Atopic dermatitis and bone health: a systematic review.

Atopic dermatitis (AD) is associated with systemic inflammation and systemic corticosteroid use which can lead to poor bone health. The aim of this systematic review is to investigate the relationship between AD and bone mineral density (BMD), osteoporosis and fractures. We searched Web of Science, Cochrane Database of Systematic Reviews, MEDLINE and Embase. Title, abstract and full-text screening, and data extraction were done in duplicate. Quality appraisal was performed using the Agency for Healthcare Research and Quality Methodology Checklist (cross-sectional studies) and Newcastle-Ottawa Scale (cohort studies). We screened 3800 abstracts and included fifteen studies (twelve cross-sectional, three cohort). In cross-sectional studies, AD was associated with decreased BMD and increased fractures. In cross-sectional studies and a cohort study, AD was associated with a higher prevalence of osteoporosis compared to controls. There was inconsistency across studies, with some finding no association. In a large cohort study, AD was associated with increased risk of fractures of the hip (HR: 1.06, 95% CI: 1.02 to 1.11), spine (HR: 1.14, 95% CI: 1.06 to 1.23) and wrist (HR: 1.06, 95% CI: 1.01 to 1.10), with further increased risk with more severe AD. Differences between studies precluded quantitative synthesis. There is some evidence supporting an association between AD and poor bone health. Research is needed to clarify this association, underlying mechanisms and develop strategies to improve bone health of individuals with AD.

The use of smartphones on General Internal Medicine wards: a mixed methods study.

OBJECTIVE: To describe the uses of institutional and personal smartphones on General Internal Medicine wards and highlight potential consequences from their use. METHODS: A mixed methods study consisting of both quantitative and qualitative research methods was conducted in General Internal Medicine wards across four academic teaching hospitals in Toronto, Ontario. Participants included medical students, residents, attending physicians and allied health professionals. Data collection consisted of work shadowing observations, semi-structured interviews and surveys. RESULTS: Personal smartphones were used for both clinical communication and non-work-related activities. Clinicians used their personal devices to communicate with their medical teams and with other medical specialties and healthcare professionals. Participants understood the risks associated with communicating confidential health information via their personal smartphones, but appear to favor efficiency over privacy issues. From survey responses, 9 of 23 residents (39%) reported using their personal cell phones to email or text patient information that may have contained patient identifiers. Although some residents were observed using their personal smartphones for non-work-related activities, personal use was infrequent and most residents did not engage in this activity. CONCLUSION: Clinicians are using personal smartphones for work-related purposes on the wards. With the increasing popularity of smartphone devices, it is anticipated that an increasing number of clinicians will use their personal smartphones for clinical work. This trend poses risks to the secure transfer of confidential personal health information and may lead to increased distractions for clinicians.

Perceptions of urgency: defining the gap between what physicians and nurses perceive to be an urgent issue.

INTRODUCTION: Through our research into the design and evaluation of technology systems to improve the quality and safety of clinical communication, we have discovered that physicians and nurses differ in perspective regarding clinical prioritization and desirable response times. This has a number of important consequences including unnecessary interruptions, escalating conflict and deterioration in interprofessional relationships. Understanding the differing perspectives on clinical prioritization, or the gap in perceived urgency, may improve interprofessional relationships. METHODS: We conducted a mixed-methods study utilizing both qualitative (semi-structured interviews) and quantitative (surveys) methods to determine the gap between perceived urgency among physicians and nurses. The survey comprised of real messages extracted from the clinical communication system that was implemented. Physicians and nurses reviewed the messages and assigned an urgency level to each. The semi-structured interviews used open-ended questions to act as a guide to highlight key themes of interest. Thematic analysis, frequency tabulation, and triangulation were used to analyze the data. RESULTS: Although the surveys demonstrated concordance between physicians and nurses when independently ranking the urgency of clinical messages (kappa=0.66 SE 0.15), agreement was only fair in comparison to the urgency identified by the original nurse who sent the message (kappa=0.22 SE 0.18). We hypothesize that clinical context has a major role in defining urgency and may explain this finding. The survey data was triangulated with the semi-structured interview data and it was determined that the desired response time significantly impacted the sender's message prioritization. For example, shift changes and anxious family members were associated with discordant prioritizations. DISCUSSION: This study demonstrated that the perceived communication urgency gap between sending nurses and receiving physicians was primarily related to timeframe and context, not clinical condition. Most disagreement occurred when nurses used urgent messaging for time sensitive but not clinically urgent issues in an effort to expedite the resolution of their issue by the physicians. These results indicate the need for clinical communication systems to incorporate decision support around both clinical prioritization and expected response time in their design. Effective interprofessional communication is essential to the provision of safe, quality-based healthcare; these results highlight some of the sociotechnical aspects of health information technology implementation that must be considered.

Understanding interprofessional communication: a content analysis of email communications between doctors and nurses.

BACKGROUND: Clinical communication is recognized as a major source of errors in hospitals. The lack of documentation of communication, especially among verbal interactions, often creates hindrances and impedes improvement efforts. By providing smartphones to residents and encouraging nurses to communicate with residents by email shifted much of the communication to emails which permitted analysis of content. OBJECTIVE: Description on the interprofessional email communication between doctors and nurses occurring on the general internal medicine wards at two academic hospitals. DESIGN: A prospective analysis of email communications between doctors and nurses. SETTING: 34 out of the 67 residents who were on the general medicine clinical teaching units consented to allow analysis of their emails over a 6 month period. MAIN MEASURES: Statistical tabulations were performed on the volume and frequency of communications as well the response time of messages. Two physicians coded the content of randomly selected emails for urgency, emotion, language, type of interaction, and subject content. KEY RESULTS: A total of 13,717 emails were available for analysis. Among the emails from nurses, 39.1% were requests for a call back, 18.9% were requests for a response by email and the remaining 42.0% indicated no response was required from physicians. For the messages requesting a response by email, only 50% received an email response. Email responses had a median response time of 2.3 minutes. Content analysis revealed that messages were predominantly non-urgent. The two most frequent purposes for communications were to convey information (91%) and to request action by the physician (36%). CONCLUSIONS: A smartphone-based email system facilitated the description and content analysis of a large amount of email communication between physicians and nurses. Our findings provide a picture of the communication between physicians, nurses and other healthcare professionals. This work may help inform the further development of information and communications technology that can improve clinical communication.

Using real-time alerts for clinical trials: Identifying potential study subjects.

BACKGROUND: Clinical trials are widely accepted as a necessary step in evaluating the safety and efficacy of new pharmaceutical products. In order for a sufficiently powered study, a clinical trial depends on the effective and unbiased recruitment of eligible patients. Trials involving seasonal diseases like influenza pose additional challenges. OBJECTIVE: This is a feasibility study of a mobile real-time alerting system to systematically identify potential study subjects for a randomized controlled trial evaluating the safety and efficacy of early intervention with interferon alfacon-1 for patients hospitalized for influenza virus infection. METHODS: The alerting system was setup in a 471-bed acute care teaching hospital, enabled with computerized physician order entry (CPOE) and a rules-based alerting system. Patients were identified from the entire hospital using two alerts types: pharmacy prescription records for antiviral drugs, and positive influenza laboratory results. Email alerts were generated and sent to BlackBerry(®) devices carried by the study personnel for a 6 month period. The alerts were archived automatically on a secure server and were exported for analysis in Microsoft Access. RESULTS: Over a period of 21 weeks, 779 total alerts were received. The study team was alerted to 241 patients, of whom 85 were potential study subjects. The alert system identified all but one of the patients independently identified by infection control. CONCLUSIONS: Real-time identification of potential study subjects is possible with the integration of computerized physician order entry and BlackBerry(®) technology. It is a viable method for the systematic identification of patients throughout a hospital, particularly for trials investigating time-sensitive disease progression.

Effect of UV light on small nuclear RNA synthesis: increased inhibition during postirradiation cell incubation.

It has been shown previously that the synthesis of small nuclear RNAs (snRNAs) U1, U2, U3, U4, and U5, in contrast to that of all other RNA species tested, decreases markedly within 2 h of cell incubation after exposure to UV light (254 nm), while pyrimidine dimers are being removed from DNA. We examined the possibility that the postirradiation cell incubation-dependent, UV light-induced inhibition of snRNA synthesis might reflect hypersensitivity of the snRNA transcriptional domains to single-stranded DNA nicks or relaxation of DNA torsional stress or both that occur during DNA repair. This late suppression of snRNA biosynthesis was as pronounced in UV light-irradiated (DNA incision-deficient) xeroderma pigmentosum fibroblasts (complementation group A) as in irradiated normal human fibroblasts. The synthesis of snRNAs was not preferentially sensitive to gamma radiation (which produces single-stranded DNA breaks) or novobiocin or nalidixic acid (which induce DNA relaxation). Neither of these two drugs prevented the UV light-induced inhibition of snRNA synthesis observed during postirradiation cell incubation. These results suggest that the late suppression of snRNA synthesis does not result from hypersensitivity of snRNA transcriptional domains to single-stranded DNA cleavages or relaxation of DNA torsional strain. The UV light-induced late inhibition of snRNA synthesis: shows an inactivation curve whose slope differs from that observed immediately after irradiation; is seen in untransformed cells as well as established cells lines; and has been conserved between birds and mammals.

Inhibition of small nuclear RNA synthesis by ultraviolet radiation.

It was reported earlier that the biosynthesis of small nuclear RNAs (snRNAs) (U1, U2, U3, U4, and U5) shows an unexpected great sensitivity to ultraviolet (UV) radiation (254 nm). In this "early" inhibition, snRNA formation is suppressed immediately after exposure to UV light. There is also a second "late" inhibition of snRNA biosynthesis which requires lower doses of UV radiation and 1-2 h of postirradiation cell incubation to develop fully. In the present work we asked which step, within the metabolic pathway leading to the accumulation of newly made snRNA, is affected by UV light. Both for the early and late UV radiation-induced inhibitions: (a) similar results were obtained after pulse labeling or pulse chasing the radiolabel, implying that UV light did not decrease the stability of newly made snRNA; and (b) gel electrophoretic analysis of radiolabeled RNA that had been hybrid selected with cloned snRNA genes showed no accumulation of putative snRNA precursors, suggesting that UV radiation did not block snRNA processing. Instead, when transcription was carried out in isolated nuclei from irradiated cells, the effects of "early" and "late" inhibition were reproduced, indicating that transcription was affected. The early suppression appears to be a separate reaction from the late inhibition, since U1 snRNA transcription in isolated nuclei was inhibited in the absence of postirradiation cell incubation. There is a small fraction of snRNA synthesis that is resistant to high UV light doses (greater than or equal to 870 J/m2) right after irradiation, but is sensitive to lower doses (less than or equal to 36 J/m2) when the cells are incubated for 2 h after irradiation.