When things go wrong: protecting patients and supporting doctors

A healthcare system should ensure that surgical errors are kept to a minimum, and if possible are avoided altogether. Unfortunately, errors do occur however carefully one tries to avoid them. Once recognized an error must be rectified as soon as possible. An appropriate apology to the patient or their relative is an absolute requirement. In this article I review the processes available to deal with errors both locally and through the regulatory authorities if considered necessary. I look at how lapses, both clinical and non-clinical, are handled locally and by the appropriate regulatory body. I also discuss how allegations relating to fitness to practise are investigated. Whilst the over-riding responsibility of all these structures is to protect patients, as mentioned it is necessary also to support doctors and to learn the lessons on how and why the errors have occurred. The maintenance of professionalism is essential. As well as supporting and protecting the patient, support for the surgeon in the workplace is a necessary requirement.     

When things don't work out: finding another job

It is extremely common for young orthopaedic surgeons find themselves in unsatisfactory practice situations early in their careers. This article highlights several points to bear in mind when considering a change of employment in the first few years of practice. Many factors should be revisited from the candidate's initial job search to fully analyze the situation. If the problems are found to be irreconcilable, then the decision can be made to find a more suitable setting, but the relocation process should be handled judiciously. There are many resources available that can be helpful to make a successful transition.     

When proton pumps go sour: Urinary acidification and kidney stones

H(+)-ATPases mediate urinary acidification along the collecting duct, and mutations in their B1 and a4 subunits result in distal renal tubular acidosis. The pathomechanisms by which these mutations affect pump activity are only poorly understood. Common polymorphisms may impair pump activity and may link the pump to a higher risk for alkaline urine and the development of kidney stones.     

When bad things happen to good surgeons: reactions to adverse events

Adverse events are, unfortunately, common components of surgical practice. Much has been done to develop safer systems to prevent these adverse events; however, there has been less focus on the surgeon experiencing these events. This article presents a framework to understand surgeons' reactions to adverse events that was derived from a more recent study as well as a review of relevant psychology literatures. This framework is then situated within the broader picture of mindful practice to explore how the psychological and social dimensions of the surgeon can affect judgment and cognition.     

When urothelial differentiation pathways go wrong: Implications for bladder cancer development and progression

Differentiation is defined as the ability of a cell to acquire full functional behavior. For instance, the function of bladder urothelium is to act as a barrier to the diffusion of solutes into or out of the urine after excretion by the kidney. The urothelium also serves to protect the detrusor muscle from toxins present in stored urine. A major event in the initiation and progression of bladder cancer is loss of urothelial differentiation. This is important because less differentiated urothelial tumors (higher histologic tumor grade) are typically associated with increased biologic and clinical aggressiveness. The differentiation status of urothelial carcinomas can be assessed by histopathologic examination and is reflected in the assignment of a histologic grade (low-grade or high-grade). Although typically limited to morphologic evaluation in most routine diagnostic practices, tumor grade can also be assessed using biochemical markers. Indeed, current pathological analysis of tumor specimens is increasingly reliant on molecular phenotyping. Thus, high priorities for bladder cancer research include identification of (1) biomarkers that will enable the identification of high grade T1 tumors that pose the most threat and require the most aggressive treatment; (2) biomarkers that predict the likelihood that a low grade, American Joint Committee on Cancer stage pTa bladder tumor will progress into an invasive carcinoma with metastatic potential; (3) biomarkers that indicate which pTa tumors are most likely to recur, thus enabling clinicians to prospectively identify patients who require aggressive treatment; and (4) how these markers might contribute to biological processes that underlie tumor progression and metastasis, potentially through loss of terminal differentiation. This review will discuss the proteins associated with urothelial cell differentiation, with a focus on those implicated in bladder cancer, and other proteins that may be involved in neoplastic progression. It is hoped that ongoing discoveries associated with the study of these differentiation-promoting proteins can be translated into the clinic to positively impact patient care.     

Functional dissociation in right inferior frontal cortex during performance of go/no-go task

The contribution of the right inferior frontal cortex to responseinhibition has been demonstrated by previous studies of neuropsychology,electrophysiology, and neuroimaging. The inferior frontal cortexis also known to be activated during processing of infrequentstimuli such as stimulus-driven attention. Response inhibitionhas most often been investigated using the go/no-go task, andthe no-go trials are usually given infrequently to enhance prepotentresponse tendency. Thus, it has not been clarified whether theinferior frontal activation during the go/no-go task is associatedwith response inhibition or processing of infrequent stimuli.In the present functional magnetic resonance imaging study,we employed not only frequent-go trials but also infrequent-gotrials that were presented as infrequently as the no-go trials.The imaging results demonstrated that the posterior inferiorfrontal gyrus (pIFG) was activated during response inhibitionas revealed by the no-go vs. infrequent-go trials, whereas theinferior frontal junction (IFJ) region was activated primarilyduring processing of infrequent stimuli as revealed by the infrequent-goversus frequent-go trials. These results indicate that the pIFGand IFJ within the inferior frontal cortex are spatially closebut are associated with different cognitive control processesin the go/no-go paradigm.