Evaluating the Effect of Unstructured Clinical Information on Clinical Decision Support Appropriateness Ratings.

OBJECTIVE: To determine the appropriateness rating (AR) of advanced inpatient imaging requests that were not rated by prospective, point-of-care clinical decision support (CDS) using computerized provider order entry. MATERIALS AND METHODS: During 30-day baseline and intervention periods, CDS generated an AR for advanced inpatient imaging requests (nuclear medicine, CT, and MRI) using provider-selected structured indications from pull-down menus in the computerized provider order entry portal. The AR was only displayed during the intervention, and providers were required to acknowledge the AR to finalize the request. Subsequently, the unstructured free text information accompanying all requests was reviewed, and the AR was revised when possible. The percentage of unrated requests and the overall AR, before and after radiologist review, were compared between periods and by provider type. RESULTS: CDS software prospectively generated an AR for only 25.4% and 28.4% of baseline and intervention imaging requests, respectively; however, radiologist review generated an AR for 82.4% and 93.6% of the same requests. During the respective periods, the percentage of baseline and intervention imaging requests considered appropriate was 18.7% and 22.9% by prospective CDS software rating and increased to 82.4% and 88.7% with radiologist review. CONCLUSION: Despite limited effective use of CDS software, the percentage of requests containing additional, relevant clinical information increased, and the majority of requests had overall high appropriateness when reviewed by a radiologist. Additional work is needed to improve the amount and quality of clinical information available to CDS software and to facilitate the entry of this information by appropriate end users.

Using Ring Strain to Control 4π-Electrocyclization Reactions: Torquoselectivity in Ring Closing of Medium-Ring Dienes and Ring Opening of Bicyclic Cyclobutenes.

Syntheses of strained cyclic dienes were accomplished via palladium(II)-catalyzed oxidative cyclizations of terminal bis(vinylboronate esters). The reactions generate strained (E,E)-1,3-dienes that undergo spontaneous 4π-electrocyclizations to form bicyclic cyclobutenes. Formation of the cyclobutenes is driven by the strain in the medium-ring (E,E)-1,3-diene intermediate. Thermal ring openings of the cyclobutenes give (Z,Z)-1,3-diene products, again for thermodynamic reasons. DFT calculations verified the thermodynamic versus kinetic control of the reactions, and kinetic studies are in excellent agreement with the calculated energy changes. An extension of the tandem coupling/4π-electrocyclization pathway was demonstrated by a palladium(II)-catalyzed oxidative homocoupling/8π-electrocyclization cascade.

Are Pediatricians Complicit in Vitamin K Deficiency Bleeding?

The American Academy of Pediatrics recommends that all newborns receive a single dose of intramuscular vitamin K to prevent vitamin K deficiency bleeding. How should the clinician respond when parents decline vitamin K? Although vitamin K deficiency bleeding can have devastating sequelae, they are uncommon; therefore, parents are generally allowed to decline vitamin K after counseling is provided. When parents ask for a vitamin K preparation of unproven effectiveness, should the clinician honor that request? To address these questions, we present a case of a healthy newborn whose parents declined intramuscular vitamin K and requested an oral preparation. Two general pediatricians discuss the medical and ethical issues these situations pose, and the parents describe their experience.

Distortion/Interaction analysis reveals the origins of selectivities in iridium-catalyzed C-H borylation of substituted arenes and 5-membered heterocycles.

The iridium-catalyzed borylation of mono- and disubstituted arenes and heteroarenes has been studied with density functional theory. The distortion/interaction model was employed to understand the origins of selectivities in these reactions. Computations revealed that the transition states for C-H oxidative addition are very late, resembling the aryl iridium hydride intermediate with a fully formed Ir-C bond. Consequently, the regioselectivity is mainly controlled by differences in the interaction energies between the iridium catalyst and arene carbon.

Characterization of an iron-ruthenium interaction in a ferrocene diamide complex.

Reaction of [fc(NH2)2]RuCl2(PPh3)2 (fc = 1,1'-ferrocenylene) with 2 equiv of KO(t)Bu led to the formation of a diamido ruthenium complex, [fc(NH)2]Ru(PPh3)2, whose solid-state molecular structure revealed a short Fe-Ru distance. A metal-to-metal charge transfer band was observed in the electronic absorption spectrum of [fc(NH)2]Ru(PPh3)2. The Fe-Ru interaction was characterized by resonance Raman spectroscopy for the first time and also by (1)H NMR, UV-vis, NIR, Mössbauer spectroscopy, and X-ray crystallography. Density functional theory (DFT) calculations including natural bond order analysis, Bader's atom in molecules method, and time-dependent DFT (TDDFT) provided further support that the iron-ruthenium bond is a weak donor-acceptor interaction with iron acting as the Lewis base.

Transfer hydrogenation with a ferrocene diamide ruthenium complex.

The use of a 1,1'-ferrocenediamide ruthenium complex as a mediator for base-free transfer hydrogenation is reported. Ketones were transformed to their respective alcohols at room temperature in 36-99% conversions with turnover frequencies up to 339 h(-1).

Nevirapine plus efavirenz plus didanosine: a simple, safe, and effective once-daily regimen for patients with HIV infection.

Conventional highly active antiretroviral therapy (HAART) regimens used to treat human immunodeficiency virus (HIV) infection typically use nucleoside reverse transcriptase inhibitors (NRTIs) and either a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI). Because PI-based regimens are associated with significant long-term toxicity and adherence difficulty, there is a need for novel regimens that maximize combination treatment options. This 12-month, observational, cohort study evaluated the efficacy, safety, and tolerability of a novel three-drug HAART regimen. Drug treatment consisted of nevirapine (NVP), efavirenz (EFV), and didanosine (ddl). Twenty-six treatment-naive and -experienced HIV-1+ men and women were included in the study. Assessment consisted of CD4+ cell count, plasma HIV-1 RNA load, and adverse effects of study medications. After one year of therapy, 11/12 treatment-naive subjects (92%) and 8/9 treatment-experienced subjects (89%) had viral loads < 400 copies/mL. Both groups also had an excellent immune response. At one year, there was a mean increase of 438 CD4+ cells/mm3 among treatment-naive subjects and 367 cells/mm3 among treatment-experienced subjects. Treatment-limiting adverse effects occurred in 3/15 treatment-naive (20%) and 2/11 treatment-experienced (18%) subjects. These preliminary data suggest that the combination of NVP, EFV, and ddl is simple, safe, and effective.