Methodological Challenges in Describing Medication Dosing Errors in Children

Summary: Although children are prescribed medications in 30 percent to 50 percent of clinic visits, little is known about medication errors in ambulatory pediatrics. In the process of completing a study to determine the prevalence of outpatient dosing errors, we identified a number of barriers to understanding the epidemiology of medication errors in children. These barriers include prescribing medication that is not labeled for use in children, discrepancies in published dosing recommendations for many medications, unclear guidelines on use of adult dosing recommendations for children of different ages and weights, and the lack of readily available documented weights to determine appropriate weight-based doses for children. In our study of pediatric medication errors, we found a wide range of doses prescribed to children for every medication we studied. Before we can truly understand medication errors in children and begin developing systems-based approaches to eliminating these errors, we need better national standards of medication doses that are appropriate for children and an improved ability to determine errors through databases that include children\u27s weights as well as prescription information

Preparation of amino-substituted indenes and 1,4-dihydronaphthalenes using a one-pot multireaction approach: total synthesis of oxybenzo[c]phenanthridine alkaloids

Allylic trichloroacetimidates bearing a 2-vinyl or 2-allylaryl group have been designed as substrates for a one-pot, two-step multi-bond-forming process leading to the general preparation of aminoindenes and amino-substituted 1,4-dihydronaphthalenes. The synthetic utility of the privileged structures formed from this one-pot process was demonstrated with the total synthesis of four oxybenzo[c]phenanthridine alkaloids, oxychelerythrine, oxysanguinarine, oxynitidine, and oxyavicine. An intramolecular biaryl Heck coupling reaction, catalyzed using the Hermann–Beller palladacycle was used to effect the key step during the synthesis of the natural products

The breadth of primary care: a systematic literature review of its core dimensions

Background: Even though there is general agreement that primary care is the linchpin of effective health care delivery, to date no efforts have been made to systematically review the scientific evidence supporting this supposition. The aim of this study was to examine the breadth of primary care by identifying its core dimensions and to assess the evidence for their interrelations and their relevance to outcomes at (primary) health system level. Methods: A systematic review of the primary care literature was carried out, restricted to English language journals reporting original research or systematic reviews. Studies published between 2003 and July 2008 were searched in MEDLINE, Embase, Cochrane Library, CINAHL, King's Fund Database, IDEAS Database, and EconLit. Results: Eighty-five studies were identified. This review was able to provide insight in the complexity of primary care as a multidimensional system, by identifying ten core dimensions that constitute a primary care system. The structure of a primary care system consists of three dimensions: 1. governance; 2. economic conditions; and 3. workforce development. The primary care process is determined by four dimensions: 4. access; 5. continuity of care; 6. coordination of care; and 7. comprehensiveness of care. The outcome of a primary care system includes three dimensions: 8. quality of care; 9. efficiency care; and 10. equity in health. There is a considerable evidence base showing that primary care contributes through its dimensions to overall health system performance and health. Conclusions: A primary care system can be defined and approached as a multidimensional system contributing to overall health system performance and health

Surface structure and frictional properties of the skin of the Amazon tree boa Corallus hortulanus (Squamata, Boidae)

The legless locomotion of snakes requires specific adaptations of their ventral scales to maintain friction force in different directions. The skin microornamentation of the snake Corallus hortulanus was studied by means of scanning electron microscopy and the friction properties of the skin were tested on substrates of different roughness. Skin samples from various parts of the body (dorsal, lateral, ventral) were compared. Dorsal and lateral scales showed similar, net-like microornamentation and similar friction coefficients. Average friction coefficients for dorsal and lateral scales on the epoxy resin surfaces were 0.331 and 0.323, respectively. In contrast, ventral scales possess ridges running parallel to the longitudinal body axis. They demonstrated a significantly lower friction coefficient compared to both dorsal and lateral scales (0.191 on average). In addition, ventral scales showed frictional anisotropy comparing longitudinal and perpendicular direction of the ridges. This study clearly demonstrates that different skin microstructure is responsible for different frictional properties in different body regions

Early to middle Eocene history of the Arctic Ocean from Nd-Sr isotopes in fossil fish debris, Lomonosov Ridge

Strontium and neodymium radiogenic isotope ratios in early to middle Eocene fossil fish debris (ichthyoliths) from Lomonosov Ridge (Integrated Ocean Drilling Program Expedition 302) help constrain water mass compositions in the Eocene Arctic Ocean between ∼55 and ∼45 Ma. The inferred paleodepositional setting was a shallow, offshore marine to marginal marine environment with limited connections to surrounding ocean basins. The new data demonstrate that sources of Nd and Sr in fish debris were distinct from each other, consistent with a salinity-stratified water column above Lomonosov Ridge in the Eocene. The 87Sr/86Sr values of ichthyoliths (0.7079–0.7087) are more radiogenic than Eocene seawater, requiring brackish to fresh water conditions in the environment where fish metabolized Sr. The 87Sr/86Sr variations probably record changes in the overall balance of river Sr flux to the Eocene Arctic Ocean between ∼55 and ∼45 Ma and are used here to reconstruct surface water salinity values. The ɛNd values of ichthyoliths vary between −5.7 and −7.8, compatible with periodic (or intermittent) supply of Nd to Eocene Arctic intermediate water (AIW) from adjacent seas. Although the Norwegian-Greenland Sea and North Atlantic Ocean were the most likely sources of Eocene AIW Nd, input from the Tethys Sea (via the Turgay Strait in early Eocene time) and the North Pacific Ocean (via a proto-Bering Strait) also contributed

Functionalized Poly(3-hexylthiophene)s via Lithium–Bromine Exchange

Poly(3-hexylthiophene) (P3HT) is one of the most extensively investigated conjugated polymers and has been employed as the active material in many devices including field-effect transistors, organic photovoltaics and sensors. As a result, methods to further tune the properties of P3HT are desirable for specific applications. Herein, we report a facile postpolymerization modification strategy to functionalize the 4-position of commercially available P3HT in two simple steps–bromination of the 4-position of P3HT (Br–P3HT) followed by lithium−bromine exchange and quenching with an electrophile. We achieved near quantitative lithium–bromine exchange with Br–P3HT, which requires over 100 thienyl lithiates to be present on a single polymer chain. The lithiated-P3HT is readily combined with functional electrophiles, resulting in P3HT derivatives with ketones, secondary alcohols, trimethylsilyl (TMS) group, fluorine, or an azide at the 4-position. We demonstrated that the azide-modified P3HT could undergo Cu-catalyzed or Cu-free click chemistry, significantly expanding the complexity of the structures that can be appended to P3HT using this method.National Science Foundation (U.S.) (ECCS-0939514

Towards successful coordination of electronic health record based-referrals: a qualitative analysis

<p>Abstract</p> <p>Background</p> <p>Successful subspecialty referrals require considerable coordination and interactive communication among the primary care provider (PCP), the subspecialist, and the patient, which may be challenging in the outpatient setting. Even when referrals are facilitated by electronic health records (EHRs) (<it>i.e</it>., e-referrals), lapses in patient follow-up might occur. Although compelling reasons exist why referral coordination <it>should </it>be improved, little is known about which elements of the complex referral coordination process should be targeted for improvement. Using Okhuysen & Bechky's coordination framework, this paper aims to understand the barriers, facilitators, and suggestions for improving communication and coordination of EHR-based referrals in an integrated healthcare system.</p> <p>Methods</p> <p>We conducted a qualitative study to understand coordination breakdowns related to e-referrals in an integrated healthcare system and examined work-system factors that affect the timely receipt of subspecialty care. We conducted interviews with seven subject matter experts and six focus groups with a total of 30 PCPs and subspecialists at two tertiary care Department of Veterans Affairs (VA) medical centers. Using techniques from grounded theory and content analysis, we identified organizational themes that affected the referral process.</p> <p>Results</p> <p>Four themes emerged: lack of an institutional referral policy, lack of standardization in certain referral procedures, ambiguity in roles and responsibilities, and inadequate resources to adapt and respond to referral requests effectively. Marked differences in PCPs' and subspecialists' communication styles and individual mental models of the referral processes likely precluded the development of a <it>shared </it>mental model to facilitate coordination and successful referral completion. Notably, very few barriers related to the EHR were reported.</p> <p>Conclusions</p> <p>Despite facilitating information transfer between PCPs and subspecialists, e-referrals remain prone to coordination breakdowns. Clear referral policies, well-defined roles and responsibilities for key personnel, standardized procedures and communication protocols, and adequate human resources must be in place before implementing an EHR to facilitate referrals.</p

Mechanistic and Kinetic Investigation on the Formation of Palladacyclopentadiene Complexes. A Novel Interpretation Involving a Bimolecular Self Reaction of a Monoalkyne Intermediate

The stoichiometric reaction between the complex [Pd(eta(2)-dmfu)(BiPy)] (dmfu = dimethylfumarate; BiPy = 2,2'-bipyridine) and the deactivated alkynes dmbd (dimethyl-2-butynedioate) and pna (methyl (4-nitrophenyl)propynoate), providing the respective palladacyclopentadienes, was investigated. The mechanism leading to the palladacyclopentadiene derivative involves a bimolecular self-rearrangement of the monoalkyne intermediate [Pd(eta(2)-alk)(BiPy)] (alk = dmbd, pna), followed by the customary attack of the free alkyne on the intermediate [Pd(eta(2)-alk)(BiPy)] itself and on the elusive and highly reactive "naked palladium" [Pd(BiPy)(0)] formed. The alkyne pna proved to be less effective in the displacement of dmfu than dmbd. The reaction under stoichiometric equimolar conditions of the latter with [Pd(eta(2)-dmfu)(BiPy)] allows the direct determination of the bimolecular self-reaction rate constant k(c) and consequently the assessment of all the rate constants involved in the overall mechanistic network