Saturday, January 31, 2009


medgadget, a site dedicated to emerging medical technologies has an annual Medical Weblog Awards and the winner for 2008 (announced recently) was KevinMD. Medgadget reports:

"The winner of the Best Medical Blog of 2008 is the legendary KevinMD. Dr Kevin Pho has built an exemplary blog that features timely news and opinion of the latest in medicine, bringing in one of the most devoted audiences and keeping thousands of curious minds satisfied with smart and funny writing."

For those eagle-eyed amongst you, you will have already spotted a KevinMD badge on the homepage of TRIP. In return we'll soon have a 'search TRIP' box on the KevinMD homepage.

Reciprocity can be very useful at times!


The health video site icyou has thousands videos, all related to healthcare. The site tells us:

"icyou is a user-generated video community that empowers you to make informed decisions about your health"

I was made aware of it via twitter and following this link will highlight the discussion - click here.

I'd welcome any other thoughts on icyou!

Thursday, January 29, 2009

Social networks in medicine

With our experience with Gwagle and the lessons learnt, I look on the explosion of clinical social networks with some interest and increasingly little expectations. A few interesting recent posts on the subject:

I feel that many of these social network initiatives are technology led, not user led and are likely to suffer as a result. It's easy to look on at the likes of Facebook and think - 'we can do that'. The likes of Ning have made entry minimal but still there appears to be no obvious social networks for clinicians that have made significant impacts.

The reasons for this are no doubt complex, but a few thoughts are below:

  • Many clinicians have developed social networks and real ones at that!
  • Social networks typically need a critical mass to make them useful.
  • Still too early on in the innovation 'cycle' to make it mainstream - this point could be said about many web 2.0 initiatives (e.g. blogs, social bookmarking etc)

For an overt social network to do well it needs to package itself differently and I have no idea how that might look. I think a better chance of success is to try and create a clinical social network at the back-end of other websites and help them power community aspects. I would also like to see some efforts at an opensocial initiative for clinical sites. If these very small sites could - loosely - band together it might just create a site big enough to have a critical mass.

I keep wondering if trust is a keypoint in all this?

Survey time

Every now and then TRIP likes to find out more about our users and how they find TRIP, what improvements they'd like to see etc. Therefore, we'd really appreciate you taking 5 minutes to take our latest survey. We have two surveys, one for health professionals (and allied professions) and one for non-health professionals.

These surveys really are useful in improving TRIP so please contibute via these links below:

Tuesday, January 27, 2009

Recent twitter activity

The following is a short selection of tweets that I enjoyed or found useful.

sciencebase @JoBrodie As you've found, there is no good evidence for glucosamine efficacy, even in conjunction with chondroitin.

joemd MD Life: For the clnician to become "patient centered" is often to become less self-centered

bengoldacre Randomised trial finds no evidence of mercury in vaccines causing brain nastiness: Where will the antivaxxers go..

bbchealth The UK's doner kebabs contain "shocking" levels of salt, fat and calories, a survey concludes.

stephenfry More filming to be done. Hospital scenes. I can't help liking myself in white coat and stethoscope. Is that sad and ridiculous?

bbchealth Reducing what you eat by nearly a third may improve memory, according to German researchers.

JRBtrip Anamnesis - when you tell your medical history to a doctor!

kevinmd Should pediatricians care about the manners of children?

Monday, January 26, 2009

Promoting info & communication technologies by health professionals

Interventions for promoting information and communication technologies adoption in healthcare professionals, a new Cochrane systematic review.

Perhaps unsurprisingly the authors conclude:

"There is very limited evidence on effective interventions promoting the adoption of ICTs by healthcare professionals. Small effects have been reported for interventions targeting the use of electronic databases and digital libraries. The effectiveness of interventions to promote ICT adoption in healthcare settings remains uncertain, and more well designed trials are needed."

Mayo on Facebook

If you want to share a good experience at the Mayo Clinic, now you can share it with friends and contacts via Facebook and other social networks and become a “fan”.

Click here for further info.

Sunday, January 25, 2009

TRIP Answers - progress to date

It's just over 6 weeks old and TRIP Answers seems to have taken off.

Since January 1st we're seen the following:

  • Had over 26,000 visits
  • Added over 350 new Q&As, all quality marked
  • Main users from UK, USA, Canada, Australia and Spain
  • We've been approached by 3 large organisations looking to add our content to their sites

The top 3 Q&As viewed are:

  • A 38-year-old lady who is a smoker is having amenorrhoea on the progesterone only pill. She has a strong family history of osteoporosis. What are the current guidelines/evidence on investigations for this lady; i.e. when should she have a bone scan or plasma oestordiols?
  • What are the expected disease prevalences in wales for the purpose of the New Contract registers (i.e. CHD/LVD, CVA/TIA, diabetes, asthma, COPD, epilepsy cancer, mental health, hypothyroidism.)
  • I have a 17-year-old female patient, normotensive, non-smoker, not overweight, with 21day heavy cycle; I'd like to start her on oral contraceptive pills. Her mother had proven DVT aged 45 on HRT when no other risk factors present. Should I do thrombophilia screen before prescribing oral contraception?

We've got a slight issue with the Tag Cloud of Clinical Uncertainty so we're not pushing that part of the site yet. Aside from that, the site is going pretty well and seems stable. We're planning a slight redesign to help usability, but again nothing too major.

So far, I'd give the site 9/10!

Saturday, January 24, 2009

The lessons pilots can teach surgeons

A great news story on the BBC news website, it starts:

"Before take-off, every pilot needs to brief their crew about what to expect.

At the end of each flight, they talk briefly about what went right, what went wrong and what could be done better.

Pilots say this brief and debrief system has reduced errors and made flying safer, and a growing number of NHS medics think this system should be adapted - to make surgery safer."

Click here to read the full story.

Friday, January 23, 2009

New and updated resources

A great new resource from Scotland has been brought to my attention - Hands on Scotland - and we've added to TRIP patient information. The site reports:

"The HandsOnScotland Toolkit is an online resource for anybody working with children and young people.

This website is designed to help you make a difference to children and young people's lives, by
giving you tools to respond helpfully when they are troubled.

It is a one-stop shop for practical information and techniques on how to respond helpfully to children and young people's troubling behaviour, build up their self-esteem and promote their positive mental wellbeing."

Also, last week I posted that I'd updated the British Association of Dermatologists guidelines. Unfortunately, I forgot about their patient information leaflets, which I've now updated. These should be fully searchable on Monday morning.

Wednesday, January 21, 2009

The Inauguration

Not related to TRIP, but two blog posts relating to yesterday's inauguration:

Blog's can give perspective that mainstream media often avoids or is too slow to get to! This follows on quickly from twitter being quicker to report on the recent plane crash in the Hudson.

Whether speed is always crucial or even welcome is another issue. I don't remember, as a child/teenager, being too bothered by there being no internet, 3/4 TV channels (that's '3 to 4' not 0.75 ) and a hand-delivered newspaper!

Monday, January 19, 2009

What creates the 'popping' when you 'click' your joints?

TRIP has a long-standing interest in answering clinical questions.

We're wondering if the large number of users of TRIP can be used to help us with clinical Q&As. We aim to test this over the coming weeks, starting with this difficult question:

  • What creates the 'popping' when you 'click' your joints?

As you will see (the link is below) the existing answer highlights a high degree of uncertainty. What we want people to do is to read the Q&A and leave suggestions via this blog or via the comment form at the bottom of the answer.

To see the existing answer click here.

Evidence-Based Health Care and Knowledge Translation

Around 5 years ago I had the pleasure in visiting the College of Medicine at King Saud University, Riyadh, Saudi Arabia. I visited to present and help run a EBM conference. Since that time I have kept a keen interest in their work (and I'm an 'international advisor' to the group). They have recently released a new website (click here) which you may enjoy.

Friday, January 16, 2009

New content on TRIP

As part of our monthly update of TRIP we have just added 587 new articles.

In addition we have 'refreshed' the content of the following providers due to URL changes:

Thursday, January 15, 2009

Examples of twitter use

I've been on twitter for a few months now, but only recently have I started to take it 'seriously'. To be fair you shouldn't take twitter too seriously. When you post a message (a maximum of 140 characters) it's actually called a tweet. Below are a selection of the tweets I've appreciated and posted myself (I'm JRBtrip). As you'll see there are tweets covering a wide variety of subject areas. For me twitter allows a great way of keeping up to date, sharing in other people's experiences and finding random serious and not so serious links.

mdconsult FDA launches program to improve safety of drugs and active drug ingredients produced outside the US

TechCrunch Yahoo Search Adds Deep Links To Wikipedia Via Search Monkey

markhawker In fact, the whole OurNHS YouTube channel is pretty good

AllergyNotes Women living in poor countries are 300 times more likely to die during pregnancy or childbirth

AllergyNotes Food allergy as "Yuppie anxiety"? -- Food allergies are nothing to laugh about

amcunningham understanding students (non)use of IT

JRBtrip Twitter set for its mainstream telly moment on Jonathan Ross's comeback show

JRBtrip Twitter set for its mainstream telly moment on Jonathan Ross's comeback show

JRBtrip SIGN's new stroke guideline & they do a gr8 job of haemorrhagic stroke - most tend 2 focus on ischaemic (4Mb!!)

stephenfry Funny how loyal to your cities you Aussies are. And not content with loving Melbourne, Brisbane etc, you have to diss Sydney. Love them all!

JRBtrip Can you improve on this Q&A on the etiology of the popping when you click your joints

brownleader @JRBtrip discussed this with 3 GP's who I work with and none of us could shed any light on the aetiology of popping/clicking joints

As you'll see from the last two tweets that I asked a question (which can be viewed by all the people who 'follow' me) and brownleader responded. So twitter can be social as well.

If you're tempted to get involved drop me a line and I'll happily be your guide.

Surgical checklist 'saves lives'

The BBC report:

"Using a simple surgical checklist during major operations can cut deaths by more than 40% and complications by more than a third, research has shown."

While the full article "A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population" has been published on the NEJM site.

A few quick observations:

  • It's not a randomised trial, which could have been very easy to arrange.
  • Not all outcomes in every site are favorable.
  • Significant positive results for 'any complication' were seen in only half of the organisations.
  • Pharma sponsored trials are often criticised for not using absolute risk reduction, I note that this trial also avoids that statistic.

Irrespective of the above, brief criticisms, any article that helps highlight simply ways to improve quality of care has to be applauded.

Wednesday, January 14, 2009

Monday, January 12, 2009

Q&As in Dermatology

This post starts with an apology to Douglas and Hywel at the Centre for Evidence Based Dermatology up at Nottingham, UK. Our analysis of dermatology Q&As should have been finished early last year. No excuses really, other than my inability to write papers!

Regular readers of the blog will know I'm very interested in better ways of procuring research, be it primary research (e.g. clinical trials) or secondary research (e.g. systematic reviews). In answering real questions from front-line clinicians the ideal is to offer good solid research. Unfortunately, all too often, the evidence is either not there or of poor quality.

My experience (of answering over 10,000 clinical questions) is that all too often the research isn't particularly focussed/designed to answer clinicians questions. It was one of my reasons for getting involved in DUETs and for creating the Tag Cloud of Clinical Uncertainty. The idea behind both these initiatives is to highlight gaps in the research with a view to improving the way research is commissioned.

One approach we're using (to highlighting gaps in the evidence) is to analyse the clinical questions we've answered and to look for themes. In this instance we're matching real questions against the existing research to see how good that is. I'm involved in the NLH's specialist library for skin disorders so selecting that area seemed sensible. We decided to analyse all the clinical questions ATTRACT and the now defunct NLH Q&A Service have answered over the years. In total that's 357 questions from primary care health professionals, the vast majority being general practitioners.

One 'quick win' is to place all the questions (just the Q's not the answer text) into wordle and see what we get. There's a thumbnail below but you can see the full cloud by clicking here. Certain junk words have been removed but that's mainly to enhance impact. This type of visualisation is so powerful in visualising themes.

May the rest of the analysis move quickly from now on!

TRIP Answers, why interaction is good!

One feature we were keen on with TRIP Answers was interaction. We have made it relatively straight forward to feedback comments and we intend to make it even easier in the future.

We realised, long ago, that there are many people out their with knowledge and experience that can be useful to improve an answer. A clear example was the Q&A "Is there any GOOD evidence to support the use of honey as a treatment for leg ulcers?". This was initially answered in January 2006 by the ATTRACT service (for initial Q&A click here). In this answer there was reference to a Cochrane Systematic Review protocol (which is a notification of a review in progress), other than that there was little else.

An e-mail over the weekend was from a clinician who highlighted new research. This research had been incorporated into the Cochrane Systematic Review that was published in late 2008. It was a relatively simply job to update the Q&A (click here to see the updated answer).

If you see an answer that needs attention, let us know - it'll always be appreciated and it helps share your knowledge with the wider world.

Sunday, January 11, 2009

How to use the Tag Cloud of Clinical Uncertainty

After posting the blog about the Tag Cloud of Clinical Uncertainty (TCoCU) I received a comment asking to explain how to read the page. So, here is an explanation of what the page represents and how to use it.
  • Tags are keywords that help describe a piece of information, in this case a clinical Q&A. A typical Q&A will have 3-7 associated tags (or keywords). You can see these tags underneath a particular question.
  • A tag cloud is visual representation of these tags. They are listed alphabetically, and the importance of a tag is shown with font size or color. The more prominent a single tag appears the more times this tag appears within the collection. Looking at the TCoCU shows that terms such as Cardiovascular disease, Women's health and Musculoskeletal disease are prominent. This shows that there are lots of questions with uncertain answers in these areas.
  • The tag cloud on the homepage aggregates all the tags in the system. However, if you do a search, the resultant tag cloud only shows tags associated with the returned search results.
  • If you click on a single tag in the TCoCU this takes you to a new page, with two main areas. Firstly, there is a list of Q&As. These are all Q&As with the tag you had clicked in the TCoCU. Secondly, there is another tag cloud. When you initially clicked on a tag in the TCoCU you created a subset of Q&As and this new tag cloud is an aggregate of the tags for that subset only.

To try and make better sense of all the above go and try the following, go and click on the diabetes tab in the TCoCU. At the time of writing this shows a list of 47 Q&As which relate to diabetes that have highly uncertain answers. The tag cloud to the right of the page shows a different list of tags from the TCoCU as the new tag cloud only shows the aggregated tags from the 47 Q&As.

I hope the above helps, if not leave a comment and I'll try and clarify further.

The Tag Cloud of Clinical Uncertainty

NOTE: We recommend you read our other recent blog on this topic 'How to use the Tag Cloud of Clinical Uncertainty', it'll help you orientate yourself!

NOTE 2: It appears the Tag Cloud of Clinical Uncertainty isn't behaving itself. When I click on the diabetes tab I get taken to one place (click here) while others report being taken here. All users should be seeing what I see. So one for the techies to sort out next week - SORRY!

Over the years our team has answered over 10,000 clinical questions and our life is made easier when we find recent research/evidence to answer questions. Unfortunately, this is frequently not the case.

Historically, the most frequently asked question has been the frequency of vitamin b12 injections in pernicious anaemia. In the UK the recommendations are typically every 3 months (although recent guidance has lowered this) while in North America the suggestion is monthly. We have never been able to find any substantial evidence to support this. What is needed is a relatively simple RCT of 1 month versus 3 month injections, but that has not been done. There are a large number of other examples, all genuine clinical uncertainties, all requiring research. It was because of my desire to try and influence the research agenda that we got involved with DUETs an Iain Chalmers initiative to map out clinical uncertainties.

When we created TRIP Answers we introduced a scoring system for each Q&A and this allowed us to easily identify questions with little or no research to answer them. As well as being utilised by DUETs it allowed us to visualise uncertainties via the wonderfully named Tag Cloud of Clinical Uncertainty. While utilising a different methodology (and hence getting different results) to DUETs we have been very successful in highlighting hotspots of uncertainty. A 'thumbnail' of the main tag cloud can be seen below but it's best seen via the site (click here).

Ultimately, our desire with the Tag Cloud of Clinical Uncertainty is to highlight real clinical uncertainties, promote debate and who knows – improve research procurement/production. In the interim, we’d love you to visit the Tag Cloud of Clinical Uncertainty (click here) and explore the uncertainties, you’re in for a few surprises!

Friday, January 09, 2009

Advanced search fixed

TRIP's advanced search may be modest, but it's well used and when it broke late last year we had a large number of e-mails asking for a fix.

After what seems like an age, the fix has been rolled out.

Twitter to update TRIP Answers

I've just finished updating a Q&A on the role of statins in preventing dementia (click here). This was stimulated by a simple message published by AllergyNotes. His message was simply:

"New study supports statin's anti-dementia effects"

I followed the link which led me to a news article on Reuters and from there to the new study in JNNP.

So, well done Twitter and AllergyNotes!

One thing that struck me in the Reuters article is a quote from a commentator that states:

"He points out that nearly 20 previous studies have assessed the effect of statin use on later risk of Alzheimer's disease in older people, and the majority found substantial benefit."

Interestingly, the other reference we use was a 2007 meta-analysis of seven trials of statins in the prevention of dementia (click here) which has the conclusion:

"The current evidence does not show any beneficial effects of statins on the prevention of dementia or AD."

My point is that the Reuters commentary says the majority support the beneficial effects of statins in preventing dementia while a recent meta-analysis finds no evidence. Why might that be? I'm thinking that it might be down to the trial methodologies.

The truth is out there....

Thursday, January 08, 2009

TRIP Answers - one month old

TRIP Answers has now been out for a little over a month and so far it has been very well received and it is starting to grow:

  • Since launch, we've added around 500 new Q&As on the site from a number of sources.
  • Site traffic is starting to increase, yesterday we had 1,489 visits with 3,545 page views.
  • Comments are slowly coming in
  • We've been approached by a variety of people/organisations wishing to get involved.
  • One large website wants to use the content.

This is the first new website that I've been really involved in since the start of the main TRIP Database. However, that grew in a different manner. So, this has been a new learning experience. By using the site and listening to initial comments there are a number of minor changes I'd like to make. Some of these are to make the site slight clearly while others are to boost interaction.

But get in touch and let us know what you feel about the site.

Sunday, January 04, 2009

The Media and the Evidence

We were asked a question about beetroot and its effect on blood pressure earlier today. This as stimulated by an article by 'Dr Know' in the Sunday Times (click here). This reported:

"Bizarrely, recent medical research backs this theory up. A study from Barts and the London School of Medicine showed that drinking 500ml of beetroot juice a day significantly reduced blood pressure levels in healthy volunteers. This benefit occurred within an hour of drinking it and was more pronounced after four hours; a degree of reduction continued to be observed for up to 24 hours.

The key beneficial ingredient appears to be nitrate, typically found in leafy green vegetables. Although the quantity consumed in this trial is more than most people would probably wish to ingest every day, it is likely some benefit still occurs if smaller quantities are drunk or indeed eaten."

However, our search for the evidence highlighted an entry in TRIP Answers "What is the evidence of beetroot juice to lower blood pressure?". This included the following:

“The study was very small and therefore should be repeated in more people.

It was conducted in healthy volunteers and should be repeated in people with hypertension or at increased risk of heart attacks.

Long-term beneficial effects of beetroot juice were not investigated, nor were any potential harms measured.”

The Sunday Times gracefully published my comment!


From those of you who've looked at TRIP Answers cannot have failed to see the large tag cloud on the site. I like tag clouds as they allow you to immeadiately see trends in data as well as aiding navigation.
Last night I came across the site Wordle which analyses text to create tag clouds. The initial link I followed to get to Wordle had used the titles of over 150 session titles at an economics conference to see what the themes were. So, the image below (click to make bigger) is a Wordle-generated tag cloud of words in this blog.

I have also pasted all the titles from Cochrane Systematic Reviews to look for themes.

I'm actually interested in what conditions Cochrane explores, so have removed a number of the main terms such as intervention, versus, preventing etc to obtain a tag cloud more to my liking.