Patient Safety Issues From Information Overload in Electronic Medical Records.

BACKGROUND AND OBJECTIVE: Electronic health records (EHRs) have become ubiquitous in medicine and continue to grow in informational content. Little has been documented regarding patient safety from the resultant information overload. The objective of this literature review is to better understand how information overload in EHR affects patient safety. METHODS: A literature search was performed using the Transparent Reporting of Systematic Reviews and Meta-Analyses standards for literature review. PubMed and Web of Science were searched and articles selected that were relevant to EHR information overload based on keywords. RESULTS: The literature search yielded 28 articles meeting the criteria for the study. Information overload was found to increase physician cognitive load and error rates in clinical simulations. Overabundance of clinically irrelevant information, poor data display, and excessive alerting were consistently identified as issues that may lead to information overload. CONCLUSIONS: Information overload in EHRs may result in higher error rates and negatively impact patient safety. Further studies are necessary to define the role of EHR in adverse patient safety events and to determine methods to mitigate these errors. Changes focused on the usability of EHR should be considered with the end user (physician) in mind. Federal agencies have a role to play in encouraging faster adoption of improved EHR interfaces.

Effect of walking on in vivo tibiofemoral cartilage strain in ACL-deficient versus intact knees.

Anterior cruciate ligament (ACL) rupture alters knee kinematics and contributes to premature development of osteoarthritis. However, there is limited data regarding the in vivo biomechanical response of tibiofemoral cartilage to activities of daily living (ADLs) in ACL-deficient knees. In this study, eight otherwise healthy participants with chronic unilateral ACL deficiency completed a stress test to assess the effect of 20 min of level treadmill walking at a speed of 2.5 mph on tibiofemoral cartilage in their ACL-deficient and contralateral ACL-intact knees. Three-dimensional surface models developed from pre- and post-activity magnetic resonance (MR) images of the injured and uninjured knees were used to determine compressive strain across multiple regions of tibiofemoral cartilage (medial and lateral tibial plateaus, medial and lateral femoral condyles, medial aspect of femoral condyle adjacent to intercondylar notch of the femur). In the ACL-deficient knees, we observed significantly increased cartilage strain in the region of the medial femoral condyle adjacent to the intercondylar notch (6% in deficient vs. 2% in contralateral, p = 0.01) as well as across the medial and lateral tibial plateaus (4% vs. 3%, p = 0.01) relative to the contralateral ACL-intact knees. Increased compressive strain at the medial intercondylar notch and tibial plateau suggests alterations in mechanical loading or the response to load in these regions, presumably related to altered knee kinematics. These changes may disrupt cartilage homeostasis and contribute to subsequent development of osteoarthritis.

In Vivo Tibial Cartilage Strains in Regions of Cartilage-to-Cartilage Contact and Cartilage-to-Meniscus Contact in Response to Walking.

BACKGROUND: There are currently limited human in vivo data characterizing the role of the meniscus in load distribution within the tibiofemoral joint. Purpose/Hypothesis: The purpose was to compare the strains experienced in regions of articular cartilage covered by the meniscus to regions of cartilage not covered by the meniscus. It was hypothesized that in response to walking, tibial cartilage covered by the meniscus would experience lower strains than uncovered tibial cartilage. STUDY DESIGN: Descriptive laboratory study. METHODS: Magnetic resonance imaging (MRI) of the knees of 8 healthy volunteers was performed before and after walking on a treadmill. Using MRI-generated 3-dimensional models of the tibia, cartilage, and menisci, cartilage thickness was measured in 4 different regions based on meniscal coverage and compartment: covered medial, uncovered medial, covered lateral, and uncovered lateral. Strain was defined as the normalized change in cartilage thickness before and after activity. RESULTS: Within each compartment, covered cartilage before activity was significantly thinner than uncovered cartilage before activity ( P < .001). After 20 minutes of walking, all 4 regions experienced significant cartilage thickness decreases ( P < .01). The covered medial region experienced significantly less strain than the uncovered medial region ( P = .04). No difference in strain was detected between the covered and uncovered regions in the lateral compartment ( P = .40). CONCLUSION: In response to walking, cartilage that is covered by the meniscus experiences lower strains than uncovered cartilage in the medial compartment. These findings provide important baseline information on the relationship between in vivo tibial compressive strain responses and meniscal coverage, which is critical to understanding normal meniscal function.

Effect of normal gait on in vivo tibiofemoral cartilage strains.

Altered cartilage loading is believed to be associated with osteoarthritis development. However, there are limited data regarding the influence of normal gait, an essential daily loading activity, on cartilage strains. In this study, 8 healthy subjects with no history of knee surgery or injury underwent magnetic resonance imaging of a single knee prior to and following a 20-min walking activity at approximately 1.1m/s. Bone and cartilage surfaces were segmented from these images and compiled into 3-dimensional models of the tibia, femur, and associated cartilage. Thickness changes were measured across a grid of evenly spaced points spanning the models of the articular surfaces. Averaged compartmental strains and local strains were then calculated. Overall compartmental strains after the walking activity were found to be significantly different from zero in all four tibiofemoral compartments, with tibial cartilage strain being significantly larger than femoral cartilage strain. These results provide baseline data regarding the normal tibiofemoral cartilage strain response to gait. Additionally, the technique employed in this study has potential to be used as a "stress test" to understand how factors including age, weight, and injury influence tibiofemoral cartilage strain response, essential information in the development of potential treatment strategies for the prevention of osteoarthritis.

Mechanical distortion of protein receptor decreases the lifetime of a receptor-ligand bond.

Substantial experimental evidence indicates that the mechanical force applied to pull apart non-covalent molecular bonds (such as receptor-ligand pairs) can significantly decrease the bond lifetime. This evidence is often generated in single-molecule experiments that are designed to specifically test effects of pulling forces. However, the effect of compressive forces on the lifetime of receptor-ligand bonds remains largely unexplored. Here we extend the common usage of the atomic force microscopy technique to study whether compressive forces applied to bound streptavidin-biotin species can significantly accelerate the rate of dissociation. Presented experimental data indicate that compressive forces can substantially decrease the lifetime of the molecular bond. Surprisingly, the efficiency of accelerating dissociation by compressive forces sometimes exceeds the enhancement of the dissociation rate measured in pulling experiments, indicating that compressive forces applied to the bound species might be efficiently used to control the lifetime of adhesion bonds.

Association kinetics from single molecule force spectroscopy measurements.

Single molecule force spectroscopy is often used to study the dissociation of single molecules by applying mechanical force to the intermolecular bond. These measurements provide the kinetic parameters of dissociation. We present what to our knowledge is a new atomic force microscopy-based approach to obtain the activation energy of the association reaction and approximate grafting density of reactive receptors using the dependence of the probability to form molecular bonds on probe velocity when one of the interacting molecules is tethered by a flexible polymeric linker to the atomic force microscopy probe. Possible errors in the activation energy measured with this approach are considered and resulting corrections are included in the data analysis. This new approach uses the same experimental setup as traditional force spectroscopy measurements that quantify dissociation kinetics. We apply the developed methodology to measure the activation energy of biotin-streptavidin association (including a contribution from the steric factor) and obtain a value of 8 +/- 1 kT. This value is consistent with the association rate measured previously in solution. Comparison with the solution-derived activation energy indicates that kinetics of biotin-streptavidin binding is mainly controlled by the reaction step.

Effects of multiple-bond ruptures on kinetic parameters extracted from force spectroscopy measurements: revisiting biotin-streptavidin interactions.

Force spectroscopy measurements of the rupture of the molecular bond between biotin and streptavidin often results in a wide distribution of rupture forces. We attribute the long tail of high rupture forces to the nearly simultaneous rupture of more than one molecular bond. To decrease the number of possible bonds, we employed hydrophilic polymeric tethers to attach biotin molecules to the atomic force microscope probe. It is shown that the measured distributions of rupture forces still contain high forces that cannot be described by the forced dissociation from a deep potential well. We employed a recently developed analytical model of simultaneous rupture of two bonds connected by polymer tethers with uneven length to fit the measured distributions. The resulting kinetic parameters agree with the energy landscape predicted by molecular dynamics simulations. It is demonstrated that when more than one molecular bond might rupture during the pulling measurements there is a noise-limited range of probe velocities where the kinetic parameters measured by force spectroscopy correspond to the true energy landscape. Outside this range of velocities, the kinetic parameters extracted by using the standard most probable force approach might be interpreted as artificial energy barriers that are not present in the actual energy landscape. Factors that affect the range of useful velocities are discussed.