Locate Your Visitors (2)

ClustrMaps

A few months ago I blogged about how to use ClustrMaps for locating your visitors (see here). I still use Clustrmaps.
The map is cumulative: you get an overview of where the visits cluster (depicted as large or small clusters, see below) and an approximate idea of the locations. Approximate, because you can’t zoom in or look up locations.

Flagcounter

Recently I put a new free widget in the side bar, Flagcounter. This tool also gives a cumulative overview, but it summarizes the counts per country, visualized with flags. Judging from the number of clicks on my Flagcounter, the flags seem popular. You can easily set your preferences (colors, number of colums and flags) and change it afterwards in your widget, i.e. by changing columns=2/maxflags=20 (2 columns with 10 flags) into columns=3/maxflags=21 (3 columns with 7 flags each). Please, consult the FlagCounter-Faq for these and other tips (to avoid starting over again and loose your gathered info).

It is cumulative, thus you get an idea of the countries of origin of visitors over time. On basis of the counts since September it can be concluded that I’m mostly visited (this month) by English speaking people from the United States, UK, Canada and Australia. Of course I’m also frequented by Dutch speaking people form the Netherlands and Belgium.

It is also nice to see from which exotic places visitors found their way to this blog: Libyan Arab Jamahiriya, Aruba, Vietnam, Belarus. Also surprising that India, Phillipines and Malaysia are in the top 15 this month, rather than Spain and Denmark for instance.

Who’s Among us

Also visually attractive is the “who is among us button”. It shows how many visitors are simultaneously present at your blog (within a time span of 10 minutes). The highest number I’ve seen on my blog is 7. For some blogs it’s ‘as usual’, for this blog it is exceptional.

While writing this post I found a bunch of other possibilities hidden behind this button, for instance a world map showing the locations of your visitors, with the people who are currently on your site blinking (light blue in the picture below; not working as a widget in WordPress, but visible when you click on the counter). In addition there is a map with statistics per hour, day, month, year. However, I don’t grasp what the numbers actually stand for. These certainly don’t represent a cumulative number per hour. (if I have 4 visitors per 10 min. than I don’t expect a maximum of 3 per hour or 3 per day?).

Sitemeter

Many of these functionalities are also present in the Sitemeter, a widget that is inconspicuously present at this blog’s sidebar, but is most frequently consulted by me together with the WordPress stats.

Similar to “who’s among us” there is a nice world map, with the most recent visit in red, the last 2-10 visits in green and the other 90 visits in white. You can zoom in, look at the exact location and ip-number of the visitor whether in day or night zone.

It is a good way to improve your topographical knowledge.

Alas you can only observe the last 100 visitors, which means that in my top days I loose the statistics within a day.
If you want to upgrade, you have to pay a few dollar per month at least.

What I like the most, besides the map: the Visit Details of last 100 visitors. This list shows visit time, visit length (however if someone is just reading the frontpage without clicking, it counts as zero seconds), number of pages visited, entry and last page, IP address etc.

You can exclude your own visits and make the stats public or privat.

By using the sitemeter (in conjunction with the WordPress stats) you get an impression which visitors visit which pages.

Sitemeter has helped me to identify the IP address and domain of someone sending me a Google Doc invitation that was really meant as spam (I found out because that IP linked to someone referred to at my blog and later found in that Google doc (see earlier post)).

The sitemeter also helped me to identify the 10.000st visitor: Wowter from Wageningen.

SurgeXperiences Grand Round

Another Grand round, now in the field of surgery: SurgeXperiences.

SurgeXperiences is a blog carnival (maintained by Jeffrey Leow of the ‘Monash Medical Student”-blog) that collects blog entries every 2 weeks on various surgical experiences. It is THE blog carnival for everything surgical and more!

This week there is a scintillating edition of SurgeXperiences at Buckeye Surgeon (see here), including 2 Dutch contributions.
One of-you-know-who and one of Dr Shock with a post about the paucity of women who actually perform self breast exams, and whether it matters. Dr. Shocks post fits in with my previous post on the unusefulness of regular breast exam (see here).

But it is certainly not all quite as serious. There is room for some surgical humor as well, making it easy digestible.

You can submit your post for the next SurgeXperience via this form on Blog Carnival.

23andMe: 23notMe, not yet

The company 23andMe was in the news thrice this month:

1. cutting the price of its service by more than a half
2. organizing a celebrity spit party
3. the husband of the 23andMe co-founder Anne Wojcicki, better known as Google co-Founder Sergey Brin, revealed he is at risk for Parkinson’s Disease, as determined by….23andMe.

Coincidence or part of a strategic plan?

23andMe is a ‘direct to consumer genetic testing’ company that as 23andMe puts it: “democratizes personal genetics”. The lowering of the service price from $999 to $399 brings personalized genomics within the range of many.

What do you get for those $399? A spit kit, you do your thing, send the tube to a certified lab, which analyzes your saliva for more than a half-million points (called SNPs) scattered across the 23 pairs of chromosomes you have (hence 23andMe), as well as your mitochondrial DNA. 23andMe shows the digital data and gives you information on certain traits and diseases. 23andMe also gives information on your ancestry and compares your DNA to your relative’s and friend’s-genes, if you want to share that knowledge with them. With your genes in their database you help 23andMe to perform more research for new discoveries, a program called 23andWe. In fact once you sign up you cannot refuse the use your (anonymous) DNA for this purpose.

The main question is: what purpose does this serve (besides as a potential for yielding income)?

According to 23andMe the main purpose is ‘for research’, ‘for education’ and ‘for fun’: “It’s fun to learn about your own genome”.

In this light, we should probably see the recent event 23andMe organized: a spit party where a few hundred people were lured away from the catwalks during the Fashion Week in New York City. On the sound track of “a whole lot of love” celebrities were spitting their DNA-containing saliva in a tube (see here and here). According Guy Kawasaki, who report on it on his blog (see here),

“even Goldie Hawn and Kurt Russell were there providing their spit, but their handlers wouldn’t let me take a picture. I found this ironical: Giving DNA was okay but not a picture.”

The aim for which Sergey Brin let 23andMe test his DNA was less funny. As Sergey (whos mother has Parkinson) explains in his brand new blog:

(…..) Nonetheless it is clear that I have a markedly higher chance of developing Parkinson’s in my lifetime than the average person. In fact, it is somewhere between 20% to 80% depending on the study and how you measure. At the same time, research into LRRK2 looks intriguing (both for LRRK2 carriers and potentially for others).

Thus this shows a 3rd aim: diagnostic?!
Formally 23andMe denies there is a diagnostic purpose (in part, surely, because the company doesn’t want to antagonize the FDA, which strictly regulates diagnostic testing for disease). However, 23andme does give information on your risk profile for certain diseases, including Parkinson.

In addition, 23andMe encourages the formation of networks of people sharing the same traits.

“If you want to have a community around psoriasis,” Ms Wojcicki said, “we’d like to be able to allow you to form a psoriasis-specific community.” (see New York Times article)

Psoriasis-specific community when you only have the genes that may enhance the risk of getting psoriasis??

That sounds like condemning you to a psoriasis patient already?!

Then lets discuss the following burning question: how well does 23andMe predict that you will get the disease?

Even the LRRK2-gene data of Mr. Brin aren’t that conclusive. A marked higher chance of 20% to 80% is often misconceived as meaning that Sergey’s chance of getting Parkison is 20-80%, or “he will almost get the disease for sure”. As explained by the Gene Sherpa in his excellent post on this subject (see here) it only means that the LRRK2-mutation increases the normal chance of Americans/Europeans getting Parkinson from 2-5% to 4-10% at the most (the chance is less than doubled). Furthermore LRRK2 isn’t the most crucial gene for getting Parkinson.

23andMe has chosen to relate personal health info only to common diseases and common genes. Thus whether you have an enhanced or lowered risk for breast cancer (normal 1 out of 8 women) is determined by 2 (not very predictive) SNPs associated with Breast Cancer, but not by determining BRCA1/2 mutations that are highly predictive for breast cancer, but rare in the entire (western) population .

Although 24andMe explicitly mentions that the tests are for non-diagnostic purposes, it is hard to imagine that people will see it otherwise. But:

• Most genes are only weakly predisposing
• Often multiple genes are working in concert in a difficult to predict way (seldom one gene-one disease)
• The environment and chance also play an important role.

Thus the value of these fun predictions is low, but how does it affect people that think they are prone to having a disease? For some it might be reason to adjust their lifestyle (but then, what is the chance you really change “your destiny”), others may get fixed on their presumptive future disease, confused, or depressed. It is not without reason that genetic screening is usually restricted to people with high risks, when a disease can be predicted accurately (without too many false positives and negatives), something can be done about it (prevention or treatment), and only as part of a genetic consultation by professionals.

Sources; further reading

23andme : https://www.23andme.com/

Blogpost Sergei: http://too.blogspot.com/2008/09/lrrk2.html

Reaction to blogpost: NYtimes.com (2008/09/19): Technology (free login needed)

http://www.social-marketing.com/blog/2008/09/too-much-information.html

http://casesblog.blogspot.com/2008/09/google-founder-sergey-brin-starts-blog.html

** http://thegenesherpa.blogspot.com/2008/09/lrrk2-and-parkinson-disease.html

Lower prices: several blogs, see blogcarnival at: Gene-Genie-37 (2008/09/14):

Party:NYtimes (2008/09/14) fashion,14spit (free login needed)

http://spittoon.23andme.com/2008/09/11/23andme-struts-its-stuff-in-nyc-during-fashion-week/

http://blog.guykawasaki.com/2007/11/23andme-party.html

Time to weed the (EBM-)pyramids?!

Information overload is a major barrier in finding that particular medical information you’re really looking for. Search- and EBM-pyramids are designed as a (search) guidance both for physicians, med students and information specialists. Pyramids can be very handy to get a quick overview of which sources to use and which evidence to look for in which order.

But look at the small collection of pyramids I retrieved from Internet plus the ones I made myself (8,9)………

ALL DIFFERENT!!!!

What may be particularly confusing is that these pyramids serve different goals. As pyramids look alike (they are all pyramids) this may not be directly obvious.

There are 3 main kinds of pyramids (or hierarchies):

1. Search Pyramid (no true example, 4, 5 and 6 come closest)
   Guiding searches to answer a clinical question as promptly as possible. Begin with the easiest/richest source, for instance UpToDate, Harrison’s (books), local hospital protocols or useful websites. Search aggregate evidence respectively the best original studies if answer isn’t found or doubtful.
2. Pyramid of EBM-sources (3 ,4, 8 )
   Begin with the richest source of aggregate (pre-filtered) evidence and decline in order to to decrease the number needed to read: there are less EBM guidelines than there are Systematic Reviews and (certainly) individual papers.
3. Pyramid of EBM-levels (1, 2, 5, 7, 9)
   Begin to look for the original papers with the highest level of evidence.
   Often only individual papers/original research, including Systematic Reviews, are considered (1, 9), but sometimes the pyramid is a mixture of original and aggregated literature (2,5)
4. A mixture of 2, 3 and/or 4 (2,5)
   

Further discrepancies:

• Hierarchies.
  • Some place Cochrane Systematic Reviews higher than ‘other systematic reviews’, others place meta-analysis above Systematic reviews (2,6). This is respectively unnecessary or wrong. (Come back to that in another post).
  • Sometimes Systematic reviews are on top, sometimes Systems (never found out what that is), sometimes meta-analysis or Evidence based Guidelines
  • Synopses (critically appraised individual articles) may be placed above or below Syntheses (critically appraised topics).
  • Textbooks and Reviews may at the base of the pyramid or a little more up.
  • etcetera
• Nomenclature
  • Evidence Summaries ?= Summaries of the evidence? = Evidence Syntheses? = critically appraised topics?
  • Etcetera
• Categorization
  • UpToDate is sometimes placed at the top of the pyramid in Summaries (4) OR at the base in Textbooks (5), where I think it should belong in terms of evidence levels, but not in terms of usefulness.
  • DARE is considered a review, but it is really a synopsis (critical appraised summary) of a Systematic Review.

Isn’t it about time to weed the pyramids rigorously?

Are pyramids really serving the aim of making it easier for the meds to find their information?

Like to hear your thoughts about this.

What my thoughts are? I will give a hint: I would rather guide the informationseeker through different routes, dependent on his background, question, available time and goal. The pyramid of evidence sources and the levels of evidence would just be part of that scheme, ideally.

Will be continued….

Finding assigned MeSH terms and more: PubReMiner

Generally when searching PubMed I use both MeSH and textwords. If you already have some nice articles, either by performing a quick and dirty search or looking at the Related Articles or your colleague gave you one or two, then you can find the MeSH assigned to these papers by looking in citation format (see Fig). However going through a set of articles looking at all indexed terms takes quite some time and one doesn’t easily get an overview of the overall frequency of MeSH in a set of records.

Therefore, Rachel Walden, asked first at Twitter and then at David Rothman’ site (see here):

“What I’d like to do is to be able to enter the PMIDs of several citations and have the tool search MEDLINE via PubMed for the assigned MeSH terms, and return a single list of the terms used by any of the entered citations with a measurement of frequency. For example, if I input PMIDs 16234728, 15674923, and 17443536, the tool would return results telling me that 100% or 3 of 3 use the term “Catheters, Indwelling”, 2 of 3 use “Time Factors,” 1 of the 3 uses “Urination Disorders,” and so on. Although this example uses 3 PMIDs, I’d like to be able to input at least 10, just based on personal experience.”
(PMID is the unique PubMed-identifier, by searching for the PMID you get one specific record.)

The suggestions made by several people were summarized by David in another post (see here). The following 3rd-party PubMed/MEDLINE tools seemed most promising:

• GoPubMed
• http://www.docmobi.com/mesh/ (adapted from GoPubMed by another David)

Both give useful results. The layout- is very user-friendly.

I tried my own sets of 20 PMIDs (from a systematic review search on “predictive models for in vitro fertilization”) and www.docmobi gave this result:

This was the result when I selected: “primary terms only“. If I selected “include secondary terms” I would find female and pregnancy as well, but at rates of 175%. First I didn’t understand, but than I realized that pregnancy occurs as “Pregnancy” and as “Pregnancy Rate”, whereas female occurs as “Female” and as “Infertility, Female”. Therefore Pregnancy and Female can occur more than once as single words in one record (thus accounting for >100%). It is odd however, that important MeSH like Pregnancy and Female (which are really check tags, MeSH that should be assigned to each article that is about pregnancy or females) are not included in the primary list.

Although useful and nicely presented I still not find this ideal:

• Check tags are not in the list (with “primary terms only”)
• Publication types and substance names are in neither list.
• Subheadings are not included. For words not captured by a single MeSH, but by a combination of MeSH and subheadings this is especially important.
  For instance, there is no MeSH for EGFR-inhibitors, you have to use:
  Receptor, Epidermal Growth Factor/antagonists & inhibitors
• Textwords are not included (not on Rachel’s wish list but on mine)
• Personally I find the list so simple that I would have find the terms immediately myself.

Coincidentally I found another 3rd party tool which does the job much better (I think): (PubMed) PubReminer, produced by Jan Koster at our hospital (AMC, Amsterdam). I looked at it, because my colleagues and I are going to discuss it today.

This is the procedure I would recommend to find assigned MeSH and more, starting from PubMed (which is not absolutely required, because you can also search directly in PubReMiner)

• Collect the PMID’s of the papers you want to analyze.
• If you have selected the papers in PubMed (on the Clipboard, in My collections or in your search set) then Set the Display Tab on: UI List (Unique identifiers), and export these PMID to a textfile by choosing “to Text” from the Send to button. You get a simple list of PMID’s that you can copy/paste to PubReMiner. (not required, but handy)

• Go to PubReminer, paste the PMID’s in the search box as one string.
• Click: “Start PubReminer” (if you enter a search you may wish to apply limits)

• You see the results, in the following columns: Year, Author, Journal, (Text)Word, MeSH, Substance, Country.

• Afterwards you can decide
  - Whether the words are searched in title only, in Title and Abstract or also in MeSH and RN.
  - which columns are displayed
  - whether similar words are merged or not.
• You can use selected terms to build up your search in PubReMiner and/or
• You can export the terms as a text-file (!)
• And, by the way, you can download a plugin for IE or Firefox (Fig. right)

This tool is not very intuitive, but the result is quite ideal.

You get both a list of MeSH plus their subheadings AND a list of textwords (and substance names).

There are very useful terms in here, for instance logistic models[mesh]. As textwords I should use ‘logistic regression’ or ‘multivariate analysis’. It is only a pity that terms are given individually and spread: the context is lost (‘analysis’ may for instance be too broad, it is only useful in combination with ‘multivariate’ or ‘regression’).
With respect to the MeSH only individual terms are given. ‘Pregnancy’ is mentioned 19 out of 20 times in the MeSH-list. Does this mean I’m missing one paper by searching “Pregnancy”[MesH]? No, because that paper is indexed with the narrower term “Pregnancy Rate”. (and you will find it by exploding Pregnancy).
So the context and the hierarchy are lost here as well.

But it is about as good as one can get.

I’m gonna use this tool (as an adjunct at least). Seems that it has some other potentials as well: look up genes, find the research interest of an author, determine the journal to submit your work to. Well I probably learn that in a few hours. Perhaps I will come back to it later.

Grand Rounds 5.1

http://www.flickr.com/photos/kurtolo/

Surprise. Surprise. This weeks Grand Rounds Medicine Show didn’t show up at Revolution Health of Dr. Val Jones.
Dr. Val. is still waiting for her new blog (www.gettingbetterblog.com) to go live.

But Luckily she found Kevin & Kim (photo left), respectively from KevinMD and Emergiblog willing to guest this edition (written by Val in her own words) of the Grand Round at their sites.

Choose between either of two addresses (I suppose no more will be added):

KevinMD: grand-rounds-51-in-your-own-words

Emergiblog: grand-rounds-51-in-your-own-words

Next week Grand Rounds will be hosted by Monash Medical Student.

Dutch Grand Round 1.3

The 3rd Dutch Grand Round is up at Medblog.nl of Jan Martens. This time there are 4 posts, 3 of them in English. Please read his summary of de Grote Visite here.

Next Dutch Grand Rounds will be hosted at Health Management RX of Jen McCabe Gorman on October 7. The deadline will be on October 5. You can submit your articles by mailing Jen or through the Blog Carnival.There is no theme for submissions, but posts should relate to medicine or health in some way.

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De 3e grote visite kunt u vinden op Medblog.nl van Jan Martens.
Lees de samenvatting hier.

De volgende ronde is op Health Management RX van Jen McCabe Gorman.
Bent u een Nederlandse blogger en heeft u iets geschreven op medisch gebied (in de breedste zin van het woord) meld uw blogpost dan uiterlijk zondag 5 oktober (voor 12.00 a.m.) bij Health Management RX of de blogcarnival aan!

Previous posts on this subject:
(2008/09/09) Dutch-grand-round-nr-2
(2008/08/26) The first Dutch grand round
(2008/08/16) 1st Dutch grand round expected soon + continuation MedblogNL-top 25 cancelled.
(2008/08/10) a Dutch grand round. Announcement + reference to Englisch-language grand rounds.

Nursing Myths (1): Post-operative Temperature Measurements.

Patients recovering from surgery at the ward, are frequented by nurses taking their blood pressure, pulse and temperature. What would happen if nurses wouldn’t routinely measure temperature? Would infections be missed? Could this lead to more serious infections and other complications?

Hester Vermeulen and colleagues have performed a study that shows that routine measurements of body temperature in postoperative patients is of limited value. This study was published in Clin Infect Dis. 2005 May 15; 40(10): 1404-10, (see here for HubMed-citation). Previous studies have also pointed in the same direction, but were less robust in design (retrospective, unblinded studies and/or surrogate endpoints). (for study designs see previous post here)

The study of Hester Vermeulen et al. was a prospective, triple-blinded diagnostic study, which means that groups of patients were followed from the beginning and neither the patient, the treating physicians nor the nurses responsible for daily care were informed about the outcome of the measurements. Independent nurses not involved in routine care did the temperature readings. Only patients with non-infectious diseases were included.

Of the 284 enrolled patients, 60 (21%) had a temperature of ≥38ºC, but only 7 out of theses 60 patients really had infections. The sensitivity did not improve for higher febrile temperatures (38,5-39ºC) or when the febrile temperature was measured on more than one occasion.

On the other hand, of the 223 patients (79%) who had a temperature less than 38ºC, 12 patients (>5%) did develop an infection.

Overall, in 19 patients (7%) a postoperative infection was detected (14 on basis of bacterial culture, 5 on clinical/laboratory grounds). Only 7 of these patients had a febrile temperature beforehand.

Eight patients developed a serious infection (pulmonary, intra-abdominal and sepsis), but six of them had no febrile temperature, meaning that infection is often not accompanied by a previous increase in temperature.
Thus routine temperature measuring might even be misleading to nurses and physicians: relying on body temperature might delay diagnosis and subsequently treatment (because a negative result reassures, but does not exclude an infection).

Experts in diagnostic accuracy studies would say that routine temperature measurements in post-operative patients have a very low sensitivity, a low positive predictive value and meaningless likelihood ratios (see Wikipedia)

Freely translated, this test performs lousy.

The study of Vermeulen et al. is part of an continuing program for the development of evidence based local guidelines. On the basis of these results Vermeulen et al adviced to abandon routine postoperative temperature measurements, but to perform these measurements only when indicated.

Still, as I understand, it is not easy to implement the guidelines. Nurses still find that they ought to check temperatures daily -it is in their routine-. And if they do adhere to the protocol many doctors still ask for the temperature data during ward rounds. Last but not least, patients find temperature measurements reassuring and rely heavily on information about the measured values. Furthermore, it is also pleasant that the nurse visits you regularly, if not for the temperature, then for the caring.

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Patienten die op zaal liggen om van een operatie herstellen worden op gezette tijden bezocht door de zuster, die hun pols opneemt, de bloeddruk meet en hen even ‘tempt’. Wat zou er gebeuren als verpleegster niet routinematig de temperatuur zou meten? Zouden infecties over het hoofd gezien worden? Zou dit tot méér ernstige infecties of tot andere complicaties kunnen leiden?

Hester Vermeulen en collega’s hebben in hun studie (Clin Infect Dis. 2005 May 15; 40(10): 1404-10; zie hier voor HubMed-citatie).aangetoond dat routinematige bepaling van de lichaamstemperatuur in geopereerde patienten weinig zinvol is. Eerdere studies wezen hier ook al op, maar hadden een minder goed onderzoeksdesign (retrospectief, niet geblindeerd, surrogaatmarkers) (voor een beschrijving van studie designs, zie eerder bericht hier).

De studie van Vermeulen et al. is een prospectieve, triple-blinded diagnostische studie. Dat houdt in dat patienten vanaf het begin gevolgd worden en dat noch de patient, noch de behandelend arts of de verpleger (die de patient verzorgt) op de hoogte is van de uitslag. Onafhankelijke verplegers doen de temperatuurmetingen. Alleen patienten zonder infectieziekten werden geincludeerd.

Van de 284 geincludeerde patienten, hadden er 60 (21%) een temperatuur gelijk van 38ºC of hoger. Maar slechts 7 van deze 60 patienten hadden ook echt een infectie. De sensitiviteit van de test ging niet omhoog als men alleen mensen van een hogere temperatuur (38,5-39ºC) of met een herhaalde hoge temperatuursmeting in beschouwing nam.

Aan de andee kant: van de 223 patienten (79%) die een normale temperatuur hadden (lager dan 38ºC), kregen er 12 (>5%) toch een infectie.

In totaal, werd in 19 patienten (7%) een postoperatieve infectie geconstateerd. Slechts 7 van de 19 patienten had tevoren koorts.

Acht patienten kregen een ernstige infectie (long- of buikinfectie of sepsis), maar slechts 2 van hen hadden tevoren koorts en 6 dus niet. Hetgeen betekent een infectie niet altijd voorafgegaan wordt door koorts.
Routinematig tempen kan dus zelfs misleidend zijn. Als verplegers en dokters zich hier teveel op verlaten, kan dit een snelle diagnose en therapie in de weg staan (omdat een negatief resultaat ten onrechte geruststelt).

Epidemiologen zouden zeggen dat de routine temperatuurmetingen in post-operatieve patienten een erg lage sensitiviteit, een lage voorspellende waarde en een nietzeggende likelihoodratio hebben. (zie Wikipedia)

Vrij vertaald: knudde met een rietje.

Bovengenoemde studie is er éen uit een reeks, bedoeld om (locale) evidence based richtlijnen te ontwikkelen. Op basis van de resultaten is het advies van Vermeulen et al. om postoperatieve patienten niet langer routinematig te temperaturen, maar alleen als daar aanleiding voor is.

Een duidelijke stelling, maar toch blijkt de praktijk weerbarstiger. Verplegers vinden dat ze toch dagelijks horen te tempen -dat zit in hun routine. En als ze de regels wel opvolgen, vragen sommige dokters tijdens hun visite er toch naar. Last but not least, patienten vinden temperatuurmetingen en andere vaste rituelen geruststellend. Ze hechten ook veel waarde aan de uitkomst van de meting. Verder vinden ze het gewoon prettig als de zuster op vaste tijden bij hen langskomt. Was het niet voor de tempeartuurmeting, dan toch voor wat extra aandacht en zorg.

Laika’s Little Party

It’s time for some reflections on this blog and for a little party. Why?

• This blog has just reached the magic milestone of 10.000 counts (I’m still waiting for Wowter to claim his price). [party + reflections]
• This blog received some nice critiques, comments and listings. [party]
• Wowter has asked appr. 90 dutch library bloggers, including me, to write about our motives for blogging, who whe reach, whether we succeed in building a community, which posts we like most etc. He will present a selection of the carnival at a Dutch congres on Library 2.0 (OCN). [reflections]

So for now I will start with the party (with some wine), the reflections will follow when I’m sober.

This week I received an unexpected email from RNCentral (“the place to learn about nursing online”), anouncing that this blog had made it to the “Top 50 Health 2.0 Blogs list ( see here).

The top 50 health 2.0 list is not based on a kind of “objective” ranking like the Healthcare 100 or MedBlogEN lists, which are a measure of how many people link to your site, find your site by searching or have subscribed to your blogposts: thus an indirect measure of “how popular you are“. In such a list I would not make the top-100.
The RNCental site gives a “subjective” top 50 list of blogs, that appear valuable to the authors. The list is introduced with a very nice definition of health 2.0 blogs, that I can subscribe to:

Health 2.0 embraces the idea of bringing health care into the community of physicians, patients, and those in the health care industry together with technology and the Internet to provide the best possible health care environment. What better way for the various parts of this community to share their thoughts and communicate ideas than through their blogs? From corporate blogs to blogs that are a part of social networks to individual blogs touching on technology or health care policy, these blogs will help bring you into the community, provide information and resources, and may perhaps help you find your voice as well.

I’m thrilled that I’m (literally) placed next to David Rothman in the “Health and Technology”-section. Although, to be honest, I see myself as a true beginner in this web 2.0 world and I learn a lot of established web 2.0 experts like David Rothman, KraftyLibrarian, Berci of Science Roll, MD Anderson on Emerging Technologies Librarian, Dean Giustini (UBC Academic Search), Sachet62 on Twitter, symtym from symtym.com, David Bradley from Sciencebase and Dutch colleagues like Wowter (with a dutch and an english blog), Dymphie (Dee’tjes) and many many more. On my blog I try to integrate what I learn elsewhere (articles, posts, twitter messages) with my own knowledge and interest.

The resultant is a rather diverse mixture of subjects in the field of (medical) librarianship, medicine, health (including consumers), evidence based medicine and web 2.0 tools.

Although such a broad mixture might not be appealing to everyone, it is appreciated by some, as is apparent from a recent blog-review in the “Library + Information Gazette“, 22 August 2008: p5 (UK). The Gazette is only available in print edition and I wouldn’t have known about it if Anne Welsh of “First Person Narrative” had not mentioned it at her blog (see post: “mainstreaming blogs as information sources”). Anne:

“This review is the first in a series “Blog Spotlight” authored by Danielle Worster (the Health Informaticist). It’s aim is to help separating the wheat from the chaff when it comes to blogs in LIS and health informatics.

Any blog that claims to be about information, research, Web 2.0 or health informatics is considered. Each blog discussed is described in terms of its audience, currency, informativeness, authoritativeness / credibility, readability and design, with a brief overview and summary. It’s a nice format, and starts well in this issue with UBC Academic Search , ResearchBuzz and Laika’s MedLibLog.”

With Anne I find it regretful that the gazette is not available online. I surely would like to follow this series.

Luckily I found Keith Nockels (Browsing) willing to make a scan of the Gazette’s review and send it to me.

The Gazette review sketched my blog with very flattering sentences (“colourful, engaging and relevant”, “easy to read and digest”) as well as apt descriptions, which made me grin: “while it does stray to discuss….. Although she writes copious amounts, it is as easy to skim as to read it all…. crammed full of visuals.”

And about Dean’s UBC Academic Blog:

“Very informative: has an uncanny ability to pick up on crucial issue”. …. the blogger’s energy comes through in his shorter sentences….. essential reading.” All true! Dean’s blog is a must in the librarian web 2.0 world!

Apart from these official listings and reviews I got some comments or links that were also heartwarming.

For instance Keith Nockels (a UK Librarian with a nice blog (“Browsing”), apparently familiar with at least a few Dutch words) refers so nicely in his blogpost “More about changes to Ovid”:

“I have since found a posting on Laikas MedLibLog about this, and Laika has obviously looked at this properly! So, I can now report that you (….)
Laikas posting is here (in English and ook in Nederlands) and is gratefully acknowledged. She talks about other things besides, so please read her posting for more!”

And Dr. Shock announcement of the dutch grand round number 1:

Laika Spoetnik presents The Best Study Design… For Dummies (in English).
She writes in English and Dutch so you have no excuse for not reading this excellent post. She clearly explains Randomized Controlled Trials (RCT’s) and the levels of evidence. She uses an example which is easy to follow: Does beta carotene prevent lung cancer.

At Medliblog (the official website of the BMI, Dutch Biomedical Information) Annie (writing about Evidence Based Dietetics refers to the same post, saying:

….handige bijlages met een checklist voor het lezen van wetenschappelijke artikelen en een statistische begrippenlijst, dat laatste blijft toch altijd wel moeilijke stof voor dummies of alfa’s.
Voor die categorie heeft Laika een zeer begrijpelijke blog (zowel Engels- als Nederlandstalig) geschreven, waarvoor mijn dank. Zo’n presentatie zou ik ook wel willen bijwonen.

meaning:

For that category (dummies or alpha people not understanding checklists and studytypes) Laika has written a very comprehensible blogpost (in English and Dutch), for which I would like to thank her. I would have loved to attend such a presentation. (I gave to historians about “how doctors search”).

These comments strengthen me to continue blogging. This is why I blog: that (some) people like to read what I write and learn from some of the posts.

Well that is probably enough shameless self-glorification for now. I do realize that beginners get mild critiques, but as you get more well known the expectations will grow along and the critiques as well.

Next time, at request of Wowter, I will reflect more on the 5W’s of this blog: why, when, who, what, where?

Grand Round 4.52

The Grand Rounds Medicine Show is up at Nurse ratched’s place. Many submissions this time, so it was not an easy task for “Mother Jones“. But she has done a wonderful job. (see here)

Next week’s edition of Grand Rounds is being hosted by Dr. Val Jones from Revolution Health.

Blog Spam and Spam Blogs (2)

In a previous post I gave two examples of Health Blogs that are really pills-selling-sites. In this post I will show two examples of real Spam Blogs.

Spam blogs or splogs are usely fake weblogs where content is often either inauthentic text or merely stolen (scraped) from other websites. All spam artificially increases the site’s search engine ranking, increasing the number of potential visitors.

Database-management blog: no longer exists

Original post at this blog above and comment below.

One Spam blog that I wanted to show you, is no longer available. It is called Database Management.

Technorati-profile (authority=51)

This blog had no own content, but scraped it from blogposts having the (WordPress?) tag “database”. Although the post does link to the original site, it doesn’t refer to the author’s proper name, but some automatically generated fake name. For instance Shamisos instead of Laikaspoetnik (see Fig).

When I tried to place a comment on their site I had to login into the WordPress-account (although I was already logged in into mine). That’s when I began to really distrust it.

It’s technorati profile still exists (see Fig.). It is clear that the blog has rapidly increased it’s “authority” in the few months it existed. From zero to 51.
Many blogs linking to this blog are also gone or peculiar. Other blogs might have just linked to the spam blog because they assumed that this was the original post, not the copy. Presumably by having so much content on ‘database management’ the splog gets more traffic (of the preferred kind). This might be an example of a splog that backlinks to a portfolio of affiliate websites, to artificially inflate paid ad impressions from visitors, and/or as a link outlet to get new sites indexed (Wikipedia).

The second example of a spamblog is a very interesting site for Medical Librarians: Generic Pub, with the webadress: http://genericpubmed.com/pub/ with posts about PubMed. Really high quality information. Why? Because the posts derive from elsewhere. All of my posts about PubMed are in there, as are those of my colleagues, and perhaps your posts as well. There is no clue as to where the post really came from. You don’t get any pingbacks, unless the (original) post linked to you. That’s how I found out. As with the other spamblogs you cannot comment. Comments are always closed.

one of my posts on Generic Pub

Blogroll of Generic Pub

Generic PubMed homepage

The site does not hide its real intentions. To the left is a huge pill “cialis” and the blogroll consists of only pills, as well as PubMed tag feeds of Technorati and WordPress.

If you strip of the web adress to: http://genericpubmed.com you arive at the homepage, which is unmistakingly a pharmaceutical e-commerce website. Why is this done? Perhaps the sites looks more reliable whith all those PubMed posts or perhaps the site might be easier to find.

One way or another, these two sites steal posts from other sites. Tags used by Technorati or by WordPress, that can be easily transformed into a feed make it very easy for these spambloggers to automatically import blogposts with a certain tag.
By the way, did you find your post in there?

Previous post, see here.

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Database-management blog: no longer exists

In een eerder post heb ik 2 voorbeelden gegeven van blogs die eigenlijk tot doel hebben pillen te verkopen.

Nu 2 voorbeelden van echte Spam Blogs.

Volgens Wikipedia: Spam blogs of splogs zijn doorgaans nep-weblogs, waarvan de inhoud vaak min of meer gestolen wordt (“scraped”) van andere websites. Dit verhoogt de ranking door zoekmachines en zorgt ervoor dat het aantal bezoekers toeneemt.

Een Spam blog dat ik jullie wilde laten zien, is niet langer beschikbaar, tw. Database Management.

Dit blog had alle inhoud gepikt van posts met de (WordPress?) tag “database”. Er wordt wel gelinkt naar de originele site, maar de naam van de auteur wordt vervangen door een of andere automatisch gegenereerde naam, bijv. Shamisos in plaats van Laikaspoetnik (see Fig in engelstalig gedeelte).

Toen ik een commentaar wilde plaatsen op deze site, werd ik gedwongen in te loggen in WordPress, terwijl ik nota bene al ingelogd was. Vanaf dat moment vertrouwde ik het echt niet meer.

Het technorati profiel van deze site bestaat nog steeds (zie fig in engelstalig gedeelte). Het blog is in enkele maanden tijd van 0,0 tot 51 gestegen in “authoriteit”.
Veel blogs die naar dit blog linken zijn ook opgeheven of zijn verdacht. Andere blogs hebben misschien slechts per ongeluk naar deze splog gelinked, omdat men dacht met de originele post van doen te hebben, niet de kopie. Waarschijnlijk krijgt de splog zo meer verkeer van mensen die juist in database management geinteresseerd zijn. Mogelijk is dit een splog die teruglinkt naar een aantal klonen en vice versa. (Wikipedia).

Het 2e voorbeeld van een splog is een erg interessante site voor medisch informatiespecialisten, nl Generic Pub met het webadres: genericpubmed.com/pub. Allemaal kwalitatief zeer goede posts over PubMed. Maar ze zijn wel gejat. Al mijn berichten met de tag PubMed zijn er te vinden, evenals die van mijn collega’s en misschien uw berichten ook wel.
Nergens is de ware herkomst van de berichten te herleiden. De echte auteurs krijgen normaal geen pingback, alleen als de oorspronkelijke post een link naar hen bevat. Zo kwam ik er eigenlijk achter. Evenals de andere splogs, kun je geen commentaar plaatsen.

De website verhult zijn werkelijke bedoelingen niet. Links staat een reuzachtige pil “cialis” en de blogroll bevat alleen namen van pillen alsmede de feeds van de PubMed tags van Technorati en WordPress.
Als je het webadres stript tot: genericpubmed.com kom je op de homepage, onmiskenbaar een e-commerce site. Waarom verschuilt men zich achter zo’n blog? Lijkt de site er betrouwbaarder door of vinden potentiele klanten de site makkelijker?

Hoe dan ook deze 2 sites stelen van andere websites. Een feed nemen op Technorati- of WordPress-tags is een eitje, en dit maakt het deze spambloggers erg makkelijk om automatisch blogposts met een bepaalde tag te importeren.
Tussen 2 haakjes, heeft u uw post al getraceerd?

Vorig bericht in deze serie, zie hier.

Blog Spam and Spam Blogs (1)

Flickr.com cursedthing (CC)

We all get our spam once in a while. Most of the time spamfilters block them. Askismet works well at this blog. Often you recognize spam by the hyperlinks or the words, i.e. “viagra”.

But sometimes spam is not so obvious. In 2 separate post I would like to give some examples of less obvious blog spam, spamblogs and something in between.

Acccording to wikipedia:

Blog spam is done by automatically posting random comments or promoting commercial services to blogs. Any web application that accepts and displays hyperlinks submitted by visitors may be a target.

Conversely, spam blogs are usely fake weblogs where content is often either inauthentic text or merely stolen (scraped) from other websites.

All spam artificially increases the site’s search engine ranking, which often results in the spammer’s commercial site being listed ahead of other sites for certain searches, increasing the number of potential visitors and paying customers.

Blogs & Spam: “Spam” by request?

David Rothman describes at his blog how he is often mailed by people asking him to post about their site, which often is “just a lousy site solely meant for pharma marketing”. He refuses if the site isn’t really useful, but apparently many of his fellow health bloggers aren’t that fussy, since those particular sites often manage to get mentioned on other health blogs anyway. David hopes that the blog-reader will read through this, but is that really the case? The blogger may be considered an expert in the field (that’s why he receives an email) and people may be inclined to take his word for granted. Striktly taken this may not be spam, but it sure works the same way.

Spam Blog (1). “Spam” hidden behind “Breaking Health News”

About a week ago, I had a look at WordPress.com and saw an interesting featured post with the (WordPress) tag “Health”.
At WordPress “Featured Posts” are at the top of a tag list -in this case “Health”-, which increases traffic to such posts). The subject captured my attention, because it was about Addison’s disease (which I have). I read it.

Somebody with primary Addison (Primary Adrenal failure, which leads to inability to make the hormones cortisol, aldosterone and dehydroepiandrosterone (DHEA)) asked whether the menstrual irregularity she developed a year ago could be caused by the replacement therapy with Hydrocortisone and Fludrocortisone and if this could lower her fertility.

The answer (see here) was rather lengthy, it discussed the causes of menstrual irregularity, primary Addison’s disease, replacement therapy, that (the often not replaced) DHEA might improve general well-being, and finally comes to possible explanations:

• changes in menstrual cycle could be related to too much or too little of the replacement hormones
• recurrence of menstrual cycles was reported in one patient treated with DHEA (also considered as a supplement, by the way).
• advice: consultation of an endocrinologist.

Nothing really wrong with this. However a more plausible explanation wasn’t mentioned, i.e. that the reduced cycling might be due to the disease itself. Nowadays the main cause for primary Addison is auto-immunity, and auto-immunity often doesn’t come alone. Gonadal failure can occur in approximately 5% of the woman with auto-immune Addison’s (Williams Textbook of Endocrinology, E-medicine).
For instance in 100 Dutch patients the distibution was as follows

… In 47% of the patients with autoimmune Addison’s disease at least one other autoimmune disorder was present. Primary hypothyroidism had the highest prevalence (20.5%), followed by vitiligo (9.6%), non-toxic goiter (8.4%), premature menopause (7.3% of the women) (….).
From: P.M.J. Zelissen et al, J Autoimmun. 1995 Feb;8(1):121-30.

I tried to place a comment. However, comments were closed (at the date of posting). Odd. I must say that I already found it weird for a patient to start with “I actually have an interesting question.” No one says that, but rather:

“Help, I’ve Addison and my menses become irregular, I want to have children, so I’m afraid that I’m becoming less fertile. Can this have anything to do with the corticosteroids I take?”

An even closer look points out that:

• both the Q & the A are written by the same person.
• The automatically generated “Possibly Related Posts” only link to posts at the same blog
• as do all “so called comments” (so a kind of self-ping).
• There is no info whatsoever about who is behind this site.
• The tab “About” is really the tab Pharmacy Store, where a bunch of “high quality medications” are offered.
• If I click on fosamax (which a lot of ex-Cushing (panhypopituitary) Addisonpatients need), I ‘m linked to a really (recognizable) commercial site: see here
  

Is this so bad? Well at least as bad as a lot of commercial-pills-selling-sites that don’t look like commercial-pills-selling-sites. It is quite misleading to use a blog on “breaking Health news” as a cover-up for real intentions: selling. Readers cannot respond, only trackback. Furthermore, in this particular case, the information was not really adequate for patients either (although “partially prepared” by pharmD candidates). One may also wonder why such a post becomes the featured Health blog at WordPress. Well, it will have suited them (and their tag “health” is well-thought-out).

But there are better (or really worse) examples of real spam blogs. Two examples will be given in the next post (see here).

Flickr.com cursedthing

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We hebben allemaal wel eens last van spam. Meestal wordt spam wel door spamfilters geblokkeerd. Askismet houdt in ieder geval het nodige tegen op dit blog (700 spam). Vaak herken je spam wel aan de (vele) hyperlinks of termen als “Viagra”.

Soms is echter niet zo duidelijk dat het om spam gaat. In tenminste 2 berichten wil ik voorbeelden geven van minder evidente blogspam, spamblogs en wat daar tussenin zit. Het zijn dingen waar ik toevallig tegenaan gelopen ben.

Eerst wat definities. Volgens Wikipedia :

Blog spam is done by automatically posting random comments or promoting commercial services to blogs. Any web application that accepts and displays hyperlinks submitted by visitors may be a target.

Conversely, spam blogs are usely fake weblogs where content is often either inauthentic text or merely stolen (scraped) from other websites.

All spam artificially increases the site’s search engine ranking, which often results in the spammer’s commercial site being listed ahead of other sites for certain searches, increasing the number of potential visitors and paying customers.

Blogs & Spam: “Spam” op verzoek?

David Rothman vertelt op zijn blog dat hij vaak een verzoek per mail krijgt om een post te plaatsen over een bepaalde site, terwijl het gewoon om een belabberde farmaceutisch e-commerce site gaat. David weigert dit als de site slecht is/zijn lezers niets biedt, maar kennelijk zijn z’n collega bloggers niet zo kieskeurig: vaak worden dergelijke sites binnen no time wel op andere gezondheidsblogs besproken. David hoopt dat de lezers van dergelijke blogs hier doorheen kijken, maar ik vraag me af of dat werkelijk zo is. Degene die erover schrijft op zijn blog wordt al gauw als expert gezien (daarom kreeg hij ook dat verzoek) en lezers zullen al gauw geneigd zijn wat hij bespreekt voor waar aan te nemen. Strikt genomen is dit wellicht geen spam, maar het resultaat is hetzelfde.

Spam Blog (1). “Spam” verborgen achter “Breaking Health News”

Ruim een week geleden zag ik een interessante post bij de “featured posts on Health” bij WordPress.com.
Bij WordPress komen “Featured Posts” bovenaan de posts met een bepaalde tag, in dit geval “Health” te staan. Ze worden daarmee extra in het zonnetje gezet en krijgen extra veel bezoek. Maar in dit geval trok ook het onderwerp mijn aandacht, omdat ik het zelf heb: de ziekte van Addison.

Iemand met primaire Addison (uitval van de bijnieren waarbij de oorzaak in de bijnieren zelf ligt, niet in de aansturing. Hierdoor worden de hormonen cortisol, aldosteron en dehydroepiandrosterone (DHEA) niet meer gemaakt) stelde een vraag over haar sinds een jaar vaak uitblijvende menstruatie. Ze wilde weten of dit iets te maken kon hebben met de substitutietherapie met Hydrocortison and Fludrocortison.

Het antwoord (zie hier) was nogal weinig to the point. Het volgende werd breeduit besproken: de oorzaken van onregelmatige menstruatie i.h.a., primaire Addison, substitutietherapie, dat het vaak niet gesubstitueerde DHEA (eigenlijk ook vaak gebruikt als voedingssupplement) de kwaliteit van leven kan verbeteren, om tot slot met enkele mogelijke verklaringen te komen:

• veranderingen in de menstruatiecyclus kunnen samenhangen met te weinig of te veel vervangende hormonen (maar niet door fysiologische doses, hetgeen het streven is bij vervanging).
• één patient kreeg weer een normale cyclus na gebruik van DHEA (overigens werden ook de andere hormonen beter ingesteld)
• tot slot een algemeen advies; ga naar je endocrinoloog.

Hier is niet echt wat mis mee (vooral met het laatste advies). Zij het dat een voor de hand liggende verklaring niet genoemd wordt, namelijk dat een onregelmatige cyclus en verlaagde vruchtbaarheid ook kunnen samenhangen met de ziekte zelf. Tegenwoordig is de belangrijkste oorzaak voor primaire Addison autoimmuniteit (afweerreactie tegen eigen weefsels/organen) en autoimmuniteit komt vaak niet alleen. Uitval van de geslachtsorganen kan in zo’n 5% van de patienten met primaire Addison voorkomen (Williams Textbook of Endocrinology, E-medicine).
Bij 100 Nederlandse patienten was de verdeling bijvoorbeeld als volgt:

… In 47% of the patients with autoimmune Addison’s disease at least one other autoimmune disorder was present. Primary hypothyroidism had the highest prevalence (20.5%), followed by vitiligo (9.6%), non-toxic goiter (8.4%), premature menopause (7.3% of the women) (….).
From: P.M.J. Zelissen et al, J Autoimmun. 1995 Feb;8(1):121-30.

Ik probeerde een reactie te plaatsen op de blogpost, maar dat was niet meer mogelijk. Nou ja niet meer: het was de dag dat het bericht geplaatst was. Raar. Ik moet zeggen dat ik al mijn wenkbrauwen fronsde bij het zien van de aanhef “I actually have an interesting question.” geen patient begint zo, maar zegt eerder:

“Help, Ik heb Addison. Mijn cycli worden onregelmatig en ik wil nog graag kinderen hebben, dus ik ben bang dat ik minder vruchtbaar wordt. Kan dit komen door de corticosteroiden die ik ter vervanging inneem?”

Geintrigeerd ging ik verder op zoek.

• De Q & de A bleken door dezelfde persoon geschreven.
• De automatisch gegenereerde “Possibly Related Posts” linken alleen naar berichten op het blog zelf.
• Dat geldt ook voor alle commentaren (een soort zelf-ping).
• Er is nergens info over wie er achter de site zit.
• De tab “About”/”Over” is eigenlijk de link naar de “Pharmacy Store“, waar een reeks “high quality medications” wordt aangeboden.
• Als je bijvoorbeeld op fosamax (vaak gebruikt door ex-Cushing Addisonpatienten) klikt kom je op een duidelijk herkenbare commerciele site terecht: zie hier
  

Is dit zo erg? Nou dit blog is net zo erg als die pillen-verkopende websites die er niet uitzien als pillenverkopende websites. Het is nogal misleidend om je blog te presenteren als een blog over “breaking Health news” om je werkelijke bedoelingen te verbloemen: pillenverkoop. Lezers kunnen niet reageren, alleen trackbacken. Verder was de informatie ook voor patienten niet helemaal volledig. Je kunt je ook afvragen hoe zo’n blog nou een featured Health blog bij WordPress wordt. Nou, het was wel lekker meegenomen (en ze kennen niet voor niets de tag “Health” toe).

Maar er zijn betere (or eigenlijk slechtere) voorbeelden van echte spam blogs. In de volgende post (zie hier) zal ik er twee bespreken.

Medical Grand Rounds 4.51

Two Medical Grand Rounds at the same day, a Dutch Grand Round (see previous post) and an International (English-language) Grand Rounds.

The latter one (no 4.51) is sung from the heart by Dr. Chris at Applequack. (see here).

The next Grand Round will be at Nurse Ratched’s.

Dutch Grand Round nr. 2

The 2nd Dutch Grand Round is up at “De gezondheidszorg leuker en effectiever” of Marjolein Fermie. This time there are 7 posts, 3 of them in English.

Next week’s Grand Rounds will be hosted at Medblog.nl. There is no theme for submissions, but posts should relate to medicine or health in some way.

Please read his summary of de Grote Visite here.

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De 2e grote visite kunt u vinden op “De gezondheidszorg leuker en effectiever” van Marjolein Fermie. Lees de samenvatting hier.

De volgende ronde is op Medblog.nl van Jan Martens.
Bent u een Nederlandse blogger en heeft u iets geschreven op medisch gebied (in de breedste zin van het woord) meld uw blogpost dan bij Medblog.nl of bij de blogcarnival aan voor de volgende ronde!

Previous posts on this subject/:
(2008/08/26) The first Dutch grand round
(2008/08/16) 1st Dutch grand round expected soon + continuation MedblogNL-top 25 cancelled.
(2008/08/10) a Dutch grand round. Announcement + reference to Englisch-language grand rounds.