Clinician Perceptions on the Use of Free-Text Communication Orders

Objective  The aim of this study was to investigate (1) why ordering clinicians use free-text orders to communicate medication information; (2) what risks physicians and nurses perceive when free-text orders are used for communicating medication information; and (3) how electronic health records (EHRs) could be improved to encourage the safe communication of medication information. Methods  We performed semi-structured, scenario-based interviews with eight physicians and eight nurses. Interview responses were analyzed and grouped into common themes. Results  Participants described eight reasons why clinicians use free-text medication orders, five risks relating to the use of free-text medication orders, and five recommendations for improving EHR medication-related communication. Poor usability, including reduced efficiency and limited functionality associated with structured order entry, was the primary reason clinicians used free-text orders to communicate medication information. Common risks to using free-text orders for medication communication included the increased likelihood of missing orders and the increased workload on nurses responsible for executing orders. Discussion  Clinicians'' use of free-text orders is primarily due to limitations in the current structured order entry design. To encourage the safe communication of medication information between clinicians, the EHR''s structured order entry must be redesigned to support clinicians'' cognitive and workflow needs that are currently being addressed via the use of free-text orders. Conclusion  Clinicians'' use of free-text orders as a workaround to insufficient structured order entry can create unintended patient safety risks. Thoughtful solutions designed to address these workarounds can improve the medication ordering process and the subsequent medication administration process.     

Telementoring facilitates independent hand-assisted laparoscopic living donor nephrectomy

Laparoscopic living donor nephrectomy is a major advance but a challenging procedure to learn even after laparoscopic training. It requires significant previous training in both laparoscopic and transplant surgery. Telementoring has been shown to reduce the laparoscopic learning curve in other fields. Of six cases of hand-assisted laparoscopic (HAL) living donor nephrectomy at our institution, an on-site mentor supervised the initial two. We present the subsequent four cases as the first documented examples of telementored HAL live donor nephrectomy. Telelink was established with a Comstation (Zydacron, UK) incorporating a Z360 telementoring codec and four ISDN lines (512 kb/s) with time delay of 500 ms for both audio and video. The remote surgeon in Minnesota (USA) could change independently between the laparoscopic and external views. The operating surgeons were able to look at the mentor and converse with him throughout. There were no adverse events in recipients and graft function was excellent. With regards to the telementored group the mean operative time was 240 minutes, the mean warm ischemic time 189 seconds, the mean estimated blood loss 171 mL, and the mean length of hospital stay 3 days. Telementoring for laparoscopic donor nephrectomy is feasible, effective, and likely to aid independent practice by providing continued supervision and reducing the learning period.     

Maxillary second premolar with three roots and three separate root canals--case reports

Aberrations in root canal systems are a commonly occurring phenomenon. Knowledge of the basic root canal anatomy and its variation is necessary for successful completion of endodontics. Maxillary second premolars usually have one root and one canal. The occurrence of these teeth having three roots and three canals is very rare. Three such cases of maxillary second premolar with three roots and three canals are presented here.     

Immunologic factors: the major risk for decreased long-term renal allograft survival

BACKGROUND: Both antigen-dependent (immunologic) and non-antigen-dependent (nonimmunologic) factors have been implicated in long-term renal allograft loss. Differentiating between these two factors is important because prevention strategies differ. METHODS: To isolate the importance of these 2 factors, we studied long-term actuarial graft survival in a cohort of adult kidney recipients who underwent transplants at a single institution between January 1, 1984 and October 31, 1998. Excluded were recipients with graft loss as a result of death with function, technical failure, primary nonfunction, and recurrent disease, leaving 1587 recipients (757 cadaver [CAD], 830 living donor [LD]) who would be at risk for graft loss secondary to both immunologic and nonimmunologic factors. These recipients were analyzed in the following 2 groups: those treated for a previous episode of acute rejection (AR) (Group1; n = 588; 328 CAD, 260 LD) and those with no AR (Group 2: n = 999; 429 CAD, 570 LD). Actuarial graft survival and causes of graft loss were determined for each group. Presumably, graft loss in Group 1 would be caused by immunologic and nonimmunologic factors; graft loss in Group 2 would be caused primarily by nonimmunologic factors. RESULTS: The 10-year graft survival rate (censored for death with function, technical failure, primary nonfunction, and recurrent disease) in Group 2 was 91%. In contrast, the 10-year graft survival rate in Group 1 was 45% (P<0.001 vs. Group 2). Causes of graft loss in Group 2 were chronic rejection in 1.8% (3.0% CAD, 0.9% LD), de novo disease, 0.4%; sepsis, 0.2%; discontinuation of immunosuppressive therapy, 0.3%; and unknown, 0.6%. In contrast, 23.8% (29.9% CAD, 16.2% LD) of recipients in Group 1 had graft loss caused by chronic rejection (P = 0.001 vs. Group 2). CONCLUSIONS: This very low incidence of chronic rejection in recipients without previous AR suggests that immunologic factors are the main determinants of long-term kidney transplant outcome; nonimmunologic factors in isolation may have only a minimal impact on long-term graft survival.     

Kidney and pancreas transplantation without a crossmatch in select circumstances – it can be done

Given the constant flux in caseload and the number of personnel available in the OR, waiting for a final XM often prolongs organ preservation time (a room available at the time a XM is started is not available when the XM is completed). Longer preservation is associated with increased DGF and decreased graft survival. We have shown in a retrospective analysis that final XMs on 0% PRA recipients were always negative (Transplantation, 1999). We now describe a policy of: a) not doing screening XM and b) proceeding to the OR without a XM, in situations where the recipients's PRA has been documented to be 0% and when there have not been any interim transfusions (and the OR is ready before XM completion). Final XM is completed after the transplant. All patients send sera every 6 weeks for PRA (antiglobulin technique). If > o r=3 consecutive PRAs are 0%, no donor-specific screening XM is done prior to calling the patient in for tx (UNOS allocation algorithm used). If there have not been any interim transfusions, we have proceeded to tx prior to completion of the final XM. Between 1/1/98-12/31/99, we did 109 CAD kidney (K) and 79 simultaneous kidney pancreas (SPK) tx; 67 (61%) K and 56 (71%) SPK had 0% PRA. Of the 0% PRA, 25/67 (37%) K and 28/56 (50%) SPK had no pre-tx XM. For K with no XM, cold ischemia was shorter (13.2+/-0.2 vs. 18+/-0.9 hrs, p=0.01) and DGF less (12% vs. 24%, p=0.3); for SPK with no XM, cold ischemia was shorter (15.2+/-2 vs. 18+/-0.9 hrs, p=0.1); no diff in DGF. All post-XM were negative and there were no hyperacute rejections; there was no diff in acute rejection episodes. Actuarial 1 yr graft survival: no XM-K=87.5%, SKP=82%; Yes XM-K=88%, SKP=86% (NS). Our data suggests it is safe, in select circumstances, to proceed to the OR without a XM. Elimination of the screening XM for 0% PRA candidates saves money. Proceeding of the OR (if available) without a final XM shortens cold ischemia time.     

Evaluation of microtensile bond strength of total-etch, self-etch, and glass ionomer adhesive to human dentin: an in vitro study.

AIM: To evaluate the microtensile bond strength of Single Bond, AdheSE, and Fuji Bond LC to human dentin. Fifteen non-carious third molars were selected for the study. The teeth were randomly divided into three groups of five teeth each. Each group was given a different bonding treatment. Group I was treated with Single Bond (3M, ESPE), group II with AdheSE (Ivoclar, Vivadent), and group III was treated with Fuji Bond LC (GC America). A T-band metal matrix was placed and composite resin bonded on to the tooth surface using appropriate bonding agents. The composite resin was packed in increments and light cured. Each tooth was sectioned to obtain 1 mm x 1 mm beams of dentin-resin samples. Tensile bond testing was done using a universal testing machine (Instron) at a cross-head speed of 0.5 mm/min. RESULTS: The mean bond strength of Single Bond (35.5 MPa) was significantly higher than that of AdheSE (32.8 MPa) and Fuji Bond LC (32.6 MPa). The difference between the microtensile bond strength values of AdheSE and Fuji Bond LC was statistically insignificant. INFERENCE: Though the bond strength of AdheSE and Fuji Bond LC was above 30 MPa, it was less than that of Single Bond as evaluated by testing of microtensile bond strength.