Technorati authority dropping due to anti-spam initiatives?!

In the previous post (Technorati rank & authority dropping like the stock market) I mentioned the acute overnight drop of my Technorati Authority from ~46 to 5 and the loss of many backlinks.

Here I suggested that this dropping in authority might be connected to the loss of Google backlinks.

From the Technorati discussion forum it is apparent that many other bloggers are having similar problems: the loss of blog reactions and thus “authority”.

Going through some of those discussion, I found that answers of the administrator gave a clue to the cause of the vanishing pings.

In the discussion string http://support.technorati.com/discussions/topic/4655 the administrator wrote on October 17, 22 and 28 respectively (see Figure):

[Note the different insight over time and the light hearted tone:

" Hello all, we did a bit of spam cleaning over the weekend..." ]

The last response links to a blogpost of Ian Kallen on October 27, entitled: Data cleanups and mishaps, that clearly confirms that the “mishaps” do relate to (finally) cleaning up Technorati spam in a very rigorous way.

Here is the integral text of the Technorati blogpost.

“Technorati has a number of initiatives in the works to improve the data in our search indexes and analytics systems. Web spam sites (splogs) have long been an issue that we’ve been working to address. The days when pings came only from legitimate blogs are long gone. Including all of the spam and duplicates, Technorati receives over 8 million pings per day. Over 90% are recognized and blocked as soon as they’re received. The remainder is allowed into the system and selectively processed – a large portion is determined to be spam later.

Recently, we’ve been focusing on link farms and pornography sites that have been getting into the system. Link farms are networks of sites linking to each other and other sites with the intention of raising search rankings. Sometimes, these sites link to legitimate blogs to “camouflage” these intentions or simply because the content has been stolen from another site. During a recent scrub of the system, a number of legitimate blogs were misidentified as spam. The flags set on those blogs were reversed, so going forward they are being indexed correctly again. However, some of the link and post data scrubbed from our search and analytics systems could not be reverted. We’re working on upgrades to make that data handling better managed but in the meantime, there are some gaps in certain blog’s data which may affect the authority of blogs they linked to. Additionally, some blogs suffered authority drops due to being the beneficiary of camouflaged links from spam sites being removed (wittingly or not); when those spam sites were removed, so was a portion of the authority of the legitimate blogs they linked to.

We have a number of technology initiatives in the works to improve the scaling characteristics and data quality of our systems. More news will be arriving on that in the weeks and months ahead.

Indeed this explains a lot. As I wrote in previous posts ( Blog Spam and Spam Blogs 1 (see here) and 2 (see here)) many splogs have linked to my blog and much of my content has been and is being stolen by such blogs!!

So I’m punished twice and hard for writing about health related issues (the desired niche for spamblogs selling cialis, viagra and those kind of drugs).

Once by blogs stealing my content and ending up high in ranking (see comment of Wowter and Keith Nockels here) and once by Technorati finally cleaning up those spamming blogs in a rigorous way, dragging me along in their slipstream!

Thanks Technorati! For shooting holes in my ranking, not responding to my mail and not adequately helping those who are hit by your rucksichtloss (excellent German term for what has been done, something like recklessly in English) weeding of the spam blogs that you’ve allowed to exist in Technorati for years! (see this critic in Wikipedia mentioned in my previous post).

Technorati, what are you going to do about it?

Technorati Rank & Authority Dropping Like the Stock Market

Technorati is a free internet search engine for searching blogs, which has indexed over 100 million blogs and 250 million pieces of tagged social media (Wikipedia). It is a potential important service for bloggers because it keeps track of how many different blogs link to your blog. So, it works similar to the citation score (i.e. H-index) for “real” authors (of peer reviewed scientific papers). The more you are linked by different bloggers, the more “important” your blog is considered.

Technorati introduced a new score, “Authority” for this purpose. The Technorati Authority is the number of blogs (irrespective of importance and including spam blogs) linking to a website in the last six months. The higher the number, the more Technorati Authority the blog has.

The Technorati Authority is often part of other “objective” blog scoring systems as well. The algorithm for the Healthcare 100 even depends on 3 Technorati scores: Authority, Ranking and Inlinks.

In addition, Technorati can be used to follow the posts of favorite blogs and linking posts.

Regularly I found that Technorati was kind of unstable and lingering behind. Some blogs linking to me were not included, but as long as the deviation is not too large, it is not that worrisome.

However, approximately 10 days ago my rank suddenly fell OVERNIGHT from ~46 to 5!!
Concurrently many linking blog post had gone: there were more than 250, now there were 50.
The old and the new posts have stayed, but those in between vanished.

New post have linked to me afterwards and my authority has “grown to 10″, but I’m sure it should be near 50.

As a consequence I made a free fall in the Top Health care list: from 198 to 351, which is entirely attributable to the drop in Technorati Authority and Ranking (highlighted scores)

Perhaps faulty Google backlinks may have something to do with it. Just before the drop in my Technorati ranking many Google Links disappeared (Google Links are the “Incoming Links” in the WordPress dashboard). And, as off yesterday, there are regularly wrong Google backlinks: links from my favorite blogs, without “Laika” being mentioned in the actual posts. (Note: this appears a different issue, blogged in a separate post)

However, in the past, Google links were quickly restored, whereas wrong or lacking Technorati links were not.

I mailed to Technorati a week ago, but didn’t receive any response yet (except for the receipt of the message).

Am I the only one with this problem? Apparently not. In the Technorati Forum discussions (see here), a lot of items deal with this very subject. See for instance the Topics Rank & Authority Dropped Like the Stock Market (Superb title, thanks! ) and Reactions and authority disappearing

Some ‘tormented’ responders like msager doubt the real value of Technorati, see for instance Why hasn’t the press noticed that Technorati has been broken for almost a year?

Even Wikipedia mentions criticism of Technorati:

(…) In May 2006 Technorati teamed up with the PR agency Edelman. The deal earned a lot of criticism, both on principle and as a result of Edelman’s 2006 fake blog scandals. Edelman and Technorati officially ended the deal in December 2006. That month, Oliver Reichenstein pointed out that the so called “State of the Blogosphere” was more of a PR-tool and money maker for Edelman and Technorati than a reliable source, explaining in particular a) why Technorati/Edelman’s claim that “31% of the blogs are written in Japanese” was “bogus” and b) where the financial profit for the involved parties was in this.
In May 2007, Andrew Orlowski writing for the tech tabloid The Register (…) suggests that Technorati has decided to focus more on returning image thumbnails rather than blog results. He also claims that Technorati never quite worked correctly in the past and that the alleged refocus is “a tacit admission that it’s given up on its original mission”.

Another point of criticism is that there is no quality ranking. Each blog that links to you (no matter if it’s a spam blog and irrespective its (real) authority) increases your Technorati Authority with 1.

Finally there are regular outages: disappearance of favorites, links, slow indexing.

Combined with inadequate response to outages and questions raised by bloggers (its clients), Technorati Authority and Technorati Ranking don’t seem to be the reliable and valuable scores, they could have been.

But what is the alternative?

The importance of early intervention in Addisonian crises

In a previous post entitled “changing care for addison patients“ (see here), I mentioned that Addison’s disease is often misdiagnosed and Addison crises not adequately dealth with.

“I’m by no means an exception. Addison’s disease is often missed or diagnosed late. That early diagnosis can be a challenge is frequently addressed in the medical literature and many poignant examples can be read on patient forums. In fact I know very few prompt and swift diagnoses.”

“…But there are far more upsetting stories of other Addison crises. Even in this era there are unnecessary deaths due to inadequate intervention.”

While preparing this post I came across a recent paper in “Het Nederlands Tijdschrift voor Geneeskunde” (something like the Dutch Lancet) with a relevant clinical lesson on this very subject. It is entitled:

“Addisonian crisis in patients with known adrenal insufficiency: the importance of early intervention”, written by Mulder of the group of Professor Hermus from the Universitair Medisch Centrum St Radboud, Nijmegen.

The paper decribes 3 fatal cases of Addisonian crisis in patients with adrenal insufficiency, which formed the basis for the development of a regional protocol to prevent any further unnecessary death from Addisonian crisis (see PubMed abstract here).

The cases

http://www.flickr.com/photos/bholak/309005330/

Patient A was a 47 year old male with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Since this leads to deficient glucocorticoid and mineralocorticoid hormone production, replacement therapy consisted of daily replacement with glucocorticoid (hydrocortisone, HC) and mineralocorticoid (fludrocortisone).
A got a sudden gastroenteritis (acute abdominal pain, watery diarrhea, no fever), for which he doubled his HC dose. The next day he became weak and dizzy. The consulted physician didn’t deem parenteral cortisol (proposed by the patient’s partner) necessary, but prescribed loperamide instead. Indeed the diarrhea improved, but the condition of the patient worsened overnight, his temperature dropped to 34,4 C, he was confused and finally became comatose. Upon arrival at ED the hypotensive patient developed ventricular fibrillation. The neurological sequelae after CPR were so severe that active medical treatment was withheld, after which the patient died.

jmr_photo/2738016554/

The other two patients had panhypopituitarism and adrenal insufficiency secondary to their ACTH deficiency. With respect to replacement of adrenal hormones, these patients only require replacement of (ACTH driven production of) glucocorticoids, not mineralocorticoids. (On the other hand, they need extra replacement of other hypophysis-(regulated) hormones, like levothyroxine, gonadotropins and growth hormone).

Patient B, a 28 year old male got a sore throat and fever (41 C), for which he didn’t increase his HC-dose. His mother called a physician in vain: patient B didn’t respond and was found dead two hours later. Obduction showed tonsillitis, bronchopneumonia and an enlarged spleen, indicative of sepsis. This all took place in one and a half day.

Patient C was vomiting and had fever during a couple of days. Soon after her doctor visited her, she suffered a cardiac arrest and died. Her family physician was not familiar with her medical history nor with the prescribed medication. In retrospect, patient C had poor treatment compliance (never came to a consult and didn’t take replacement medication, including HC, for a year).

Conclusions

Even patients known to have adrenal insufficiency can develop a life-threatening Addison crisis in case of inadequate adjustment of the glucocorticoid dosage during intercurrent illness. Treatment consists of a high parenteral dose glucocorticoids, preferentially HC (because this also has a mineralocorticoid action).

The chance of hypovolemic shock accompanying a crisis is greater in patients with primary Addison, lacking mineralocorticoids (case A).

Preventive measures

These casualties led to a new protocol. According to the authors:

“Patients with known adrenal insufficiency, as well as their relatives and general practitioners, should repeatedly receive verbal and written instructions on how to deal with physical and severe psychic stress. We teach the patients and their relatives how to use an emergency injection of hydrocortisone, and the patients can consult the on-call endocrinologist by telephone 24 hours a day.”

I. Points to be adressed in the yearly instruction of patients with primary or secondary adrenal insufficiency, preferably in presence of his/her partner or close relative:

• explain importance of glucocorticoid use.
• describe the symptoms of an Addisonian crisis
• give instruction on increasing glucocorticoid dose in case of illness or severe stress
• stress the importance of an alert bracelet
• verify whether the patient has an emergency ampule with hydrocortisone (i.e. Solucortef) at home
• give instruction on the use of an emergency intramuscular injection (standardly given by a nurse)
  
• inquire about traveling abroad, provide letter with advice in case of (written in English) if required*
• provide written information, including telephone number of on-call endocrinologist (24 hours a day service)!!
• In addition the family physician receives a yearly letter with a standard treatment advice in case of an imminent Addisonian crisis. He is advised to inform his colleagues at the Central GP post.
  

II. Advice to patients with primary or secondary adrenal insufficiency for dosage of cortisone in case of stress. Normal Dose is 15 to 30 mg HC daily (or equivalent dose of other glucocorticoid)

• outpatient or dental interventions (i.e. local anesthesia): double HC dose before intervention
• fever (>38 C), severe psychological stress** (difficult exam, death family member): at least triple HC-dose, i.e. 60 mg in the morning and 30 mg in the evening, taper till normal dose after symptoms are relieved. Contact doctor if there is no improvement.
• vomiting or diarrhea, unconsciousness: parenteral administration of 100 mg hydrocortison by patient or partner (im) or physician (im, iv); direct consult of on-call endocrinologist, always check afterwards at ED
• surgery or hospitalization: the treating physician should contact the patient’s endocrinologist for advice on dose adjustments.

What is special about this protocol is the 24h endocrinologist on call service, the earlier (and consistent) referral to endocrinologists and ED, in case of possible emergency, and the structural approach: all patients with adrenal insufficiency, including their relatives and physicians, are well-informed about the preventive measures that should be taken (including HC emergency ampule and alert bracelet).

That is a great improvement! Hopefully other regions and countries will follow this example.

Notes and Sources:

Sources: Mulder AH, Nauta S, Pieters GF, Hermus AR. Addisonian crisis in patients with known adrenal insufficiency: the importance of early intervention. Ned Tijdschr Geneeskd. 2008 Jul 5;152(27):1497-500. [Article in Dutch] (see PubMed abstract here).

* The Dutch Addison and Cushing Society NVACP since long has a small booklet “SOS stressboekje”, which is specially designed to inform physicians abroad when on vacation. Short guidelines for dosages of (hydro)cortisone in stress and medical information for physicians is translated in 6 languages.

** Advices based on what is usually advised in the literature. There is little evidence for a particular dose in case of physical or psychological stress.

Photo’s acknowledgments.

Burning and burned matches derive from Flickr, respectively from
http://www.flickr.com/photos/bholak/309005330/ and http://www.flickr.com/photos/jmr_photo/2738016554/

———————————————

De Nederlandstalige samenvatting van het artikel:
Addison-crisis bij patiënten bekend wegens bijnierschorsinsufficiëntie: het belang van vroegtijdig ingrijpen
A.H.Mulder, S.Nauta, G.F.Pieters en A.R.M.M.Hermus in het Ned Tijdschr Geneeskd. 2008 5 juli;152(27)

Dames en Heren,
Patiënten met een bijnierschorsinsufficiëntie kunnen over het algemeen goed functioneren indien zij worden behandeld met glucocorticoïden en – in geval van een primaire bijnierschorsinsufficiëntie – mineralocorticoïden. Tijdens ziekte, koorts en ernstige psychische stress is de natuurlijke
behoefte aan cortisol verhoogd. Patiënten met een bijnierschorsinsufficiëntie moeten in deze gevallen dan ook de substitutiedosering glucocorticoïden verhogen. Alhoewel zij tijdens de poliklinische controles hierover uitleg ontvangen blijken de instructies niet altijd adequaat te worden opgevolgd. De ernst van de situatie wordt soms door de patiënt zelf, en soms door de geraadpleegde huisarts of specialist, onvoldoende onderkend.
Met de beschrijving van de volgende drie ziektegeschiedenissen willen wij onder de aandacht brengen dat een addison-crisis bij patiënten met een bekend hypocortisolisme levensbedreigend is, en dat vroegtijdig adequaat ingrijpen noodzakelijk is. Tevens beschrijven wij de maatregelen die wij namen om patiënten nog beter te informeren over glucocorticoïdgebruik bij lichamelijke en psychische stress en om de bewustwording bij medebehandelaren te verhogen.

Long Weekend Cap Griz and Blanc Nez

http://flickr.com/photos/birgerstichelbaut/

Tomorrow (uuh today) we are going a long weekend to France, near Calais. Somewhere near Cap Griz Nez and Blanc Nez. Hope it will stay dry most of the time.

Well anyway we will enjoy fruit de mer. My eldest daughter loves it. Probably will take extra oysters as well.

http://flickr.com/photos/henia/2825823680/

Palin & Obama, Fun & Photo’s

Two times Palin and once Obama (and another celebrity)

1. Sarah Palin as President. Seen on Dr. Shock’s website. Played a while with it, and liked it. Move with your mouse through the oral office and click on objects in the roome. Don’t forget the telephone! You have to go to the website (click here), the photo below is not clickable

   

2. Sarah Palin again, but now an interview with John Cleese about her, or is it about parrots?
   I was first tipped by Bercalan Mesko (scienceroll) on Twitter (@Berci), but I found a shorter version on You Tube that I preferred (without another comedian, Cleese will do).
   Both versions I later found on…… Dr Shock’s weblog again. He wrote that the you tube video’s originated from the CleeseBlog. Interesting to follow I suppose. The longer version is also on youtube.
3. A series of beautiful Obama photo’s by Callie Shell. See here.
   Hattip: Gerard Bierens (weblog zonder haast) via twitter (@gbierens).
4. An extra one, again from Gerard on another celebrity. http://tinyurl.com/59moz7. LOL! Added Wednesday November 5th, the day that Obama became president of the US.
5. McCain and Palin Sing (by Henry Hey) (hattip @berci)
   
6. Funny Obama Song with a guest performance of Hillary
   
7. Awwwwww … poooooor Ron Paul:http://bayimg.com/HalgkAabm (hattip @courosa )
8. And many, many more Obama video’s on You Tube. I won’t show them all, but you can look at “related video’s. This is one about Barrack Obama funny Pictures and quotes, using the same music as 8.
9. @gbierens referred to a comic strip in a Dutch local newspaper (ED).
   Obama pays for a drink and leaves the bar. Bartender: “Hey, Obama, don’t you want change?
10. And finally Obama 08: There is No Spoon. Unique pro-Obama shirt for sci-fi liberals, progressives, Democrats everywhere. Obama is the neo Neo. Break out of the Matrix. See the t-shirt here (hattip @mdbraber)
    

Grand Rounds 5.5

This week’s Next Grand Rounds is now up at Pallimed.

As I said last week: “Each week the grand rounds seem to get larger and larger. Fascinating how the hosts manage to present it in a digestible way”.

The present host Christian Sinclair, MD has an original solution for it. He made two different sections, one in the main post and one in the comments to

“get back to the heart of what I think Grand Rounds is meant to be. The best of the blogosphere per the host that week.” “I did not want to feel like an automaton transposing links into a link farm.“

Although there are two sections all blogpost are included (see here).

Next week’s Grand Round will be hosted by Kim at Emergiblog.

Grote Visite 1.5 (Dutch Grand Round)

Welcome to the October 21, 2008 edition of ‘grote visite’ or Dutch Grand Rounds.

This week there were 6 submissions to the blog carnival, only 2 of which were genuine (Dutch/health-related/not-commercial/no-spam).

Jan Martens of MedBlog.nl refers to an interesting article on Reuters about teleradiology and remote medicine. During the night shift medical images of patients in for instance the United States and Singapore are sent for appraisal to Indian radiologists because of lower costs and shortage of staff at night. Jan gives various examples of other interesting applications, but wonders whether this kind of telemedicine will be easily implemented in the Netherlands.

I know what lumpers and splitters are, but I’m not familiar with lurkers. As explained by Dr Shock MD PhD, with respect to online support groups, posters are the ones actively engaged by sending postings, and lurkers the ones that use online support groups in a passive way. Dr Shock summarizes recent research, revealing that participation in an online support group had the same overall profound effect on lurkers’ self-reported feelings of being empowered as it had on posters. Please read more details about the research at Dr. Shock’s excellent post “Lurkers in Health 2.0, Do They Benefit?”

By the way, Dr Shock has many other recent interesting posts as well and has an international reputation as medical blogger. For instance Pallimed hosting this week Grand Round refers to dr Shock as follows:

Dr. Shock consistently comes up with some very interesting journal articles. I really appreciated his take on impact of medical student biases towards patients with mental illness. So you may read that one as well!

******************************************************************************************

Below are my own choices from blogs form the Dutch medical blogosphere. I hope it will inspire other Dutch Medical Bloggers to participate more actively in the Dutch Grand Rounds.

The blog Health Management Rx of Jenn McCabe Gorman is already reviewed in another blog carnival, i.e.Medicine 2.0 Blog Carnival Edition #33.

People from SugarStats talked with Jennifer McCabe Gorman, one of Health 2.0’s most ‘visible’ online evangelist as they called her. By the way Jennifer wants you to know that her blog, Health Management Rx, is not dead. The reason her posts have been slow is because she is intensively preparing for Health 2.0: User-Generated Healthcare conference, which will be held in San Francisco, California from October 22nd – 23rd 2008.host

Of course we already knew that Health Management Rx was not dead, because Jenn hosted the previous Dutch Grand Round.

Many other Dutch Bloggers are also heavily involved in health 2.0, and many of them are also on Twitter. For instance apart from Jenn: @mdbraber (also in San Fransisco at the moment), @martijnhulst of martijnhulst.nl, @Zorg20 of www.azo.nl (Acute Zorgregio Oost) and @fackeldeyfinds of fackeldeyfinds.com.

October 10th, most of these twitterers were attending the master thesis presentation of Maarten Den Braber (mdbraber) about the value of business models for hospitals, either live in Enschede or virtually (livestreaming!). Interested in this subject? You can find the links to the final document and the powerpoint he used for his presentation on this blogpost.

Below are some excerpts from other MEDNL-blogs, all in Dutch

A previous host of de Grote Visite, Marjolein Fermie of “De gezondheidszorg leuker en effectiever” gives a short overview of what makes working (in Healthcare) fun.
Another C3-log-ger, Frank Wolterink reflects about franchising health using the same franchise methods as fast-food chain McDonald’s (and others). Very aptly called: ‘Franchising Health Instead of French Fries’ in another (english) post on delivering health care.
Bettinepluut discusses the new “zorgplan” and wonders whether this will really improve the living environment of patients

At A day in the life of a shrink there is a very interesting post on “the” critical care physicians of today, who completely rely on scans and lab results without physical examining and sometimes without even having real contact with the patient. Apart from unnecessary long waiting for some diagnosis (i.e. prominent pancreas cancer metastases felt instantly), this can make the patient feel very lonely. People aren’t numbers!

This blog has numerous posts on music, as has Vrouwmenszorg.web-log, a very nice diary-like blog of a family physician. From Music (Pink Floyd, In a gadda da vida, Child in Time: my style!) and beautiful photo’s to ‘a day in the life of’: “No, don’t dial 911 for an ambulance, but take a taxi and see your doctor first”. Sometimes she writes for Paramedic WorldWide.

Wonder what Vrouwmenszorg or Paramedic Worldwide would think of my previous post on (acute) care (for Addison patients). Apparently paramedics are allowed to give infusions to diabetic patients with a hypo. Read the story “met gillende sirene door de stad” (here) about a young diabetic who hurries too much (and eats too little) on the first day of his new job.

Another colorful blog on acute care, music and personal matter is 100% Mike. One of his post begins with mentioning a very special legacy of his mother: ice creams she won in a contest. The same night an elderly woman came in for a paracetamol, but had to stay for pneumonia and lung embolisms.

Another blog about acute care, from an emergency nurse: ECGreetje. Easy to digest information on hobbies (shopping) and acute (heart) care. Here latest post is on the (recently published) positive effect of the song Stayin’ Alive of the Bee Gees on heart resuscitation, not only because of the text but more so because of the beat, which is exactly the rhythm one should use for a successful resuscitation attempt: ~103 beast per minute. ECGreetje, however, is afraid that she will start dancing when listening to this song.

The Quack (and the Scream) from http://forthebirdsblog.blogspot.com/

The provocative physicians Dr. Lutser and Creiptocheilus keep on ranting against (alternative) QUACK. Dr Lutser, who takes a blog pause for a while, is highly surprised that the advocate of the controversial anti-cancer “medicine” DCA (Dichloroacetic acid), Wim Huppes, does not use this or any other alternative medicine himself, now his cancer has returned.

Cryptocheilus mentions at his blog that he has been banned from the forum of the tv program TROS-RADAR, because he was considered too offensive against mister Braam, another ‘healer’. “C’est la ton qui fait la musique”, perhaps? Good reasoning convinces more than ranting. In his earlier post, Cryptocheilus shows some examples of selective use of evidence and ‘misinterpretation’ of a Cochrane Review by Braam. Pitty that Tros-Radar only hears the tone, without understanding the text.

Finally, clinical librarian and second life specialist Guus den Brekel of DigiCMB has some interesting post on SL, for instance about how to spend an $60,000 grant for a project entitled “AIDS Information and Outreach in the Virtual World of Second Life”. He also gives a nice overview of customizabe-widgets, i.e. for blogs, technology and education.

Liked the review of your post? Would have liked a review of your post? Like to read (some of the) posts? Then Huize Sonnendael, MedBlog, Patient en EPD, Man in de Zorg, Sister Nightfall, Zorglog, Ervaringen met een verpleeghuis, Cees Sterk, Zorg voor klanten, Manager zorg vertelt, Club Confabula, Over ZN, Zo! Communicatie, Ouderenzorg in de nieuwe werkelijkheid, De gezonde patient, Medisch Contact, Huntingtondaily.web-log.nl, MediGO, MaCoAd, Verpleeghuisarts.web-log.nl, Aria Rad, Herre Kingma, Metabool.web-log.nl, Werken in de zorg, Fontys Mediatheek, Ambupleeg, Weblog voor fysiotherapeuten, Verpleegkundige, Dokter Rob, Trimbos Online 2011, Pekke.nl, Electroconvulsive Therapy, Zorggemak.nl en Bas Leerink’s Blog as well as and some of the abovementioned bloggers become a lurker too, or perhaps a poster!

Contributing is very simple, just copy the link to the post that you would like to submit here (the blogcarnival).

Just want to read: the next carnival will be hosted November 4th at Dr Shock MD PhD.

Please contribute to the upcoming Dutch Grand Rounds, so we can advocate health blogs in the Netherlands and keep informed about each other work! Mag ook in het Nederlands, hoor! Graag zelfs!

Changing care (for Addison patients)

This post is inspired by the theme for this weeks Grand Rounds at PalliMed, a Hospice and Palliative Medicine Blog: “Changing Goals of Care”. According to Christian Sinclair, M.D. of Pallimed:

It can be changing the goals in any direction, not just the curative towards palliative route, although I expect that is a common touchstone for many in the medical field.

‘Goals of Care’ is a subject that is outside of my area of professional expertise, being a medical biologist and an information specialist.

But as a consumer and patient I can easily see how I would like health care to change.

• affordable healthcare for everyone who needs it
• More personal and personalized care
• And -indeed- more attention for palliative healthcare (my mother in law has a bearable life, since low doses morphine were prescribed)

But those issues can be better addressed by persons in the field. I just simply want to restrict to “changing care in a very specific area, adrenal diseases, simply because I’m a hands-on expert, having secondary Addison’s Disease (Sheehan’s syndrome)”.

Main conclusions:
Healthcarefivers look (and act) beyond your specialty! Try to be a good generalist as well. Please adapt protocols if it suits the patients. Take the patient seriously.

Diagnosis
Primary Addison (damage or destruction of the adrenal cortex) as well as secondary Addison (absent pituitary signal(s)) often have a slow onset and are difficult to diagnose.
In theory this may be different for Sheehan’s Syndrome. According to Google Knol:

Sheehan’s syndrome (…) is a condition in which the pituitary gland is injured as result of heavy blood loss during complicated childbirth. This heavy loss of blood deprives the pituitary gland of oxygen and other nutrients and leads to necrosis (death) of pituitary tissue and therefore pituitary failure (hypopituitarism). Failure to produce breast milk after delivery (due to lack of the pituitary hormone prolactin) may be a presenting sign of Sheehan’s syndrome. Fortunately, Sheehan’s syndrome is now rare cause of pituitary failure, particularly in developed countries as a result of improved obstetric care.

Looking back I’m stunned that Sheehan was not directly diagnozed by the gynecologists themselves.
And perhaps even more surprised why it happened to me in the first place, being hospitalized in Europe, and having a previous cesarean. (For good reason it is: “Once a cesarean, always a cesarean” According to present protocols I had many negative predictors for success (no prior vaginal birth, short stature, age >40, induction of labor, gestational age almost 43 weeks, failed second stage), but worst of all they didn’t take me serious when I said I didn’t feel well and got a sudden neck pain. When standing up I fainted. So I have every reason to believe all this could have been prevented).

I lost more than 3 litres of blood (and had puerperal fever as well), developing all signs of Sheehan (and Addison crisis) in the days that followed: breast milk “disappearing”, loss of appetite, severe muscle pain, fatigue, headache, lethargy, extreme nausea, diarrhea & vomiting and finally speaking with double tongue, feeling like I fell when lying down, sensitive to cold etc. But nurses pressed to try to give breastmilk (till bleeding), reprimanded me in presence of other patients (you have to break the circle, please do your best (!) and eat something; you have to take care of your child, come on!) and a psychiatrist was being ordered. Finally (after 10 days), when I plead them to check whether I was not dehydrated, they did some tests and found out my blood Natrium was dangerously low (106; normal 140), and could apparently not be corrected by giving saline transfusion. I “missed’ this part, but when I woke up the internist told me proudly he found out I had Sheehan (practically no cortisol or any other hormones under regulation of the anterior hypophysis). Normal natrium levels were achieved after giving cortisol-replacement.

I’m by no means an exception. Addison’s disease is often missed or diagnosed late. That early diagnosis can be a challenge is frequently addressed in the medical literature and many poignant examples can be read on patient forums. In fact I know very few prompt and swift diagnoses.

For instance (from the Newsletter of “The Canadian Addison Society”, issue 27, 2002

After being admitted and discharged what seemed to feel like every weekend, I was finally admitted for bronchitis that affected my asthma. I went on Prednisone* to treat the infection. I felt much better to my surprise. After being “cured” of bronchitis, back in the hospital I went. The pain was unbearable; doctors were questioning if I was anorexic, I saw a psychiatrist who put me on Paxil because I “appeared” to be depressed. Demerol became my new best friend and was the only thing that put me at ease.
My mother continued to stay by my side the entire time. Whether it be stroking my hand, brushing my hair, or encouraging me to walk just a few steps a day. This felt like a marathon to me; in reality it was only a few steps.
After every “possible” test was completed my internist had suggested performing one more test. The results had come back positive! Addison’s Disease….**
(*Prednisone is a glucocorticosteroid that can replace cortisol; this patient also had pigmented handpalms, specific for primary Addison.)

well-ville.com/images/adrenalQA2.jpg

The same is true for other adrenal diseases. Cushing’s Disease (excess of cortisol) is often mistaken for (manic) depression. See for instance wrongdiagnosis.com or here (Dutch).

After years of non-recognized Cushing one of my fellow patients was treated by many specialists. One expert (being an orthopedic, I believe) totally missed the Cushing, because she fixated on other causes of the severe osteoporosis and didn’t notice the patient’s bruises, mania, belly fat, striae to name just a few other symptoms, typical for Cushing. Missing her diagnosis means she is mostly in a wheel chair now, and not able to do the things she liked to do (for those interested and able to read Dutch she has written a book about it: “Aftakelen and Ophijsen”)

Action (in case of a crisis)
With hormone replacement therapy, most Addison patients disease are able to lead normal lives. However extreme stress can precipitate an Addison crises, which is a medical emergency. Patients therefore often wear alert bracelets or necklaces, so that emergency personnel can identify them as having adrenal insufficiency and provide stress doses of steroids in the event of trauma, surgery, or hospitalization.

Luckily I don’t seem very vulnerable to crises (still producing aldosterone), but the one time I had something like it (presumably due wrong capsules, thus more insidious), family physicians reacted inadequatly. One gave me a lab form emphasizing twice that lab tests should ONLY be done when I was really, really ill. Very stupid, because determining Natrium costs nothing compared to hospitalization, and my pride prevented me taking the test, afraid that I made a fool of myself. My own physician said a few weeks later that I should consult a endocrinologist, because he found Addison “much too difficult”. I thought that wasn’t bad, but my endocrinologist didn’t agree, because “he would have been too late in case of a real emergency”. (I had a Na of 123, but was hospitalized, because my endo (a wonderful female doctor) found I behaved differently and wasn’t ok – I also lost >18 pounds in 2 months)

But there are far more upsetting stories of other Addison crises. Even in this era there are unnecessary deaths due to  inadequate intervention. What is also worrying is that paramedics often miss the alert bracelets. A Dutch paramedic wrote on the bulletin board of our patient’s association, that paramedics don’t even look at it, because they aren’t allowed to do anything going beyond first aid and stabilization. However, if my husband may give me an intramuscular injection of corticosteroids, why can’t a paramedic? It is the most essential emergency measure that can and should be taken. He advised that we would bundle our forces with other patient groups to change the protocols of the ambulance personnel. Paramedics won’t do anything when they are not legally entitled to.

I also hear from many Addison patients that it takes ages before there is adequate action. Apparantly routine tests have to be performed first. A nurse even told me that glucose is tested first, because it is such an easy and fast test. O.k. an addison crisis is often accompanied by low blood glucose. So what? Get those corticosteroids in!!! Intravenous injection is often difficult, because of the low blood pressure. It often takes too long and often fails, at least that is what I hear from other patients.

Iatrogenic Cushing and Addison

Apart from natural causes, Cushing and Addison’s disease can have a iatrogenic cause (unintended harmful effects by a physician’s activity, manner, or therapy). It is well known that longlasting treatment and/or high doses of corticosteroids can give Cushing-like symptoms as well as Addison-crises in case of sudden withdrawal (because of feedback mechanisms the body can’t make cortisol any longer).
Laurens Mijnders has developed long lasting Addison’s Disease because of his asthma treatment. His letter in Contrastma, a paper of a Dutch Asthma Foundation (Astma fonds) evoked many responses of patients who had used high doses corticosteroids (up to 50 mg/day Prednison per day). The reactions showed that doctors had given little or no information about adverse effects of corticosteroids and had never warned against a possible Addison crisis (see here).
An endocrinologist revealed at a meeting that they still regularly see Addison crises in patients who received high-dose steroids for their asthma, rheuma, dermatologic or other inflammatory condition
Of course some of these diseases can only be controlled by corticosteroids, but the treating physician should try to sail safely between Scylla and Charybdis, and prepare the patient for any (anticipated) danger.

Wasn’t it: “Primum non nocere” (Latin for “First, do no harm”)?!

Thus physicians, look beyond the border of your specialty and always take patients seriously, please?

Another Search Bug? Now in the Cochrane Library!

It seems that I’m becoming an expert in search problems and bugs.
Partly because I search a lot, but also because my colleagues and I often share our search problems.

This time, while giving a class, Hanny and Heleen noticed that (a) combining two terms in the Cochrane Library Search Bar with ‘and’ gives less hits than when you (b) search for those terms individually and combine them in the History with ‘and’ (see Figures). This is odd, because it should not make any difference whether you look these words up individually (which takes more time) or combine them directly. The field in which both these terms should occur is in the title, abstract and/or keyword field.
(c) Searching via advanced search has the same effect as searching the terms separately in the search bar (#7, #9)

The 3 search modes (click to enlarge)

Two examples are given below: (1) obesity and sibutramine (sets #1-#9) and (2) sibutramine and body weight (#10-#14).
Both obesity and body weight are MeSH (key words from MEDLINE).

Search History showing results two examples (click on Figure to enlarge)

It is unclear why certain records can’t be found when combining them in the search bar. The order doesn’t matter, for instance. It might have something to do with certain keywords not being found when the keyword command is not directly next to term sought (set #12 in Search History, and figure below).

Anyway this is highly undesirable. Especially for the beginner, who just wants to find a cochrane systematic review by doing a quick search. Hopefully this ‘bug’ will be fixed soon, because important papers might be missed (see below).

Missed papers (have one of the terms exclusively in the keyword (MeSH)section

Ex soccer player now a med student; tv shots at our library

Wanna see the previous soccer player Arjan de Zeeuw now continuing his medicine study, after a long intermezzo in the English league?? Or wanna see tv-shots of our academic Medical Centre (AMC) and our Medical Library than follow this link and click at the video (Voetballers in vergetelheid). Takes less than 4 minutes.

No surprise that Arjan, who is father of 4 kids, wants to become a sports doctor.

(Notably Arjan seems to read mostly books, whereas most students are behind the pc)

Special thanks to my collegue Marjan of Bidocblog for providing me the link.

http://voetbal.nos.nl/nieuws/artikel/ID/tcm:45-429888/

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Ex-voetballer nu geneeskunde student: opnames in AMC-bibliotheek!

Arjan de Zeeuw heeft zijn studie geneeskunde weer opgepakt na een lange onderbreking als voetballer in de Engelse voetbalcompetitie. Hij is nu te zien in een serie van de NOS: ‘vergeten voetballers’.

Arjan is inmiddels vader van 4 kinderen, heeft zo te zien een aardig woonstekje en tuft elke dag heen en weer naar het AMC. Hij wil graag sportarts worden.

Het leuke is nu dat de opnames in het AMC en met name in onze bieb gemaakt zijn. Dus wil je daar een indruk van krijgen en/of wil je graag iets meer weten over Arjan als medische student, kijk dan naar de volgende video (klik op de tekst naast het oranje-witte pijltje). Tussen 2 haakjes wel opvallend dat hij vooral boeken erop naslaat en niet achter de computer in het digitorium zit.

Met speciale dank aan mijn collega Marjan van het Bidocblog die me op de link gewezen heeft.

http://voetbal.nos.nl/nieuws/artikel/ID/tcm:45-429888/

Another bug in My NCBI?

This bug is now fixed (15-11-2008) !!!

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It is confusing, but each week I have another post on the appearance, disappearance or reappearance of a bug in PubMed’s My NCBI:

• October 1: the (History) set numbers could not be saved in PubMed’s My NCBI (Saved Searches) (see here)
  
• October 8: the bug seemed to be repaired (see here)
• October 15: another bug appears to be reintroduced: you can save relevant records in My Collections to run them later in PubMed. However, although the search is executed, it does not appear in the Search History.

For me this is an essential feature of My Collections.Often, when I develop a sensitive search, I collect all relevant studies, especially the ones that were not in my search (i.e. found by checking references or ‘related articles’). Then I optimize the search and hope all the relevant records will be found. This can be checked by combining (a) search(es) with the collection(s). If the search is good all relevant records will be found.

Of course this will only work when you CAN combine the collection from My NCBI with one or more searches in the History.

A cumbersome solution, that only works for one collection at the time, is that you send the collections (executed in PubMed) to the Clipboard and combine this set (#0) with the searches, but I prefer a simpler solution. In fact it has always been possible in the past….

Well we will write again to the help desk.
Hopefully I will report the bug repair next week and there will be no follow up.

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Voor de tweede keer een bug in My NCBI. Dit keer gaat het om “My Collections”. Als je een “collection” activeert, worden de desbetreffende records (in het voorbeeld 39 items) wel uitgevoerd in PubMed, maar komen ze niet in de History terecht.

Dat vind ik erg vervelend, omdat ik My Collections vooral gebruik om uitgebreide zoekacties op te zetten.

Ik sla alle relevante artikelen op in My Collections en voer ze op een later tijdstip uit. Dan combineer ik ze met een of meer searches. Ik kan zo checken of ik met zo’n search alle relevante artikelen (bijv. gekregen van klant of via related articles) vind. Is dat niet het geval, dan is het een manier om ontbrekende termen te vinden.

Deze procedure werkt nu dus niet meer, omdat een set uit My Collections niet in de History terechtkomt.

Ik heb wel een voorlopige kunstgreep bedacht, t.w. deze items in Pubmed naar het Clipboard sturen, zodat ze alsnog als set #0 in de History komen te staan. Dat werkt natuurlijk maar met 1 set tegelijk en is tamelijk omslachtig.

Voorheen werkte dit trouwens wel altijd, dus het zal wel weer liggen aan de overhaaste ‘reparaties’ en aanpassingen.

Nou, dat wordt weer een mailtje richting helpdesk.

Hopelijk wordt het snel verholpen en hoort u even niet meer van mij..

Grand Rounds 5.4

Dubious: the third post in sequence about Grand Rounds, I know. It is time for some primary posts after this one.

Just wanna mention that this week’s Next Grand Rounds is now up at Notes of an Anesthesioboist.

Each week the grand rounds seem to get larger and larger. Fascinating how the hosts manage to present it in a digestible way. This week the rounds is organized into six major sections (preceeded by nods to her favorite “movies”).

Well and that is a good excuse to place a little picture of my favorite series: Twin Peaks, which I first saw when watching tv with a colleague during a congress (ASH) in Boston 1990. “Damn good coffee, and hot!”. Damn good grand rounds, too.

Next week the grand round will be hosted by Christian Sinclair, M.D. at Pallimed. Please read the call for submission (with theme) here.

Grand Rounds 5.3

I totally forgot to inform you that this weeks grand round is (still) up at MDOD (docsontheweb.blogspot.com) in ….. MDOD style (what else would you expect?). Please read the summary here.

Previous week the grand round was hosted at Monash Medical Student.

The Next Grand Rounds will be hosted at Notes of an Anesthesioboist (no typing error) on October 14.

Deadline is Sunday October 12 (midnight, but check the timezone!!).

Dutch Grand Round 1.4

The 4rd Dutch Grand Round is up at Health Management RX of Jen McCabe Gorman.

Someone said my blog was colorful, but Jen certainly defeats me with her multi-colored post with the intriguing theme: “What’s with the Dutch?”

According to Jen:

It’s a privilege to provide inside perspectives from my adopted homeland. This is a rare chance for the American health and medical blogosphere to hear what’s really going on over there in the Netherlands, and how Dutch bloggers view international healthcare fumblings. (see here for the Grote Visite)

Next Grand Rounds will be hosted at Laika’s MedLibLog (yes this blog!) on October 21.

The deadline will be on October 19 (12.00 am, Dutch time!).
You can submit your articles through Blog Carnival or by email at (laika dot spoetnik at gmail dot com – without spaces; well check the figure).

All posts will be accepted if they broadly relate to health and are written by Dutch or are about Dutch or are related to Dutch. Blogs that are clearly (semi-) commercial or with unclear motives (no about section or no clear statement) are not eligible. If I find it unclear I will let you know in time (you will get a second chance).

So Dutch Medical Bloggers: I’m looking forward to your postings!!

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The 4de Grote visite is al een aantal dagen te bewonderen op Health Management RX van Jen McCabe Gorman. Jen verslaat mij als het om de kleurenrijkdom van de posts gaat (en dat wil wat zeggen). Ze heeft een intrigerend thema: “What’s with the Dutch?”

Volgens Jen (die wel wortels heeft met Nederland, maar momenteel vooral in de VS is -als ze niet reist):

It’s a privilege to provide inside perspectives from my adopted homeland. This is a rare chance for the American health and medical blogosphere to hear what’s really going on over there in the Netherlands, and how Dutch bloggers view international healthcare fumblings.

De volgende ronde vind plaats op Laika’s MedLibLog (ja dit blog!) op 21 Oktober

De deadline is 19 Oktober.
U kunt uw bijdrage via de Blog Carnival indienen of via email naar laika dot spoetnik at gmail dot com (zonder spaties).

Alle artikelen worden geaccepteerd mits ze op de een of andere manier met geneeskunde of gezondheidszorg te maken hebben en in het Nederlands OF door Nederlanders gescheven zijn (of evt. OVER de nederlandse gezondheidszorg gaan). Blogs die louter commercieel lijken te zijn of waarvan de herkomst niet duidelijk is komen niet in aanmerking. (p.s. als ik twijfel stuur ik wel eerst een bericht.)

Dus medische bloggers. Ga lekker aan het schrijven! Ik kijk uit naar jullie blogposts!