Ethics and Q&A

A bit of a grand title, but what happens when we get a question that has potentially very serious consequences? We had one yesterday. The question:

"A friend presenting with raised ESR, spontaneous bruising and temporal arteritis - any ideas, please? Awaiting haemo consult which could be two months hence."

I saw it and initially was unhappy as it was about the persons friend. So I asked our medical director for his view. Well, he felt it could be a medical emergency (especially as the GP seemed to have a two month timescale). Apperently, in TA there is a danger of blindness unless suitably managed.

The dilemma we had was how directive we should be? Our answer can be seen by clicking here. I also sent a separate, private e-mail, to the GP reinforcing the need to take this seriously.

I wonder if we'll hear any feedback from the GP!

TRIP and RSS

Microsoft catering to masses is the title on an article in The Seattle Times. This highlights the embracing of RSS in the new Internet Explorer 7. The authors view is that the move by Microsoft will finally propel RSS into the mainstream.

Currently, we use 'old fashioned' e-mail to alert people of new content. Perhaps it's time to shift to RSS.

Keeping SRs up to date

Clinical Evidence has a chapter on tennis elbow and one of the interventions is corticosteroid injections. For the short-term relief of pain it is rated as likely to be beneficial (based on a search carried out in 2005). Late last month the BMJ published a RCT on tennis elbow and one of the interventions was corticosteroid injections (click here). This concluded:

"Physiotherapy combining elbow manipulation and exercise has a superior benefit to wait and see in the first six weeks and to corticosteroid injections after six weeks, providing a reasonable alternative to injections in the mid to long term. The significant short term benefits of corticosteroid injection are paradoxically reversed after six weeks, with high recurrence rates, implying that this treatment should be used with caution in the management of tennis elbow."

The Clinical Evidence chapter relied on a 1999 systematic review and subsequent RCTs.

So, we have one SR (from 1999) and a number of other RCTs. This begs the question 'how long before these RCTs are incorporated into a new systematic review?'. This question must be true for any number of interventions.

Given the massive changes in technology and open-access, is it really too hard to free up the meta-analyses and allow (with strict conditions) users to simply add new trial data as it comes along? Each review would have inclusion criteria and as long as these were met then the data could be added. Doing this online would allow for the instantaneous updating of the meta-analysis.

This issue came up as a GP contacted the ATTRACT service asking how he should react to the new BMJ article. Our response, probably unhelpfully, is that it is not our role to weigh up new research against prior research. Ultimately, you need to wait for a new systematic review! Using the olds methods we'd need to wait for months or more likely years. With an online system you could update it in hours.

The software, if not already there, would hardly be tough to create. Those wanting up to date information would surely want it. So why is there no pressure for this to happen?

A paper from Pakistan

Open and Free Access to Full Text Journal Articles and Medical Databases in Disaster Affected Developing Countries

Inverse document frequency

My post of two days ago was slightly premature! After using the new algorithm I started noticing some strange results. So much digging around with the maths helped me discover a variable I had overlooked - inverse document frequency. After understanding this concept, a bit, I have now used it to our advantage.

The net result being the algorithm is now, without doubt, a significant improvement on algorithm we launched with - just 7 weeks ago. If the first algorithm was version 1, the version earlier this week must have been version 2, then I guess we're now at version 2.1.

Happy searching and as ever please let us know if you conduct a search and receive strange results!

IE 7

Internet explorer is now available for download.

It looks very good and seems intuitive and so far no complaints. An added bonus is the embedded search box - which I've defaulted to search TRIP. It works in the same way as the recently released firefox extension. (see top right corner of screen shot below).

Search algorithm update - 2

Following on from my earlier post the new algorithm has now been implemented. Our testing regime returned results quicker than anticipated. While still not perfect it is a definate improvement on the previous version. We are not assuming that we cannot tweak the algorithm further. We will continue to monitor performance and anticiapte further testing soon.

Search algorithm update

The new system is gradually being rolled out. No massive changes and whether users will notice much difference is open to debate. I'm sure some will but the majority probably not.

The system works exceptionally well (my view) when a category is selected (e.g. systematic reviews). However, the first set of results, where all the categories are mixed, is more problematic. Generally, it is very good. However, in a small set of results <10% the results trouble me. They're not overly bad but they could certainly be better.

My concern is that users of TRIP do not, necessarily, filter the results by category - so they get the mixed results. So two possible directions - and I'd welcome input from the readers of this blog:

1) Remove the first set of results, so users are forced to select a category to see results.

2) Continue to work with the algorithm and be happy that for the vast majority of searches the results are pretty good.

Over to you........

How to Answer Your Clinical Questions More Efficiently

An interesting paper I found while looking through the rapidly expanding UBC HealthLib-Wiki. This paper was published in the American Family Practice Management journal - click here to view the paper.

September - record month

Our first month of being free has seen a huge surge in use - as we had hoped. The total number of searches of TRIP, for September, was 132,538 - amazing!

September zeitgeist

The full September zeigeist with the Steve Irwin influence at number 1!

1. Stingray Envenomations (eMedicine) - viewed 474 times
2. Failure to thrive (ganfyd) - 368
3. Exercise therapy for multiple sclerosis (Cochrane) - 289
4. Growth reference charts (RCPCH) - 276
5. Increasing the cultural competency for healthier living (NHMRC) - 273
6. Failure to thrive (GP Notebook) - 251
7. Children and healthy eating (EPPI) - 210
8. Buprenorphine transdermal patches (Norspan) for chronic severe pain (NPS) - 198
9. Management of patients with dementia (SIGN) - 182
10. Hypertension (PRODIGY) - 179

TRIP Answers – When TRIP lets you down

An idea in early planning stages – TRIP Answers.

Our view, at TRIP, is that if someone searches TRIP and can’t find what they’re after, then TRIP has let them down. So what can we do?

Our idea is to allow users to record their clinical questions on the TRIP site; the ones TRIP has failed to help answer. What’s the point?

Well we see this as having two main purposes:

1) It will allow us to identify themes in where TRIP is letting users down. Once we know where these are we can seek suitable, evidence based, resources.

2) We’ll try and get as many answered!

The process we’re planning is to have a banner on the results page – inviting users to go to TRIP answers if the site has let them down. They will then be presented with the following options:

1) UK health professionals get directed to a relevant Q&A Service
2) A non-UK health professionals get sent to TRIP Answers
3) Non health professionals get sent to a relevant ‘answers’ site (e.g. Microsoft QnA, Yahoo answers)

Those sent to TRIP Answers will record their questions and we will attempt to ‘answer’ as many as possible. We do not have the resources to answer many questions and therefore have decided to return ‘Personalised results pages’. Our view is that a user of TRIP expects a page of pertinent results. So TRIP Answers will return a set of highly pertinent, human derived, results. Those unanswered will be recorded and used for analysis.

An additional feature is that we will prioritise questions from the ‘developing’ world. To that end we have started discussions (still at very early stages) with the Global Healthcare Information Network. Our thinking around TRIP Answers has coincided with the launch of their new campaign ‘Healthcare Information for All by 2015’.

If there are any willing volunteers out there who want to get involved, we'd be delighted to hear from you.

Watch this space for further developments.

Smart answers

http://searchenginewatch.com/showPage.html?page=3623646

Firefox extension

Yet more excitement! A UK doctor has written a firefox extension for TRIP - click here.

Q&A Feedback

A little while ago I started inviting feedback on a small number of answers on the NLH Q&A Service. After two weeks we've had our first response, and very interesting and useful it was. This response has now been added to our What causes a yellow tongue, and what is the best available treatment? answer.

I'm quite excited by this development and surely a sign that this 'invite a comment' needs expanding!

Improved algorithm

While getting to grips with our new search algorithm we noted that, whatever we did certain eTextbooks appeared 'too' high on our results page. When I say 'too' high it's a reflection that eTextbooks might not be as evidence-based as other resources. Ok, they might be the best available evidence - but if they appear above 'better' evidence then the problems arise. So, to cut a long story short - we've built a fix and this will be tested, and dispatched, sometime next week.