Health Care Reform 2010- Obama, USA, Bill, Dutch, Plan, Doctors, Letterman, Pills, $ & other Random Thoughts

“I do believe the only way we can end all preventable deaths and the suffering of millions is to provide decent health care to all.”
Hilary Benn, 2006
———————

The next Grand Rounds will be hosted by Evan Falchuk at SEE FIRST (Insights into the Uncertain World of Healthcare).  Evan’s theme is Health Care Reform.

How will it affect your life, your medical practice, your experience as a patient, as an insured, an employer, an employee, someone without insurance?  What are your reactions to the politics, and what do you think will happen next?  I’m asking for your candid views on health care reform seen from whatever perspective you bring.  Medicine, politics, business, humor, left, right, center, up, down, you name it.

Health Care Reform has been a theme more than once in this Grand Rounds, i.e. February 10th at the Health Care Blog, and at Obama’s inauguration day (Ten Suggestions For Healthcare Reform) by Val Jones, MD.

The question is which health care reform? Because after all, this is an international Grand Round with bloggers from the US, Europe, Africa, Australia & Asia.
Probably, just as Google.nl (Dutch) already suggests the theme is meant to be about the USA health care bill of Obama, the future plan, and its costs (see Google Fig).

Since I’m from the Netherlands my non-US readers probably need an introduction first:

Recently  the Patient Protection and Affordable Care Act (known as the “Senate bill”) became law on March 23, 2010 and was shortly thereafter amended by the Health Care and Education Reconciliation Act of 2010 and passed by both houses on March 25 without any support from republicans (source: Wikipedia).  Please see Reuters and CNN for an overview of the March 2010 reforms and the year in which they take effect  and the New York Times [1] for the effect per types of household (i.e. Fig. at the right)

The legislation will tighten regulation of insurance companies and is expected to extend medical coverage to more than 30 million uninsured Americans. As explained by Barack Obama in the CNN-video [2] below, it will take 4 years to implement fully may of these reforms, but some desperately needed reforms will take effect right away.  For instance, having a child with a pre-existing medical condition will no longer be the basis for denial of coverage or higher premiums in the old system.

more about “Health Care:What happens when”, posted with vodpod

As a Dutch citizen, I simply can’t imagine that an insurance would be refused because my girl has asthma and I would to have pay a lot more because I happen to have a chronic disease. I can’t imagine that so many people (from a rich country) are uninsured.

As of January 2006 Our Dutch Health Care has been reformed as well. (Officially) there is no longer a fragmented system with compulsory social insurance for the majority and private health care insurance for people with a higher income. Now there is a standard insurance for all, where the insurers have to accept all patients, with no difference in premium, and no surcharges. Children up to the age of 18 years are insured for free.
Both employer and  government will contribute to the Health Insurance fund, and the insured will pay a nominal premium for their standard insurance directly to the health insurer. People with a low income can apply for a care allowance.
To avoid that health insurers seek to avoid less healthy clients, insurers are entitled to compensation for expensive customers. Although not as ideal as conveyed by the Dutch Government in their commercial-like video [3] (a too central role for the insurers, considerably less covered by the basic health insurance) it still is a pretty good and affordable health care system.

more about “MinVWS | The new health care system i…“, posted with vodpod [press T for English translation]

It is often difficult to imagine how things work in another country unless you’ve been there or hear it through somebody else.

A Dutch correspondent in the US, Tom-Jan Meeus wrote a eye-opening article in the Dutch NRC newspaper [4] about the US health care.

When Meeus collected his first prescriptions from a US pharmacy, he had to pay six times as much for the same pills (same brand, logo, packing) as in the Netherlands. And he was even more surprised that the prices were negotiable. But he got used to the US health care system: he gets an expensive check-up each 2 months instead of the once yearly (when needed) doctor visit back in Holland. In this way his doctor safeguards himself against health insurance claims. Furthermore, his doctor “has to keep the pot boiling too”.
This man knows many influential people and has valuable inside information, i.e. about the health status (botox, psychoses) of some of the key players in the health care system. In addition, he was one of the doctors who thwarted Clintons Health Reform: his glory years. This friendly conservative doctor wants freedom of choice, for himself and his patients. When Meeus objects that this freedom of choice becomes a little expensive, the doctor argues that top health care costs a little (US doctors know they are “the best in the world”)  and continues: “do you really think the health care becomes any cheaper when Obama subsidizes 30 million people to get insured? Hanky Panky, that is what it is.” But he knows a way to circumvent the rules. He cut the ties with two insurance companies that reimburse too little. “Perhaps, we can’t stop Obama, but we can undermine him. Why should we help people when we don’t make money out of it…”.

Hopefully not all the doctors think this way (I’m sure the blogging doctors that I know, don’t), but lets give a moments thought to two statements: That the US Healthcare is “the best” (as it is) and that the new health care system costs too much.

We first have to find out whether the money was well spend before the health care renewal.

I’ve shown the figures before (see [5] and [6]), but here are some other representations.

1. According to the Organization for Economic Cooperation and Development (OECD), the US spent 15.3 percent of its GDP on health care in 2006 and this number is rising. As you can see this is far more than the other countries spend.

This trend was already visible in the early eighties: the last 10-20 years the US spend far more money on health care than other rich countries..

And although the U.S. Medicare coverage of prescription drugs began in 2006, most patented prescription drugs are more costly in the U.S. than in most other countries. Factors involved are the absence of government price controls (Wikipedia).

Perhaps, surprisingly, the higher health expenditure hasn’t lead o a higher life expectancy. (78 years in the US versus 82 years in Japan in 2007). The differences are huge if one plots health spending per capita against life expectancy at birth.

Just like the international comparison, higher health care expenditures in different parts of America don’t result in a better health care for all this extra spending. Miami spends 3 times as much money per person health care than Salem (Oregon). Many doctors in Miami, for instance, perform a bunch of tests, like ECG’s, after chest complaints, because they have the necessary devices, not because all these tests have proven useful. Despite all expensive tests and treatments, Miami (and comparable great spenders)  has the worst death rate following a heart attack.* [ source, video in ref 5 and the Organisation for Economic Co-operation and Development's Health Data 2009 site.]

And this is how the US health care works:  simply more treatments and tests are available, but the incentives are wrong: physicians are paid for the quantity of care not the quality.

Just like the doctor of Tom-Jan Meeus, who did a two-monthly unnecessary check-up.

Or as the internist Lisa Bernstein suggests in the New York Times [7]:

For instance, if an asymptomatic, otherwise healthy, patient comes to me wanting a whole-body CT scan to make sure they do not have something bad hiding inside of them, I would decline and educate him or her that there is no data to show that this test has any significant benefit to offset the potential radiation or other harm and the major medical societies do not recommend this test.”

Mind you this is the situation before the current health care reform.

But there is another thing not yet addressed: the expectations of the US-citizens. Americans (and more and more Europeans too) want those check-ups and screenings, because it gives them a (false) feeling of security and because they feel they have the right. That is why it is so difficult for people to give up unnecessary CT-scans, PSA-screening and mammograms.

One reason why Americans have a higher risk for certain diseases (diabetes, overweight, cardiovascular diseases) might be their lifestyle. And lifestyle is something you can change to a certain extent and can have great effects on your health. Lifestyle is also something you can learn. You can learn to enjoy good food, you can avoid the 3 times daily coca cola  and it can be fun to do some exercise or for children to play outside. But still some people rather have a pill to stay healthy or  undergo all kind of (poor performing) tests to see how they’re doing.

Am I exaggerating?

No. This is reality. A few days ago. I saw Letterman in his show [8] telling Jamie Oliver (on his crusade to change the US diet habits) that “he believed diet pills were the only successful way to lose weight in the U.S. and that he expected humans to ‘evolve to the point where 1,000 years from now we all weigh 500-600lbs and it will be OK’ and that “If you would go to doctor they would be happy to give you as many pills as you need and you weight 80 pounds”

Do I fail to see Lettermans warped sense of humor?

Does he really belief this? And, more important, does the majority of Americans believe this?

For here is much to gain, both in health and health care costs.

* As far as I can tell these are only associations; other possible reasons are not taken into consideration: busy live in a metropolis or the population composition might also play a role.

Main References (all accessed 29 March 2010)

1. NY-Times (2010/03/24) How Different Types of People Will Be Affected by the Health Care Overhaul.
2. CNN.com (2010/03/23) Health care timeline (including video)
3. Ministerie van VWS: The new health care system in the Netherlands
4. NRC (2010/03/20) Tom-Jan Meeus: Mijn dokter won ook van Clinton (Dutch; subscription required).
5. Laika’s MedLibLog (2009/09/10) Visualization of  paradoxes behind US Health Care.
6. Laika’s MedLibLog (2009/09/25) Friday Foolery [4]: Maps & Mapping.
7. NY Times.com (2010/03/27) health/27patient.html?src=twt&twt=nytimeshealth.
8. The dail Mail UK (Last updated 210-03-25). Simon Cable. Don’t cry Jamie! Now David Letterman lectures Oliver and says his healthy eating crusade won’t work in America

Photo Credits

• Wikipedia Commons: Healthcare spending as %25 GDP
• Unemployed single mother, from the NY-times, Ref  [1]
• Animated graph: International health data changing the parameters produces different graphs (2 shown). The data for the graph can be found in the Organisation for Economic Co-operation and Development’s Health Data 2009 see ref [4]
  

This map shows the ability of the health service of each territory to provide good basic health care to a number of people. The health service quality score for 1997 was applied to the population. The world average score for health service quality was 72 out of 100. This means that the equivalent of 4.5 billion people had access to good basic health care.The populations with the poorest health care provision live in Sierra Leone and the Central African Republic. The Sierra Leonean health system scored 36 out of 100 – that is half the world average score. Note that only the most basic care is measured here.

“I do believe the only way we can end all preventable deaths and the suffering of millions is to provide decent health care to all.” Hilary Benn, 2006

Territory size shows the proportion of people worldwide who receive good basic health care that live there.

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Friday Foolery #21 – Syphilis by Facebook

The Daily Telegraph* had a shocking headline two days ago:

Facebook ‘linked to rise in syphilis’

Facebook has contributed to a resurgence in the sexually-transmitted disease syphilis, a health expert has claimed.

So the Internet is not only spreading viruses, but also bacteria? Facebook as a route of transmission of syphilis? These Facebook-users probably use Touch Screens, too.

All the commotion was based on two vague “findings”, one conclusion, and a personal observation:

1. Syphilis cases have increased fourfold in Sunderland, Durham and Teesside
2. These are the areas of Britain where Facebook* is most popular, well at least young people in Sunderland, Durham and Teesside are 25 per cent more likely to log onto social networking sites than those in the rest of Britain.
   (Hum, so not only Facebook?)
3. Thus (?) Facebook is linked to rise in syphilis.
4. Since Prof. Peter Kelly, director of pubic health in Teesside “saw that several of the people had met sexual partners “through” these sites”, he concludes that “Social networking sites are making it easier for people to meet up for casual sex.” (Note*: he didn’t say: Facebook, so this conflicts with 2 again) (emphasis mine)
   

Poor that the “research” may be, it was big news and started of a chain reaction. The Birmingham Mail, had added a local spin on the Syphilis story (login required) which according to the medical student of  The magic of medicine contained information of an outreach officer at Birmingham, Ms Hyland, who said that according to figures from the Heartlands Clinic a 2,000 per cent (!) increase in reports of syphilis had been logged in 2007 in Birmingham.” (!  and bold are mine)

But an email correspondence of this student with Ms Hyland pointed out that she wasn’t (a) a health care worker and (b) had nothing to do with the figures reported. “She was upset by it all, and said that “I never said I was an expert and the figures are nowhere near what have been published! Figures can be obtained from the Health Protection Agency, and the rise of syphilis is nowhere near that of say, herpes or warts.”

Drama. Comedy. Burlesque.

But where do the figures come from, then? At least “@unibirmingham, in contrast to NHS Tees and their DPH, r investigating & challenging the facebook/syphilis media dumbness attrib to them” according to Ben Goldacre at Twitter.

Indeed Goldacre is trying to gather more details from NHS Tees (NHS Hartlepool, NHS Middlesbrough, NHS Redcar and Cleveland and NHS Stockton-on-Tees), but according to his tweets “Nhs Tees are slowly giving me yearly figures on syphilis/STIs in their area, almost one at a time, and with inconsistent denominators” (and less then 2 hrs later)  “omg, NHS Tees are now actively refusing to give me these figures.”

Nick Harding found where the 2000% rise in the Birmingham-area came from: heartofengland.nhs.uk, but after reporting this, the information could no longer be accessed.

Below some of the figures Goldacre did obtain via Twitter (Blue= all syphilis; Red: primary/secondary infections, note Facebook is just 6 years old). And here is a beautiful UK sexual health atlas.

Well it was not my intention to report exhaustively on this incident, because whatever the precise figures that were fabricated, the conclusion is  bulshit not justified anyway, because the NHS-Tees and/or Prof. Peter Kelly mix up correlation with causation. Or as a facebook spokesman said: “The assertion that Facebook is responsible for the transmission of syphilis is ridiculous. Facebook is no more responsible for STD transmission than newspapers responsible for bad vision.”

Oh, and comments to the initial publications (i.e. in the Telegraph) were even whittier, like:

• That must mean water is dangerous. You know 100% of people who drink it eventually die.
  Also, eating utensils can be linked to obesity. (ruddler)
  

• Quick – where is Al Gore? I am sure he will find a way to somehow relate Facebook to Climate Change. (Conservative)

Webcomic from: http://xkcd.com/552/ hattip: @doctorblogs

*I read the news in the Telegraph, but it was reported in the Sun first. Juicy Detail: Rupert Murdoch owns the rival social networking site Myspace. This is one of the aspects discussed in this excellent, more serious  post by Dr. Petra Boynton here.

Note added (27/3 0:15): Ben Goldacre just wrote a post to be published in the Guardian that deals more in-depth with the subject.

More about the Research Blogging Awards

In my previous post I mentioned that the winners of the very first edition of the Research Blogging Awards are now known.

In Beyond the book* you can hear the First Research Blogging Awards announced (see post).
Here are the podcast and the  transcript of the live interview with the Award organizers Dave Munger of ResearchBlogging.org and Joy Moore of Seed Media.

Dave and Joy talk about blogs in the research space and the reasons behind some of the winners, which include Not Exactly Rocket Science, Epiphenom, BPS Research Digest and Culturing Science.

In the interview Dave and Joy not only talk about the winners but also discuss why it is important that science bloggers write about peer review and form a community. It is also meant “to give people the broader picture about the state of research blogging today online and how all of this is helping to promote science and science literacy and culture throughout the world.”

Two Excerpts from the Transcripts by Moore (which highlights why research blogging is important:

(…..) and what we’re seeing, and it’s quite exciting, is that bloggers, scientist bloggers around the world are putting a lot of very, very thoughtful effort into spontaneously writing about peer reviewed research in a way that is very similar to what you’ll see in say the news and views sections of some of the top science journals. And so what we’re able to see is not only a broader spectrum of coverage of peer reviewed research and interpretation, but we’re also seeing the immediate accessibility to that interpretation through the blogs and it’s open and it’s free and so it’s really opening up the accessibility to views and interpretations of research in a way that we’ve never seen before.

(…..)  One of the most critical aspects of being not only a scientist, but also a blogger is ensuring that you get your work out there and you have recognition and attribution for it and therefore, to continue to encourage the Research Blogging activity, we feel that we can help play a role by ensuring that the bloggers are recognized for their work.

*Beyond the Book is an educational presentation of the not for profit Copyright Clearance Center, with conferences and seminars featuring leading authors and editors, publishing analysts, and information technology specialists.

Researchblogging Awards. Beaten by a (Former) Rat.

The winners of the Researchblogging contest have been selected.

I was rudely confronted with the harsh reality that I lost from a fellow Philosophy, Research, or Scholarship blogger, Richard Grant of Confessions of a (former) Lab Rat (and  previously of Life of a Lab Rat).

Very subtle Richard just left a note: “Sorry”.

“Thanks” Richard! And congratulations from the bottom of my heart… (no kidding, I really mean congrats!)
But in one respect you were wrong. You said: “We don’t have the sort of blogs that win awards” Well at least you were half wrong.

Ed Yong of Not Exactly Rocket Science (No?) deserves a special mention, because he won in 3 (!) categories: Research blog of the year, blog post of the year and best lay-level blog. So if you don’t know this blogger it may well be worthwhile to take a look at his blog.

Of course this is also true for all other winners (depicted below).
You can visit their blogs and/or see their Research Blogging (RB) Page.

Congrats to all winners! And heads up to all other finalists. You’re winners too!

• Research Blog of the Year: Not Exactly Rocket Science (RB page)
• Blog Post of the Year Not Exactly Rocket Science Ballistic penises and corkscrew vaginas – the sexual battles of ducks
• Research Twitterer of the Year : Bora Zivkovic
• Best New Blog (launched in 2009): Culturing Science (RB page)
• Best Expert-Level blog: Brain Windows (RB page)
• Best Lay-Level blog: Not Exactly Rocket Science (RB page)
• Funniest Blog: NCBI ROFL
• Best Blog — Biology: A Blog Around The Clock (RB page)
• Best Blog — Chemistry, Physics, or Astronomy: Uncertain Principles (RB page)
• Best Blog — Clinical Research: Virology blog (RB page)
• Best Blog — Conservation or Geosciences: Highly Allochthonous (RB page)
• Best Blog — Health: Respectful Insolence (RB page)
• Best Blog — Psychology: BPS Research Digest (RB page)
• Best Blog — Philosophy, Research, or Scholarship: The Scientist [now: Confessions of a (former) Lab Rat] (RB page)
• Best Blog — Neuroscience: Neurotopia (RB page)
• Best Blog — Social Sciences or Anthropology: Epiphenom (RB page)

Stories [5] – Polly Matzinger, the Bunny & the Dog

Stories is a new series that tells a selection of my personal stories, mostly from the time I was a student or worked as a scientist.
I wrote the draft of this post a year ago. The theme of the Grand Round hosted by Ramona Bates at Suture for a Living “posts that have to do with women in medicine as patients, as providers, as scientists” prompted me to take up the thread.

The present story took place at my first job as a scientist in the early eighties. I worked with Pavol Ivanyi, a well known immunologist, specialized in inbred mice strains and the MHC (Major Histocompatibility Complex, i.e. major transplantation antigens). Once a week we held a sort of Journal Club, that took place in our office, a small and dark room without any windows. There was a table, a blackboard and our desks. Pavol often wore the same brown woolen sweater. We had no computers, not to mention powerpoint presentations. We just had a flip-over and a blackboard.

Once it was my turn. The paper I discussed was written by P. Matzinger as first author and if I remember it well R. Zamoyska.

Little was known at that time about how the immune response reacted to foreign material but not to “self”. The MHC plays a major role in this and P Matzinger had  truly original ideas about how this worked.
I guess I must have been nervous, because it was quite a difficult theoretical paper (for me at that time).

Many times I said: “he thinks, he had the bright idea, he proposes, he concludes…”.

After I finished my presentation, Pavol took a deep breath and said frowning:

“…..It is not a HE.”

I gazed with a kind of wonder. He continued with his typical Czech accent, serious but with a twinkle in his eyes.

“It is a SHE” …….

“It is a she and ….… a very beautiful one”

Then he told us that Polly Matzinger, for that was her name, was once a Playboy bunny and a waitress at a bar frequented by scientists. A well known professor noticed her talent and persuaded her to become a scientist and get her PhD.
She appeared to be a very original, but also controversial lady. Pavol knew her well.

Pavol carried on:

“Polly has written a paper together with Galadriel Mirkwood* (see pdf here). Do you know who that is?

I nodded: “No” (how should I know?). The name Galadriel, one of the elves of  Lord of the Rings, might have been a hint.

“Mirkwood is her Afghan Hound, it is a dog, She found that her dog was as much involved in research as many other coauthors.”

According to Ted Anton’s book Bold Science, the dog was put on as a coauthor for this Journal of Experimental Medicine paper [1], because  she refused to write in the usual scientific passive voice (‘steps were taken’) but was too insecure to write in the first person (‘I took the steps’). Once discovered, papers on which she was a major author were then barred from the journal until the editor died and was replaced by another (see Wikipedia).

But as a matter of fact, one of her main ideas originated from observing her sheepdog (she is a sheepdog expert as well, and a jazz musician, carpenter, lab technician and problem-dog trainer). “I suddenly realized that there was a cell in the body which behaves like a good sheepdog – the dendritic cell. The dendritic cell would be activated by a cell dying in its midst and kickstart the immune response. And that puts the model together”. (The Independent)

Polly Matzinger is famous for her Danger Model, published in many prominent journals, like Science,  Ann N Y Acad Sci, J Immunol, Transplant Proc, Nature Med, Nature Immunology (see refs).

The BBC even made a Horizon -edition about her and her ideas. Horizon, as you may know, is a current and long-running BBC popular science and philosophy documentary program. She does now how to stand out, although sometimes this desire to stand out can overshadow her skills as a scientist and presenter according to some.

Her Danger theory challenges core beliefs about how our immune system works.

The paradigm developed by Janeway (and the Nobel Price winners Medawar/Burnet) is that non-self (foreign) triggers an immune response, while self does not. According to Polly the “self/non-self” model is not adequate.

A system that attacked everything foreign would lead to the system attacking the food we eat; a mother’s body would reject the foetus it carried. Instead, Matzinger thinks, what the body (and notably the dendritic cells) notices is danger.

This is how she explains her danger theorie in the New York Times (1998):

Q. How does your Danger Model differ from the standard Self/Nonself Model of the immune system?

A. It isn’t really insurrectionary — it’s just a different way of looking at things. Let me use an analogy to explain it. Imagine a community in which the police accept anyone they met during elementary school and kill any new migrant. That’s the Self/Nonself Model.

In the Danger Model, tourists and immigrants are accepted, until they start breaking windows. Only then, do the police move to eliminate them. In fact, it doesn’t matter if the window breaker is a foreigner or a member of the community. That kind of behavior is considered unacceptable, and the destructive individual is removed.

The community police are the white blood cells of the immune system. The Self/Nonself Model says that they kill anything that enters the body after an early training period in which ”self” is learned.

In the Danger Model, the police wander around, waiting for an alarm signaling that something is doing damage. If an immigrant enters without doing damage, the white cells simply continue to wander, and after a while, the harmless immigrant becomes part of the community.

She emphasize for instance that tumors are often not seen as dangerous and therefore not attacked by the immune system, until they outgrow their blood supply, undergo chemotherapy, or otherwise are harmed. Then the damaged tumor cells release endogenous danger signals that help trigger the adaptive response. (see this excellent blog post at Mystery Rays from Outer Space for more detailed discussion).

Her theory also implies that transplants could be permanently accepted if the danger signals could be blocked at the time of the transplant with a short course of drugs. Indeed some of her experiments point that way.

Others insist that it is not much different from the original theory, if one implies the need of a second signal (danger-signals, besides the recognition of non-self).

However, whether she is right or wrong doesn’t really matter in the long run.

Indeed like she said in the NY times:

“It is said the scientist who is willing to stick his neck out and be clear will contribute to the field whether he or she is wrong or not, because if they are wrong someone will do the experiments to prove they’re wrong and in the process will learn something about nature. So whether I’m right or wrong doesn’t matter.”

Her truly original ideas have stimulated the progress of science. She is an outstanding scientist. According to her own definition science is ” about describing nature, and so is art: We’re painting nature.(…) Actually, it’s a sandbox and scientists get to play all of our lives.“

She is a scientist who is changing our world.

References

1. Matzinger, P. and Mirkwood, G. (1978). In a fully H-2 incompatible chimera, T cells of donor origin can respond to minor histocompatibility antigens in association with either donor or host H-2 type. Journal of Experimental Medicine, 148, 84-92.
2. Ted Anton. Bold Science: Seven Scientists Who Are Changing Our World (Paperback) 193 pages; Publisher: W. H. Freeman (May 1, 2001) ISBN-10: 0716744481 ;ISBN-13: 978-0716744481
3. Matzinger P. The danger model: a renewed sense of self. Science. 2002 Apr 12;296(5566):301-5.
4. Matzinger P. An innate sense of danger. Ann N Y Acad Sci. 2002 Jun;961:341-2. Review. No abstract available.
5. Alpan O, Rudomen G, Matzinger P. The role of dendritic cells, B cells, and M cells in gut-oriented immune responses. J Immunol. 2001 Apr 15;166(8):4843-52.
6. Celli S, Matzinger P. Liver transplants induce deletion of liver-specific T cells. Transplant Proc. 2001 Feb-Mar;33(1-2):102-3. No abstract available.
7. Guimond M, Veenstra RG, Grindler DJ, Zhang H, Cui Y, Murphy RD, Kim SY, Na R, Hennighausen L, Kurtulus S, Erman B, Interleukin 7 signaling in dendritic cells regulates the homeostatic proliferation and niche size of CD4+ T cells. Nat Immunol. 2009 Feb;10(2):149-57. Epub 2009 Jan 11.

Information is Beautiful. Visualizing the Evidence for Health Supplements.

In a world driven by data, we need a simple means of digesting it all. Visualization of data may help to coop with the information overload. Good visualizations enable people to look at vast quantities of data quickly.

Bram Hengeveld at Geriatric Care (geriatricare.wordpress.com) told me of Snake Oil, a fantastic visualization of scientific evidence for popular health supplements. A well chosen name too, because Snake oil  is both a traditional Chinese medicine, as a  term for “medicines” that are fake, fraudulent, quackish, or ineffective. The expression is also applied metaphorically to any product with exaggerated marketing but questionable or unverifiable quality or benefit. (Wikipedia).

Snake oil is just one visualization at Information is Beautiful (link), the site created by David McCandless, a London-based author, writer and designer who wrote for The Guardian, Wired and others, and nowadays an independent data journalist and information designer. His passion: visualizing information – facts, data, ideas, subjects, issues, statistics, questions – all with the minimum of words (see about).

When you see snake oil you intuitively understand it all.

The image is a “balloon race”. The larger the bubble the higher its popularity in terms of number of Google hits. Orange bubbles look promising but have (yet) a low evidence.

The higher a bubble, the greater the evidence for its effectiveness. But the supplements are only effective for the conditions listed inside the bubble. Evidence is only shown for supplements, taken orally by an adult with a healthy diet.

Some supplements may be represented by multiple bubbles, one for each condition:  after all, the evidence may vary across conditions. For example, there’s strong evidence that Green Tea is good for cholesterol levels. But evidence for its anti-cancer effects is conflicting.

Another nice thing about Snake oil is that it is interactive. You can show (filter) the results for specific conditions or supplement types. Below I selected cardio. Most bubbles disappear. The evidence seems strong for green tea, fish oil and red yeast rice and low for vitamin E and omega-3. When you move your mouse over a bubble it pops up and you can read the supplements name and the condition to which the evidence applies.

Truly amazing.

One might ask how GOOD are the data on which these bubbles are based?

Well I haven’t checked, but the visualization generates itself from this Google Doc. The Google spread sheet shows all the data on which the visualization is based. These can be PubMed Records, Cochrane Systematic Reviews, Medline Plus or a full text paper. The image is automatically regenerated when the google doc is updated with new research that has come out.

The only thing that strikes me as a information specialists is that the way the evidence is retrieved is not stated. Probably this isn’t done in an evidence based way, because each piece of evidence is based on ONE article only. The choice of the paper seems rather random. And some supplements are rather vague. What is meant with “anti-oxidants?” Many of the supplements have anti-oxidant activity for instance.

But the idea in itself is great. Suppose we could gather the evidence in a more evidence based way, share it in Google Docs, appraise it and visualize it. Wouldn’t that be wonderful?

• Information is Beautiful: http://www.informationisbeautiful.net
• Snake Oil: http://www.informationisbeautiful.net/play/snake-oil-supplements/

An Evidence Pyramid that Facilitates the Finding of Evidence

Earlier I described that there are so many search- and EBM-pyramids that it is confusing. I described  3 categories of pyramids:

1. Search Pyramids
2. Pyramids of EBM-sources
3. Pyramids of EBM-levels (levels of evidence)

In my courses where I train doctors and medical students how to find evidence quickly, I use a pyramid that is a mixture of 1. and 2. This is a slide from a 2007 course.

This pyramid consists of 4 layers (from top down):

1. EBM-(evidence based) guidelines.
2. Synopses & Syntheses*: a synopsis is a summary and critical appraisal of one article, whereas synthesis is a summary and critical appraisal of a topic (which may answer several questions and may cover many articles).
3. Systematic Reviews (a systematic summary and critical appraisal of original studies) which may or may not include a meta-analysis.
4. Original Studies.

The upper 3 layers represent “Aggregate Evidence”. This is evidence from secondary sources, that search, summarize and critically appraise original studies (lowest layer of the pyramid).

The layers do not necessarily represent the levels of evidence and should not be confused with Pyramids of EBM-levels (type 3). An Evidence Based guideline can have a lower level of evidence than a good systematic review, for instance.
The present pyramid is only meant to lead the way in the labyrinth of sources. Thus, to speed up to process of searching. The relevance and the quality of evidence should always be checked.

The idea is:

• The higher the level in the pyramid the less publications it contains (the narrower it becomes)
• Each level summarizes and critically appraises the underlying levels.

I advice people to try to find aggregate evidence first, thus to drill down (hence the drill in the Figure).

The advantage: faster results, lower number to read (NNR).

During the first courses I gave, I just made a pyramid in Word with the links to the main sources.

Our library ICT department converted it into a HTML document with clickable links.

However, although the pyramid looked quite complex, not all main evidence sources were included. Plus some sources belong to different layers. The Trip Database for instance searches sources from all layers.

Our ICT-department came up with a much better looking and better functioning 3-D pyramid, with databases like TRIP in the sidebar.

Moving the  mouse over a pyramid layer invokes a pop-up with links to the databases belonging to that layer.

Furthermore the sources included in the pyramid differ per specialty. So for the department Gynecology we include POPLINE and MIDIRS in the lowest layer, and the RCOG and NVOG (Dutch) guidelines in the EBM-guidelines layer.

Together my colleagues and I decide whether a source is evidence based (we don’t include UpToDate for instance) and where it  belongs. Each clinical librarian (we all serve different departments) then decides which databases to include. Clients can give suggestions.

Below is a short You Tube video showing how this pyramid can be used. Because of the rather poor quality, the video is best to be viewed in full screen mode.
I have no audio (yet), so in short this is what you see:

• The Search Pyramid on the medical library home page for medical students.
• The links in the first layer: “Original Research”, follow link to PubMed
• View databases in other layers.
• Searching TRIP for evidence what works the best in the treatment of recurrent (anterior) nosebleeds in children: cautery or cream. Note that just searching for a single word “nosebleed” results in 3 relevant hits (if I only search on the green colored high evidence using the slider, see search):
  • Clinical Evidence : Nosebleeds in children (2008)
    
  • Cochrane Review : Interventions for recurrent idiopathic epistaxis (nosebleeds) in children (2004)
    
  • Best Bets : Cautery or cream for epistaxis in children (2001)
    

Made with Screenr:  http://screenr.com/8kg

The pyramid is highly appreciated by our clients and students.

But it is just a start. My dream is to visualize the entire pathway from question to PICO, checklists, FAQs and database of results per type of question/reason for searching (fast question, background question, CAT etc.).

I’m just waiting for someone to fulfill the technical part of this dream.

————–

*Note that there may be different definitions as well. The top layers in the 5S pyramid of Bryan Hayes are defined as follows: syntheses & synopses (succinct descriptions of selected individual studies or systematic reviews, such as those found in the evidence-based journals), summaries, which integrate best available evidence from the lower layers to develop practice guidelines based on a full range of evidence (e.g. Clinical Evidence, National Guidelines Clearinghouse), and at the peak of the model, systems, in which the individual patient’s characteristics are automatically linked to the current best evidence that matches the patient’s specific circumstances and the clinician is provided with key aspects of management (e.g., computerised decision support systems).

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.

Friday Foolery #20 What is in an element’s name?

You probably know the periodic table of elements. The  table contains 118 confirmed elements, from 1 (H, hydrogen) to 118 (Uuo, Ununoctium).

In Wikipedia. you have a nice large periodic table with chemical symbols, that link to the Wikipedia pages on the individual elements (left).

As a chemist, David Bradley at Sciencebase must have been bored with it, because he designed an unusual version of the periodic table, where the chemical symbols will take you to his various accounts online rather than information about a given chemical. Quite a few elements remained and he invited other research bloggers to claim an element if your or your blog’s name fit in terms of initial letters. David started this morning and in about a few hours almost the entire table was filled.

I claimed Li (my surname), but that was already taken by David’s Linkedin account and he suggested that I should take La of Laikas. La is Lathanum.

Of course this can be hilarious. I tweeted to Andrew Spong that he would surely fit As (Arsenicum) -poisonous as you may know- and he replied he would rather choose absinth, which unfortunately isn’t an element.

There are still a few elements left. Thus if you would like your site highlighted as an element, let David know via Twitter, give him the link to your blog and an appropriate element.

This is how the table looks. You can go to the table here (with real links).
The original post is here

And if you don’t particularly care about this table, perhaps the following adaptation suits you better. It is still available via Amazon (click on the Figure).

This table was also found on David’s blog ( see here)

Packrati.us = Twitter + Delicious = Useful + Simple

To me, Twitter is an essential source for information. It is an easy way to keep updated in my field, it is fast and it is an ideal networking site to build relationships. Without it I wouldn’t have ‘met’ so many excellent and interesting people. In fact those people are my living filter to the Twitter noise (see previous post): I only follow people with whom I share the same interest (at least in some respects). Twitter also is one of my inspirational sources for blogging, and vice versa it is an outlet for my blog posts.

Unfortunately, Twitter has one shortcoming: Tweets are volatile. Twitter is designed to catch conversations real time. Therefore it is not easy to “keep” Tweets or read them later. Usually your tweets get lost after 7 to 10 days and cease to be found by  Twitter Search. Some tweets can still be Googled, but that is not a secure way of keeping tweets.

At least I safeguard my favorited tweets by taking a RSS to my favs (yellow starred in Fig).

But this is just a way to conserve your favorite tweets for a (more) prolonged time.

What you also would like is to “archive” the URLs of the actual pages that seem interesting (the red http links in the tweets).

I used Google Notebook for that. That was near perfect: the free online Google application allowed saving and organizing clips of information (via a Firefox add-on) while online (see Wikipedia). The information was saved to “notebooks” that could be made “public” and automatically fed into Twitter to share with others. It was easy tracing articles back by searching or browsing.

But that is no more. Google decided to drop the development of Google Notebook. In addition, several of of my notebooks  were flagged as violating Program Policies?!

I tried Evernote as an alternative, but it could never win my heart. Too time-consuming, for one thing.

I may not have tried hard enough, but testing tools is not my job. I ‘m just looking for tools/ways that make my live in the web 2.0 world easy. The tools must be easy to understand and easy to use.

A new tool Packrati.us. (http://packrati.us/) seems to meet all my needs in this respect. A week ago, I read about it in a Tech Crunch paper entitled:  Packrati.us: A Dead Simple Way To Make Delicious Bookmark The Links You Tweet. Dead simple that was what I needed!

Packrati.us is a simple bookmarking service. Once you register, they follow your Twitter feed, and whenever one of your tweets contains URLs, they are added to your Delicious.com bookmarks.

So, for instance I retweeted @amcunningham and @jrbtrip, who link to an interesting article regarding bias in dissemination & publication of research. The link is a shortened URL.

When I visit My Delicious (http://delicious.com/) via an add-on in Firefox, I see that the link is automatically saved in Delicious.

The bookmark shows

1. the link to the URL (title),
2. the number of people bookmarking the link,
3. the actual tweet mentioned in notes (more notes can be added),
4. the extended url,
5. an automatic tag (packrati.us) chosen to indicate that this bookmark is automatically imported from Twitter and other tags that I manually added to facilitate retrieval.

When you click on the link you go to the actual article. I can always find the bookmark when I search for tags like bias

The following links can be automatically loaded into Delicious:

• Links in your tweets and retweets (tweets you resend)
• Links in tweets directed to you (send by others)
• Links in your favorited tweets (!) (quite new)

You can choose to:

• Expand the URLs that have been shortened with an URL shortening service
• Replace existing bookmarks (no duplication, old tags are kept.
• Not convert hashtags from tweets to tags for the bookmarks (default = tagging hashtags)
• Exclude tweets with specific tags (new)
• Exlude tweets from a selection of sources
• Add the sender of the tweet (other than yourself)

Packrati.us is under continuous development, some features have just been added. I love the new feature that favorited tweets can be kept (alas it doesn’t work retrospectively, so the above favs are not included).

In practice you can get a lot of bookmarks if you tweet/favorite a lot. It is good to exclude some tweets beforehand and imo necessary to prune the tweets afterwards and add tags. Otherwise it becomes a (disorderly) mess.

Although Packrati.us links only Twitter and Delicious, you can use each platform separately. I also use Delicious to manually add bookmarks of websites I like. Yes, thanks to Packrati.us I learned to love delicious again.

Sugar-Sweetened Beverages, Diet Coke & Health. Part I.

At Medical and Technology of Joseph Kim, the upcoming Grand Rounds host, I saw the blog post “Need your help on Facebook to get Diet Coke to Donate $50,000 to the Foundation for NIH”.

National Heart Lung and Blood Institute has started a national campaign in the US, The Heart Truth^®. They issued a challenge in support of heart health, raising awareness on the fact that  heart disease is the #1 killer of women, to identify risk factors and take action to lower them. Diet Coke is one of their corporate-partners, helping to spread the word through visibility on 6.7 billion packages of Diet Coke featuring The Heart Truth and Red Dress symbol. It has also started a Facebook cause: Diet Coke will donate $0.50 for every person that joins the cause and $1.00 for every person that donates $1, for a total donation of up to $50,000!

O.k. Donation Fine, NIH fine, but Coca Cola as a main sponsor to raise awareness against heart disease?? Its almost feels like a tobacco company raising awareness against lung cancer. It is as odd as McDonalds, Lego & Mars preaching online advertising awareness to kids...

You could object that any money to raise awareness is  a welcome bonus and that diet coke, unlike normal coke, doesn’t contain any calories. But then you could ask whether diet coke is really healthy… Plus Coca Cola does sell a lot of beverages with loads of sugar, with a possible adverse effect on health, including cardiovascular disease (see below). It looks a lot like hypocrisy to me, meant only to improve the BRAND.

Well, I was to write about sweetened beverages anyway, since I came across several interesting news items the last weeks.

Sugar-Sweetened Beverages Have Major Effects on Diabetes and Cardiovascular Health

During the joint EPI/NPAM Conference (Cardiovascular Disease Epidemiology and Prevention &- Nutrition, Physical Activity and Metabolism), Mar 2-5, 2010 (link), Litsa Lambrakos presented a poster “Sugar-Sweetened Beverage Consumption and the Attributable Burden to Diabetes and Coronary Heart Disease” that was covered in a press release and in the media (Elsevier Global Medical News; All Headline News)

Based on data from several large observational studies demonstrating a link between higher rates of sugar-sweetened beverages (SSB) consumption and subsequent risk of incident diabetes, Lambrakos and colleagues assumed that daily consumption of SSBs is associated with an increased risk of incident diabetes (RR 1.32 for those with daily consumption compared with adults consuming less than one sugar-sweetened beverage per month).  Next they estimated that the increased consumption of sugar-sweetened beverages (including sugar-sweetened soda, sport and fruit drinks) between 1990 and 2000 contributed to 130,000 new cases of diabetes, 14,000 new cases of coronary heart disease (CHD), and 50,000 additional life-years burdened by coronary heart disease over the past decade. They derived these data from the 1990-2000 National Health and Nutrition Examination Survey (NHANES) on consumption of sugar-sweetened beverages, combined  with the CHD Policy Model, a computer simulation of heart disease in U. S. adults aged 35-84 years.

Through the model, the researchers also estimated that the additional disease caused by the drinks has increased coronary heart disease healthcare costs by 300-550 million U.S. dollars between 2000-2010. This is probably an underestimation, because it does not account for the increased costs associated with the treatment and care of patients with diabetes alone.

How does this ($300.000.000-$550.000.000) compare to the $50,000 (max) that Coca Cola is willing to contribute to The Heart Truth?

Admitted, the comparison is not entirely fair. There are far more soft drinks than the sodas from Coca Cola. More importantly, the reliability of the  figures is highly dependent on the accuracy of the assumptions. Furthermore it is hard to review a study that is not yet published.

Other studies on possible harm of SSB consumption. 1. Effects on BMI, overweight & obesity.

To get an idea about the evidence on the ‘harm’ of SSB I did a quick search in PubMed (see PubMed tips).

First I searched for secondary (aggregated) sources.

((Dietary Sucrose AND beverages) OR soft drink* OR sugar-sweetened beverag* OR soda*[tiab]) AND “systematic”[Filter]

This yielded 27 hits.

Five Publications centered on the effect of beverages on weight, obesity or BMI.

The effect on overweight seems the most obvious side-effect of SSB’s. First the increase in obesity over time has been paralleled by an increase in soft drink consumption. Second the daily sweetener consumption in the United States increased by 83 kcal per person, of which 54 kcal/d  from soda. If these calories are added to the normal diet without reducing intake from other sources, 1 soda/d could lead to a weight gain of 6.75 kg in 1 year. [refs in 2]

Still the evidence is not that clear.

Malik [2], and an almost overlapping systematic review [3] conclude that large cross-sectional studies, well-powered prospective cohort studies with long follow-up, and short-term experimental studies (including 2 RCT’s), show a positive association between greater intakes of SSBs and weight gain and obesity in both children and adults and yield sufficient evidence for public health strategies to discourage consumption of sugary drinks as part of a healthy lifestyle.

Two later reviews [4,5] point out that Malik et al. had erroneously concluded that the evidence was ‘strong’, because “several studies were reported as positive when only a selected sub-group had a positive result, or classified as ‘positive non-significant’ where coefficients are near zero and P values in excess of 0·2. Furthermore, the results of two studies were confounded by the inclusion of diet soft drinks.”[4]

On the contrary, Forshee et al [4] conclude that the  association between SSB consumption and BMI was near zero. Interestingly, the funnel plot analysis was consistent with publication bias against studies that do not report statistically significant findings!

Gibson [5] concludes that that the effect of SSB on body weight is small except in susceptible individuals or at high levels of intake. She also points out that the totality of evidence is dominated by American studies (including the positive NHANES study), “that may be less applicable to the European context where consumption is substantially lower and composition or formulation may differ (high-fructose corn syrup v. sucrose, proportion of diet v. non-diet, etc).”
Indeed in a systematic review primarily including European studies [6], overweight was not associated with the intake of soft drinks, but with lower physical activity and more tv watching time.

Thus the effect of SSB (alone) on BMI and overweight is inconclusive, based on the current body of evidence.

It is not excluded though that high intake of SSB alone or regular consumption of SSB in combination with other unhealthy lifestyle factors (unsaturated fat, lower physical activity) do contribute to obesity.

Since lack of sleep is also unhealthy (and possibly obesogen), I will leave it here.

Next time I will discuss any cardiovascular or other harmful effects of sugar sweetened beverages ànd diet sodas.

Meanwhile enjoy the sugar and coca cola video below.

Whatever the evidence, daily consumption of SSB, with many calories and no nutritional value, doesn’t seem overtly healthy to me. I won’t allow my kids to drink soda as a habit.

References

1. Litsa K Lambrakos, Pamela Coxson, Lee Goldman, Kirsten Bibbins-Domingo (2010). Sugar-Sweetened Beverage Consumption and the Attributable Burden to Diabetes and Coronary Heart Disease, poster  365, Joint Cardiovascular Disease Epidemiology and Prevention &- Nutrition, Physical Activity and Metabolism – Conference Mar 2-5, 2010.
2. Malik VS, Schulze MB, & Hu FB (2006). Intake of sugar-sweetened beverages and weight gain: a systematic review. The American journal of clinical nutrition, 84 (2), 274-88 PMID: 16895873
3. Wolff E, & Dansinger ML (2008). Soft drinks and weight gain: how strong is the link? Medscape journal of medicine, 10 (8) PMID: 18924641
4. Forshee RA, Anderson PA, & Storey ML (2008). Sugar-sweetened beverages and body mass index in children and adolescents: a meta-analysis. The American journal of clinical nutrition, 87 (6), 1662-71 PMID: 18541554
5. Gibson S (2008). Sugar-sweetened soft drinks and obesity: a systematic review of the evidence from observational studies and interventions. Nutrition research reviews, 21 (2), 134-47 PMID: 19087367
6. Janssen I, Katzmarzyk PT, Boyce WF, Vereecken C, Mulvihill C, Roberts C, Currie C, Pickett W, & Health Behaviour in School-Aged Children Obesity Working Group (2005). Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their relationships with physical activity and dietary patterns. Obesity reviews : an official journal of the International Association for the Study of Obesity, 6 (2), 123-32 PMID: 15836463

Photo Credits

1. Diet Coke: http://en.wikipedia.org/wiki/File:Diet_Coke_can_US_1982.jpg
2. Sugar in Coca Cola: http://www.sugarstacks.com/

They used data from the 1990-2000 National Health and Nutrition Examination Survey (NHANES) on consumption of sugar-sweetened beverages. She combined that with the Coronary Heart Disease Policy Model, a computer simulation of heart disease in U. S. adults aged 35-84 years.

#Friday Foolery 19: #Funnydoctornames

Last Tuesday I went to my dentist named Joy and I tweeted:

1. 
   laikas Although my dentist’s name is Joy and although she is the best dentist in the world, going to the dentist is still not my favorite thing! 09 Mar 2010 from TweetDeck

Within no time other people (doctors, healthcare workers as well as librarians) responded to this tweet with their own funny Doctor-names.
Doc_rob even created the hashtag #funnydoctornames. Searching for this hashtag, I found tweets I had missed, because they were directed to doc_rob and not to me.

Below some of the tweets, oldest ones first:

1. 
   laikas Although my dentist’s name is Joy and although she is the best dentist in the world, going to the dentist is still not my favorite thing! 09 Mar 2010 from TweetDeck
2. 
   grasshopperlibr @laikas my dentist is Dr. Grimm 09 Mar 2010 from FriendFeed in reply to laikas
3. 
   doc_rob @laikas We had a cardiologist named Dr. Killam. 09 Mar 2010 from TweetDeck in reply to laikas
4. 
   EnableOT @doc_rob @laikas – my husband works with Dr Evill! 09 Mar 2010 from TweetDeck in reply to doc_rob
5. 
   EnableOT @laikas @doc_rob at school I was taught by german teacher Herr Cutts! 09 Mar 2010 from TweetDeck
6. 
   bmljenny @laikas I worked at a place where there was a Dr. Medline. I thought that was pretty hilarious. 09 Mar 2010 from TweetDeck in reply to laikas
7. 
   doc_rob I heard of a proctologist named Ben Dover, but that may have been fictitious. #FunnyDoctorNames 09 Mar 2010 from TweetDeck
8. 
   MatthewBowdish @doc_rob I know a gastroenterologist named Dr Bowlus #funnydoctornames 09 Mar 2010 from web in reply to doc_rob
9. 
   dockj @doc_rob #FunnyDoctorNames We had a resident, Dr. Merlo rotating with Dr. Pino. Fortunately not many Pediatric patients needed Detox. 10 Mar 2010 from Twitterrific
10. 
    sevinfo @laikas A friend goes to a dentist called Dr. Jolly 10 Mar 2010 from TweetDeck

– this quote was brought to you by quoteurl

Doc_rob (although mentioning Bend-Over as proctologist) warned: “Just not the obvious urologist names… #FunnyDoctorNames!

But of course these are the most hilarious. Symtym for instance points at a funny story regarding vasatomy featuring Dr. Donald Snyder, an urologist and dr Dick Chopper, a surgeon. Medpiano immediately mentioned Dr Seaman, the urologist, while  Doc_Rob himself linked to a whole page with funny medical names, listed per discipline. Like:

• OB/GYN: Dr. Wiwi, Dr Ono; , Dr Fillerup (as in fill-her-up), Dr Dildy; Dr Cherry, Dr Love, Dr Semen, Dr In Hur, Dr Bunn, Dr Hooker, Dr Finger, Dr Cocks, Dr Nippel, Dr Beaver (3), Dr Biggerstaf
• GI: Dr. Puppala, Dr Butt
• Surgeons: Dr Cutts, Dr Slaughter (3), Dr Kutteroff, Dr Butcher
• Urology: Dr Peter Poor , Dr Waterhouse and Dr Dick Finder
• Psychs: Dr Alter, Dr Brain, Dr Strange, Dr Moodie, Dr Nutt, Dr Crabb, Dr Dement
• Pediatricians:  Dr Jelley; Dr Small,  Dr Tickles,  Dr Sno White, Dr Toy, Dr Kidd (4 )

Of course there are many other lists on the Internet like this one. But the above list is very thorough and is preceded by a list of references pertaining to “Research into nominative determinism”. This may not be surprising as the list was started by Kathy Tacke, a Library Manager, on the MEDLIB-List.

Know any other funny medical/doctor names? Please tell me!

———————

Voor Nederlanders: wij hebben natuurlijk ook heel grappige doktersnamen. Mijn vorige tandarts heette bijv. Dr Snijders (en als marinier deed hij zijn naam eer aan). Mijn ex-collega heette dr. Quack. En Beenhakker is ook een naam die veelvuldig voorkomt onder orthopeden & chirurgen. Hier is een NL-lijst met wat namen, zoals

• Dr. I.L. Boor, Dr. Snoep, Dr. Vulinghs (Tandarts)
• Dr. Knipscheer, Dr. Lips, Mevr. Ooievaar (Gyneacoloog, vroedvrouw)
• Dr. Kortleve
• Dr. Plasmans, van den Fonteyne, Daisy Dratatie (uroloog)
• Dr. Zuur (Scheikundige)
• Drs. Pillen (apotheker)

Kent u meer grappige namen van mensen uit de gezondheidszorg, zeg het mij!

Dr Wiwi; Dr Blessing (FP with OB sideline), Dr Ono; Dr Risk, Dr Fear, Dr Yell, Dr Lecher, Dr Dibble, Dr Fillerup (as in fill-her-up), Dr Hyman, Dr C. Surgeon, Dr Risk, Dr Beavers, Dr Polke, Dr Jamm, Dr Boddy (pronounced body, “bawdy”); Dr Dildy; Dr Cherry, Dr Love (many Loves, especially the partnership Drs. Love and Nerness), Dr B. Savage, Dr Dickman, Dr Pillow, Dr Fear; Dr Fingerhut.; Dr Popp, Dr Spoon, Dr Hyman, Dr Bush, Dr Kuntz, Dr Pap, Dr Storck, Dr Kum, Dr Semen, Dr In Hur, Dr Hatch.; Dr Heinie.; Dr Bunn, Dr Wiwi, Dr Dick, Dr Grab, Dr Catching, Dr Gass, Dr Handwerker, Dr Born, Dr Angel, Dr Sunshine, Dr Fagnant, Dr Hatcher, Dr Hooker, Dr Finger, Dr Cocks, Dr Nippel, Dr Lipps, Dr Payne, Dr Beaver (3), Dr Biggerstaf

The Placebo & Homeopathy effects

Ben Goldacre is the man behind the book “Bad Science“, the blog “Bad Science” (http://www.badscience.net/) and the weekly Bad Science column in the Guardian. He is a medical doctor who specializes in “unpicking dodgy scientific claims made by scaremongering journalists, dodgy government reports, evil pharmaceutical corporations, PR companies and quacks.“

One of Ben’s favorite subjects is “the placebo effect”.  He wrote a two-part documentary series called The Placebo Effect on BBC Radio 4.

Recently Ben also made a short video, released by NHSChoices, on the placebo effect. Here he explains this difficult topic in a clear and comprehensible fashion.

Somehow I always think of Ben as his logo suggests: dr. Frankenstein. It is a relief to see that dr. Ben is almost the opposite: friendly, enthusiastic and crystal clear (without needing a crystal ball .

The video is not only recommended for people who don’t have a clue about the placebo effect but also for those (like me) who already know that a placebo is a dummy treatment.
Did you know, for instance, that one placebo can be more effective than another, depending on your expectations or the color of the capsule/pill or the expectations of the one who treats you?

Seeing the video I wondered in what respect homeopathy would differ from the placebo.

And you know what? Ben Goldacre explains that too in an older video. Really wonderful how “magically” homeopathic dilutions are graphically explained.

———

The first video has been tweeted about and blogged about several times. First that was a reason not to blog about it. But on the other hand the topic is well suited for this blog and many people who aren’t on Twitter or don’t follow those blogs might like it anyway.

To you my dear reader the following question: do you like me to include such videos, short notes or  trendy topics on my blog alternating with the longer in depth posts)?

Research Blogging Awards 2010

It is now possible to vote for the winners of the 2010 Research Blogging Awards.

Yet another blog contest, I can hear you say.

Yes, another blog contest, but a very special one. It is a contest among outstanding bloggers who discuss peer-reviewed research.

There are over 1,000 blogs registered at ResearchBlogging.org., responsible for 9,500 posts about peer-reviewed journal articles.

By February 11, 2010, readers had made over 400 nominations. Then, according to researchblogging.org, “the expert panel of judges painstakingly assessed the nominees to select 5 to 10 finalists in each of 20 categories”.

The categories include:

• Research Blog of the Year  with some excellent blogs like Neuroskeptic (RB page) and Science-Based Medicine (RB page)
• Blog Post of the Year
• Research Twitterer of the Year including David Bradley, Dr. Shock and Bora Zivkovic
• Best New Blog (launched in 2009)
• Best Expert-Level blog 
• Best Lay-Level blog 
• Funniest Blog 
• Blogs in other languages, like German and Chinese
• Blogs according to specialty like Biology, Health, Clinical Research, NeuroScience, Psychology etc

I was surprised and honored to note that Laika’s MedLiblog is finalist in the section Philosophy, Research, or Scholarship. Another librarian, Anne Welsh of First Person Narrative is also finalist in this section.

1. First Person Narrative (RB page)
2. Christopher Leo (RB page)
3. The Scientist (RB page)
4. Laika’s MedLibLog (RB page)
5. Good, Bad, and Bogus (RB page)

It is now up to you, researchbloggers to vote for your favorite blogs. You don’t need to vote for all categories. It is simply too much and in case of Chinese blogs wouldn’t make much sense either.

You can only cast your vote if you are registered with ResearchBlogging.org.
If you’re not registered (and you blog about peer-reviewed research), you still have time to register. See here for more information. This way you can vote, and most important, can contribute to ResearchBlogging.org. with your review of peer reviewed scientific articles.

Voting closes on March 14, and awards will be announced on ResearchBlogging.org on March 23, 2010.

Searching Skills Toolkit. Finding the Evidence [Book Review]

Most books on Evidence Based Medicine give little attention to the first two steps of EBM: asking focused answerable questions and searching the evidence. Being able to appraise an article, but not being able to find the best evidence may be challenging and frustrating to the busy clinicians.

“Searching Skills Toolkit: Finding The Evidence” is a pocket-sized book that aims to instruct the clinician how to search for evidence. It is the third toolkit book in the series edited by Heneghan et al. (author of the CEBM-blog Trust the Evidence). The authors Caroline de Brún and Nicola Pearce Smith are experts in searching (librarian and information scientist respectively).

According to the description at Wiley’s, the distinguishing feature of this searching skills book,  is its user-friendliness. “The guiding principle is that readers do not want to become librarians, but they are faced with practical difficulties when searching for evidence, such as lack of skills, lack of time and information overload. They need to learn simple search skills, and be directed towards the right resources to find the best evidence to support their decision-making.”

Does this book give guidance that makes searching for evidence easy? Is this book the ‘perfect companion’ to doctors, nurses, allied health professionals, managers, researchers and students, as it promises?

I find it difficult to answer, partly because I’m not a clinician and partly because, being a medical information specialist myself, I would frequently tackle a search otherwise.

The booklet is in pocket-size, easy to take along. The lay-out is clear and pleasant. The approach is original and practical. Despite its small size, the booklet contains a wealth of information. Table one, for instance, gives an overview of truncation symbols, wildcards and Boolean operators for Cochrane, Dialog, EBSCO, OVID, PubMed and Webspirs (see photo). And although this is mouth watering for many medical librarians one wonders whether this detailed information is really useful for the clinician.

Furthermore 34 pages of the 102 (1/3) are devoted on searching these specific health care databases. IMHO of these databases only PubMed and the Cochrane Library are useful to the average clinician. In addition most of the screenshots of the individual databases are too small to read. And due to the PubMed Redesign the PubMed description is no longer up-to-date.

The readers are guided to the chapters on searching by asking themselves beforehand:

1. The time available to search: 5 minutes, an hour or time to do a comprehensive search. This is an important first step, which is often not considered by other books and short guides.
   Primary sources, secondary sources and ‘other’ sources are given per time available. This is all presented in a table with reference to key chapters and related chapters. These particular chapters enable the reader to perform these short, intermediate or long searches.
2. What type of publication he is looking for: a guideline, a systematic review, patient information or an RCT (with tips where to find them).
3. Whether the query is about a specific topic, i.e. drug or safety information or health statistics.

All useful information, but I would have discussed topic 3 before covering EBM, because this doesn’t fit into the ‘normal’ EBM search.  So for drug information you could directly go to the FDA, WHO or EMEA website. Similarly, if my question was only to find a guideline I would simply search one or more guideline databases.
Furthermore it would be more easy to pile the small, intermediate and long searches upon each other instead of next to each other. The basic principle would be (in my opinion at least) to start with a PICO and to (almost) always search for secondary searches first (fast), search for primary publications (original research) in PubMed if necessary and broaden the search in other databases (broad search) in case of exhaustive searches. This is easy to remember, even without the schemes in the book.

Some minor points. There is an overemphasis on UK-sources. So the first source to find guidelines is the (UK) National Library of Guidelines, where I would put the National Guideline Clearinghouse (or the TRIP-database) first. And why is MedlinePlus not included as a source for patients, whereas NHS-choices is?

There is also an overemphasis on interventions. How PICO’s are constructed for other domains (diagnosis, etiology/harm and prognosis) is barely touched upon. It is much more difficult to make PICOs and search in these domains. More practical examples would also have been helpful.

Overall, I find this book very useful. The authors are clearly experts in searching and they fill a gap in the market: there is no comparable book on “the searching of the evidence”. Therefore, despite some critique and preferences for another approach, I do recommend this book to doctors who want to learn basic searching skills. As a medical information specialist I keep it in my pocket too: just in case…

Overview

What I liked about the book:

• Pocket size, easy to take a long.
• Well written
• Clear diagrams
• Broad coverage
• Good description of (many) databases
• Step for step approach

What I liked less about it:

• Screen dumps are often too small to read and thereby not useful
• Emphasis on UK-sources
• Other domains than “therapy” (etiology/harm, prognosis, diagnosis) are almost not touched upon
  
• Too few clinical examples
• A too strict division in short, intermediate and long searches: these are not intrinsically different

The Chapters

1. Introduction.
2. Where to start? Summary tables and charts.
3. Sources of clinical information: an overview.
4. Using search engines on the World Wide Web.
5. Formulating clinical questions.
6. Building a search strategy.
7. Free text versus thesaurus.
8. Refining search results.
9. Searching specific healthcare databases.
10. Citation pearl searching.
11. Saving/recording citations for future use.
12. Critical appraisal.
13. Further reading by topic or PubMed ID.
14. Glossary of terms.
15. Appendix 1: Ten tips for effective searching.
16. Appendix 2: Teaching tips

References

1. Searching Skills Toolkit – Finding The Evidence (Paperback – 2009/02/17) by Caroline De Brún and Nicola Pearce-smith; Carl Heneghan et al (Editors). Wiley-Blackell BMJ\ Books
2. Kamal R Mahtani Evid Based Med 2009;14:189 doi:10.1136/ebm.14.6.189 (book review by a clinician)

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