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PubMedDate not supplied

Access flow measured during hemodialysis.

Hemodialysis accesses must supply adequate blood flow to perform hemodialysis and maintain access patency. Access flow (QA) is not measured routinely during hemodialysis. The purpose of this study was to evaluate whether access flow changes during hemodialysis and to determine which factors correlate with QA. The authors measured hemodialysis access flow by ultrasound dilution (QA-T) (Transonic HD01 hemodialysis monitor; Transonic Systems, Inc., Ithaca, NY) and duplex ultrasound, with time-domain correlation (QA-S) (Philips CVI Phillips Medical Systems, Santa Ana, CA) hourly, in 19 patients during hemodialysis. Mean arterial pressure (MAP) (Fresenius automated blood pressure cuff) and cardiac output (CO) (Transonic hemodialysis monitor; Transonic Systems, Inc.) also were measured sequentially. Using duplex ultrasound, access flow was unchanged. However, it fell 132 +/- 137 ml/m (p < 0.05) by ultrasound dilution in hr 4. Cardiac output fell 586 +/- 840 ml/ m (p < 0.05), and MAP fell 11.9 +/- 13.0 mmHg (p < 0.01). There were small positive correlations between CO and QA (correlation coefficient (r) = 0.32, QA-T; r = 0.27, QA-S; p < 0.05), and between CO and MAP (r = 0.35; p < 0.01). In conclusion, access flow, CO, and MAP decreased modestly during hemodialysis. Further studies are necessary to see if access flow is similar off dialysis, and whether in-line access flow measurements can decrease access thrombosis.

Arteriovenous Shunt, Surgical↗

PubMedDate not supplied

Intervention based on monthly monitoring decreases hemodialysis access thrombosis.

We randomized 103 patients (68 arteriovenous [AV] fistulas, 35 polytetrafluoroethylene [PTFE] grafts; mean follow-up 197 days) to monthly measurement of access flow (QAT), monthly measurement of static venous pressure (VPS), or no monthly monitoring (control patients) to determine whether access thrombosis would decrease. Patients with access flow <750 cc/min or with static venous pressure > or =0.5 were referred for angiography and angioplasty of stenotic lesions > or =50%. Six of sixty-two (9.7%) of monthly monitored patients (MM) developed access thrombosis vs. 9 of 41 (22%) of control patients (p<0.05). Fewer MM patients developed thrombosis in AV fistulas (2.4% [2 of 42] vs. 15.4% [4 of 26] control patients; p<0.05). Monthly monitored patients had fewer thrombotic episodes than control patients (19 vs. 125 per 100 patient-years; p<0.01). Thrombosis rates were lowest in patients receiving monthly access flow measurement (5.9 [QAT] vs. 30.3 per 100 patient-years [VPS]; p<0.05). In conclusion, intervention based on monthly access flow measurement or static venous pressure decreased hemodialysis access thrombosis. Measurement of access flow tended to result in lower thrombosis rates than after static venous pressure. We believe that monthly access flow measurement will ensure the lowest incidence of thrombosis and decrease the cost of access maintenance.

Arteriovenous Anastomosis↗

PubMed2004

Residency training in percutaneous renal access: does it affect urological practice?

PURPOSE: We evaluated the impact of residency training in percutaneous renal access on subsequent urological practice. MATERIALS AND METHODS: Surveys evaluating practice and training in percutaneous renal access were mailed to residents who graduated between 1981 and 2001. A statistical analysis was performed to determine the effect of percutaneous access training on current practice patterns in percutaneous renal procedures. A subgroup analysis was conducted for graduates with more than 10 years after residency. RESULTS: Responses were received from 37 of 48 surveys mailed (77%) and 35 surveys were eligible for analysis. A total of 92% of urologists trained in percutaneous access currently perform percutaneous surgical procedures compared to only 33% of those untrained (p <0.001). Urologists trained in access perform a mean of 14.0 percutaneous renal procedures annually while those untrained perform 3.3 procedures (p = 0.02). Only 27% of urologists trained in percutaneous access continue to perform percutaneous renal access compared to 11% of those untrained (p = 0.33). A subset analysis of urologists trained more than 10 years ago shows similar results. The primary reasons stated for not performing their own access are that the radiologist has better equipment (61%) or skills (44%), or obtaining access requires extra time (50%). CONCLUSIONS: This study suggests a relationship between training in percutaneous renal access and subsequent use of percutaneous renal procedures in the urologist's practice. Emphasis should be placed on providing continuing education opportunities to maintain competency in this important technique.

Clinical Competence↗

PubMed2006

Importance of free access to research articles on decision to submit to the BMJ: survey of authors.

OBJECTIVES: To determine whether free access to research articles on bmj.com is an important factor in authors' decisions on whether to submit to the BMJ, whether the introduction of access controls to part of the BMJ's content has influenced authors' perceptions of the journal, and whether the introduction of further access controls would influence authors' perceptions. DESIGN: Cross sectional electronic survey. PARTICIPANTS: Authors of research articles published in the BMJ. RESULTS: 211/415 (51%) eligible authors responded. Three quarters (159/211) said the fact that all readers would have free access to their paper on bmj.com was very important or important to their decision to submit to the BMJ. Over half (111/211) said closure of free access to research articles would make them slightly less likely to submit research articles to the BMJ in the future, 14% (29/211) said they would be much less likely to submit, and 34% (71/211) said it would not influence their decision. Authors were equally divided in their opinion as to whether the closure of access to parts of the journal since January 2005 had affected their view of the BMJ; 40% (84/211) said it had, 38% (80/211) said it had not. In contrast, 67% (141/211) said their view of the BMJ would change if it closed access to research articles. Authors' comments largely focused on disappointment with such a regressive step in the era of open access publishing, loss of a distinctive feature of the BMJ, a perceived reduction in the journal's usefulness as a resource and global influence, restricted readership, less attractive to publish in, and the negative impact on the journal's image. CONCLUSIONS: Authors value free access to research articles and consider this an important factor in deciding whether to submit to the BMJ. Closing access to research articles would have a negative effect on authors' perceptions of the journal and their likeliness to submit.

Authorship↗

PubMed2006

Association of clinic vascular access monitoring practices with clinical outcomes in hemodialysis patients.

BACKGROUND: Early identification of access dysfunctions may be associated with improved patient outcomes. We examined whether patient outcomes were associated with vascular access monitoring practices in an incident dialysis cohort. METHODS: We conducted a national prospective cohort study and analyzed 363 hemodialysis patients who had a first permanent vascular access (arteriovenous fistula or graft) by 6 months after the start of dialysis. Multivariate methods were used to examine associations between monitoring practices and 6-month Kt/V (reaching Kt/V >/=1.2), access intervention, access failure, and 2-year septicemia and all-cause hospitalization and mortality. RESULTS: Patients who received monitoring weekly or more often (49%) were more likely to have an access intervention (adjusted RH = 1.40, 95% CI, 1.07-1.84) than those who received monitoring less frequently. Additionally, patients treated at clinics that reported performing regular access monitoring (80% of patients) were less likely to be hospitalized for septicemia (IRR = 0.35, 95% CI, 0.21-0.61) or for any cause (IRR = 0.77, 95% CI, 0.60-0.99). There were no statistically significant differences between patients exposed to different vascular access monitoring practices in access failure, achievement of Kt/V, or survival. CONCLUSION: Frequent monitoring of dialysis access may initially increase the number of interventions but is beneficial to longer-term outcomes, including septicemia-related and all-cause hospitalization.

Cohort Studies↗

PubMed1996

Lipoprotein(a) and vascular access survival in patients on chronic hemodialysis.

Lipoprotein(a) [Lp(a)] is an independent risk factor for atherosclerotic and cardiovascular complications in the general population and in hemodialysis patients. Increased Lp(a) levels have been also described as a possible predictor of vascular access occlusion in patients on chronic hemodialysis. We have studied prospectively the relationship between vascular access survival and Lp(a) levels in 40 hemodialysis patients. The Lp(a) plasma concentrations were measured by enzyme-linked immunosorbent assay in all patients in April 1993. Throughout the following year, evolution and survival of their vascular accesses were analyzed. Failure of vascular access was established when there were complications requiring surgical repair or transluminal angioplasty. Fourteen patients showed failure of vascular access, and the cumulative survival of vascular accesses after 1 year of follow-up was 63.8%. The Lp(a) levels were higher in patients with failure of vascular access than in the others (35.2 +/- 31 vs. 22.4 +/- 25 md/dl), but this difference did not reach statistical significance (p = 0.064). The vascular access survival in patients with Lp(a) levels > 75th percentile (52.5 mg/dl) was significantly lower than in the remaining patients (40 vs. 72%; p = 0.045). This difference increased when we analyzed the patients with Lp(a) levels > 90th percentile (76 md/dl; 25 vs. 68%; p = 0.002). Our results suggest that patients with the highest levels of Lp(a) are at risk of developing complications in their vascular accesses, and they also have lower vascular access survival.

Adult↗

PubMed2006

The open access advantage.

A study published today in PLoS Biology provides robust evidence that open-access articles are more immediately recognized and cited than non-OA articles. This editorial provides some additional follow up data from the most recent analysis of the same cohort in April 2006, 17 to 21 months after publication. These data suggest that the citation gap between open access and non-open access papers continues to widen. I conclude with the observation that the "open access advantage" has at least three components: (1) a citation count advantage (as a metric for knowledge uptake within the scientific community), (2) an end user uptake advantage, and (3) a cross-discipline fertilization advantage. More research is needed, and JMIR is inviting research on all aspects of open access. As the advantages for publishing open access from a researchers' point of view become increasingly clear, questions around the sustainability of open access journals remain. This journal is a living example that "lean publishing" models can create successful open access journals. Open source tools which have been developed by the Public Knowledge Project at the University of British Columbia with contributions from the Epublishing & Open Access group at the Centre for Global eHealth Innovation in Toronto are an alternative to hosting journals on commercial open access publisher sites.

Bibliometrics↗

PubMed2003

Evaluation of cat and owner characteristics and their relationships to outdoor access of owned cats.

OBJECTIVE: To examine characteristics of cats and their owners with regard to outdoor access of owned cats. DESIGN: Cross-sectional study. ANIMALS: 184 owned cats admitted to a veterinary referral center for nonemergency health concerns. RESULTS: Cats acquired recently were less likely to be allowed outdoors than those acquired during previous years. Outdoor access was often limited during the day; few owners allowed their cats to remain outdoors at night. Cats acquired from shelters were more likely to be kept exclusively as indoor pets than those cats acquired as strays. The presence of dogs but not other cats in the household was associated with increased outdoor access. Age, health status, and onychectomy status were not significantly associated with outdoor access. Cats allowed outdoor access were more likely to have been bitten by other cats. CONCLUSIONS AND CLINICAL RELEVANCE: The basis for an owner's decision to allow outdoor access appears to be multifactorial, and there may be regional differences in outdoor access of owned cats. Acquisition source is associated with outdoor access of owned cats. Availability of information regarding outdoor access of cats may influence decision making. Educational efforts targeted at specific groups of cat owners, as well as programs that acknowledge owner beliefs regarding quality of life for their cats, may help to address the health, safety, and population concerns associated with outdoor access of owned cats.

Age Factors↗

PubMed2000

Survival of vascular access during daily and three times a week hemodialysis.

AIM: A major cause of morbidity for hemodialysis patients is vascular access failure and/or occlusion. It is commonly believed that an increased frequency of dialysis sessions, among other factors, might lead to a higher rate of fistula complications. MATERIALS AND METHODS: To evaluate if patients on daily hemodialysis carry a higher risk of vascular access occlusion, we examined the incidence rate of access occlusion and the survival function of native vascular accesses in patients undergoing daily dialysis (DD; n = 24) as compared to patients on standard three times a week hemodialysis (TWD; n = 124). RESULTS: The mean follow-up time was 3.6 years. In the TWD group 42 patients had a first-access closure, whereas only 2 patients out 24 had a similar event in the DD group. The proportion of first-access closure was 33.9% for TWD and 8.3% for DD (p < 0.01). The incidence rate was 9.8 (95% CI: 7.2 -13.2) and 2.2 (95% CI: 0.4 - 7.1) events per 100 patient-years for TWD and DD, respectively. The rate difference was 7.6 (95% CI 3.4 - 11.9) events per 100 patient-years, and the unadjusted risk ratio was 4.5 (95% CI: 1.2 - 16.9; p < 0.01). The mean vascular access survival before closure was 3.3 years in TWD and 3.7 years in DD. Survival curves, obtained considering the first-access closure as the endpoint, showed a significant difference between DD and TWD (log-rank 5.16; p < 0.05). In a Cox-proportional hazard model the relative risk (RR) of vascular-access closure in TWD remained significant (RR = 4.3; 95% CI 1.1 - 18.2) after adjustment for age. CONCLUSION: The results of this observational study, conducted on a limited number of DD patients, suggest that daily dialysis might not have an adverse prognostic significance for access closure.

Arteriovenous Shunt, Surgical↗

PubMed2003

[Value of preserved saphenous vein graft for the creation of access ports in hemodialyzed patients: report of 309 cases].

INTRODUCTION: Biological grafts are rarely used for the creation of vascular access, despite their many advantages. Our group prefers to use distal vascular accesses with interposition of a biological graft when direct access cannot be achieved. The objective of this study was to determine the long-term patency and the complication rate of a series of 309 vascular access procedures using a preserved saphenous (PS) vein homograft. MATERIALS AND METHODS: 410 (27%) of the 1,500 vascular access procedures performed by our group required the use of a graft, including 376 PS vein homografts (25%). This retrospective study comprised complete data collection for 309 arteriovenous fistulas (AVF) using preserved saphenous (PS) vein graft in the forearm performed in 267 patients between 1985 and 2000. Primary patency was defined as the interval between creation of the vascular access and the first complication requiring surgical or radiological correction; secondary patency was defined as the interval between creation and loss of the graft, with or without revision of the fistula. Survival rates were calculated according to the Kaplan-Meier method. Inter-group comparison was performed by the Logrank test and analysis of variance was performed by logistic regression. RESULTS: Primary patency rates were 77%, 40% and 27% at 1,2 and 5 years, respectively. Secondary patency rates were 79% and 47% at 1 year and 5 years, respectively. The thrombosis rate was 42%. Two episodes of thrombosis occurred in 25% of grafts and 3 episodes were observed in 10% of cases. Infection rates were 1.9% postoperatively and 5% after dialysis, respectively. An aneurysm occurred on 10% of grafts. The operator's experience (RR = 1.58; p < 0.05) and diabetic nephropathy (RR = 1.89; p = 0.059) significantly influenced graft patency. In contrast, the position of the graft, the fact that it crossed the elbow joint, and the site of the arterial anastomosis did not have any negative impact on graft patency. DISCUSSION: Preservation of the patient's vascular capital is an essential objective in patients with chronic renal insufficiency, which is sometimes difficult to reconcile with the need to create vascular accesses with a long life span. The strategic choice between a distal access requiring a graft and a direct proximal access depends on the clinical context: cardiac function, waiting list for renal transplantation. Our preferred material in the case of bypass graft is the PS graft, as it presents the same resistance and the same patency rates as synthetic grafts, without the associated septic complications. CONCLUSION: The PS vein graft is a good material for the creation of vascular accesses with similar patency rates to those of prosthetic grafts. Vein grafts present a number of advantages, particularly a greater ease of use facilitating distal implantation of the graft and a low infection rate.

Adolescent↗

PubMed2004

Current topics on vascular access for hemodialysis.

Vascular access remains the lifeline for end-stage renal failure patients, which have been treated by chronic intermittent hemodialysis. Due to the steady increase in the number of patients with difficulties to create access, in particular in elderly with various comorbidities, the need for more insight and regulations have evolved into the publications of the American and European guidelines. From the latter it may be obvious that an adequate preoperative assessment followed by the creation of autogenous arteriovenous fistulas (AVFs) is far better and preferred to the implantation of grafts. Vascular access maintenance by monitoring and elective percutanuous or surgical revision is of utmost importance to keep the access site functional. Despite up-to-date measures for vascular access maintenance, various complications may treaten not only the access site but also quality and expectance of life. Thrombotic occlusion remains a major event, leading to permanent failure in 10% of AVFs and 20% of grafts each year. Interventional (percutaneous transluminal angioplasty and/or stent implantation) or surgical revision of thrombosed accesses have similar outcomes with a high rate of reinterventions. The elderly diabetic population with peripheral arteriosclerotic obstructive disease is in particular prone to angio-access induced handischemia. When not timely and properly treated this may lead to minor or major amputation, further hampering quality of life. Also, the enormous application in the past 2 decades of acute central venous lines has lead to a significant increase of central venous obstruction with concomittent morbidity and problems creating vascular access in the upper extremities. Radiological intervention in these cases is a primary option, leaving surgical reconstruction as a second best method. It may be obvious that creation and maintenance of hemodialysis vascular access has become an important and time-consuming speciality. Only an up-to-date multidisciplinary management with involvement of nurses, nephrologists, interventionalists and surgeons, will lead to the desired outcome.

Arm↗

PubMed2006

[Comparative morbidity for different accesses in percutaneous nephrolithotripsy].

BACKGROUND: Over the last decades percutaneous nephrolithotripsy (PCNL) has been developed as an alternative for open renal operations in the treatment of complex renal stones. Currently, different approaches are used for the collecting system. OBJECTIVES: To estimate the overall morbidity of different approaches to the collecting system during PCNL; to compare the complication rates for PCNL through the upper pole of the kidney with lower pole access and multiple access approaches. METHODS: We retrospectively reviewed 174 patients (178 renal units) who underwent PCNL. They formed three groups according to surgical access: upper pole (n = 107), lower pole (n = 51) and multiple (n = 20). Inter-group data on procedure related complications were compared. RESULTS: Postoperative fever was more frequent in the upper pole group (34%) compared to the other two groups (25% each, p < 0.49). There was a higher rate of pulmonary complications in the upper pole and multiple access groups (21% and 20%, respectively) compared with the lower pole group (2%, p=0.007). The rate of bleeding and need for blood transfusion was significantly higher in the multiple access group than in the other groups (20% vs 5% and 6%, respectively, p < 0.05). CONCLUSIONS: The upper and multiple access approaches were associated with a higher overall incidence of pleural effusion compared with the lower pole access. The incidence of bleeding and transfusion rates were similar using the upper and lower pole accesses but higher in the multiple access group. Provision of an enhanced surgical field and greater maneuverability together with 'the treatable nature of the associated complications favor an upper pole access, especially for removing a large stone burden.

Fever↗

PubMed1988

[Implantable direct intravenous access: technic, complications, outcome. Apropos of 237 cases].

From june 1983 to december 1987, 441 direct accesses were implanted, 237 intravenous, 51 intraperitoneal and 153 intra-arterial. The surgical procedure, the indications, the post-operatory and later complications and the issue of the direct intravenous accesses implanted by the same surgical team are presented. 237 direct access implants were placed intravenously in 228 patients. There are many indications for implanting direct access: absence of a superficial venous network, continuous chemotherapy, preservation of the superficial venous network, thrombosis of the hepatic artery after, inoperable hepatic metastasis (jaundice). Direct venous access was implanted for many pathologies essentially for breast cancer (120 cases), large bowel cancer (36 cases). Surgical procedure for direct intravenous access is easy with catheter's control with fluoroscopy monitoring. Only rarely did any later complication occur when using the direct intravenous access (12 cases) representing 5% of all complications. Certain precautions should be taken to reduce the number of complications. Prophylactic antibiotic therapy, surgical procedure for implanting the direct access excision of excess fatty subcutaneous tissue, minutious skin disinfection, heparinization, avoid using the chamber for blood sampling, use intra-arterial direct access. Direct access is used either for sequential chemotherapy or for continuous protocols which vary in length.

Adolescent↗

PubMed2005

Access to trauma centers in the United States.

CONTEXT: Previous studies have reported that the number and distribution of trauma centers are uneven across states, suggesting large differences in access to trauma center care. OBJECTIVE: To estimate the proportion of US residents having access to trauma centers within 45 and 60 minutes. DESIGN AND SETTING: Cross-sectional study using data from 2 national databases as part of the Trauma Resource Allocation Model for Ambulances and Hospitals (TRAMAH) project. Trauma centers, base helipads, and block group population were counted for all 50 states and the District of Columbia as of January 2005. MAIN OUTCOME MEASURES: Percentages of national, regional, and state populations having access to all 703 level I, II, and III trauma centers in the United States by either ground ambulance or helicopter within 45 and 60 minutes. RESULTS: An estimated 69.2% and 84.1% of all US residents had access to a level I or II trauma center within 45 and 60 minutes, respectively. The 46.7 million Americans who had no access within an hour lived mostly in rural areas, whereas the 42.8 million Americans who had access to 20 or more level I or II trauma centers within an hour lived mostly in urban areas. Within 45 and 60 minutes, respectively, 26.7% and 27.7% of US residents had access to level I or II trauma centers by helicopter only and 1.9% and 3.1% of US residents had access to level I or II centers only from trauma centers or base helipads outside their home states. CONCLUSION: Selecting trauma centers based on geographic need, appropriately locating medical helicopter bases, and establishing formal agreements for sharing trauma care resources across states should be considered to improve access to trauma care in the United States.

Air Ambulances↗

PubMed1996

Equity in the access to mammography in Spain.

The purpose of this study is to measure the access to mammography of women aged 40-70 in Spain and to analyze the factors related to access to the test. Women were considered to have access to mammography if they have received at least one mammogram in the preceding 2 years. Numerous studies have shown that breast cancer mortality is reduced in women receiving periodic mammography, although experts disagree about the most appropriate age range for screening. An equitable health care system should provide access to effective procedures to all persons who need them. A number of factors influencing the access to mammography have been described. We conducted a cross-sectional population-based survey of 3218 women residing in Spain who were between 40 and 70 years of age. The sample was selected using a multi-stage stratified cluster technique, with proportional assignment to each stratum. Data collection took place between March and May 1994 by means of individual oral interviews using a standardized questionnaire. The questionnaire included information on the dependent variable (mammography use) and the independent variable (those potentially associated with access to the test). Information on other independent variables was collected in official institutions or from existing publications. Data analysis consisted of univariate and multivariate analyses. Only about 28% of all women had received a mammogram in the last 2 years. According to the univariate analysis, access to mammography is most strongly associated with number of gynaecologist visits, residence in the autonomous community of Navarre, and physician referral for mammography. In the multivariate analysis, the factors most strongly associated with access to mammography are gynaecologist visits at least once in the last 2 years (OR = 8.71; CI = 6.84-11.10), existence of a breast cancer screening programme (OR = 7.64; CI = 5.24-11.10), and physician referral for testing (OR = 4.78; CI = 3.83-5.96). The multivariate analysis also showed a significant association with place of residence and with women's attitudes about testing. A small proportion of Spanish women who could potentially benefit from mammography have received the test in the last 2 years. Establishing breast cancer screening programs equitably throughout the nation, and carrying out educational interventions aimed at women and especially at physicians, will help to reduce inequalities and increase the access to mammography in Spain.

Adult↗

PubMed2005

Direct access in primary care and patient satisfaction: a European study.

OBJECTIVE: This study addressed the question to what extent gate-keeping or direct access to health care services influences the satisfaction with GP-services by the population in 18 European countries ("old" EU-countries plus Norway, Iceland and Switzerland). METHODS: Two datasets were collected. Firstly, country experts were asked to indicate for 17 different health care providers whether they were directly accessible. A direct accessibility scale was computed from the percentage of services that were directly accessible. Secondly, for patient satisfaction the EUROPEP study was used. This dataset contained information about patient satisfaction with general practitioners services in 14 European countries. RESULTS: If more health care providers were directly accessible in a country, patients showed a higher satisfaction with general practice than in countries where more referrals were required (Pearson's r = 0.54, p = 0.05). Satisfaction with organisational aspects of general practice (concerning amongst others waiting time and possibilities to make appointments) correlates significantly with a high score on our direct accessibility measure (Pearson's r = 0.67, p = 0.01). Satisfaction with patient physician communication (Pearson's r = 0.46, p = 0.10) and medical technical content of the care (Pearson's r = 0.41, p = 0.14) are not influenced by direct accessibility. CONCLUSIONS: Direct accessibility appeared to be important for patients. Apparently, if patients have freedom of choice for the type of health care provider, they evaluate the GP-services more positively. However, this mainly concerns satisfaction with organisational aspects of GP-services; the accessibility does not influence patient's judgement about the actual care provided by their GP.

Europe↗

PubMed2006

Comprehensive management of the access to the electronic patient record: towards trans-institutional networks.

BACKGROUND: A system ensuring tight control access is used since 5 years at the University Geneva Hospitals (HUG) over a four campuses health care system with ambulatory care settings behaving like a small community care network. Access to identified clinical information is limited to care providers that have a therapeutic relationship with the patient and to those data needed for that relation. The same policy applies to administrative or scientific research accesses. This paper presents how the HUG met the challenging goal of protecting patient privacy within regulatory limits while keeping the system operational in terms of use and management. SOLUTION: The main characteristics of the system are: (a) an institution-wide policy for access rights to the computerized patient record; (b) an institutional management of the contracts of the collaborators; (c) access profiles based on application-independent, fine-grained access rights; (d) a decentralized attribution of profession-specific access profiles; (e) a complete, centralized log of all accesses to the clinical information system; and (f) a decentralized verification of the accesses. Many of these characteristics can be maintained when evolving towards a trans-institutional computerized patient record, but new constraints need to be taken into account.

Access to Information↗

PubMed2026

Influence of endodontic access on the fracture resistance, retention and microleakage of full-coverage restorations in vitro: A systematic review and meta-analysis.

BACKGROUND: Endodontic access through retained full-coverage restorations (FCRs) is a preferred option for patients because of its high cost-effectiveness. However, the clinical performance of FCRs after repaired access cavity remains insufficiently characterized. This systematic review investigates the effects of endodontic access cavity preparation through retained FCRs on fracture resistance, retention, and microleakage based on in vitro studies. METHODS: A comprehensive search was performed in PubMed, Web of Science, and Scopus databases. Studies investigating the influence of endodontic access on the fracture resistance, retention, and microleakage of FCRs were included. Two independent reviewers conducted study selection, data extraction, and risk-of-bias assessment using the QUIN tool. Meta-analysis was employed to estimate fracture resistance and retention, with sensitivity analysis and subgroup evaluation also performed. Microleakage was summarized qualitatively. RESULTS: Twentythree studies were included: fracture resistance (n = 15), retention (n = 5), and microleakage (n = 3). Endodontic access significantly reduced fracture resistance for zirconia (p = 0.0002) and lithium disilicate (LD) restorations (p = 0.007), but not for resin-matrix ceramic (RMC) restorations (p = 0.25). Abutment tooth type contributed to heterogeneity within the LD and RMC subgroups. Retention was significantly reduced when access cavities were left unrepaired (p = 0.03), whereas appropriate repair protocols restored or enhanced retention relative to baseline. Accelerated aging increased microleakage in retained FCRs. Surface pretreatments and flowable resin liners tended to reduce microleakage, but findings were inconsistent. CONCLUSIONS: Endodontic access significantly reduces fracture resistance of zirconia and LD FCRs, whereas RMC restorations show no significant change. Appropriate repair protocols can restore or improve retention, potentially exceeding original values. Limited evidence suggests that effective sealing is achievable with appropriate materials. However, well-designed and in-vivo researches are needed to provide more detailed clinical guidance. CLINICAL SIGNIFICANCE: When performing endodontic access through retained FCRs, reduced fracture resistance must be carefully considered for zirconia and LD restorations, while RMC restorations may be exempt from this concern. Loss of retention with access can be restored after repair. Surface pretreatment and flowable resin liners help decrease microleakage.

Humans↗