Can the Reboot coaching programme support critical care nurses in coping with stressful clinical events? A mixed-methods evaluation assessing resilience, burnout, depression and turnover intentions.

BACKGROUND: Critical care nurses (CCNs) are routinely exposed to highly stressful situations, and at high-risk of suffering from work-related stress and developing burnout. Thus, supporting CCN wellbeing is crucial. One approach for delivering this support is by preparing CCNs for situations they may encounter, drawing on evidence-based techniques to strengthen psychological coping strategies. The current study tailored a Resilience-boosting psychological coaching programme [Reboot] to CCNs. Other healthcare staff receiving Reboot have reported improvements in confidence in coping with stressful clinical events and increased psychological resilience. The current study tailored Reboot for online, remote delivery to CCNs (as it had not previously been delivered to nurses, or in remote format), to (1) assess the feasibility of delivering Reboot remotely, and to (2) provide a preliminary assessment of whether Reboot could increase resilience, confidence in coping with adverse events and burnout. METHODS: A single-arm mixed-methods (questionnaires, interviews) before-after feasibility study design was used. Feasibility was measured via demand, recruitment, and retention (recruitment goal: 80 CCNs, retention goal: 70% of recruited CCNs). Potential efficacy was measured via questionnaires at five timepoints; measures included confidence in coping with adverse events (Confidence scale), Resilience (Brief Resilience Scale), depression (PHQ-9) and burnout (Oldenburg-Burnout-Inventory). Intention to leave (current role, nursing more generally) was measured post-intervention. Interviews were analysed using Reflexive Thematic Analysis. RESULTS: Results suggest that delivering Reboot remotely is feasible and acceptable. Seventy-seven nurses were recruited, 81% of whom completed the 8-week intervention. Thus, the retention rate was over 10% higher than the target. Regarding preliminary efficacy, follow-up measures showed significant increases in resilience, confidence in coping with adverse events and reductions in depression, burnout, and intention to leave. Qualitative analysis suggested that CCNs found the psychological techniques helpful and particularly valued practical exercises that could be translated into everyday practice. CONCLUSION: This study demonstrates the feasibility of remote delivery of Reboot and potential efficacy for CCNs. Results are limited due to the single-arm feasibility design; thus, a larger trial with a control group is needed.

Rifabutin for treating tuberculosis in solid organ transplant recipients: A retrospective observational study and literature review.

BACKGROUND: The treatment of tuberculosis (TB) in solid organ transplant (SOT) recipients is challenging owing to interactions between rifampin and immunosuppressive drugs. Rifabutin, a rifamycin with excellent activity against Mycobacterium tuberculosis and that induces cytochrome p450 less, may facilitate treatment. We report our experience with rifabutin for treating TB in SOT recipients and review the available literature. METHODS: A retrospective observational study of all SOT recipients with TB between January 2000 and December 2019. The clinical characteristics and outcomes of patients treated with and without rifabutin-containing regimens were compared and a literature review was conducted. RESULTS: We included 31 SOT recipients with TB, among whom 22 (71%) were men and the median age was 62 years (interquartile range 50-20). There were no significant differences between patients treated with rifabutin (n = 12), rifampin (n = 14), and non-rifamycins (n = 5) in clinical cure rates (83.3%, 64.3%, and 100%, respectively; P = .21), side effects (25%, 37.5%, and 20%, respectively; P = .74), or mortality (16.7%, 35.7%, and 0%, respectively; P = .21). Only one patient, treated with rifampin, suffered graft rejection. The literature review identified 59 SOT recipients with TB treated with rifabutin-containing regimens from 8 publications. Overall, the clinical cure, graft rejection, and mortality rates were 93.2%, 5.1%, and 6.8%, respectively. CONCLUSIONS: Rifabutin-containing regimens offer a reliable alternative to rifampin when treating TB in SOT recipients.

Clinical and genetic characteristics of xeroderma pigmentosum in Nepal.

BACKGROUND: Little is known about xeroderma pigmentosum (XP) in Himalayan countries. OBJECTIVE: To describe clinical characteristics of XP in Nepal and investigate its genetic bases. METHODS: This study was carried out on all consecutive patients referred for XP to a Nepalese tertiary referral centre in 2014-2015. Clinical data were collected using a standardized questionnaire. DNA was extracted from salivary samples, and next-generation sequencing (NGS) was conducted using a panel covering all 8 known XP genes (classical XP (XP-A to XP-G) and XP variant) and a skin cancer modifier gene, the melanocortin 1 receptor gene (MC1R). RESULTS: Seventeen patients (median age: 15 years; range: 1-32) were included. Twelve had skin cancers (including a total of 8 squamous cell carcinomas, 60 basal cell carcinomas, ocular carcinomas requiring an orbital exenteration in 3 patients, but no melanoma). Fifteen patients carried the same homozygous non-sense XPC mutation c.1243C>T, p.R415X. A homozygous non-sense XPA mutation (p.W235X) was found in the only patient with a history of early severe sunburn reaction and associated neurological symptoms. Associated genetic alterations included heterozygous missense variants in XPD/ERCC2 gene and the presence of MC1R variant R163Q in 5 and 9 patients, respectively. CONCLUSION: Although not previously reported, XP seems frequent in Nepal. Patients often presented with a very severe phenotype after a long history of excessive sun exposure without knowledge of the disease. Fifteen of 17 had the same p.R415X XPC mutation, which seems very specific of XP in Nepal, suggesting a founder effect. NGS analyses frequently revealed associated genetic alterations which could play a modifier role in the clinical expression of the disease.

Mutations in LCA5, encoding the ciliary protein lebercilin, cause Leber congenital amaurosis.

Leber congenital amaurosis (LCA) causes blindness or severe visual impairment at or within a few months of birth. Here we show, using homozygosity mapping, that the LCA5 gene on chromosome 6q14, which encodes the previously unknown ciliary protein lebercilin, is associated with this disease. We detected homozygous nonsense and frameshift mutations in LCA5 in five families affected with LCA. In a sixth family, the LCA5 transcript was completely absent. LCA5 is expressed widely throughout development, although the phenotype in affected individuals is limited to the eye. Lebercilin localizes to the connecting cilia of photoreceptors and to the microtubules, centrioles and primary cilia of cultured mammalian cells. Using tandem affinity purification, we identified 24 proteins that link lebercilin to centrosomal and ciliary functions. Members of this interactome represent candidate genes for LCA and other ciliopathies. Our findings emphasize the emerging role of disrupted ciliary processes in the molecular pathogenesis of LCA.

A multicentre study to determine the value and safety of drug patch tests for the three main classes of severe cutaneous adverse drug reactions.

BACKGROUND: Drug patch tests (PTs) can reproduce delayed hypersensitivity to drugs and entail a moderate re-exposure of patients to offending drugs. OBJECTIVES: To determine the value of PTs for identifying the responsible drug in severe cutaneous adverse drug reactions (SCARs) such as acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS) and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). METHODS: In a multicentre study, PTs were conducted on patients referred for DRESS, AGEP or SJS/TEN within 1 year of their SCAR. All drugs administered in the 2 months prior to and the week following the onset of the SCAR were tested. RESULTS: Among the 134 patients included (48 male, 86 female; mean age 51·7 years), positive drug PTs were obtained for 24 different drugs. These included positive tests for 64% (46/72) of patients with DRESS, 58% (26/45) of those with AGEP and 24% (4/17) of those with SJS/TEN, with only one relapse of AGEP. The value of PTs depended on the type of drug and the type of SCAR (e.g. carbamazepine was positive in 11/13 DRESS cases but none of the five SJS/TEN cases). PTs were frequently positive for beta lactams (22 cases), pristinamycin (11 cases) and in DRESS with pump proton inhibitors (five cases), but were usually negative for allopurinol and salazopyrin. Of 18 patients with DRESS, eight had virus reactivation and positive PTs. In DRESS, multiple drug reactivity was frequent (18% of cases), with patients remaining sensitized many years later. CONCLUSIONS: PTs are useful and safe for identifying agents inducing SCAR.

Study protocol for the online adaptation and evaluation of the 'Reboot' (Recovery-boosting) coaching programme, to prepare critical care nurses for, and aid recovery after, stressful clinical events.

BACKGROUND: Critical care nurses (CCNs) are routinely exposed to highly stressful events, exacerbated during the COVID-19 pandemic. Supporting resilience and wellbeing of CCNs is therefore crucial to prevent burnout. One approach for delivering this support is by preparing critical care nurses for situations they may encounter, drawing on evidence-based techniques to strengthen relevant psychological coping strategies. As such, the current study seeks to tailor a Resilience-boosting psychological coaching programme [Reboot] for CCNs, based on cognitive behavioural therapy (CBT) principles and the Bi-Dimensional Resilience Framework (BDF), and (1) to assess the feasibility of delivering Reboot via online, remote delivery to CCNs, and (2) to provide a preliminary assessment of whether Reboot could increase resilience and confidence in coping with adverse events. METHODS: Eighty CCNs (n=80) will be recruited to the 8-week Reboot programme, comprised of two group workshops and two individual coaching calls. The study uses a single-arm before-after feasibility study design and will be evaluated with a mixed-methods approach, using online questionnaires (all participants) and telephone interviews (25% of participants). Primary outcomes will be confidence in coping with adverse events (the Confidence scale) and resilience (the Brief Resilience Scale) measured at four time points. DISCUSSION: Results will determine whether it is feasible to deliver and evaluate a remote version of the Reboot coaching programme to CCNs, and will indicate whether participating in the programme is associated with increases in confidence in coping with adverse events, resilience and wellbeing (as indicated by levels of depression).

Identification of a novel splice-site mutation in the Lebercilin (LCA5) gene causing Leber congenital amaurosis.

PURPOSE: Leber congenital amaurosis (LCA) is one of the most common causes of hereditary blindness in infants. To date, mutations in 13 known genes and at two other loci have been implicated in LCA causation. An examination of the known genes highlights several processes which, when defective, cause LCA, including photoreceptor development and maintenance, phototransduction, vitamin A metabolism, and protein trafficking. In addition, it has been known for some time that defects in sensory cilia can cause syndromes involving hereditary blindness. More recently evidence has come to light that non-syndromic LCA can also be a "ciliopathy." METHODS: Here we present a homozygosity mapping analysis in a consanguineous sibship that led to the identification of a mutation in the recently discovered LCA5 gene. Homozygosity mapping was done using Affymetrix 10K Xba I Gene Chip and a 24.5cM region on chromosome 6 (6q12- q16.3) was identified to be significantly homozygous. The LCA5 gene on this region was sequenced and cDNA sequencing also done to characterize the mutation. RESULTS: A c.955G>A missense mutation in the last base of exon 6 causing disruption of the splice donor site was identified in both the affected sibs. Since there is a second consensus splice donor sequence 5 bp into the adjacent intron, this mutation results in a transcript with a 5 bp insertion of intronic sequence, leading to a frameshift and premature truncation. CONCLUSIONS: We report a missense mutation functionally altering the splice donor site and leading to a truncated protein. This is the second report of LCA5 mutations causing LCA. It may also be significant that one affected child died at eleven months of age due to asphyxia during sleep. To date the only phenotype unambiguously associated with mutations in this gene is LCA. However the LCA5 gene is known to be expressed in nasopharynx, trachea and lungs and was originally identified in the proteome of bronchial epithelium ciliary axonemes. The cause of death in this child may therefore imply that LCA5 mutations can in fact cause a wider spectrum of phenotypes including respiratory disease.

Effect of antiretroviral therapy on asymptomatic malaria parasitaemia in HIV-1 infected children.

OBJECTIVE: To investigate the effect of antiretroviral (ARV) therapy on the level of asymptomatic malaria parasitaemia in HIV-1 infected children. METHODS: Sixty-six HIV infected children had blood films prepared for malaria parasite identification and count. Mean parasite densities were compared across clinical stages and immunologic categories of disease and antiretroviral treatment status. RESULTS: Forty-five (68%) were less than 6 years old and 50 (75.7%) had advanced HIV disease. Twenty seven (41%) were on antiretroviral therapy. The prevalence of ASMP in the treated and untreated group was 44.4% and 15.4% respectively (p<0.01). The mean parasite density in the ARV treatment group was also significantly higher than in the untreated group (p=0.0071). CONCLUSIONS: ARV therapy seems to be associated with higher rates of ASMP and higher mean parasite counts.

Effect of antiretroviral therapy on asymptomatic malaria parasitaemia in HIV-1 infected children.

OBJECTIVE: To investigate the effect of antiretroviral ARV) therapy on the level of asymptomatic malaria parasitaemia in HIV-1 infected children. METHODS: Sixty-six HIV infected children had blood films prepared for malaria parasite identification and count. Mean parasite densities were compared across clinical stages and immunologic categories of disease and antiretroviral treatment status. RESULTS: Forty-five (68%) were less than 6 years old and 50 (75.7%) had advanced HIV disease. Twenty seven (41%) were on antiretroviral therapy. The prevalence of ASMP in the treated and untreated group was 44.4% and 15.4% respectively (p<0.01). The mean parasite density in the ARV treatment group was also significantly higher than in the untreated group (p=0.0071). CONCLUSIONS: ARV therapy seems to be associated with higher rates of ASMP and higher mean parasite counts.

[Chromium-induced vasculitis-like purpuric allergic contact dermatitis]. / Dermite de contact purpurique au chrome simulant une vasculite.

INTRODUCTION: Purpuric allergic contact dermatitis is a rare and poorly understood condition. CASE REPORT: A 27-year-old male patient with a personal history of atopic dermatitis since childhood consulted for chronic papular-purpuric rash present for 7 years. Moderate pruritus was seen. Profuse lesions were observed on the palms and soles and on the upper and lower limbs, with sparing of the trunk. These lesions consisted of purpuric papules, in some cases with crusts, forming large plaques. The clinical picture was initially suggestive of vasculitis, but this diagnosis was ruled out by histological examination and laboratory tests. Skin patch tests were evocative of chromium-induced contact dermatitis. Retrospective directed history-taking confirmed the relevance of the latter test since it revealed regular wearing of leather clothing. Lasting cure was achieved following eradication of the allergen. DISCUSSION: Reports of contact purpuric dermatitis are rare. This condition has been described principally for allergens consisting of rubber or dyes used in clothing. Our case was notable on account of the severity of the lesions, mimicking vasculitis, as well as the novelty of the incriminated allergen, chromium, found in leather garments. It underlines the value of routine skin patch tests in the event of chronic non-specific dermatitis. To our knowledge, this is the first reported case of chromium-induced purpuric allergic contact dermatitis.

[Hypersensitivity to fluindione (Previscan). Positive skin patch tests]. / Syndrome d'hypersensibilité à la fluindione (Préviscan). Positivité des tests épicutanés.

INTRODUCTION: Fluindione (Previscan) is an oral anticoagulant belonging to the vitamin K antagonist class and is very widely used in France. While bleeding is a common complication, severe immunoallergic reactions are less frequent. The authors report a case of drug-induced hypersensitivity syndrome. CASE REPORT: A 75 year-old woman was hospitalized for diffuse erythematous papular rash associated with facial oedema. These symptoms appeared 3 weeks after the beginning of treatment with fluindione, allopurinol and perindopril. Laboratory tests showed hyperleukocytosis, mixed hepatitis and moderate renal failure, with the entire picture being evocative of drug-induced hypersensitivity reaction. The eruption was associated with eosinophilia, hepatic cytolysis with cholestasis, and acute renale failure. While allopurinol and perindopril were stopped definitively, fluindione was only suspended temporarily following overdosage. On reintroduction, rapid recurrence of clinical and biologic signs was observed with increased severity. The skin rash resolved completely on withdrawal of the drug. Patch tests performed later were positive for fluindione and negative for allopurinol and perindopril. DISCUSSION: These manifestations were consistent with the diagnosis of drug-induced hypersensitivity syndrome due to fluindione. Very few cases have been described with fluindione despite widespread prescription of the treatment is in France. While there may be no skin involvement, immunoallergic signs such as fever, hepatitis and acute tubular interstitial nephritis have been described with fluindione and these may be related to this syndrome (DRESS - Drug Reaction with Eosinophilia and Systemic Symptoms). Skin patch testing, which is easily performed, can be extremely helpful in determining a causal relationship with medication.

Lactose malabsorption among adult Indians of the Great Basin and American Southwest.

The prevalence of primary adult lactose malabsorption and the pattern of milk use were studied among 109 Indians from various tribes of the American Great Basin and Southwest. Included were 100 persons who reported being full-blooded Indians as well as three with Mexican admixture and 6 with some European ancestry. Lactose malabsorption was found in 92% of the full-blooded Indians but in only 50% Indians who acknowledged European admixture. These results agree with those of studies of native Americans done elsewhere which show very high prevalences of such lactose malabsorption among adults reported as fullblooded and lower prevalences among individuals with admitted European ancestors. The suggestion made is that in pre-Colombian times, before interbreeding with Europeans began on any scale, such lactose malabsorption may have been nearly universal among native American adults. Most of the Indians studied consumed abundant milk since childhood but were nevertheless predominantly malabsorbers as adults. This argues against the induction hypothesis advanced by some to explain the striking ethnic differences that occur around the world in primary adult lactose malabsorption.

Environmental screening of acidic compounds based on capillary zone electrophoresis/laser-induced fluorescence detection with identification by gas chromatography/mass spectrometry and gas chromatography/high-resolution mass spectrometry.

This paper describes the application of capillary zone electrophoresis/laser-induced fluorescence detection (CZE/LIF) to the discovery of acidic compounds in environmental matrixes or the screening of extracts for acidic components. Published studies indicate that coal-derived materials contain a significant fraction of acidic compounds relative to materials derived from petroleum and shales. Such compounds may be useful as marker compounds for site assessment and source apportionment issues, and their identification may be important in toxicological and other health issues. We used deep-UV light from the frequency-doubled Ar ion laser at 244 and 257 nm to study extracts of samples. The CZE/LIF technique possesses good sensitivity and therefore overcomes one of the limitations of CZE with UV detection. The present work depends on high pressure/temperature solvent extraction of polynuclear aromatic hydrocarbon (PNA)-contaminated soil, followed by separation using CZE. The anionic analytes were separated by using borate or phosphate buffer (pH 9.2-12.3) after a chemical class separation. Samples were also characterized by gas chromatography/mass spectrometry (GC/MS) using full scans at low resolution, and elemental compositions were determined unequivocally by GC/high-resolution MS (GC/HRMS) using mass peak profiling (MPP). The similarity of low-resolution electron ionization mass spectra for a standard, 1-hydroxypyrene, and for a series of compounds in a contaminated-soil extract suggested that several types of phenolic and hydroxy-PNAs were present, including hydroxylated derivatives of fluorenes, fluoranthenes, and pyrenes. GC/HRMS using MPP confirmed the elemental compositions of the hydroxyfluorenes and hydroxypyrenes (and presumably hydroxyfluoranthenes) as [C13H10O] and [C16H10O], respectively. A new version of the MPP software was written for the Finnigan-MAT 900S-Trap and was similar to that developed previously for the VG 250SE. Inclusion of a calibration ion in addition to a lock mass ion in the multiple-ion detection descriptor provided errors of <1 ppm for the 3 partial profiles of the analytes. A mass resolution of 31,000 was used to resolve the analyte signals from interferences evident in the full M+1 and M+2 profiles in the case of the hydroxyfluorenes. Derivatization was also performed to form the tert-butyldimethylsilyl derivatives of phenolic hydroxy groups as a further confirmation of structure.

Modular methodology for determination of polychlorinated biphenyls in soil as Aroclors and individual congeners.

A comprehensive screening and confirmatory method was developed for monitoring polychlorinated biphenyls (PCBs), both as Aroclors and as individual congeners. This approach incorporates extraction, extract cleanup, and analysis modules designed to match cost, time, and data quality requirements. Soxhlet, sonication, supercritical fluid, and accelerated solvent extractions were evaluated. Carbon chromatographic cleanup procedures were used for separation of congeners on the basis of ortho substitutions, which permitted calculation of toxicity equivalents. Individual congener determinations, congener total histograms, and peak comparison techniques for Aroclor identification were elaborated by using high and low resolution mass spectrometric data. A screening procedure based on immunoassay using the Ohmicron PCB RaPID Assay kit gave results comparable to those obtained by gas chromatography with electron capture detection in the range 0.40-230 ppm, when the appropriate Aroclor calibrator was used.

Tuberculous panophthalmitis.

The case of a one-year-old Nigerian with tuberculous panophthalmitis is reported. He presented initially with a localised episceleral mass which was thought to be retinoblastoma due to rapid spread over the fundus induced by subconjunctival depromedrol. Histological examination of the enucleated eye showed that the lesion was due to tuberculosis. The subsequent favorable response of the ocular and radiological chest lesions to antituberculous therapy was quite remarkable. In contrast, there was an adverse response to radiotherapy which had followed enucleation on the strong suspicion of retinoblastoma. Not unnaturally, ocular tuberculosis was not thought of because of the rarity of ocular involvement with this disease. To our knowledge, this is the first case of its type reported from the African Continent.

Applications of capillary electrophoresis/laser-induced fluorescence detection to groundwater migration studies.

Capillary electrophoresis has been applied to the determination of groundwater migration based on laser-induced fluorescence (LIF) detection and traditional spectrofluorimetry. Detection limits of injected dye-fluorescent whitening agent (tinopal) in the low ppt ranges have been accomplished with both a spectrofluorometer and with CE/LIF based on the HeCd laser. The real-world problem was the determination of groundwater migration between adjacent Resource Conservation and Recovery Act (RCRA) and Superfund sites. Fluorescent dyes were injected into wells and were discovered in monitoring wells by extracting pads that adsorbed the dye. The methodology based on CE/LIF exhibits increased specificity over existing methodology due to the separation and unique migration time of the dye. Additional studies were aimed at achieving sub-ppt levels in the water directly using solid-phase extraction (SPE) and field-amplified injection techniques.

[Non-hospitalization orders for subjects with presumed alcoholic intoxication]. / Le certificat de non hospitalisation des sujets présumés en état d'ivresse.

OBJECTIVES: French law requires all persons in an apparent state of alcoholic intoxication taken into police custody to be examined at hospital to determine whether medical observation is necessary. A do-not-hospitalize order is required to return the person to police custody. We attempted to ascertain the number of orders delivered and the quality of medical management of these persons. METHODS: Over a one-month period, 140 persons in an apparent state of alcoholic intoxication and under police custody were seen at the University Hospital emergency ward at Tours, France. Do-not-hospitalize orders were delivered for 131 of them who were returned to police custody. Among the 66 other persons admitted for acute intoxication, 4 were also returned to police custody. Nurse and physician reports were assessed. RESULTS: The 135 persons, accounting for 12.7% of all emergency ward activity, were predominantly men (96%) and young (mean age 33 years). Many were aggressive (12.7%) and 80% arrived between 6 p.m. and 6 a.m. Nurse records revealed care was less rigorous at night and for the more aggressive subjects. Reasons for delivery of the do-not-hospitalize order were not sufficiently explicit in the physician records. CONCLUSION: The large volume of activity involved in caring for these persons and the difficulty encountered in correct medical management, together with legal implications, suggest that medical and paramedical teams need better training for the management of persons in an apparent state of alcoholic intoxication.

Anthropometric measurements in the detection of low birth weight infants in Lagos.

The present study was undertaken to determine the anthropometric risk indicators in the detection of infants with low birth weight. A total of 788 consecutive, singleton, live born infants had anthropometric measurements determined within 24 hours of life using standard methods. There were 389 (49.37%) males and 399 (50.63%) females; 136 (17.56%) of the infants were of low birth weight (LBW). Birthweight was significantly correlated with occipitofrontal circumference (OFC; r = 0.66), length (r = 0.86), mid-arm circumference (MAC; r = 0.88) and maximum thigh circumference (MTC; r = 0.95) (p < 0.001). Furthermore, OFC of 33.6 cm and 32.3 cm, length of 47.7 cm and 45.5 cm, MAC of 9.6 cm and 9.1 cm, and MTC values of 15.5 cm and 14.9 cm were the corresponding cut-off values with the best combination of sensitivity, specificity and predictive values (p < 0.001) for identifying infants with birth weights of < 2500 g and < 2000 g respectively. The use of these risk indicators would help to identify newborns for close supervision and care, as well as prevent mortality and postnatal developmental retardation.

Patients' rights to access their healthcare records.

Improving communication between different healthcare disciplines and with patients is hampered by professional insecurity. In this article, the authors examine the compelling reasons for making records more accessible to patients and describe the potential benefits for patients and professionals.

Patient documentation. On the records.

Documentation of patient care is frequently the Achilles heel of clinical services. The use of a multidisciplinary, semi-structured healthcare record may achieve improvements, but it needs to be coupled with appropriate strategies to overcome professional and cultural barriers to unified documentation. When implementing changes, clinical staff may overestimate their clinical information needs while underestimating the problems of its routine collection.