset Still's disease and collapsing glomerulopathy: successful treatment with intravenous immunoglobulins and mycophenolate mofetil.

In this Grand Round we present a 32-yr-old African man who became severely ill after a 5-month history of weight loss, pyrexia, arthralgia, sweats and rash. He went on to develop pericarditis, pericardial effusion with tamponade, hepatomegaly with abnormal liver function tests, lymphadenopathy, massive proteinuria and required ventilatory, circulatory and renal support. The differential diagnosis was adult onset Still's disease, systemic lupus erythematosus (SLE), infection and lymphoma.

Renal artery stenosis in the antiphospholipid (Hughes) syndrome and hypertension.

Background: Hypertension is common in the antiphospholipid (Hughes) syndrome (APS) and its cause is poorly understood. Anecdotal evidence suggests that renal artery stenosis (RAS) may be a relevant and treatable cause of hypertension.

Objective: To investigate the prevalence of RAS in patients with APS and hypertension.

Anti-dsDNA, anti-Sm antibodies, and the lupus anticoagulant: significant factors associated with lupus nephritis.

Background: Lupus nephritis (LN) is a common manifestation in patients with systemic lupus erythematosus (SLE). Autoantibodies and ethnicity have been associated with LN, but the results are controversial.

Objective: To study the immunological and demographic factors associated with the development of LN.

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.

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.

Mycophenolate mofetil for systemic lupus erythematosus refractory to other immunosuppressive agents.

Background: Mycophenolate mofetil (MMF) is an immunosuppressive drug widely used in solid organ transplantation, and it may play an increasing role in autoimmune disease. MMF has been introduced as a novel immunosuppressive agent in systemic lupus erythematosus (SLE), often in patients intolerant of or resistant to conventional immunosuppressive regimens.

Methods: We studied 21 patients with SLE, most of whom had previously received courses of cyclophosphamide therapy and had also received courses of azathioprine or methotrexate.

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.

Hypertension as the presenting feature of the antiphospholipid syndrome.

The antiphospholipid or Hughes syndrome is the association between antiphospholipid antibodies (aPL), venous and arterial thromboses and pregnancy morbidity. Antiphospholipid syndrome (APS) commonly coexists with autoimmune diseases usually systemic lupus erythematosus (SLE), when it is known as secondary APS. When present in isolation it is known as primary APS (PAPS).

Dimethylarginines in chronic renal failure.

Background: Nitric oxide (NO) is a potent chemical mediator involved in many functions. In vivo production of NO is thought to be regulated by endogenous analogues of L-arginine: asymmetric dimethylarginine (ADMA).

Aim: To examine the effect of renal function and dialysis on the serum concentrations of ADMA and symmetric dimethylarginine (SDMA).