Welcome to the latest edition of Grand Rounds, the weekly compilation of the best of the medical blogosphere! I presume you would rather take a tour through the Netherlands, visiting windmills and tulips, but we will save this for another time. Right now, let’s take a trip around the library.
Because you know what William Osler, the Father of Modern Medicine said:
“For the teacher and the worker a great library… is indispensable. They must know the world’s best work and know it at once. They mint and make current coin the ore so widely scattered in journals, transactions and monographs.”
- William Osler, in Books and Men, in Aequanimitas, 210.
Although books are the library brand, libraries -including medical libraries- have been changing dramatically from book shelves to learning centers, print storage to digital storage, from loaning at the desk to loading from the web, from catalog-centered to database searching and education.
Well librarians adapt as well. We are also Internet-dependent.
Now let me take you by the hand and lets go through the first steps of searching.
Of course, if you have no time for this guided tour, feel free to skip the introductory sentences and read the posts that have been submitted to this round…
Readers of this blog know that I mostly search for Systematic Reviews and Evidence Based Guidelines. Although not really applicable to the submitted posts, I will briefly mention the way such subjects could have been structured for a search.
We don’t search for this…
On most occasions there is no need to look up literature. A patient needs empathy of the ones he/she loves, wants to be well informed by ready-to-use and understandable information, needs to be in the hands of a skillful doctor and is happy with some useful tips. For a doctor experience and (social and technical) skills are a prerequisite.
The National Invisible Chronic Illness Awareness Week is held annually in September. The “How to cope with pain blog” gives 10 tips to make your invisible illness visible. This post proposes ways to educate others, decrease isolation and stigma, and allow others to help, when you have an invisible illness such as pain.
Jolie Bookspan of the “The Fitness Fixer” shows a simple mechanical stretching technique that can be applied by a partner to ease symptoms of menstrual cramps.
Moving books or whole labs requires some effort. But how much more effort does it take to move to a new children’s hospital, and at Christmas-time? Beth (Elizabeth Nelsen) of “Not Terribly Ordinary” wrote down her thoughts on the night before the move.
Ramona Bates at “Suture for a Living” writes down her thoughts on the increase of suicides in ‘our soldiers’ and the way to prevent this. Thoughts that were generated by events close to her heart. A sad subject, but beautifully written.
Background questions.
There’s a distinction between background and foreground questions. A background question asks for general knowledge or “facts” (questions often starting with who, what, when, why, which). “What is type 2 diabetes?” “How can one diagnose appendicitis?” “Which treatments are available for advanced prostate cancer?” These questions can be best answered by books, databases like UpToDate and good quality websites. The novice in a field usually has more background questions than the expert.
More and more doctors use the Internet to quickly access or to keep abreast of new information. “Clinical Cases and Images Blog” describes how doctors can add expert insights and comments about websites in the recently launched Google Sidewiki.
Books are good for background questions, and are especially useful if they debunk long existing myths. Amy Tenderich at “Diabetes Mine” describes one such book, “Diabetes Rising”. She received this book (coming out in 2010) as an advance review copy and simply could not put it down. Read her review of the book and an overview of some of the diabetes-causes-and-cure-myths here.
An excellent review allowing the readers to get good background knowledge about antiplatelet agents is offered by Flavio Guzman at “Pharmamotion”. His post gives an overview on the currently used agents in clinical practice, their classification, mechanisms of action and therapeutic use. It includes charts, figures and a video that reviews the most relevant aspects of antiplatelet therapy.
Foreground questions: Domain Therapy
Foreground questions ask specific clinical questions that try to find relationships between a patient and their condition, an exposure (therapeutic, diagnostic), and an outcome. They are generally very detailed questions that can best be answered with the information contained in published research studies (website UMDJ) or syntheses therof.
Foreground Questions are usually structured in 5 parts: P I C O and domain (or study type) and are answered by searching for the best available evidence.
The most common domain is Therapy/Prevention. The PICO stands here for Patient/Population/Problem, Intervention, Comparison/Control and Outcome
When looking for the best evidence one searches for a few (not all) components and for the best study design, in the case of therapy: controlled clinical trials in the first place and -if not found- for cohort and case control studies.
“P” is definitively the most important letter in the PICO. It is the person suffering from a disease, the patient one desires to cure, the problem a doctor wants to solve. All health care should be ‘about them’: Patients.
The patient-centered and sympathetic Rob Lamberts (alias Dr. Rob) of “Musings of a Distractible Mind” muses about The Medically Homeless. He summarizes his post as follows: There’s much ado about the quality of medical care and the plight of the patient in all of this (it’s about them, remember?), but what’s the central problem? In this post I put forth the concept of “Medical Homelessness,” which is a description of the patient who doesn’t have any one place where things are in order. Data is scattered all over the place and confusion comes at a high cost. Why does this happen? What can be done about it?
The number of people affected by Alzheimer’s is growing at a rapid rate, and the increasing personal costs will have significant impact on the world’s economies and health care systems, according a new report on Alzheimer’s predicted rates. Alvaro Fernandez at “Sharp Brains” thinks that this report should act as wake-up calls for healthcare systems to focus on education & risk reduction initiatives and shares the main recommendations from an upcoming report prepared for the City of San Francisco. Recommendations include risk reduction (promote cognitive health and create a culture of “brain fitness” through mental stimulation, social engagement, physical exercise, and diet, early identification of dementia and ensuring that caregivers are aware of and have access to community resources, training and support.
“I” is also an important component of the PICO. In case of a therapeutic or preventive question the I stands for Intervention.
Dr Shock, a psychiatrist from the Netherlands has an outstanding blog with the electrifying name “Dr Shock MD”. With respect to interventions, the emphasis is not only on electroconvulsive therapy, but also on sex, drugs and….. chocolate! Which may or may not be typically Dutch. It should be noted, however, that the large number of posts mentioning a positive effect of chocolate, may imply a positive publication bias towards chocolate in favor of “good” results. Last week he claimed that Chocolate Saves Your Teeth, but his current submission is about the strong reverse association between (one year) chocolate consumption and cardiac mortality after a first acute myocardial infarction. It should be noted that this was a retrospective study, thus the evidence is much less convincing than would be obtained by long-term, randomized controlled trials.
Another post about nutrition, but more about the direct “Special Nutrition Needs for the Rescued (and the Rescuer!)” can be found at the “Medicine for the Outdoors blog”. Here, Paul Auerbach summarizes the key points from a presentation given at the Wilderness Medical Society Annual Meeting. The medical and psychological importance of providing proper nourishment to rescued individuals is of utmost importance.
I don’t know whether it is our (Dutch) reputation, but there were (relatively speaking) an awful lot of sex-related submissions: almost 15%…
First Daryl Rosenbaum at “Listed as Probable” looks at the pros and cons of “sex before the match”, as has been advocated by the coach of India’s cricket team; the coach tells his players to have more sex in order to improve performance on the field. But is this really the case? Well everything preceded by “too” is “too much”, my mother used to say…
Dr. Val at “Better Health” is wondering whether Francis Collins, former director of the Human Genome Project and new director of the NIH is “bringing sexy back to science” In an age where celebrities are treated as credible sources of health information, scientists need to find a way to communicate with the public in a new and more engaging way. Collins, has started a new initiative called “Rock Stars of Science” to promote the field, protect people from misinformation, and get the public excited about science again. “Whatever works”, dr Val concludes.
The “UN Guidelines for Sex Education” are stirring opposition (before they are even published) from conservative and religious groups who are attacking the guidelines because of their portrayal of issues like sex education, abortion and homosexuality. Nancy Brown of “Teen Health 411″ mentions 9 convincing reasons why these guidelines should not be blocked. Nancy concludes with: “Need I see more?” No, you don’t Nancy.
Most intervention studies compare an “I” with a “C”, Comparison or Control. Preferably efficacy should be tested in a randomized controlled trial (RCT), which has the least form of bias if well performed.
Only one submitted post presents evidence that has been gathered through an RCT. Faith Martin of “Highlight Health” highlights a recent RCT published in the journal Health Technology Assessment (HTA). Results of this non-inferiority trial showed that home-based care in the United Kingdom is no worse than attendance at a day hospital for older adults. Surprisingly, the cost of the home-based rehabilitation provision was not significantly different to that of day hospital rehabilitation, Indeed, given there is no difference found in outcomes or costs, patients could potentially be given the choice.
The “O” in interventions is the outcome. It is important to look for outcomes that matter most to the patients and not for surrogate markers.
Once it has been established that a treatment is effective it is important that there is compliance and the patients know “what to do”. With two videos “Allergynotes” shows how MDIs, Spacers, and Dry Powder Inhalers should and should not be used. Patients often use them wrong.
It is in itself not enough to show the effectiveness of an interventions Costs aspects also come into play, politics, insurances, and decision support systems. The following 3 posts kinda fit in this subject. Since my knowledge of these US-specific subjects is poor I will stick to the descriptions given.
Elyse Nielsen at “Anticlue” wrote “Using Rules to support clinical decisions“. “It is all about using the CDS 5 rights model to plan to have the right rule based support in the right place in the systems.”
“InsureBlog”’s Henry Stern makes the case that CMS (The Centers for Medicare & Medicaid Services) overstepped its bounds by slapping down Humana’s efforts to educate its policyholders.
Jeffrey Seguritan at “Nuts for Healthcare” writes about the Baucus bill. The Baucus bill being considered in the Senate Finance Committee is depending on an excise tax on high-end (“Cadillac”) plans as the biggest revenue driver for reform. While President Obama and health economists agree that this tax discourages wasteful health spending, many Democrats are pointing out how the tax would easily hit the middle-class. According to Jeffrey, this issue touches on the greater problem of our highly regressive and unfair tax subsidy on health benefits.
Domain Diagnosis
In EBM, diagnosis studies are mostly diagnostic accuracy study: one wants to know how good a test can predict or exclude a suspected disease. No examples of diagnostic accuracy studies here, but two examples of when diagnostic tests should be applied or not.
At “Life in the Fast Lane” Toxicology Conundrum 018 (written by Chris Nickson) deals with the myth that “necrotizing arachnidism” can be caused by a spider bite of white-tailed spiders. A wrong diagnosis (i.e. a patient thinking a nasty sore is due to a spider bite) may lead to other disorders, often infections or cancers, being mistreated. One of the embedded videos is typical of the misinformation about white-tailed spiders in Australia (presented by an exported Dutchman no less!).
Bongi feels bad about the time when a registar “forced” him and another fourth year medical student to perform a useless “diagnostic test” on a stillborn baby just as a precautionary measure against the anticipated rage of her professor at handover: “you!” she indicated my friend and i, “you are going to go down to the morgue and get that baby’s blood. and you’d better move it. the sun will be up soon.”
Soon the juniors found out that sampling of blood from a dead baby is not that easy. A very morbid story indeed.
The best description is given by Bongi in South-African – a language I can understand (thanks Bongi):
“dis ‘n storie van die ou dae tydens my mediese opleiding to iets gebeur het met ‘n oorlede baba wat nooit moes gebeur nie.
ek is ‘n chirurg in nelspruit in suid afrika. die spesifieke ervarings van hierdie deel van die wereld voorsien baie interessante stories.” (inderdaad)
Please read the entire story (in English) at “Other Things Amanzi”.
Domain: Etiology/Harm
Otherwise than regularly suggested the best evidence of harm or causality is often not provided by RCT’s, but by observational studies (preferably prospective cohort studies). RCT’s are either not ethical, or are not suited to detect rare or late harmful effects. The same is true for the domain prognosis, which studies the influence of prognostic factors in the natural course of disease
Other than with interventions the Outcome in this domain is the disease and the P is the population. The I is the causative factor.
Although “causation” can seldom be demonstrated by controlled clinical trials, care must be taken that any conclusions are based on sound observational studies. Anne Marie Cunningham, a doctor from the UK with interest in the use of social media and technology in education wondered whether a news article on the BBC with the Headline “Tech addiction ‘harms learning’” was based on good evidence. Downloading (at $24.99) and reading the report confirmed her suspicions that the BBC-conclusion about the relationship between Internet and mobile phone addiction and poor learning was based on poor science. Read the details on her blog “Wishful Thinking in Medical Education”.
Sometimes new studies reveal that causes are different than thought. The failure of the U.S. to match longevity statistics of other developed countries is well-known, but Stacey Butterfield of the “ACP Internist blog” points at a study of the demographer Dr. Preston (reviewed in a column in the New York Times) that offers a different explanation for the gap. Stacey explains: “To put it simply, the study shows that it is lifestyle (particularly smoking) that sets Americans apart from other countries, not the quality of the health care. Other researchers have calculated that if deaths due to smoking were excluded, the United States would rise to the top half of the longevity rankings for developed countries. However, the good news is that many Americans have quit smoking in the past decade, so we should be seeing continuing gains in health. The bad news is that we’re working hard to make up the difference by getting fatter.”
Indeed obesity is becoming a pandemic. Astoundingly, WHO figures from 2005 suggested that there are more people suffering from overweight-related problems than malnutrition. David Bradley Science Writer based in Cambridge, UK, reviews a recent study on his blog “ScienceBase” showing evidence from the UK with respect to the effects of current dietary trends and consumption patterns on health. Although the rewards of developing a safe and effective anti-obesity medication will be in the tens of billions of dollars, David regards it “highly unlikely that the growing epidemics of overweight and obesity are to be solved by popping a pill”.
Sometimes harm is caused by mistakes. In “Fertility Clinic Mistake Ends Up Good“ Toni Brayer of “EverythingHealth” tells about the accidental implantation of an in-vitro embryo into another woman at the clinic. But some lemons can be made into lemonade: the woman with the wrong embryo kept the baby (without demanding custody) and recently gave birth to a healthy baby boy.
Adverse conditions in a patient can result from the activity of physicians. Mostly this will be unintentional, but sometimes “doctors” deem other factors more important than what is best for the patient. Technology consultant and blogger, Sarah Cortes, went by ambulance to a rural Hospital after she suffered a serious spinal fracture after diving. The hospital staff intimidated and coerced her into accepting unnecessary reconstructive spinal surgery. Unnecessary, because she was able to swim and thus mobile, after the diving accident. Sarah thinks that boosting of accreditation was the main motive for the hospital. This story, too, has a happy ending: with the help of Twitter, Sarah was able to leave for Boston, where she was successfully treated without the need for surgery. Without Twitter it might have had a less happy ending. Read her story here at her blog “Security Watch”.
Thoughts about social media and patient safety can also be found on “Florence dot com”, the blog of Barbara Olson. She wrote the post to suggest that social networking sites can help reveal beliefs, practices, and norms in healthcare systems that undermine patient safety. She noted that these might not be readily visible using more traditional means.
An article in last month’s New England Journal of Medicine documented some disturbingly high exposures of Low-Dose Ionizing Radiation from Medical Imaging Procedures among patients. David Williams has been writing about patients getting too much radiation from diagnostic imaging for years. At least in the US, patients and physicians have no way of tracking their lifetime dose. At the “Health Business Blog” David applauds a local initiative of a Boston hospital to track radiation exposure. He reasons that Personal Health Records could help keep track and also reduce the need for excessive scans.
Well this concludes the official part of the Grand Rounds. I hope you enjoyed it. Thanks for your submissions.
It was a pleasure reading them, although -I must admit- quite an effort writing them down….
Acknowledgements
Thanks to Nick Genes for starting the Grand Round and Dr. Val Jones at Better Health and Colin Son at Residency Notes for keeping the carnival up and running.
The Next Round will be hosted by Christian Sinclair, see here for the announcement
Bonus
I asked the contributors to spend one line telling me their thoughts on medical information (MI) and/or medical librarians (ML). Here is a selection of answers (I will leave out too obvious examples of self-promotion). I especially liked that doctors mentioned their own librarian or somebody they knew (i.e. from Twitter). In order of appearance:
Beth (Elizabeth Nelsen) of “Not Terribly Ordinary“ (ML): They help to bridge the gap between what We (the medical establishment know) and what They (patients and families) should know. Our new hospital will have a family resource center staffed by a medical librarian!
Ramona Bates of “Suture for a Living” (ML): Invaluable
Rob Lamberts at “Musings of a Distractible Mind” (MI): chose this post because it focuses on medical information – both that of the patient and the information that informs decisions. The crux of our problem is not a lack of information, it is a lack of organization of the information we have.
Alvaro Fernandez at “Sharp Brains” (ML, MI): libraries overall, and medical libraries in particular, can play a crucial role in educating professionals and lay audiences on the cognitive health implications from growing research on cognitive neuroscience and neuropsychology. In fact, I just gave a talk yesterday at New York Public Library precisely on this topic!
Daryl Rosenbaum at “Listed as Probable” (ML): Don’t have any creative thoughts about medical librarians, just that our department has one that works with us and she is a very valuable resource.
Dr Val at “Better Health” (ML): they are the unsung guardians of truth in medicine. We need their help to combat the tidal wave of Internet misinformation that is confusing and harming patients everywhere.
Nancy Brown at “Teen Health 411″ (MI): “Teens need adults they can talk with and medically accurate information to facilitate healthy decisions. The habits they start as teens and the choices they make will influence their adult health.”
Jeffrey Seguritan at “Nuts for Healthcare” (ML): With the rise of the Internet as the premier information portal, medical librarians are essential in helping providers navigate through sources of information that are accurate and credible. An alarming poll this year suggested that 50% doctors use Wikipedia, not the authority patients are looking for.
Chris Nickson at “Life in the Fast Lane” (ML): Well, as you well know, we love medical librarians – especially the helpful tech-savvy ones that populate the Web!
AnneMarie Cunningham at “Wishful Thinking in Medical Education” (MI): We have more publications (journals, guidelines and user-generated content) than ever but still many of those searching (clinicians and patients) can not find what they want or need. That is the challenge. Hopefully as time passes it will feel as if we are getting closer to the solution
David Bradley at “ScienceBase” (ML): Medical, and subject specialist, librarians in general now play an even more critical role in helping their “customers” keep on top of the vast quantities of information available to them. Thankfully, there are some around who are quite expert and can pin down even the rarest of information beasts.
Barbara L. Olson at “Florence dot com” (ML): I recently compiled a list of tweeps people interested in patient safety should watch on Twitter I’ve been following Sarah Vogel @sevinfo (Pharma/Biotech information researcher, librarian) for awhile and included her.
David E. Williams at the “Health Business Blog” (MI, ML): Providing information at the point of care is critical to improving quality and reducing costs. Medical librarians can help clinicians learn to access and apply these tools
Several contributors spontaneously said that they were going to, loved or had happily lived in The Netherlands. Amy even had a baby while over here!
Interview will appear at http://www.medscape.com/index/section_2624_0
Image Credits (CC-licence)
- Library Book Shelves, Wikimedia
- PAR-TIC-I-PA-TION, or 37 pieces of library flair Flickr.com: trucolorsfly-611479605
- Stone Horses: Flickr.com: automania-73655708
- The Background/Foreground picture is used everywhere, I’ve adapted it from the excellent book: Guyatt G, Rennie D, Meade M, Cook D. JAMA Evidence Users’ Guides to the Medical Literature. A Manual for Evidence-Based Clinical Practice. 2nd ed. Chicago, IL: McGraw Hill Co; 2008.
- Dolk-Banana Therapy Flickr.com: imagesniper- 2463850234
- P Flickr.com:duncan-104311636
- I [Aye-Aye] Flickr.com: urbanmkr-247846944
- C Flickr: urbanmkr-477120721
- O Flickr: urbanmkr-249722873
- Stethoscope Flickr: ponyapprehension-733162553
- An Honest Question Flickr: photos/hryckowian/3880192862/
- Another Dead Librarian by Doug! Flickr.com: librarygeek- 741879088
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(one of assessed guidelines in one the Ann Intern Med papers is Dutch). But people still find the long established guidelines difficult to accept: coincidentally I saw tweets today asking to sign a petition to advance the age of screening ‘because breast cancer is more and more frequently observed at young age…(??)’ Young, well educated, women are very willing to sign…
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as follows:
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