Essential and Nonessential Blood Testing in the Clinical Teaching Unit.

OBJECTIVES: The aim of the study was to evaluate the essential and nonessential blood tests ordered on the internal medicine clinical teaching units (CTUs) at Kingston General Hospital. Our aim was to establish a baseline performance measure identifying appropriate use of laboratory tests that could be used to inform improvement over time. METHODS: For an 8-week period, 14 CTU attending physicians at Kingston General Hospital were surveyed. They were asked for each of their patients, "What blood tests do you consider to be essential for tomorrow morning to maintain appropriate care for this patient?" The following day, blood tests that were ordered were compared with the "essential" list previously given by the attending physicians. RESULTS: Of 291 processed blood tests, 148 (51%) had not been considered essential by attending physicians; of the 203 tests considered essential, 60 (30%) were not ordered. Total agreement between "essential" and processed tests was poor (κ = 0.51; confidence interval, 0.45-0.56). CONCLUSIONS: Inadequate use of blood tests for CTU patients is common. Quality improvement initiatives should aim to address the lack of observed consensus between attending physicians' views and the ordered tests and to streamline decision-making and the ordering/communication processes. Clinical standards and guidelines regarding ordering of laboratory tests should be clearly defined.

Anhydrous TEMPO-H: reactions of a good hydrogen atom donor with low-valent carbon centres.

In this paper, we report a novel synthesis of anhydrous 1-hydroxy-2,2,6,6-tetramethyl-piperidine (TEMPO-H). An X-ray crystal structure and full characterization of the compound are included. Compared to hydrated TEMPO-H, its anhydrous form exhibits improved stability and a differing chemical reactivity. The reactions of anhydrous TEMPO-H with a variety of low-valent carbon centres are described. For example, anhydrous TEMPO-H was reacted with 1,3-bis(2,4,6-trimethylphenyl)imidazol-2-ylidene (IMes), an unsaturated NHC. Crystals of [CHNC(6)H(2)(CH(3))(3)](2)C···HO(NC(5)H(6)(CH(3))(4)), IMes···TEMPO-H, were isolated and a crystal structure determined. The experimental structure is compared to the results of theoretical calculations on the hydrogen-bonded dimer. Anhydrous TEMPO-H was also reacted with the saturated NHC, 1,3-bis(2,6-diisopropylphenyl)imidazolidin-2-ylidene (SIPr), giving the product [CH(2)Ni-Pr(2)C(6)H(3)](2)CH···O(NC(5)H(6)(CH(3))(4)). In contrast, the reaction of hydrated TEMPO-H with 1,3-bis(2,6-diisopropylphenyl)imidazolidin-2-ylidene gave small amounts of the hydrolysis product, N-(2,6-diisopropylphenyl)-N-[2-(2,6-diisopropylphenylamino)ethyl]formamide. Finally, anhydrous TEMPO-H was reacted with (triphenylphosphoranylidene)ketene to generate Ph(3)PC(H)C(=O)O(NC(5)H(6)(CH(3))(4)). A full characterization of the product, including an X-ray crystal structure, is described.