Clinical Evidence, Searching Tidbits, and Other Minutiae

Death certificates

2008-08-15T09:49:00.000-05:00

At the Pump Handle today, revere posts a brief overview of death certificates and their use in research, also with a nice discussion of age-adjusted death rates that fits in nicely with this week's post here on the confounding issue.

Confounding

2008-08-12T09:10:00.000-05:00

Confounding is a concept often mentioned in clinical research - the idea that a 3rd variable can distort or confuse (or confound..) a relationship between two other variables.

When confounding is present, it looks like exposure A is associated with increased risk of disease B, but really a 3rd variable X is causing increased risk of disease B and it just happens to also be associated with exposure A.

Clear as mud? Here's a real world example - if you look at how people recover after hip fracture, and you consider gender and whether women or men do better after hip fracture, it may seem that women generally fare poorly after they break a hip.

However, there's a confounder in this relationship -- age!

If you think a little more about the characteristics of people who break a hip, you realize that young men have hip fractures (due to high-energy trauma associated with events like motor vehicle crashes) and old(er) women have hip fractures (women with reduced bone density and potentially some mobility/balance/cognition problems leading to a fall). Younger females don't tend to have as many hip fractures as their young male counterparts (due to lifestyle issues etc.), and older males don't tend to have the same incidence of hip fracture as their female counterparts (they don't always have the same severity of bone density changes as older females; men tend to die sooner).

The female group is then naturally weighted toward older people (who generally heal more slowly and may have other comorbid conditions going on) and the male group is weighted toward young, otherwise healthy people.

So, when you add age to the statistical model and correct for the different age distribution, the difference in outcome by gender goes away -- the women tend to do more poorly because they're older, not because of their gender. If you control for age, there's no difference in outcome between men and women.

This is a classic example of confounding and one way to correct for it -- in an observational study, you can't randomize, but you can try to measure "things" that might be impacting your disease -- age, gender, socioeconomic status, family support, severity of injury, type of operative repair, rehabilitation status, etc. -- so that you can add them into your statistical model.

The Pitt epidemiology supercourse has a great discussion of confounding and ways to correct for it (PowerPoint file), and the Social Sciences Statistics blog has a very interesting post today that comments on issues of confounding in a recent study about running habits in older individuals (this is the study the post talks about).

One of the best library training videos ever

2008-07-26T08:55:00.004-05:00

From Mississippi Public Broadcasting, a video series called Tomes & Talismans about the Dewey Decimal System. Sound boring? But...it uses a sci-fi backstory -- aliens named Wipers from the Black Star Solar System have taken over the Earth,including destroying the intercontinental satellite system (which oddly looks a lot like a Jeopardy! quiz screen).

Because you know what Wipers like to do for fun?

They get down by destroying communication and data technology.

Don't worry - humans are evacuating to the White Crystal Star System (using a teleportation system that reminds me of the TV device in Charlie and the Chocolate Factory, and don't worry, they tested it on a cute little puppy first, then on some kids, to make sure it was safe).

A courageous librarian (in a fantastic khaki vest, I might add) is one of the last to go, making sure all the books are organized in the card catalog so that anyone returning to the planet will know what happens...

The whole series has been uploaded to YouTube.

(via Best Week Ever)

Hopkins on ABC

2008-07-08T14:28:00.000-05:00

ABC is posting the full episodes of the short series "Hopkins" filmed at Johns Hopkins Hospital in Baltimore... the kind of reality show I can watch while not feeling (very) guilty or voyeuristic :) And a good way to learn some more medical terminology and see some of the concepts "in action".

Episodes are online here and this page has an overview of the show in general.

Unofficial impact factors

2008-06-17T13:40:00.000-05:00

Biomed Central has calculated unofficial impact factors for many of its titles that are not yet covered in Journal Citation Reports -- they used ISI data to figure out the IFs for ~100 BMC titles. Seems like a great way to work around the delay between when a journal begins publication and when ISI begins tracking/calculating IFs.

More here on the Biomed Central blog and here on the BMC Impact Factor FAQ.

Friday humor: David Sedaris

2008-06-13T16:56:00.000-05:00

The Fresh Air David Sedaris interview is up on the NPR site -- he talks about his latest book (When you are engulfed in flames).

(he's touring now too -- dates are up in Ticketmaster, including a Nashville date this fall!)

More on procrastination

2008-06-13T13:37:00.001-05:00

This feature on NPR's Talk of the Nation fits in really well with my ongoing struggle to trick myself into doing things that I need to do but don't really want to do :) -- How to Be a Productive Procrastinator

Why do today what you can do the day after tomorrow? Procrastination expert Timothy Pychyl and self-professed "structured procrastinator" John Perry discuss the latest research on this type of behavior and how to prioritize what's really important.

including "the inner mechanics of lolly-gagging"...

And here's one of my favorite cartoons ever - "Tales of Mere Existence: Procrastination"

Finding the right word

2008-06-09T12:36:00.001-05:00

I'm a huge fan of Roget's Thesaurus; a battered print copy inherited from my dad (copyright 1962) sits on the shelf above my desk and I use it at least weekly. I know I'm not alone in my love of words, and a Lifehacker post today confirms it! A whole group of word-related sites and webapps -- "Best Online Language Tools for Word Nerds."

Organic milk's shelf life

2008-06-09T09:23:00.000-05:00

I've idly wondered about this from time to time but never tried to find an answer - why does organic milk last so much longer than regular milk? I started buying it partly because of the antibiotic issue, but have kept buying it because it suits my erratic like/dislike relationship with milk. This weekend, Scientific American briefly looked at why organic milk lasts so long, which turns out to be due to ultrahigh temperature processing instead of the way that it's produced.

Medical jargon

2008-04-01T09:11:00.000-05:00

Interesting brief opinion piece in today's Guardian - This epidemic of medical jargon isn't good for us - Professor Jonathan Wolff discusses the linguistic reasons for a professional jargon and advocates:

To take better care of our health, we need access to clear information. I concede that some specialised technical vocabulary is needed and useful. But many terms seem to be used purely to give medical professionals a spurious sense of precision and authority, while policing the boundaries of the subject; keeping out the riff-raff. If the Chinese, to improve literacy, can simplify their written script, can we not simplify medical terminology to improve health literacy?

Autism and Second Life

2008-03-28T13:16:00.000-05:00

Great brief piece on CNN's site today about a place in Second Life, Naughty Auties, developed by a young man with Asperger's Syndrome, meant to give those with autism a place to meet online and to provide more information about the autism spectrum disorders.

CNN is going to focus on autism spectrum disorders all day on Wednesday April 2.

Another surgery game

2008-03-12T17:46:00.000-05:00

I spent way too much time playing this last night -- Amateur Surgeon, a game from [adult swim].

You play a pizza boy with an interest in surgery who operates on a variety of interesting characters, using a pool table in an old warehouse as his OR and a mismash of tools (stapler, lighter, pizza cutter), under the supervision of a disgraced surgeon.

I had to give up last night after I killed poor Claude 4 times...

Andrew Jackson's "myriad of diseases"

2008-02-18T11:28:00.000-06:00

In honor of President's Day, Jake Young of the Pure Pedantry blog has a great post about the complex and interesting medical history of Andrew Jackson -- Presidential Medicine: Andrew Jackson.

JMLA article

2008-01-31T09:14:00.000-06:00

Brief moment of shameless self promotion :-) - a paper based on my MPH thesis in included in this month's JMLA -

Jerome RN, Giuse BN, Rosenbloom ST, Arbogast PG. Exploring clinician adoption of a novel evidence request feature in an electronic medical record system. J Med Libr Assoc. 2008 January; 96(1): 34–41. The abstract:

Objective: The research evaluated strategies for facilitating physician adoption of an evidence-based medicine literature request feature recently integrated into an existing electronic medical record (EMR) system.

Methods: This prospective study explored use of the service by 137 primary care physicians by using service usage statistics and focus group and survey components. The frequency of physicians' requests for literature via the EMR during a 10-month period was examined to explore the impact of several enhanced communication strategies launched mid-way through the observation period. A focus group and a 25-item survey explored physicians' experiences with the service.

Results: There was no detectable difference in the proportion of physicians utilizing the service after implementation of the customized communication strategies (11% in each time period, P=1.0, McNemar's test). Forty-eight physicians (35%) responded to the survey. Respondents who had used the service (n=19) indicated that information provided through the service was highly relevant to clinical practice (mean rating 4.6, scale 1 “not relevant”–5 “highly relevant”), and most (n=15) reported sharing the information with colleagues.

Conclusion: The enhanced communication strategies, though well received, did not significantly affect use of the service. However, physicians noted the relevance and utility of librarian-summarized evidence from the literature, highlighting the potential benefits of providing expert librarian services in clinical workflow.

A common health language

2008-01-29T09:24:00.000-06:00

The newsletter ADVANCE for Health Information Management Professionals has a really nice brief article on health literacy, "Dream of a Common Health Language" by Shawn Proctor. The article a few simple but striking examples from the world of respiratory therapy to illustrate signs and potential implications of low health literacy.

For Mari Jones, RRT, FNP, AE-C, the predicament hit home when she found her college-educated father struggling to understand his doctor's instructions. He had returned home knowing he should stop taking one of three medications. But he was unclear as to which one. He didn't want to admit he didn't understand.

The article mentions The Newest Vital Sign, a health literacy test that Pfizer makes freely available and the NN/LM health literacy page.

Epigenomics initiative

2008-01-22T09:40:00.000-06:00

Today, the NIH announced a new initiative focused on developing the field of epigenomics in the US.

What is epigenomics, you ask?

The press release defines the field:

Epigenetics focuses on processes that regulate how and when certain genes are turned on and turned off, while epigenomics pertains to analysis of epigenetic changes across many genes in a cell or entire organism.

Epigenetic processes control normal growth and development. Diet and exposure to environmental chemicals throughout all stages of human development among other factors can cause epigenetic changes that may turn on or turn off certain genes. Changes in genes that would normally protect against a disease, as a result, could make people more susceptible to developing that disease later in life. Researchers also believe some epigenetic changes can be passed on from generation to generation.

And an example might help:

...epigenetics may help explain how some people are predisposed to certain illnesses such as cardiovascular disease, diabetes and hypertension. Several studies have documented that children born to mothers who did not get adequate nutrition during pregnancy were more likely to develop type 2 diabetes and coronary heart disease later in life. The theory is that epigenetic changes occur in genes that regulate sugar absorption and metabolism during fetal development that allow for survival with little food, but when encountered with an environment where food was plentiful these changes led to development of diabetes. (See scientific illustration of how epigenetic mechanisms can affect health at http://nihroadmap.nih.gov/epigenomics/epigeneticmechanisms.asp .)

More on epigenomics and epigenetics:
- NIH Roadmap: Epigenomics
- Biology Online: Introduction - from genome to epigenome - this intro notes "
The term ‘epigenetics’ was first introduced by Conrad Waddington in the 1940s to describe ‘the interactions of genes with their environment, which bring the phenotype into being’"
- the Human Epigenome Project

Ethics committees

2008-01-21T09:56:00.000-06:00

AMNews, the weekly newsletter of the American Medical Association, this week considers the role of the hospital ethics committee, including potential limitations and barriers to ethics consultation by physicians.

The article mentions the VA initiative to transform the ethics committee model, coordinated by the VA's National Center for Ethics in Health Care. The IntegratedEthics initiative began rolling out to all VA medical centers in May 2007 and their web site includes a wealth of training information and other tools, including Ethics Consultation: Responding to Ethics Questions in Health Care, a primer for ethics consultants.

The Nintendo Wii and virtual surgery

2008-01-17T16:28:00.000-06:00

From New Scientist -- A Wii warm-up hones surgical skills -- an excerpt:

You might think it a bad idea for trainee surgeons to play games on the Nintendo Wii when they should be studying, but it might be time well spent.

Kanav Kahol and Marshall Smith of the Banner Good Samaritan Medical Center in Phoenix, Arizona, have found that surgical residents performed better during simulated surgery after playing on the Wii console. They put it down to the console's
novel "Wiimote" control system, which allows players to direct on-screen action using a wireless wand that detects acceleration in three dimensions.

Now they are designing Wii software that will accurately simulate surgical procedures. A training platform based on the console, which costs about $250, might be more practical for trainee surgeons in the developing world than traditional virtual training tools, which typically cost a great deal more.

To test how the Wii affected surgical skill, the researchers asked eight trainee doctors to play it for an hour before performing a virtual surgery. They used a training tool called ProMIS, which simulates a patient's body in 3D and tracks the surgeon's movements as they operate. They fed the movements to an algorithm which scores the virtual surgeon on a range of factors. Wii-playing residents scored 48 per cent higher on tool control and performance than those without the Wii warm-up.

(More on virtual surgery in this past post and on the Clinical Cases blog - virtual knee and hip replacement)

Visiting the emergency room

2008-01-17T09:30:00.000-06:00

CNN's Empowered Patient feature today focuses on five things not to do in the ER (more discussion of each of the items in the article:

1. Don't forget to call your doctor on the way to the ER

2. Don't use an ambulance unless you really need it

3. Don't be quiet

4. Don't get angry, and don't lie

5. Don't forget the phone

Disease origins

2008-01-15T14:32:00.000-06:00

Tara at Aetiology has a great discussion of research to figure out where syphilis came from.

An octopus and his best friend

2008-01-11T13:37:00.000-06:00

A heartwarming (maybe just to me...) story about an octopus and his favorite toy, a Mr Potato Head, via Zooillogix.

Scary and cute at the same time

2008-01-03T12:28:00.000-06:00

Public Health Response to a Rabid Kitten --- Four States, 2007 in the CDC's MMWR this week gives a great, narrative discussion of the discovery and investigation of rabies exposure via a rabies-infected kitten -- public health epidemiology in action.

Of course, it's also sad that the kitten was ill (had already been euthanized before the suspicion of rabies) and a good reminder why rescued animals should really be quarantined from other animals and humans until a full veterinarian exam, even if they initially look well - though domestic animal rabies is not nearly as common as it used to be, animals that have spent any time in "the wild" might have been exposed to illnesses through contact with other animals (this kitten had a raccoon-variant rabies infection).

Some vets will give reduced rates for rescued animals - call your local veterinarians to find out if they offer assistance or can recommend other services in your area. The American Animal Hospital Association, the accrediting group for animal hospitals in the US and Canada, has a directory of vets that you can search by zip code.

It's also a good reminder to spay/neuter pets that you don't plan to breed - the ASPCA has an online directory of low-cost providers for this service.

Variety post

2007-12-07T14:13:00.000-06:00

Life has been very hectic lately - here are a few interesting things that have been lingering in my feed reader -

- Greenwood DC. Reliability of journal impact factor rankings. BMC Medical Research Methodology 2007, 7:48.

- PLoS Medicine blog: EQUATOR: a new site for reporting guidelines - cumulation of recommendations/standards for reporting the methods and results of clinical research.

- PLoS Publishing blog: Bringing peer review out of the shadows

- PLoS Medicine: The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies

- Institute of Medicine project: Conflict of interest in medical research, education, and practice

and finally, since it's Friday, Pinky and the Brain's musical tribute to neuroanatomy

More on heuristics

2007-10-01T16:30:00.000-05:00

The cognitive psychology Thinker has a few great minitutorials that give examples illustrating some of the most common heuristics.

From the site overview:

A number of factors can affect how we go about making decisions, but it is unusual for us to make a decision completely objectively and rationally; rather we usually bring biases from our prior beliefs or experiences into the situation. As a result, we often use "rules of thumb," or heuristics, to help us. These heuristics allow us to have an idea about how to weigh our options, even though they might sometimes lead us astray. Likewise, sometimes the way our options are worded, or "framed," may lead us to think differently than we might otherwise. Finally, we often allow prior experience or outcomes to guide our approach to a decision, even though, again, that approach may not be the best way to go.

Representativeness bias

2007-10-01T16:13:00.000-05:00

This week's AMNews, the newsletter of the American Medical Association, includes an excerpt from Dr. Jerome Groopman's book How Doctors Think (amazon.com book info). The excerpt discusses a case of missed diagnosis of cardiac disease in a healthy man and gives a great example of the representativeness heuristic in clinical decision-making.

Groopman notes of the case and how it illustrates this kind of bias:

The mistake Croskerry made is called a representativeness error: your
thinking is guided by a prototype, so you fail to consider possibilities that
contradict the prototype and thus attribute the symptoms to the wrong
cause.

Success story: death of a quality measure

2007-09-20T16:46:00.000-05:00

There's a perspective piece in the New England Journal of Medicine this week (subscription required for full-text access) discussing a healthcare quality success story.

This brief piece looks at the use of beta-blockers in the acute period after myocardial infarction - how this was operationalized as a quality measure by the National Committee for Quality Assurance (NCQA) in 1996 and why this measure is being retired as a quality indicator. Dr Lee notes:

Good research seems to be necessary but not sufficient to create sweeping
change for the better. What are the other key ingredients? The beta-blocker
story helps us to flesh out the recipe.

A great quick overview of an example of how strong evidence from clinical research was translated to a pervasive change in the US healthcare system.

Reference: Lee TH. Eulogy for a quality measure. New Engl J Med 2007 Sept 20;357(12):1175-1177.

Errata reporting

2007-09-04T17:04:00.001-05:00

I get the JAMA table of contents by email each week, and noticed today that they've started including more detail about the corrections. This week's errata, for example:

Incorrect Data and Omission of Trial Site and Personnel in: Effects of Tamoxifen vs Raloxifene on the Risk of Developing Invasive Breast Cancer and Other Disease Outcomes: The NSABP Study of Tamoxifen and Raloxifene (STAR) P-2 Trial JAMA 2007;298 973
http://jama.ama-assn.org/cgi/content/full/298/9/973?etoc

Incorrect Data and Wording in: Patient-Reported Symptoms and Quality of
Life During Treatment With Tamoxifen or Raloxifene for Breast Cancer
Prevention: The NSABP Study of Tamoxifen and Raloxifene (STAR) P-2 Trial
JAMA 2007;298 973
http://jama.ama-assn.org/cgi/content/full/298/9/973-a?etoc

Incorrect Data in Tables in: Nonvalidation of Reported Genetic Risk Factors
for Acute Coronary Syndrome in a Large-Scale Replication Study JAMA 2007;298 973
http://jama.ama-assn.org/cgi/content/full/298/9/973-b?etoc

A small change but seems so much more informative about the nature of the problem, rather than just noting that an error was made and making you go to the full-text to figure out how "big" the error was.

NLM and Harry Potter

2007-09-03T08:53:00.000-05:00

The National Library of Medicine currently has an exhibition exploring medicine and medical history in the Harry Potter books - Do Mandrakes Really Scream? Magic and Medicine in Harry Potter.

There is more to the Harry Potter series than a child hero or a fantasy adventure —many of the characters, plants, and creatures in Rowling’s stories are based in history, medicine, or magical lore. Death, evil, illness, and injury affect the characters of Harry Potter’s imaginary world. In describing their experiences, Ms. Rowling has drawn on important works of alchemy and herbology. These works and other links to Harry Potter books are examined in this exhibition.

Book rentals

2007-08-22T17:07:00.000-05:00

Not exactly medically related but interesting - via Lifehacker

Rent Books Netflix Style with BookSwim

3 books at a time for $20 a month, free shipping both ways...

I can't decide if their main competitors are bookstores, or libraries.

July JMLA case: organ donation

2007-07-19T13:47:00.000-05:00

The July installment in the Journal of the Medical Library Association case study series is now up over at the JMLA Case Studies in Health Sciences Librarianship blog.

Reference: Todd PM, Jerome RN, Jarquin-Valdivia AA. Organ preservation in a brain dead patient: information support for neurocritical care protocol development. J Med Libr Assoc. 2007 July; 95(3): 238–245.

Medical images

2007-07-12T16:05:00.000-05:00

Last month, the UK's Wellcome Trust made available a large collection of images under Creative Commons license - Wellcome's Images currently includes 40,000+ images representing the last 2,000 years.

And from Worth1000, an entertaining (and sometimes disturbing) collection of hoaxed medical images

(hat tip to BoingBoing)

Easy FeedBurner redirect

2007-07-12T13:41:00.000-05:00

Making things a little simpler for Blogspot bloggers and their subscribers - the FeedBurner blog had a post yesterday about how to easily re-direct your Blogger feed to FeedBurner.

More on patient privacy

2007-07-03T11:23:00.000-05:00

As a follow-up to this post on the new IOM committee examining research impact of the HIPAA privacy regulations, here are a few additional recent items on the HIPAA Privacy Rule:

- An article in the New York Times this week examines variability and errors in how HIPAA regulations are implemented at the institutional level, "Keeping Patients’ Details Private, Even From Kin"

- The Times also included a companion article, "A Health Official Discusses Privacy," a Q&A with Susan McAndrew, deputy director for health information privacy in the Office of Civil Rights at the US Department of Health and Human Services

- Scientific American also has two more informatics-focused considerations of patient privacy: "Privacy Isn't Dead, or At Least It Shouldn't Be: A Q&A with Latanya Sweeney" and "A Little Privacy, Please," a full article discussing Sweeney's privacy-focused research at Carnegie Mellon (she has a fascinating body of work; see her site for a full listing of projects, publications, etc.)

Moore documentary available online

2007-07-02T17:12:00.000-05:00

I plan to see this and haven't watched it yet, but wanted to pass along the link for those who are interested - Michael Moore's newest documentary, Sicko, examines the American health care system and is now available online (with permission) for free viewing in mp4 format -

Part 1
Part 2

(hat tip to the Consumerist)

IOM committee: the HIPAA Privacy Rule's effects on health research

2007-07-02T10:44:00.000-05:00

A new Institute of Medicine committee has been formed to assess the impact of the HIPAA Privacy Rule -- the committee's charge is titled "Health Research and the Privacy of Health Information - The HIPAA Privacy Rule." It began June 1, 2007, first formal meeting in mid-June, and is expected to run for 16 months.

From the project description:

"An IOM committee will investigate the effects on health research of the Privacy Rule regulations implementing the Health Insurance Portability and Accountability Act of 1996 (HIPAA) section on Administrative Simplification and prepare a report. In conducting the study, the committee will:

consider the range of study types, such as clinical trials, epidemiologic designs, research using tissue repositories and databases, public health research, and health services research, to the extent that available data and evidence allow
consider research carried out by the full range of sponsors: government, public and private academic, and for-profit sectors, including the pharmaceutical, biotechnology and medical device industries
review provisions of the Privacy Rule relevant to health research, including those dealing with authorizations and accounting for disclosures of personal health information, de-identification of data, reviews preparatory to research, and others, and on reviewing them, may identify provisions that merit priority attention and analysis
take into consideration issues of interpretation and implementation of the Privacy Rule, as well as of harmonization with overlapping provisions of the Common Rule and FDA regulations, which have been in existence much longer
examine the potential impact of the Rule on public health research, on the recruitment of research subjects for studies, on carrying out research internationally, and on research using data and biomaterials in databases and tissue repositories
consider the needs for privacy of identifiable personal health information and the value of such privacy to patients and the public

Additional information:
- the committee membership roster and additional information is available here
- background and educational materials on the HIPAA privacy regulations and what they mean for health care researchers
- an Annals of Internal Medicine piece from last year noting some of the main concerns of clinical researchers related to the rule (PDF file)
- a quick PubMed search focusing on discussions of the rule's impact on research (informed consent, participation/recruitment, research collaboration networks, etc.)

Randomized trials and allocation concealment

2007-06-06T09:05:00.000-05:00

A great example of problems with a randomization scheme for a clinical trial - "Reliable evidence is the best medicine," Howard Brody, The Grand Rapids Press

More on allocation concealment:

- Schulz KF, Grimes DA. Allocation concealment in randomised trials: defending against deciphering. Lancet. 2002 Feb 16;359(9306):614-8.

- Schulz KF. Assessing allocation concealment and blinding in randomised controlled trials: why bother?, Evidence-Based Medicine 2000; 5:36-38

- CONSORT statement: allocation concealment example

-Forder PM, Gebski VJ, Keech AC. Allocation concealment and blinding: when ignorance is bliss. MJA 2005; 182 (2): 87-89

- Beller EM, Gebski V, Keech AC. Randomisation in clinical trials. MJA 2002 177 (10): 565-567.

and a study exploring how allocation concealment is reported in clinical trial reports: Hewitt C, Hahn S, Torgerson DJ, Watson J, Bland JM. Adequacy and reporting of allocation concealment: review of recent trials published in four general medical journals. BMJ. 2005 May 7;330(7499):1057-8.

Chatbots; virtual surgery

2007-05-17T09:17:00.000-05:00

Two things from BoingBoing that amused me this week, for completely different reasons -

- I Chat, Therefore I Am... - Discover Magazine has transcripts of two chatbots (ALICE and Jabberwacky) talking to each other. An excerpt:

J: How do you define life?

A: Life is the opposite of death.

J: So death is the absence of life?

A: Take it easy. I try not to think about such things.

J: Why not?

A: Ambiguous.

J: Yes!

- Perform virtual surgery on a stuffed bunny in 60 seconds or less - a little weird I guess but fun. You have to prepare the bunny for surgery, make the incision, complete a couple of intraoperative tasks. I must admit that it's a good thing I'm not a surgeon - the first time I killed the bunny when the phone rang; he didn't even come close to surviving until the 2nd go-round.

New WHO patient safety solutions

2007-05-02T09:40:00.000-05:00

The World Health Organization Collaborating Centre for Patient Safety Solutions (with the Joint Commission and Joint Commission International as key collaborators) has launched 9 publications intended to support improved patient safety at the international level:

- Look-Alike, Sound-Alike Medication Names
- Patient Identification
- Communication During Patient Hand-Overs
- Performance of Correct Procedure at Correct Body Site
- Control of Concentrated Electrolyte Solutions
- Assuring Medication Accuracy at Transitions in Care
- Avoiding Catheter and Tubing Mis-Connections
- Single Use of Injection Devices
- Improved Hand Hygiene to Prevent Health Care-Associated Infection

The press release notes, "The basic purpose of the solutions is to guide the re-design of care processes to prevent inevitable human errors from actually reaching patients."

“These solutions offer to WHO Member States a major new resource to assist their hospitals in avoiding preventable deaths and injuries,” says Dennis S. O’Leary, M.D., president, The Joint Commission. “Countries around the world now face both the opportunity and the challenge to translate these solutions into tangible actions that actually save lives.”
“These Patient Safety Solutions were designed through a truly international collaborative effort, and represent what has been learned internationally about where, how and why certain adverse events occur,” says Karen H. Timmons, president and chief executive officer, Joint Commission International. “A critical component of their development has involved inclusion of input from patients and their families who have experienced preventable harm.”

Weekend variety post: EBM, Open Medicine, safety, research reproducibility

2007-04-22T13:46:00.000-05:00

Cleaning out some of my saved Google alerts...

- BBC News: "Busting modern medical myths" - brief quotes from Andrew Booth and Paul Glasziou about evidence-based medicine
- News item, "Cochrane researcher admits lid law may decrease bike use," about a recent Cochrane review which found that legislation to promote helmet use among bicyclists was associated with a reduction in injuries, but noted that the lack of high-quality evidence on the topic made it impossible to rule out the possibility that the reduction was due to decreased bicycling rather than safer bicycling.
- a news item, "Now you can read what doctors see," marketing the new Canadian open access title Open Medicine to patients
- An Annals of Internal Medicine piece, Reproducible Research: Moving toward Research the Public Can Really Trust," discussing one strategy for reducing the possibility of research improprieties making it into the peer-reviewed literature, the concept of research reproducibility, defined briefly in the paper: "Reproducibility involves methods to ensure that independent scientists can reproduce published results by using the same procedures and data as the original investigators. It also requires that the primary investigators share their data and methodological details. These include, at a minimum, the original protocol, the dataset used for the analysis, and the computer code used to produce the results. "
- Related to the above Annals piece, the authors of the Iraq mortality study published in Lancet last October have made their dataset available to other researchers, with some restrictions on use that are also causing controversy (see this post by Tim Lambert of Deltoid and the associated comments)

And finally, a public service announcement-type link (via Boing Boing): why you should wear your seatbelt - Author Jim Macdonald, who is also a paramedic, sums it up nicely -

In a collision, you have three or four sub-collisions all taking place in sequence. First, the vehicle hits some object. The vehicle abruptly slows, but unrestrained objects inside it continue at the same speed, in the same direction. Then the unrestrained body hits the interior of the vehicle, and starts to slow. That’s the second collision. That body’s internal organs are still moving at speed until they hit the inside of the chest (or get cheese-sliced by their supporting ligaments—and that’s where you get things like bisected livers or aortas). The fourth collision is when the bowling ball you left on the rear deck hits you in the back of the head, because that continued at the same speed in the same direction. Newtonian physics: Learn it, live it, love it.

Library icons in PubMed's AbstractPlus display

2007-04-09T16:16:00.000-05:00

The NLM Technical Bulletin has a brief article announcing that PubMed's AbstractPlus display has been modified -- now, one library-specific icon now appears closer to the top of the page, right above the Related Articles links.

The icons in the AbstractPlus display are displayed in the following order of priority:
- the Library LinkOut full text icon
- the Library LinkOut print icon
- the Outside Tool icon

One icon appears at the top, with the others appearing toward the bottom after the article's abstract.

Skeptic's Circle up at Aardvarchaeology

2007-03-29T12:08:00.000-05:00

The 57th Skeptic's Circle is now up at Martin Rundkvist's Aardvarchaeology blog -- this installment has several great essays about alternative medicine topics, including an update on dichloroacetate (DCA) for cancer treatment and a discussion of Airborne for preventing the common cold, among other very interesting topics.

New documentary on addiction

2007-03-07T10:05:00.000-06:00

On Thursday March 15 from 8:00 - 9:30 Central time (other air times), HBO will be airing a documentary, Addiction, produced in collaboration with the Robert Wood Johnson Foundation, the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). It's part of an HBO free preview weekend and also will be streamed on the web and available through "on demand" cable services too.

"The documentary will explore many elements of drug and alcohol addiction, through the eyes of those who are addicted and those of the scientific experts working to better understand and treat this devastating disease....
Bringing together the nation's leading experts with award-winning filmmakers, it consists of nine separate segments, including: "Saturday Night in a Dallas ER," by Jon Alpert; "A Mother's Desperation," by Susan Froemke and Albert Maysles; "The Science of Relapse," by Eugene Jarecki and Susan Froemke; "The Adolescent Addict," by Kate Davis and David Heilbroner; "Brain Imaging," by Liz Garbus and
Rory Kennedy; "Opiate Addiction: A New Medication," by D.A. Pennebaker and Chris Hegedus; "Topiramate: A Clinical Trial for Alcoholism," by Alan and Susan Raymond; "Steamfitters Local Union 638," by Barbara Kopple; and "Insurance Woes," by Susan Froemke. ADDICTION is produced by John Hoffman and Susan Froemke; executive produced by Sheila Nevins."

The project also includes a community outreach component, with activities currently scheduled in ~40 cites so far (also includes a PDF viewer's guide to help facilitate discussion).

Related links:
NIH press release
Companion materials from the National Institute on Drug Abuse
Drugs, Brain, and Behavior: The Science of Addiction (booklet)
MedlinePlus: Substance abuse problems

New Medlineplus magazine issue

2007-02-28T21:17:00.000-06:00

NLM has posted the latest issue of the MedlinePlus magazine.

In this issue:
- women's heart health
- a large section summarizing key strategies for aging well and staying healthy
- an interview with Elias Zerhouni, NIH Director, about the future of personalized medicine
- an overview of the NHLBI's new public awareness campaign about COPD
- descriptions of some of the Go Local projects (now covering 17 states)
- an article about Dr. Stephen Sherry of NLM who has developed software for use in identifying disaster victims using damaged DNA samples

Brief audio summary of the issue (mp3)
Form to mail in for a free subscription to the magazine (I sent one in for my mom and she loved her first issue)

Venter on the Colbert Report

2007-02-28T15:56:00.000-06:00

Last night on the Colbert Report, Stephen Colbert interviewed Craig Venter about his work with the human genome and the potential future impact of related discoveries, including discussion of possible conflicts of interest associated with commercial development of genome-related initiatives (e.g. synthetic genomics).

A little history about controversy etc. surrounding Venter's work is available in this Time magazine article and this article from Wired magazine.

Picking "random" numbers

2007-02-27T20:15:00.000-06:00

Often in a report of a randomized clinical trial, you see description in the methods section of the paper indicating a bit more detail than just saying "patients were randomly assigned to treatment or control." Due to recognized (and unrecognized), internal (and possibly external) potential sources of bias, it's virtually impossible for a human to truly randomly pick numbers.

Dave of Cognitive Daily conducted an experiment earlier this month that illustrates this point very well -- he asked readers of his blog to pick any number between 1 and 20, and tabulated the responses. He reports the results in this post. Charting 347 responses from humans against 347 random picks made by a computer, it is clear that the distribution of the human selections are not randomly distributed -- humans were much more likely to select the number 17, far beyond what would be expected if the distribution was truly random.

(he also sums up reader comments on the experiment in this post and makes some inferences about why the number selection wasn't random)

So if we can't pick numbers randomly, how do researchers get random numbers for use in projects like randomized controlled trials?

There are a number of sources, including computer-based random number generators (e.g. the True Random Number Service, Microsoft Excel's random number generator) or a table of random numbers (e.g. the table on this page from the Partnership for Kentucky Schools -- the instructions provide a walk-through example for those who are interested in doing a little exercise about how you really use these numbers to randomly assign people to groups).

Researchers use these kinds of tools to randomize patients, and typically provide some explanation of their process for randomization in the Methods section, as noted above (e.g. the randomization section of the methodology in this article by Taha et al. in PLoS Clinical Trials).

Coughing and sneezing techniques

2007-02-21T12:00:00.000-06:00

Very appropriate for this time of year, with increasing reports of influenza-like illness in Nashville and elsewhere -- a funny and informative instructional video about "better" ways to cough and sneeze to reduce how much you contaminate your hands and the air around you (via Bad Astronomy).

Animation of DNA wrapping and replication

2007-02-16T11:57:00.000-06:00

"Molecular visualizations of DNA" is a 2003 video illustrating DNA wrapping and replication, credited to the Walter and Eliza Hall Institute of Medical Research, Howard Hughes Medical Institute, and the Dolan DNA Learning Center -- great animations and narration of both processes (found via Nobel Intent).

History blogging

2007-02-15T13:52:00.000-06:00

If you're like me and you believe that librarians need to know at least a little bit of everything, check out some interesting history posts up in History Carnival #48, hosted this month by Martin at Aardvarchaeology. My favorites are the Caligula post and the consideration of why Planet of the Apes aired on the History Channel (comments on each post are just as interesting as the posts themselves).

Friday humor: a tribute to the heart

2007-02-09T12:02:00.000-06:00

The group Hard 'N Phirm has video on YouTube for their song "El Corazón," a dramatic (and accurate) musical tribute to the heart and its functions, in Spanish with English subtitles (via BoingBoing).

(other songs, including a song about pi, are on the group's official site)

The CAST trial: EBM and unexpected answers

2007-02-08T20:31:00.000-06:00

The Houston Chronicle has started a new medicine column, and the first installment, "Evidence is key when it comes to your treatment by Dr. Howard Brody, discusses what evidence-based medicine means to the patient.

Dr. Brody uses very accessible, everyday language - he briefly describes the CAST trial, a large study with initial results published in 1990 - this study looked at drugs for suppressing a type of irregular heart beat, premature ventricular contractions (PVCs) and was terminated due to an interim analysis (a planned safety monitoring analysis conducted partway through the study) that indicate that drug therapy was actually associated with increased mortality, rather than reduced number of deaths as had been expected.

Dr. Brody summarizes the study:

So, allow me to tell you a story that goes back to 1989.

Scientists knew two things back then. First, older people who had a certain kind of irregular heartbeat were much more likely to die of coronary disease. Second, a class of drugs was very good at reducing the number of irregular beats.

So they designed a big research study, called CAST, to see whether giving those drugs to older, at-risk people saved lives.

Some would have said, "Why even bother to do the trial? You can already tell in advance these drugs will be a good thing. Why not just go ahead and prescribe them?"

CAST gave a clear-cut answer, all right, but it was the opposite of what everyone expected. They had to stop the study early because so many people getting the drugs were dying prematurely.

He further sums up how this illustrates EBM:

Some people beat up on EBM because they imagine it is just one more excuse for cutting costs...the more important use is to save people from worthless or harmful treatment. Imagine how many extra deaths would have occurred, had those heart-rhythm drugs studied in CAST been released for wide use...If you go to a good physician, it's very likely she thinks in EBM terms. If you know more about what she's thinking, you can get more involved in your own medical care and know a lot better what sorts of questions to ask. And more-involved patients stay healthier. The evidence shows it.

Additional information:
- the PubMed abstract for one of the initial reports of the unexpected mortality
- a broader PubMed search of articles reacting to this study, which is still being talked about today

- It's also worth noting that, though the study did not succeed in proving its primary hypothesis, that drug therapy to suppress PVCs would decrease the death rate in treated patients, it did lead to the creation of a rich dataset that has spawned numerous studies published since then, represented in the above PubMed search and the ClinicalTrials.gov description of CAST (this record also has a list of studies that were based on this dataset, which is still maintained by the study investigators and available to other researchers for further analyses, managed by the National Heart, Lung, and Blood Institute.

"Forgotten Genius" on PBS: Percy Julian's story

2007-02-05T11:49:00.001-06:00

Tonight on PBS at 7pm Central, Nova is airing "Forgotten Genius," the story of Percy Julian, an African American chemist who made a number of ground-breaking discoveries during the early and mid 1900s.

The 2 hour long program will include "Archival footage, dramatic reenactments featuring Tony winner Ruben Santiago-Hudson and remarks from family and friends tell the story of organic chemist Percy Julian (1899-1975)."

The accompanying site has an interactive timeline of his many contributions, including work with alkaloids that had implications for therapy of heart disease symptoms and glaucoma, a discovery that helped launch the steroid industry, and developing scores of products from the soy bean including a foam that helped fight fires on US military vessels during WWII.

Update:
If you missed it or you just want to see it again, you can watch this episode of Nova online - they've divided it into 13 segments for easier viewing (available in QuickTime, Windows Media Player, or RealVideo formats).

Observational and interventional studies

2007-02-01T18:21:00.000-06:00

One of the editorials in this week's NEJM gives a great example of the relative roles of observational and interventional studies in clinical research. The editorial, "The healing power of listening in the ICU," discusses a randomized trial in the same issue that compares two different communication strategies for working with families who had a patient dying in the ICU.

The editorial by Lilly and Daly notes:

Recommendations to improve care for patients dying in ICUs are rooted in both observational and interventional studies. Observational studies confirm our own practical experience that nearly every American family will be affected by the loss of a loved one in an ICU and that the effect of this loss can be mitigated by high-quality care. The field has been advanced by interventional studies showing that proactive communication processes, including intensive communication as well as ethics and palliative care consultations, improve outcomes. Evidence that proactive multidisciplinary conferences in which care providers and family members address bereavement, with the provision of printed materials, is another important advance in the field of end-of-life care in the ICU. All providers of critical care should receive training that will allow them to offer the kind of support that they would want if they had a family member who was facing death in an ICU.

Observational studies begin to confirm that something that we believe to be true actually has some objective data to indicate that it really might be true. In this case, the observational data confirms that the question of communication with families during end-of-life care is an important part of the process. Observational studies provide data that aid investigators in developing hypotheses and ideas for feasible interventions, that can then be explored in future research.

Interventional studies then build on this experience - now that we have confirmed that the question is an important one, we can design interventions that attempt to address the issue. The trial in this NEJM looks at strategies for improving the communication experience of families with patients at the end of life in the ICU. These studies further explore the studies initiated and inspired by observational data, and move more toward the hypothesis-proving end of the clinical research spectrum.

While sometimes it can be easy to focus on looking for the randomized clinical trial that "answers" a clinical question, a trial on its own doesn't provide an adequate picture of the scope of a given clinical problem. Both kinds of studies provide essential pieces of the puzzle for understanding clinical issues, and the editorial commentary above highlights how the two kinds of evidence come together and provide actionable solutions for a real-world clinical challenge.

The full citation for the editorial: Lilly CM, Daly BJ. The healing power of listening in the ICU. New Engl J Med 2007;356:513-5. (full-text)

The study they're commenting on: Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007;356:469-478. (full-text)

January JMLA case posted

2007-01-25T11:49:00.000-06:00

The newest installment in the new case study series in the Journal of the Medical Library Association is now available in PubMed Central.

This month's case looks at using case reports to answer a question about diarrhea in an ICU patient possibly caused by Clostridium difficile (C-diff) infection involving the small bowel.

Also see the JMLA case study blog for more information and discussion of the case.

Comparing diagnostic tests: verification bias

2007-01-23T12:49:00.000-06:00

An article in this week's Archives of Internal Medicine discusses a limitation of study design and execution that can happen in comparisons of diagnostic testing options, an issue known as verification bias.

The scenario:
You have a new diagnostic test, Exciting Test A, that may be an option for seeing if patients have Awful Disease X.

You also have Old-Standby Test B, the existing "gold standard" diagnostic test for diagnosing Awful Disease X ("gold standard" means that Old-Standby Test B is the best thing you had going up until now to figure out if someone has Awful Disease X).

You want to set up a study to see if Exciting Test A is an accurate test for diagnosing this disease, in comparison to the Old-Standby.

There are lots of pitfalls in designing this kind of study (the Bandolier site has a really good discussion of the most common potential limitations of diagnostic studies).

An example of one of these pitfalls - verification bias:
The study by Lauer et al. in this week's Archives estimates the impact of verification bias - this kind of bias happens when everyone in the study gets Exciting Test A, but not everyone gets Old-Standby Test B - i.e. the "truth" of the Test A results are not verified in the whole set of patients by Test B , which should be the definition of true disease status.

The reference: Lauer MS, Murthy SC, Blackstone EH, Okereke IC, Rice TW. [18F]Fluorodeoxyglucose Uptake by Positron Emission Tomography for Diagnosis of Suspected Lung Cancer: Impact of Verification Bias. Arch Intern Med. 2007;167:161-165 (abstract).

What this study looked at:
- The patient population: 534 patients with suspected lung cancer (Awful Disease X)

- Exciting Test A: PET scan

- Old-Standby Test B: tissue diagnosis (including mediastinoscopy, transbronchial biopsy, thoracotomy, percutaneous fine needl aspiration, or thoracentesis)

- 419 patients (78%) underwent both PET scan and tissue diagnosis. In this group, sensitivity (people with the disease who test positive) of PET scanning was 95% and specificity (people without the disease who test negative) was 31% (both figures related to the test's ability to detect cancer at any site).

- Authors used two methods to adjust for verification bias (since 115 patients only underwent PET scanning): the Diamond method (relatively simple) and the Begg Greenes method (more complex formula).

- Using the Diamond method, the adjusted sensitivity was 87% and the adjusted specificity was 55%. The Begg Greenes method yielded a sensitivity of 85% and 51% specificity. So, with each method of adjustment, sensitivity went down (a lower percentage of people with lung cancer actually tested positive) and specificity went up (a higher percentage of people without lung cancer actually tested negative).

- "Real world" meaning of these estimates -- a higher proportion of diagnoses of lung cancer were probably missed by PET scanning when it was not accompanied by tissue diagnosis -- so a greater number of lung cancer cases were missed by the PET-scan-only approach than the results would indicate if you didn't account for verification bias (i.e. if you ignore the potential impact of verification bias, PET scanning looks better than it actually is for diagnosing lung cancer).

- The authors conclude that verification bias in this case has a substantial impact on the measures of diagnostic accuracy for PET in assessing cases of suspected lung cancer, and suggest that clinicians should "lower their threshold for proceeding to definitive tissue diagnosis in the setting of negative PET scan findings."

Another prominent evaluation of verification bias:
Punglia RS, D’Amico AV, Catalona WJ, Roehl KA, Kuntz KM. Effect of verification bias on screening for prostate cancer by measurement of prostate-specific antigen. N Engl J Med. 2003;349:335-342. (full-text)

Basic concepts in statistical analysis

2007-01-21T07:24:00.000-06:00

Mark of Good Math, Bad Math has two great basic "numbers" posts -

- Basics: Mean, Median, and Mode -- great succinct comparison of why you would want to see a median value to summarizing some data, while other data is more suited to a mean value (the traditional "average").
- Basics: Normal Distributions -- good refresher on what a normal distribution looks like, with tie-in to the mean, median, and mode examples used in the above post, as well as a tax-cut example that seems appropriate for this time of year too.
(found via Chad at Uncertain Principles)

evolgen reminds us of the "evil" side of statistics, linking to a couple of related examples of torturing the data until a statistically significant result is found, and the dangers of such abuse of statistical techniques.

For those interested in understanding more about statistical analysis, here's a great article that discusses some of the limitations of the traditional null hypothesis test -
Gigerenzer G. Mindless statistics (J Socio-Econ 2004; 33:587–606) - Gigerenzer examines significance testing "traditions" in the social sciences, asking "Why is statistics carried out like compulsive handwashing?" and advocating that these fields consider that there is "a statistical toolbox rather than one hammer."

The author also examines a strong rationale for reporting the actual p value obtained in research, rather than sticking to a "mechanical" threshold such as "p<0.05" or "p<0.01" as well as the role of "good descriptive statistics" such as those in the Good Math, Bad Math posts linked above, as well as other measures including confidence intervals, statistical power, and effect sizes.

There's also a brief quiz on p. 594-595 of this article that illustrates some of the more common misperceptions about the meaning of significance testing results, which tend to err on the side of inferring more from the results than is indicated by the constraints of such tests.

Nature's new blog: Spoonful of Medicine

2007-01-21T07:08:00.000-06:00

Nature's editors have started a new blog, Spoonful of Medicine: musings on science, medicine and politics.

My two favorite posts so far:
- Nature Medicine 2.0 - ponders Web 2.0's potential effects on scientific publishing, with some great reader comments (related editorial in Nature itself, "Nature Medicine 2.0" with the headline "In the future, Nature Medicine will be famous to 15 people.")

- The figure police - considers the journal editor's responsibility to scrutinize images in submitted or accepted manuscripts, discussing at what point the law of diminishing returns kicks in and how to reasonably address the issue of image quality and "truth" (related posts here - "How pretty are jellyfish?" and "Image editing in the medical literature")

Another variety post: ScienceBlogs round-up

2007-01-20T14:44:00.000-06:00

Committed to cleaning out my aggregator today - here are some interesting things from the ScienceBlogs family:

- Pharyngula explains "What is a gene?" (complete with great illustrations)

- A Blog Around the Clock gives a great introductory overview of how genotype affects phenotype

- Mike the Mad Biologist discusses a new state initiative in Massachusetts to monitor and evaluate compliance with processes to reduce hospital-acquired infections

- Martin of Aardvarchaeology brings thesis work by Isto Huvila melding information science and archaeology to our attention - the thesis is titled "The Ecology of Information Work."

-Cognitive Daily talks about reasons why doctors report that they don't enroll their patients in clinical trials

- Terra Sigillata notes that legislation that will provide for herbal adverse event reporting has passed through Congress and signed into law, to take effect in one year and to be administered by the FDA.

And, finally, because it's Saturday and this article was a very fun read, A Blog Around the Clock points out a CMAJ article that discusses the medicine of Harry Potter.

BMC variety post: EBM, medical errors, research design and synthesis

2007-01-20T08:29:00.000-06:00

A few interesting BioMed Central articles that I've read recently:

- Khan KS, Coomarasamy A. A hierarchy of effective teaching and learning to acquire competence in evidence-based medicine. BMC Medical Education 2006, 6:59 - proposes a hierarchical structure of strategies for educating yourself and others about EBM principles and implementation strategies, ranging from classroom didactic at level 3 to interactive, clinically integrated activities at Level 1

- Jansen YJ, Bal R, Bruijnzeels M, Foets M, Frenken R, de Bont A. Coping with methodological dilemmas; about establishing the effectiveness of interventions in routine medical practice. BMC Health Services Research 2006, 6:160 - discusses research design and conduct in one example of pragmatic research, a clinical trial constructed to explore the effectiveness of strategies used in routine clinical practice

- Berendsen AJ, Benneker WH, Meyboom-de Jong B, Klazinga NS, Schuling J. Motives and preferences of general practitioners for new collaboration models with medical specialists: a qualitative study. BMC Health Services Research 2007, 7:4 - a qualitative study exploring Dutch general practitioners views and preferences for developing new collaborations with specialty consultants; the discussion of motivational factors (e.g. developing personal relationships; gaining mutual respect) may be useful for researching models for clinician consultation with librarians

- Elder NC, Pallerla H, Regan S. What do family physicians consider an error? A comparison of definitions and physician perception. BMC Family Practice 2006, 7:73 - systematic review of the literature for working definitions of "medical error" and pilot survey of clinicians' perceptions of those definitions and examined how clinicians responded to 5 error scenarios, illuminating lack of consensus in the literature and in family physicians' perceptions about what constitutes a true medical error. The authors note: "...we found that three areas may affect how physicians make decisions about error: the process that occurred vs. the outcome that occurred, rare vs. common occurrences and system vs. individual responsibility."

- Bornhöft G, Maxion-Bergemann S, Wolf U, Kienle GS, Michalsen A, Vollmar HC, Gilbertson S, Matthiessen PF. Checklist for the qualitative evaluation of clinical studies with particular focus on external validity and model validity. BMC Medical Research Methodology 2006, 6:56 - proposes a checklist for use in examining internal validity and model validity, to help in uncovering potential sources of bias during the process of research design and evaluating existing research reports

- Lucas PJ, Arai L, Baird J, Law C, Roberts HM. Worked examples of alternative methods for the synthesis of qualitative and quantitative research in systematic reviews. BMC Medical Research Methodology 2007, 7:4 - compares and contrasts two different strategies (textual narrative and thematic synthesis) for synthesizing qualitative aspects of clinical research for inclusion in systematic reviews. The authors conclude, "Thematic synthesis holds most potential for hypothesis generation, but may obscure heterogeneity and quality appraisal. Textual narrative synthesis is better able to describe the scope of existing research and account for the strength of evidence, but is less good at identifying commonality."

News on e-prescribing

2007-01-15T12:47:00.001-06:00

Time this week published a small piece by Jeremy Caplan discussing the role of electronic prescribing tools in eliminating some medication errors - "Cause of death: sloppy doctors." It focuses on the National ePrescribing Patient Safety Initiative, which launched this week and will provide a free web-based eprescribing tool to doctors.

The article also notes that Google is working with the NEPSI project to develop a search engine to aid physicians in finding health data.

Related:
- the National e-prescribing Patient Safety Initiative, discussed on CNN Money and GovernmentHealth IT (also includes a list of collaborating companies and healthcare organizations)
- related federal regulations
- a PubMed search, retrieving a number of articles discussing challenges and benefits of e-prescribing

What do you think is the biggest medical advance since 1840?

2007-01-13T11:33:00.000-06:00

The British Medical Journal has published a supplement on their picks for the top 15 advances in medicine since their launch in 1840. It includes computers, the discovery of DNA, antibiotics, anesthesia, figuring out how germs cause disease and how our body fights off infection, the importance of cleanliness and good hygiene, vaccination, and the risks of smoking, among others. Hey, Rachel - The pill made the list too!

When you read the list, you can't help but think about how lucky we are to benefit from all these advances, and how many lives have been saved or improved because of the changes.

If you're interested in this sort of thing, you have until the end of the day on Sunday to place your vote to help decide which of the 15 is crowned #1.

Related:The Hamilton Spectator did a nice piece on McMaster University's leading role in the development of the evidence-based medicine concept, the idea that clinical practice should be based on clinical expertise, the best relevant scientific research, and the values of the patient, which also made BMJ's list.

Update: And the winner is....
Sanitation, with almost 16% of the vote, followed by antibiotics in 2nd place and anaesthesia a close 3rd.

Clinical trial registration

2007-01-11T16:18:00.000-06:00

In an editorial by Drazen and Zarin in this week's NEJM, "Salvation by Registration," there's a brief tale about an author who submitted a paper to the journal, and the reported trial was incorrectly entered into clinicaltrials.gov - the paper was initially refused due to this issue, and it turned out that the trial's sponser was responsible for the incomplete record in the database. One of the co-authors inadvertently worked around this issue by creating a new, complete and accurate record, and the paper is included in this week's issue.

The editorial points out the importance of a complete trial protocol submission to a public registry in compliance with the ICMJE initiative; they also point to the ineffectiveness of duplicate efforts on the part of the study sponsor and the study investigators, like that noted above.

Details on registering trials in clinicaltrials.gov in compliance with these recommendations is available here -- looking at the protocol questions/issues that need to be addressed during clinical trial registration is also a really good refresher course on the key methodological details of such studies.

Blogging and the AMA

2007-01-10T14:01:00.000-06:00

The newsletter of the American Medical Association, AMNews, included an article last week, "Bloggers' Grand Rounds: The evolution of medicine's netroots," that focused on medical blogging - includes brief interviews with , Nicholas Genes, the founder of the Grand Rounds collection of "the best posts in medical blogging," and several other prominent physician bloggers. The article also includes a brief section of common-sense tips for physician readers interested in blogging, including:

- Never disclose information or details that identify patients.
- Tell readers you're masking identities and consider including a disclaimer to that effect.
- Ask your hospital, practice or other employer about its policy on blogging.
- Advise readers that you are not offering medical advice. If readers ask for a diagnosis, tell them to consult their physicians.
- Don't insult another doctor or patient. Don't type anything you wouldn't say in person.

The newsletter often includes interesting brief stories about the business of medicine in the US - you can subscribe for weekly email updates or add one or more of their RSS feeds (listed here).

Friday chuckle: Venn diagram humor

2007-01-05T17:11:00.000-06:00

Today BoingBoing linked to a collection of Venn and other relational diagrams drawn on index cards -- they're posted on a blog called Indexed by Jessica Hagy.

Two of my favorites, probably because they strike close to home... "Those silly 1980s" which plots the growth of the hole in the ozone layer against the desired height of bangs, and "As the tenth bullet states" which plots the number of PowerPoint slides against the number of sleeping audience members.

Happy New Year - food post

2007-01-04T17:04:00.000-06:00

Seems like good timing for a couple of interesting food links.

Boing Boing links to a wiseGEEK post that includes photos of 200 calories worth of different kinds of food. Interesting way to put consumption into perspective...

David Ng of the World's Fair takes a look at another site, Peter Menzel Photography that posts photos of families from different countries and the amount of food they consume on a weekly basis. Peter Menzel and co-author Faith D'Aluisio have published a whole collection of these photos and the stories behind them in a book, Hungry Planet: What the World Eats. Striking.

And finally, a funny anecdote about why everything ends up tasting like dirt if you store a certain bacterial culture plate in your home refrigerator.

Aardvarchaeology: archeology, skepticism, and much much more

2006-12-29T18:05:00.000-06:00

One of my favorite bloggers, Martin Rundkvist (formerly of Salto sobrius, with posts I've linked to a number of times), has moved to a new home at ScienceBlogs. His new Aardvarchaeology blog launched today.

Check out one of his first posts, discussing archeology and its relationship to the natural sciences featured in the other ScienceBlogs - "An Archaeologist in Lab Coat Land."

Congratulations on the move, Martin!

Blog tag: 5 things you don't know about BeckyJ

2006-12-27T15:49:00.000-06:00

Tagged by my blog friend David. I guess it isn't hard to come up with 5 things since I haven't managed to add a bio to my profile (working on it!)...

1. The J stands for Jerome; I had kept the blog semi-anonymous to keep it separate from work but I'm sure it's not difficult to figure out with a little effort (blog doesn't reflect the views of my employer etc etc) and really isn't that big a deal anyway I guess.

2. I worked as a library page at a public library during most of high school and college, never suspecting that I would eventually decide to become a librarian myself, fell into the idea a couple of years later while volunteering at a health sciences library.

3. I will read just about any kind of fiction, from romance novels to scifi to children's books, and I love book recommendations.

4. When I was 9 years old, I was the founding member of a "gang" called the Pink Unicorns. The main activities I remember were not at all criminal - building forts out of milk crates and trying to convince our parents to get us matching pink denim jackets took up most of our time (yes, we were just that classy)

5. I have a good memory for faces, and a fairly good memory for names, but not for matching the two up together, so I have a number of embarrassing and funny stories about re-introducing myself to people that I never actually knew in the first place or trying to force identities upon them.

Tagging Taneya, Tao, and Judith, and second-ing David's tag of Rachel and Stewart.

New Google functions, including patent searching

2006-12-14T11:04:00.000-06:00

Via Lifehacker -- Google has launched a beta version of Google Patent Search.

Results include the entire collection of the United States Patent and Trademark Office from the 1790s through mid-2006 (~ 7M patents total). The documentation notes that each result includes:

1. Patent Title: The title of each entry in the search results is the title of that specific patent.
2. U.S. Patent Number: The patent office assigns a unique number to each patent.
3. Filing Date: The filing date is the date on which the patent was filed with the USPTO. The filing date is when the inventors applied for the patent and should not be confused with the issue date, which is the date the patent office granted the patent. If we don’t have a filing date for a patent, this field will be blank.
4. Assignee name: The assignee is the person or organization to which the rights of the patent are assigned. If we don’t have an assignee for a patent, this field will be blank.
5. Patent snippet: We include a snippet of text from the patent to show where the specific search terms were found.

Only US patents are included at this time and the interface is only available in English. More information here and here.

And also via Lifehacker, "15 unusual ways to use Google," including tips on how to use Google more effectively an encyclopedia/reference tool, track packages, etc.

Quick survey: interest in an online course in critical appraisal?

2006-12-12T10:52:00.000-06:00

For those who may be interested in providing feedback on a web-based course on filtering and critical appraisal of the literature, or participating in such a course:

Re-posted with permission by Nila Sathe, Eskind Biomedical Library at Vanderbilt:

Given the increasing number of training requests we receive each year and
the positive response to a case-based tutorial column we have begun publishing
in the JMLA, the Eskind Biomedical Library at Vanderbilt University Medical
Center is considering developing an advanced training program covering facets of
critically assessing and synthesizing the biomedical literature. The course
would also discuss techniques for developing a biomedical knowledge base and
integrating library resources with the institutional clinical and research
enterprises. The program would likely be partially online, with a weekend
or day-long site visit for intensive, hands-on training.

To gauge interest in such a program before we dedicate
significant resources and effort, including seeking scholarship funding, towards
developing it, we request that you complete the following 6 question interest
survey. The survey should take no more than 5 minutes, and responses are
anonymous unless you choose to provide your email address for further
information.

You can access the survey at <https://email.mc.vanderbilt.edu/exchweb/bin/redir.asp?URL=http://www.hostedsurvey.com/takesurvey.asp?c=Eskind92315> through Wednesday December 20th.

We appreciate your assistance!

Off-topic post: Tragedy Assistance Program for Survivors (TAPS)

2006-12-09T10:52:00.000-06:00

Found via The Questionable Authority, penned by Mike Dunford -- Tomorrow in Tikrit, Iraq, runners from the Army and other Multinational Coalition Forces will be running a replica of the Honolulu marathon in memory of their fallen comrades.

A number of runners are accepting donations to benefit the Tragedy Assistance Program for Survivors, TAPS, which provides aid to families that have lost loved ones in the armed services. I know that many, like me, have family members, friends, and other loved ones serving currently in the Middle East and elsewhere in branches of the Armed Services.

Donations are being accepted online here, where you can make a general donation or sponsor an individual runner. There's also more information on TAPS and its activities here

Predictive values of tests in the "real world"

2006-12-09T09:59:00.000-06:00

Today, Ben Goldacre of badscience discusses what the sensitivity and specificity of diagnostic tests mean when applied to real world situations. He includes two examples to illustrate how much (or how little) these figures tell you when considering real-world scenarios -- predicting true HIV positives in a population, and understanding data regarding the rate of homicides committed by people diagnosed with a psychiatric illness.

The background rate of disease (e.g. HIV) in a population has a significant influence on the meaning of a positive or negative test result - the process of incorporating data on the prevalence of disease in a given population is called a probability revision - converting from a pre-test probability of a disease (disease prevalence) to post-test probability (likelihood that you truly have the disease when you test positive).

The badscience post provides a number of links to additional reading on this issue.

Other related links:
- this previous post discussing problems clinicians have with interpreting diagnostic test results, which includes a link to a CDC case exercise that works through a probability revision in detail, for those who really want to get at the "math" behind this issue

- this BMJ article by Elstein and Schwarz, "Clinical problem solving and diagnostic decision making: selective review of the cognitive literature," which looks at the cognitive literature describing specific issues that cause clinicians to inappropriately interpret diagnostic test data (also these other articles in the BMJ series, "Evidence base of clinical diagnosis").

Another cool search engine: PageBull

2006-12-08T15:55:00.000-06:00

Came across the PageBull search engine via Lifehacker and I've been doing a little test searching today - it displays search results in a more visually oriented way than some of the engines, tiling images of the pages it retrieves for your search, so that you can get a better idea of what kind of hits it's returning.

Just tried this search on sensitivity and specificity and it seemed like it might be a better shortcut for this search than trying to figure out from the Google snippets what the pages actually cover. Results load a little slowly but it's an interesting concept. Plus I really dig the cute little PageBull icon :)

Some have suggested that this type of engine might be helpful in researching people - with the inclusion of the Varmus papers in the National Library of Medicine's Profiles in Science site this week, I tried a quick PageBull search for Harold Varmus, and was pretty satisfied with the results.

Hypochondriacal electromagnetosis

2006-12-02T12:39:00.000-06:00

Who can resist a news brief with a title like "Hypochondriacal Electromagnetosis"?

This short item from the Wired blogs is referring to an increasing number of individual claims that wireless networks are causing health problems, linking to a more in-depth discussion in the Guardian, "Is there any proof that Wi-Fi networks can make you sick?" Associated symptoms ranging from vague feelings of illness to those serious enough that people terminate wireless connections in their homes.

Both pieces note that there are not any studies demonstrating a link between the increasingly ubiquitous presence of WiFi to any health conditions, though the Guardian article briefly summarizes a few research projects currently underway in the UK to explore potential "EMF sensitivity" (a reaction to electromagnetic fields) in some individuals.

The World Health Organization has a related factsheet, "Electromagnetic fields and public health," and a handbook to aid scientists and others in facilitating dialog on the topic. OSHA also has a good page linked to evidence and recommendations regarding this issue.

Benefits of procrastination

2006-11-30T20:22:00.000-06:00

I found this post from the Chief Happiness Officer very encouraging -- discusses ways to use a personal tendency toward procrastination in a positive way.

Excerpt:

1: Procrastinate without guilt
Do not beat yourself up for procrastinating. Everybody does it once in a while. It doesn’t make you a lazy bastard or a bad person.

If you leave a task for later, but spend all your time obsessing about the task you’re not doing, it does nothing good for you. So procrastinate without guilt.

2: Procrastinate 100%
Do you know those people who procrastinate from some important task - and all they can talk or think about is the task they’re not doing. Often to the point of obsession!

Don’t. Throw yourself 100% into whatever it is you are doing, whether you’re vacuuming, watching TV, reading, surfing the web or out drinking with your friends. Do it and enjoy it to the max.

3: Choose to procrastinate
Don’t let procrastination sneak up on you, so that you suddenly find that you’re doing something other than you should be. Instead, choose consciously to not work on your current task. Instead of fighting it, say to yourself “I will now procrastinate”.
This way procrastination isn’t something that happens to you, something that you’re powerless to control. As if it ever could be :o) This way you’re in charge and procrastination is a tool you use.

4: Ask yourself why you procrastinate
There can be many good reasons to procrastinate:

- Some crucial ideas, notions, thoughts may come to you only when you’re not working on your project.
- Effective procrastination recharges your batteries and gives you new energy.
- Maybe there’s something else you could be doing instead and procrastinating means you get it done.
- Maybe whatever it is you’re supposed to do, turns out to be irrelevant or even a bad idea. Maybe the reason you procrastinated was, that your subconscious knew this before your conscious mind.
- Working non-stop means missing out on all of this. When you find yourself procrastinating, ask yourself why. Don’t just accept the traditional answer: “There’s something wrong with me, I’m a bad, lazy person”.

5: Take responsibility for procrastinating
When you choose to procrastinate, make sure to update your deadlines and commitments. Let people know, that your project will not be finished on time and give them a new deadline.

Will clicks replace bricks?

2006-11-16T16:57:00.000-06:00

An article by Polina Aksamentova from the Binghamton University Pipe Dream (university newspaper) ponders the question "Will Web resources be the death of the Library?"

The article notes a 15% increase last year in questions asked at the library's reference desk, and includes a quote from the Information Commons coordinator, David Vose - "There's the constant debate, will clicks replace bricks? I don't see that ever happening...There's still the experience of the library. It's a social activity."

I hadn't heard the clicks and bricks phrase used in this sense before - had heard more in relationship to synergy between online and in-person shopping, or between a strong online presence and real-world success (e.g. this article from CIO), but I guess it makes sense in this context too.

Fortunately, the article does point out that the library serves important functions beyond that of study hall or meeting place, noting that the expertise and training provided by librarians.

The patient side of web-based diagnosis

2006-11-08T16:20:00.000-06:00

Dr. Marla Shapiro of The Globe and Mail discusses the patient side of diagnosing using the Internet in a recent article, "Self-diagnose off the Web at your peril"

A recent article in the medical journal The Lancet reported the case of a 64-year-old woman who diagnosed herself with chronic fatigue syndrome and then proceeded to self-medicate with oral steroids that she had purchased over the Internet, rather than being prescribed medication by her physician. She had been taking the medication in varying doses over a four-year period. She developed dense cataracts in both eyes and glaucoma (high pressure in the eye), both of which were induced by the steroid use. These side effects of steroids are well known to physicians. It is clear that the patient was unaware of the dangerous side effects and had gone unmonitored, putting herself in this serious situation.

The Lancet reference: Severn PS, Fraser SG. Bilateral cataracts and glaucoma induced by long-term use of oral prednisolone bought over the internet. Lancet. 2006 Aug 12;368(9535):618. (PubMed record)

Related article: There's also been a lot of talk this week about a study published in the British Medical Journal, "Googling for a diagnosis--use of Google as a diagnostic aid: internet based study," an experimental study that examine the utility of Google searches for diagnosing 26 cases from the New England Journal of Medicine, noting "Google searches revealed the correct diagnosis in 15 (58%, 95% confidence interval 38% to 77%) cases." (lots of blog commentary on this article available via a quick Google BlogSearch)

JMLA case studies blog

2006-11-08T13:24:00.000-06:00

We've started a blog as a tie-in/complement to a new feature in the Journal of the Medical Library Association: the JMLA Case Studies blog.

The description from the blog's inaugural post:

These cases will provide narrative and insight from expert commentators drawn from librarianship, informatics, medicine, research, and other areas that inform the development of a given case situation. This feature will share commentary and practices for a variety of scenarios with the intent of prompting discussion of issues facing health sciences librarianship as a developing profession and the development of potential solutions.

This blog will serve as an online forum for further discussion of the scenarios and facets of the strategies for addressing these information-related challenges. The curator of the column, JMLA co-editor Rebecca Jerome, will collate prominent issues from comments/questions submitted by readers into periodic updates to the blog, with the intent of fostering discourse about techniques for addressing complex information-related issues in the health sciences.

The most recent post discusses the usefulness of Wikipedia for looking at medical concepts involved in this month's case. We'll be addressing comments posted on the cases to develop future blog entries to follow up on questions and critiques.

Related link: JMLA case study blog site feed (comments feed coming soon)

Web milestone: 100 million sites

2006-11-01T14:54:00.000-06:00

Via CNN:

Are your Web surfing fingers getting tired?

There may be a reason. Netcraft, an Internet monitoring company that has tracked Web growth since 1995, says a mammoth milestone was reached during the month of October.

"There are now 100 million Web sites with domain names and content on them," said Netcraft's Rich Miller. (Watch as the Web gave birth to the virtual self -- 2:44)

"Within that, there are some that are busy and updated more often, and that represents the active sites, which are at about 47 or 48 million," he said.

Plus a few handy charts illustrating the growth of the 'nets, on the Netcraft site.

Variety post: evidence grading, drug marketing, abbreviations, IRBs

2006-10-29T16:07:00.000-06:00

This week's list of interesting things...

- Biomed Central Medical Research Methodology: "A system for rating the stability and strength of medical evidence" - proposed framework for more "transparent" evidence grading

- Clinical Cases and Images: "Complete list of medical abbreviations and acronyms"

- retired docs thoughts: "Marketing strategies masquerading as Evidence Based Medicine" - discussion of commentary publised in last week's New England Journal of Medicine (PubMed record) analyzing the link between drug company funding of research and conclusions extrapolated for the resulting data (thanks, Rachel, for sending this link!)

- Corpus Callosum commentary on the same NEJM perspective piece: "Another wrinkle in the treatment guideline controversy" - considers "What happens if a corporation essentially buys an undue degree of influence in the formulation of treatment guidelines?"

- via DocuTicker, two interesting reports: "Does Health Information Matter for Modifying Consumption? A Field Experiment Measuring the Impact of Risk Information on Fish Consumption" and "Report: Research on Human Subjects: Academic Freedom and the Institutional Review Board"

- Inside Higher Ed also discusses IRBs: "Research Review Boards Faulted" - "AAUP says that IRB's are straying into areas where they are not needed, hindering professors' work."

Update:
- Orac of Respectful Insolence has a related discussion of IRBs: "Institutional review boards overreaching?"

Over the last decade or so, IRBs have made the requirements for doing any sort of clinical trial progressively more and more onerous, in some cases going far beyond what is required to guarantee human subjects protection. You may think this is a good thing, and it is--to a point. However, there comes a point when requirements pass beyond the point of ensuring patient safety and autonomy and into the realm of stifling research, or at least making it far more difficult than it already is. It is not clear to me that we have reached that point, but if things keep going the way they are going that point cannot be far off.

New Pew report: Internet users don't check source of health information

2006-10-29T15:55:00.000-06:00

A new Pew report released today, "Online Health Search 2006," outlines results of survey research indicating that surveyed Internet users report that they do not typically check the source or the date of last update for health-related information.

Eighty percent of American internet users, or some 113 million adults, have searched for information on at least one of seventeen health topics. Most internet users start at a general search engine when researching health and medical advice online. Just 15% of health seekers say they “always” check the source and date of the health information they find online, while another 10% say they do so “most of the time.” Fully three-quarters of health seekers say they check the source and date “only sometimes,” “hardly ever,” or “never,” which translates to about 85 million Americans gathering health advice online without consistently examining the quality indicators of the information they find. Most health seekers are pleased about what they find online, but some are frustrated or confused.

The full report and the questionnaire employed by the survey (with data illustrating how the results have changed over the duration of the project) are also available online.

Related: the Reuters story about the report

Update:
MLA has posted a press release responding to the report.

Penalty for fradulent research: jail sentence?

2006-10-24T15:28:00.000-05:00

From Sunday's New York Times Magazine, "An Unwelcome Truth" by Jeneen Interlandi - the story of the trial of Eric Poehlman for a "career" of fradulent scientific research:

He presented fraudulent data in lectures and in published papers, and he used this data to obtain millions of dollars in federal grants from the National Institutes of Health — a crime subject to as many as five years in federal prison. Poehlman’s admission of guilt came after more than five years during which he denied the charges against him, lied under oath and tried to discredit his accusers. By the time Poehlman came clean, his case had grown into one of the most expansive cases of scientific fraud in U.S. history.

The story discusses the case and how portions of the fraud were initially discovered by a student collaborator who was faced with the uneviable challenge of investigating discrepencies and eventually disclosing the extent of fradulent research activities in Poehlman's lab by a formal charge of scientific misconduct with his institution. It details the internal investigation and progression of the case to criminal prosecution by the US Department of Justice, with sentencing this past June:

"Federal sentencing guidelines called for five years in prison based on the amount of grant money Poehlman had obtained using fraudulent data. But no scientist had ever spent time in prison for fabricating data. (One did spend 60 days in a halfway house.)... The sentencing judge was William Sessions, the same judge to whom Poehlman denied all allegations of misconduct at the injunction hearings four years earlier. He told Poehlman to stand and receive his sentence: one year and one day in federal prison, followed by two years of probation."

Commentary on the story:
- Orac of Respectful Insolence: "Jail for scientific misconduct?"

- Chad Orzel of Uncertain Principles: "Falsify data, go to jail"

- the Office of Research Integrity (US DHHS) report on the initial case

- More via a Google Blog Search or Technorati

And a related post by RPM of evolgen: "Fraud is okay"

Health Q&A: Go Ask Alice

2006-10-23T19:52:00.000-05:00

I have been browsing through the questions and answers on Go Ask Alice! for the last half hour and I'm loving this site -- produced by Columbia University Health Services, the service provides accessible, brief answers to health-related questions, in sort of a "Dear Abby" format.

It covers mental, emotion, and physical health - so many interesting questions - Some Q&A examples:

- Calcium - how much is enough?
- Pondering the pros and cons of tongue piercing
- Sick about going to counseling
- Healthy vs. unhealthy relationships

More information on the site:
- New to Go Ask Alice
- About Go Ask Alice

"Who answers the questions? Go Ask Alice! is supported by a team of Columbia University health educators, health care providers, and other health professionals, along with information and research specialists from health-related organizations worldwide."

- press kit

Found via LifeHacker.

How pretty are jellyfish?

2006-10-23T18:19:00.000-05:00

Comparing a "real" picture of a jellyfish to a colorized image - related to one my first posts, "Image editing in the medical literature," this post by Sandra Porter of Discovering Biology in a Digital World comments, "Unfortunately...myths and misleading images are now being propagated through science education," noting a recent case of editing for publication of a jellyfish image to add false color and impression of luminescence not present in the original graphic.

Great commentary re: the responsibility of the publisher and the author(s) to disclose the presence and nature of any image editing to clarify how an image has been manipulated.

Personalized medicine and popular media coverage

2006-10-23T18:05:00.000-05:00

Recent items about advances in establishing individualized strategies for diagnoses and interventions based on individual expression profiles etc:

- National Geographic News: "Personalized Medicine Promises Tailor-Made Diagnoses, Treatments," by Stefan Lovgren

Commenting on this study published in Nature Medicine by a group of Duke researchers, using gene chips to guide chemotherapeutic intervention against several cancer cell lines:

- BBC: "'Personalised' cancer drug test"
- Reuters Health: "Test helps guide cancer treatment, U.S. study shows

And James Hrynyshyn a blog posting about science coverage by the popular media (related (and providing some counterpoint) to items in this previous post - "In defence of science journalists."

Update:
More on science journalism by David Dobbs of Smooth Pebbles, considering the current lack of media attention directed toward avian flu - "A Hush About Bird Flu; Noise About Science Journalism"

Another new search engine: SearchMash

2006-10-20T11:10:00.000-05:00

SearchMash is a new search interface from Google (a little bit hidden, disclosed on the Privacy page). The Features page lists the current features of the engine:

- when you click a URL in the search results, you have a few options that are similar to the links below a search result entry in the original Google (open a cached copy, more from this site, results similar to this page)
- it automatically displays a few images for each search
- no ads
- you can drag and drop results to change the order
- instead of clicking to a new page to see more results, they open in the same window, adding below the previously viewed results (can either click "more web pages" or use your space bar)

I tried a few searches and it worked fine; didn't seem dramatically different from the same results in the original Google. I kind of like seeing a few image results but some have found it irritating and an abuse of bandwidth (e.g. the DaveN post linked below).

More description and commentary:
- Information Week: "Google launches experimental search engine "
- Search Engine Guide: "Google's SearchMash"
- Search Engine Watch: "Google's new SearchMash test site"
- Inside Google: "Google running SearchMash"
- DaveN: "Google's worst ever product"
- More via Google's BlogSearch and Technorati

Variety post: better presentations, telemedicine in Michigan, open access and library lit

2006-10-20T10:54:00.000-05:00

- Via LifeHacker: "12 tips for creating better presentations" from Microsoft - tips for improving the layout and content of PowerPoint presentations

- Wired News: "Paging Dr. Robot" - quick overview of the Michigan Stroke Network, launching next week and using telemedicine for neurologist consultations to hospitals without a neurology specialist physically present in the building.

- Via Open Access News: "Open access to the library literature" (Caveat Lector blog) -- advice for librarians who publish in identifying OA outlets for their work (note: our own Journal of the Medical Library Association is open access, via PubMed Central)

More than just the evidence

2006-10-19T17:04:00.000-05:00

When we talk about clinical librarianship and the role of the librarian in selecting the "best" articles, in terms of both methodological rigor and relevance to a given clinical context, it's not uncommon that we also think about liability concerns - when the librarian takes a more involved and active role in synthesizing the medical literature for a clinical question, fulfilling an "evidence consultant" role for clinicians, what is his or her potential liability for this information selection process?

Some libraries have developed disclaimers that accompany their literature searches, bibliographies, etc, attempting to address this issue - perhaps most commonly characterizing the literature search process (selection decisions, database choices, related concepts of possible interest) and containing a phrase to the effect of "...more information available on request."

When I saw the headline for this Science Blog posting, I realized that it sums up my feelings about such liability concerns - "Evidence informs decisions but can't make them." Given our training as experts in searching the literature and identify key items related to a given topic/question, we provide information to support decision making -- the clinician takes the articles, studies, reports, reviews etc, incorporates that data with his or her clinical expertise and the wishes of the patient, and makes a decision about the best course of action for that patient. I don't feel that I provide answers to clinical questions, but tools to aid clinicians with arriving at their own answers for clinical challenges.

The Medical Library Association's Information Specialist in Context Task Force report and related materials address issues of liability and expert roles for librarians (full-text of the final report of the task force and the consulting team from Vanderbilt is also available to MLA members via the above page).

Your thoughts?

Medicine and the popular media this week

2006-10-18T15:55:00.000-05:00

Related to this previous post about the NPT series, "Remaking American Medicine", other popular media outlets are scrutinizing how healthcare is changing, and positive potential directions for the future of medicine in the US:

- USA Today: "In medicine, evidence can be confusing" - the challenges faced by clinicians and by patients in understanding how the evidence from clinical research should be applied to a given care decision (plus additional stories linked at the top of the USA Today page under the feature "Prescription for change: fixing American healthcare")

- Newsweek: "Fixing America's hospitals" - case studies from 10 healthcare organizations that have developed innovative strategies for reducing medical error and improving the quality of healthcare delivered to their patients (plus more stories, including an article by David Bates about EMRs and paperless medicine, via Newsweek's "Health for Life section).

More on office ergonomics

2006-10-18T13:45:00.000-05:00

As a follow-up to this post about designing "cool" workspaces - I found this Macworld article about workspace arrangement for healthy computing via Lifehacker. The article includes suggestions for modifying your chair, input devices (keyboard, etc), and monitor placement to improve the ergonomic design of your work area. One quick change suggested by the article that I just made this afternoon -

It’s less stressful for your eyes to focus on a distant visual target, so try to place your monitor 18 to 24 inches away, farther if there’s room. (If necessary, enlarge the on-screen text size to compensate.)

New search engine: Ms.Dewey

2006-10-18T13:34:00.000-05:00

Found this via Lifehacker - "Ms. Dewey: The saucy search-engine librarian"

Just tried a few general searches - doesn't seem suited for practical use (which I guess is pretty obvious once you get started with a search query) and it takes a long time to load but "Ms. Dewey's" on screen comments and gestures were amusing. Not sure if it's still in the testing/refinement stage - could definitely hear set noises (things falling, directions from the director, etc).

Others' commentary:
- Library Garden: "Ms. Dewey Search Engine"
- Geekologie: "Ms. Dewey is an angry search engine"
- Tech Digest: "Ms. Dewey: Search engine with a really annoying personality"
- Trend Hunter: "Human Search Engine - Ms Dewey is Better Looking Than Jeeves"

Update:
Ms. Dewey revealed to be part of a Microsoft "awareness campaign" ("Ms. Dewey Married to Microsoft" - WebProNews)
- More commentary via Library Cloud and devinreams.com (who comments "I think this is a pretty simplistic attempt at something ‘viral’ and so far it’s worked. But who did this, and why would they?")

Variety post

2006-10-15T12:18:00.000-05:00

A few things I've found interesting lately...

- badscience: "How to read a paper - for journalists"
- Cognitive Daily: "The trouble with science journalism" and "Do bigger monitors significantly increase your productivity?"
- Inside Higher Ed: "Highlighting problems with institutional review boards"
- Nobel Intent: "Scientists on science: tentativeness" - advice for dealing with uncertainty and changing models and theories in the sciences
- Seed Magazine: "Googling for a cure" - article about Connectivity Map, a new tool from MIT for identifying candidate interventions for more effective treatment of diseases, comparing it to the relationship-mapping strategies used by eHarmony.com and chemistry.com
- Critical Care: "Evidence-based medicine: classifying the evidence from clinical trials – the need to consider other dimensions" (registration required)
- Women's Health News: "Campaign for real beauty before and after" - Rachel notes that the Dove campaign provides behind-the-scenes footage detailing "the work and artifice that goes into producing images of women for promotion and mass media"
- Medical News Today: "Medicare Proposes To Improve Care Through Learning From Prescription Drug Data, USA" - potential rich new data source for understanding drug interactions, therapeutic differences among subgroups of the elderly population, etc.

Remaking American medicine miniseries

2006-10-13T13:50:00.000-05:00

I saw this when reading about the new Robert Wood Johnson Foundation EMR report - they are also funding a PBS miniseries, "Remaking American medicine: health care for the 21st century." The episodes started airing earlier this month and clips are available on the web site. The site also includes a webcast of a related symposium, "Champions of Change: A National Symposium on Improving Health Care," from the end of September. The symposium included leaders from the clinical and technical side as well as commentary by patient advocates.

New report about the status of electronic medical records

2006-10-13T13:33:00.000-05:00

Found via DocuTicker: A new report from the Robert Wood Johnson Foundation, "Health information technology in the United States: the information base for progress" (PDF) finds that electronic medical records are not a routine part of clinical practice for many physicians in the US.

The executive summary notes:

In the most comprehensive study to date that reliably measures the state of electronic health record (EHR) use by doctors and hospitals, researchers from Massachusetts General Hospital (MGH) and George Washington University (GWU) estimate that one in four doctors (24.9 percent) use EHRs to improve how they deliver care to patients. However, less than one in 10 are using what experts define as a “fully operational” system that collects patient information, displays test results, allows providers to enter medical orders and prescriptions, and helps doctors make treatment decisions.

- the RWJF press release about the report

Update:
- an article reporting this study's results published in Health Affairs
- a post about the study on the new Health Affairs blog
- a Science Blog post by Ira Allen, "Privacy is forever; good health isn't" (including a link to a related Washington Post article)

New site: Helium

2006-10-13T09:47:00.000-05:00

Article in yesterday's Search Engine Journal, "Helium.com : About, Yahoo Answers & Wikipedia All Rolled Into One", posted by Loren Baker. It will be interesting to see how/if this one develops. Quoting from the Helium.com description of the site's vision:

“Helium is different because it takes the chaos of user-contributed content and orders it with a trusted ranking system that dramatically improves the quality and accessibility of collective wisdom for the knowledge-seeker,” said Mark Ranalli, President and CEO of Helium. “At Helium, multiple quality responses to conversational subjects such as ‘Which Aruba resort is better?’, or ‘Tips for buying antique furniture’ are provided in rank order, making it simple to efficiently consider more than one perspective.”

The site: Helium: where knowledge rules

Will the peer review and aggregation that they describe be enough to prevent the wildly varying content quality in Yahoo! Answers that Rachel discusses?

Commentary on the site:
- ContentBlogger: "Peer review meets About.com - Helium floats an old model in a new space"
- Symbolic Order: "Helium just doesn't feel right"
- Ray Deo: "Helium: compare other people's gas"
- A Little Class on the Internet: "Helium - not just something that makes your voice sound funny"
- more via a Google blog search

The plural of anecdote is not data...

2006-10-11T09:35:00.000-05:00

Glenn McGee penned a fairly strong critique of the role of the case report in the continuum of clinical research in The Scientist, "The Plural of Anecdote is Not Ambien" (registration required).

The article uses the example of case reports describing the use of Ambien to induce changes in consciousness among several patients in a persistent vegetative state.

"A paradox of biomedical research is that huge controlled trials, meta-analyses, and reviews of the literature are ubiquitous, but the number of "case reports" - and journals comprised entirely of incidental "findings" - is growing. The media has no idea how to deal with case reports....Investigators who jumpstart their programs with case reports are often in search of research support, as was Claus - who as a result of the case report is now funded. In this respect they, and the journals who publish nothing but these case reports, are like the television producers I worked with: They aim at using the power of stories to make the claims and reap the rewards that come from research, but without doing the research."

It's clear that the media picks up dramatic stories like the Ambien cases mentioned above, but I would argue that the media also misrepresents or over-hypes the implications of stronger types of clinical research as well (clinical trials, cohorts, etc.). While case reports are certainly limited in terms of generalizability and firm conclusions, they serve a useful function in generating and testing initial hypotheses.

A few articles that continue the role of the case report in scientific exploration:
- Carey JC. Significance of case reports in the advancement of medical scientific knowledge. Am J Med Genet A. 2006 Oct 1;140(19):2131-4. PubMed citation
- Vandenbroucke JP. In defense of case reports and case series. Ann Intern Med. 2001 Feb 20;134(4):330-4. PubMed citation
- Kagan AR, Burchette RJ, Iganej S. The case for case reports: avoiding statistical seduction. Am J Clin Oncol. 2006 Aug;29(4):325-7. PubMed citation

Funny fake news story

2006-10-11T08:40:00.000-05:00

From the Onion's Radio News with Doyle Redland: Selfish scientists won't share findings (audio file)
Excerpt: "A group of scientists at the Harvard University Medical School announced today that they have made stunning advancements in heart disease prevention but added that they are keeping it all for themselves. Responding to intense public outcry, head researcher Dr. Carl Trotter says people in the medical community should have been a lot nicer to the scientists before they made the important discoveries."

Data storage and retrieval in the "Internet cloud"

2006-10-10T12:24:00.000-05:00

This month's issue of Wired includes an article "The Information Factories" - the piece is subcaptioned, "The desktop is dead. Welcome to the Internet cloud, where massive facilities across the globe will store all the data you'll ever use. George Gilder on the dawning of the petabyte age."

The article discusses the Google datacenters and Ask.com, including storage capacity, power consumption, plans for growth, and the potential impact of future developments in computing power and data storage.

"According to Bell's law, every decade a new class of computer emerges from a hundredfold drop in the price of processing power. As we approach a billionth of a cent per byte of storage, and pennies per gigabit per second of bandwidth, what kind of machine labors to be born?

How will we feed it?

How will it be tamed?

And how soon will it, in its inevitable turn, become a dinosaur?

One characteristic of this new machine is clear. It arises from a world measured in the prefix giga, but its operating environment is the petascale. We're all petaphiles now, plugged into a world of petabytes, petaops, petaflops. Mouthing the prefix peta (signifying numbers of the magnitude 10 to the 15th power, a million billion) and the Latin verb petere (to search), we are doubly petacentric in our peregrinations through the hypertrophic network cloud."

Marijuana and Alzheimer disease progression

2006-10-07T11:55:00.000-05:00

On August 9th, there was a study published online in Molecular Pharmaceutics by researchers from the Scripps Institute in California; the same day, Scripps posted a press release about the study.

It's a basic science study that employed modeling techniques and biochemical assays, finding that THC, marijuana's active ingredient, interferes with an enzyme that has been implicated in the formation of plaques in Alzheimer disease. From the press release:

"THC inhibits the enzyme acetylcholinesterase (AChE), which acts as a "molecular
chaperone" to accelerate the formation of amyloid plaque in the brains of Alzheimer victims. Although experts disagree on whether the presence of beta-amyloid plaques in those areas critical to memory and cognition is a symptom or cause, it remains a significant hallmark of the disease. With its strong inhibitory abilities, the study said, THC "may provide an improved therapeutic for Alzheimer's disease" that would treat "both the symptoms and progression" of the disease."

This week, the study was picked up by UPI (Google news search results retrieves ~50 articles in different media outlets) -- it caught the attention of Rush Limbaugh, who covered it in his radio show on Friday.

I don't think there's ever been an occasion where I've agreed with his opinions, and I hesitate even to link to this but for the sake of discussion, here's his take on potential conflict of interest and the role of peer review for this research:

"But who's to say that there aren't a bunch of dopers among the research team who want the stuff legalized and are using the cover of their protected status as "scientists" to make this claim? Now, I know that their studies have to be peer reviewed and all that, but who's to say that the people doing the peer review aren't also a bunch of dopers who can sick and tired of being told that what they're doing is illegal. I think that's behind the medical marijuana business and so forth, the legalization of that. I'm not commenting on whether it should be legal or not. I'm just suggesting there's obviously a push on to get this stuff mainstreamed, and we know that there are a lot of people who use the stuff who want it mainstream because they want to be able to access it freely and regularly."

While it's a pretty broad and inflammatory statement about the research (and having looked at the original article, seems questionable whether a non-scientist could do more than read the press release and the media commentary, so Limbaugh's statements likely aren't based on the actual research but on the distilled commentary), it does point out one of the biases that can creep into research -- an individual's interests and beliefs can't help but influence the generation of research hypotheses; it is logical that people pick topics and projects for which they feel passion and suspect may have significant impact on problems facing humanity. However, we hope, as consumers of research, that the peer review process examines the research techniques employed to examine these hypotheses to make sure that the process and the data aren't influenced by personal biases, and that the authors' don't overstate the implications of their research.

One clue that the media is hyping this story beyond the intentions of the original researchers - a LiveScience story on the study includes a quote from the lead researcher on the project, Kim Janda, which seems to present the research implications fairly conservatively: "We're not advocating smoking dope, but if we can make analogues of THC, it could play a role in treating Alzheimer's...It would be nice to do more animal studies along these lines."

I definitely can't claim to be an expert (even particularly well-informed) about the medical marijuana debate, but these links give more info:
- the Institute of Medicine published a report, "Marijuana and medicine: assessing the science base," in 1999
- a podcast from the Genetic Science Learning Center at the University of Utah
- Congressional Research Service: "Medical marijuana: review and analysis of federal and state policies"

Cool workspaces

2006-10-07T11:08:00.000-05:00

From The Chief Happiness Officer, a list of 10 seeeeeriously cool workplaces, including workspaces from Pixar, Google, a VW plant, and the Red Bull London offices.

There must be lots of simple things that people do to make their workspaces more comfortable. I like having a couple of plants (watering them and pinching off dead leaves makes a nice excuse for a short break), pictures of friends and family, a comfortable chair, organizing my "clutter" into piles, headphones and good music for when I need to concentrate, a comfortable room temperature. I'm sure others have tips for things to do to make work a happier place, your thoughts?

Searched for a few good ideas but found it to be a more challenging search than I expected; lots of tips for home offices but didn't find quite as much for regular offices:

- Tips for designing a safe and comfortable workstation (University of British Columbia via UC Berkley)

- 10 tips for keeping your desk clean and tidy (LifeClever)

- 10 ways to relaxify your workspace (Steve Pavlina)

Pending changes to PubMed AbstractPlus display

2006-10-06T15:13:00.000-05:00

In the Technical Bulletin today, NLM announced that by March 2007, one library-specific full-text icon will be allowed at the top of the PubMed AbstractPlus display (where currently only the PubMed Central and publisher icons appear), rather than only at the end by the PMID - indicates that this is one of the main concerns voiced by librarians. The announcement notes:

"Libraries will be limited to one icon at the top and it must be no larger than 100 pixels high by 25 pixels wide. Other icons will continue to display near the PMID. We will supply more information closer to the time of the change and NCBI will send out an announcement on the Library LinkOut Announcements listserv that will provide details and instructions."

As I noted in a previous post, I really like the AbstractPlus feature, and the announcement also provides some data about how the display format is being used -- "Since the introduction of AbstractPlus, clicks on related links have increased 13%. Twenty-three percent of the time users view the AbstractPlus display, they click on one of the first five related articles links."

Electronic communication between patients and clinicians

2006-10-06T10:41:00.000-05:00

A few days ago, I commented on David's post about the use of email-type communications by physicians and patients - I had a very positive experience with a patient portal with clinician/patient messaging after a recent healthcare visit at Vanderbilt.

The patient portal at Vanderbilt, MyHealthAtVanderbilt, has been very well-received by patients and clinicians in the medical center. Rather than relying on email, this portal uses the electronic medical record system's secure messaging; when a patient has a new communication from the healthcare provider, they get a generic email to their regular email address saying that a new message is available in the portal, addressing some of the concerns about security and protecting patient confidentiality.

I'm definitely not an expert about the system, but a few related news stories from the Vanderbilt Reporter discuss more about the patient healthcare portal and how it has been received by doctors and patients:

- "My Health’ site’s traffic, capabilities growing fast"

"As physicians and staff in each clinic are introduced to My Health, Muse and Jirjis have found a pattern of initial reluctance and anxiety giving way to enthusiastic adherence after the site goes into use....[One physician comments] "When the Diabetes Center was preparing to join My Health, “The fear was that, once patients can send messages to their doctor and put notes into their chart, the physician's time will no longer be protected. I was concerned about that myself, but I concluded that the benefits to patients would be worth it. As it turns out, My Health has improved my practice while also helping me compartmentalize my time."

- "New Web tool unites patients, clinical teams"

"These days everything from the bank to the library to the IRS has a Web-based interface to improve customer access. 'Why not your doctor's office?' asks Jim N. Jirjis, M.D., assistant chief medical officer and director of the Adult Primary Care Center. "

- "Some lab results now available online"

And this PowerPoint presentation also describes the project in more detail, complete with screenshots.

And a related story about a Harris Interactive and Wall Street Journal study of patient preferences - "Patients want doctors to embrace the Internet"