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Preview: Clinical Evidence, Searching Tidbits, and Other Minutiae

Clinical Evidence, Searching Tidbits, and Other Minutiae

Updated: 2018-02-23T06:22:37.984-06:00


Death certificates


At the Pump Handle today, revere posts a brief overview of death certificates and their use in research, also with a nice discussion of age-adjusted death rates that fits in nicely with this week's post here on the confounding issue.



Confounding is a concept often mentioned in clinical research - the idea that a 3rd variable can distort or confuse (or confound..) a relationship between two other variables.

When confounding is present, it looks like exposure A is associated with increased risk of disease B, but really a 3rd variable X is causing increased risk of disease B and it just happens to also be associated with exposure A.

Clear as mud? Here's a real world example - if you look at how people recover after hip fracture, and you consider gender and whether women or men do better after hip fracture, it may seem that women generally fare poorly after they break a hip.

However, there's a confounder in this relationship -- age!

If you think a little more about the characteristics of people who break a hip, you realize that young men have hip fractures (due to high-energy trauma associated with events like motor vehicle crashes) and old(er) women have hip fractures (women with reduced bone density and potentially some mobility/balance/cognition problems leading to a fall). Younger females don't tend to have as many hip fractures as their young male counterparts (due to lifestyle issues etc.), and older males don't tend to have the same incidence of hip fracture as their female counterparts (they don't always have the same severity of bone density changes as older females; men tend to die sooner).

The female group is then naturally weighted toward older people (who generally heal more slowly and may have other comorbid conditions going on) and the male group is weighted toward young, otherwise healthy people.

So, when you add age to the statistical model and correct for the different age distribution, the difference in outcome by gender goes away -- the women tend to do more poorly because they're older, not because of their gender. If you control for age, there's no difference in outcome between men and women.

This is a classic example of confounding and one way to correct for it -- in an observational study, you can't randomize, but you can try to measure "things" that might be impacting your disease -- age, gender, socioeconomic status, family support, severity of injury, type of operative repair, rehabilitation status, etc. -- so that you can add them into your statistical model.

The Pitt epidemiology supercourse has a great discussion of confounding and ways to correct for it (PowerPoint file), and the Social Sciences Statistics blog has a very interesting post today that comments on issues of confounding in a recent study about running habits in older individuals (this is the study the post talks about).

One of the best library training videos ever


From Mississippi Public Broadcasting, a video series called Tomes & Talismans about the Dewey Decimal System. Sound boring? uses a sci-fi backstory -- aliens named Wipers from the Black Star Solar System have taken over the Earth,including destroying the intercontinental satellite system (which oddly looks a lot like a Jeopardy! quiz screen).

Because you know what Wipers like to do for fun?

They get down by destroying communication and data technology.

Don't worry - humans are evacuating to the White Crystal Star System (using a teleportation system that reminds me of the TV device in Charlie and the Chocolate Factory, and don't worry, they tested it on a cute little puppy first, then on some kids, to make sure it was safe).

A courageous librarian (in a fantastic khaki vest, I might add) is one of the last to go, making sure all the books are organized in the card catalog so that anyone returning to the planet will know what happens...

The whole series has been uploaded to YouTube.

(via Best Week Ever)

Hopkins on ABC


ABC is posting the full episodes of the short series "Hopkins" filmed at Johns Hopkins Hospital in Baltimore... the kind of reality show I can watch while not feeling (very) guilty or voyeuristic :) And a good way to learn some more medical terminology and see some of the concepts "in action".

Episodes are online here and this page has an overview of the show in general.

Unofficial impact factors


Biomed Central has calculated unofficial impact factors for many of its titles that are not yet covered in Journal Citation Reports -- they used ISI data to figure out the IFs for ~100 BMC titles. Seems like a great way to work around the delay between when a journal begins publication and when ISI begins tracking/calculating IFs.

More here on the Biomed Central blog and here on the BMC Impact Factor FAQ.

Friday humor: David Sedaris


The Fresh Air David Sedaris interview is up on the NPR site -- he talks about his latest book (When you are engulfed in flames).

(he's touring now too -- dates are up in Ticketmaster, including a Nashville date this fall!)

More on procrastination


This feature on NPR's Talk of the Nation fits in really well with my ongoing struggle to trick myself into doing things that I need to do but don't really want to do :) -- How to Be a Productive Procrastinator
Why do today what you can do the day after tomorrow? Procrastination expert Timothy Pychyl and self-professed "structured procrastinator" John Perry discuss the latest research on this type of behavior and how to prioritize what's really important.

including "the inner mechanics of lolly-gagging"...

And here's one of my favorite cartoons ever - "Tales of Mere Existence: Procrastination"

Finding the right word


I'm a huge fan of Roget's Thesaurus; a battered print copy inherited from my dad (copyright 1962) sits on the shelf above my desk and I use it at least weekly. I know I'm not alone in my love of words, and a Lifehacker post today confirms it! A whole group of word-related sites and webapps -- "Best Online Language Tools for Word Nerds."

Organic milk's shelf life


I've idly wondered about this from time to time but never tried to find an answer - why does organic milk last so much longer than regular milk? I started buying it partly because of the antibiotic issue, but have kept buying it because it suits my erratic like/dislike relationship with milk. This weekend, Scientific American briefly looked at why organic milk lasts so long, which turns out to be due to ultrahigh temperature processing instead of the way that it's produced.

Medical jargon


Interesting brief opinion piece in today's Guardian - This epidemic of medical jargon isn't good for us - Professor Jonathan Wolff discusses the linguistic reasons for a professional jargon and advocates:
To take better care of our health, we need access to clear information. I concede that some specialised technical vocabulary is needed and useful. But many terms seem to be used purely to give medical professionals a spurious sense of precision and authority, while policing the boundaries of the subject; keeping out the riff-raff. If the Chinese, to improve literacy, can simplify their written script, can we not simplify medical terminology to improve health literacy?

Autism and Second Life


Great brief piece on CNN's site today about a place in Second Life, Naughty Auties, developed by a young man with Asperger's Syndrome, meant to give those with autism a place to meet online and to provide more information about the autism spectrum disorders.

CNN is going to focus on autism spectrum disorders all day on Wednesday April 2.

Another surgery game


I spent way too much time playing this last night -- Amateur Surgeon, a game from [adult swim].

You play a pizza boy with an interest in surgery who operates on a variety of interesting characters, using a pool table in an old warehouse as his OR and a mismash of tools (stapler, lighter, pizza cutter), under the supervision of a disgraced surgeon.

I had to give up last night after I killed poor Claude 4 times...

Andrew Jackson's "myriad of diseases"


In honor of President's Day, Jake Young of the Pure Pedantry blog has a great post about the complex and interesting medical history of Andrew Jackson -- Presidential Medicine: Andrew Jackson.

JMLA article


Brief moment of shameless self promotion :-) - a paper based on my MPH thesis in included in this month's JMLA -

Jerome RN, Giuse BN, Rosenbloom ST, Arbogast PG. Exploring clinician adoption of a novel evidence request feature in an electronic medical record system. J Med Libr Assoc. 2008 January; 96(1): 34–41. The abstract:
Objective: The research evaluated strategies for facilitating physician adoption of an evidence-based medicine literature request feature recently integrated into an existing electronic medical record (EMR) system.

Methods: This prospective study explored use of the service by 137 primary care physicians by using service usage statistics and focus group and survey components. The frequency of physicians' requests for literature via the EMR during a 10-month period was examined to explore the impact of several enhanced communication strategies launched mid-way through the observation period. A focus group and a 25-item survey explored physicians' experiences with the service.

Results: There was no detectable difference in the proportion of physicians utilizing the service after implementation of the customized communication strategies (11% in each time period, P=1.0, McNemar's test). Forty-eight physicians (35%) responded to the survey. Respondents who had used the service (n=19) indicated that information provided through the service was highly relevant to clinical practice (mean rating 4.6, scale 1 “not relevant”–5 “highly relevant”), and most (n=15) reported sharing the information with colleagues.

Conclusion: The enhanced communication strategies, though well received, did not significantly affect use of the service. However, physicians noted the relevance and utility of librarian-summarized evidence from the literature, highlighting the potential benefits of providing expert librarian services in clinical workflow.

A common health language


The newsletter ADVANCE for Health Information Management Professionals has a really nice brief article on health literacy, "Dream of a Common Health Language" by Shawn Proctor. The article a few simple but striking examples from the world of respiratory therapy to illustrate signs and potential implications of low health literacy.
For Mari Jones, RRT, FNP, AE-C, the predicament hit home when she found her college-educated father struggling to understand his doctor's instructions. He had returned home knowing he should stop taking one of three medications. But he was unclear as to which one. He didn't want to admit he didn't understand.
The article mentions The Newest Vital Sign, a health literacy test that Pfizer makes freely available and the NN/LM health literacy page.

Epigenomics initiative


Today, the NIH announced a new initiative focused on developing the field of epigenomics in the US.

What is epigenomics, you ask?

The press release defines the field:

Epigenetics focuses on processes that regulate how and when certain genes are turned on and turned off, while epigenomics pertains to analysis of epigenetic changes across many genes in a cell or entire organism.

Epigenetic processes control normal growth and development. Diet and exposure to environmental chemicals throughout all stages of human development among other factors can cause epigenetic changes that may turn on or turn off certain genes. Changes in genes that would normally protect against a disease, as a result, could make people more susceptible to developing that disease later in life. Researchers also believe some epigenetic changes can be passed on from generation to generation.

And an example might help:
...epigenetics may help explain how some people are predisposed to certain illnesses such as cardiovascular disease, diabetes and hypertension. Several studies have documented that children born to mothers who did not get adequate nutrition during pregnancy were more likely to develop type 2 diabetes and coronary heart disease later in life. The theory is that epigenetic changes occur in genes that regulate sugar absorption and metabolism during fetal development that allow for survival with little food, but when encountered with an environment where food was plentiful these changes led to development of diabetes. (See scientific illustration of how epigenetic mechanisms can affect health at .)
More on epigenomics and epigenetics:
- NIH Roadmap: Epigenomics
- Biology Online: Introduction - from genome to epigenome - this intro notes "
The term ‘epigenetics’ was first introduced by Conrad Waddington in the 1940s to describe ‘the interactions of genes with their environment, which bring the phenotype into being’"
- the Human Epigenome Project

Ethics committees


AMNews, the weekly newsletter of the American Medical Association, this week considers the role of the hospital ethics committee, including potential limitations and barriers to ethics consultation by physicians.

The article mentions the VA initiative to transform the ethics committee model, coordinated by the VA's National Center for Ethics in Health Care. The IntegratedEthics initiative began rolling out to all VA medical centers in May 2007 and their web site includes a wealth of training information and other tools, including Ethics Consultation: Responding to Ethics Questions in Health Care, a primer for ethics consultants.

The Nintendo Wii and virtual surgery


From New Scientist -- A Wii warm-up hones surgical skills -- an excerpt:

You might think it a bad idea for trainee surgeons to play games on the Nintendo Wii when they should be studying, but it might be time well spent.

Kanav Kahol and Marshall Smith of the Banner Good Samaritan Medical Center in Phoenix, Arizona, have found that surgical residents performed better during simulated surgery after playing on the Wii console. They put it down to the console's
novel "Wiimote" control system, which allows players to direct on-screen action using a wireless wand that detects acceleration in three dimensions.

Now they are designing Wii software that will accurately simulate surgical procedures. A training platform based on the console, which costs about $250, might be more practical for trainee surgeons in the developing world than traditional virtual training tools, which typically cost a great deal more.

To test how the Wii affected surgical skill, the researchers asked eight trainee doctors to play it for an hour before performing a virtual surgery. They used a training tool called ProMIS, which simulates a patient's body in 3D and tracks the surgeon's movements as they operate. They fed the movements to an algorithm which scores the virtual surgeon on a range of factors. Wii-playing residents scored 48 per cent higher on tool control and performance than those without the Wii warm-up.
(More on virtual surgery in this past post and on the Clinical Cases blog - virtual knee and hip replacement)

Visiting the emergency room


CNN's Empowered Patient feature today focuses on five things not to do in the ER (more discussion of each of the items in the article:

1. Don't forget to call your doctor on the way to the ER

2. Don't use an ambulance unless you really need it

3. Don't be quiet

4. Don't get angry, and don't lie

5. Don't forget the phone

Disease origins


Tara at Aetiology has a great discussion of research to figure out where syphilis came from.

An octopus and his best friend


A heartwarming (maybe just to me...) story about an octopus and his favorite toy, a Mr Potato Head, via Zooillogix.

Scary and cute at the same time


Public Health Response to a Rabid Kitten --- Four States, 2007 in the CDC's MMWR this week gives a great, narrative discussion of the discovery and investigation of rabies exposure via a rabies-infected kitten -- public health epidemiology in action.

Of course, it's also sad that the kitten was ill (had already been euthanized before the suspicion of rabies) and a good reminder why rescued animals should really be quarantined from other animals and humans until a full veterinarian exam, even if they initially look well - though domestic animal rabies is not nearly as common as it used to be, animals that have spent any time in "the wild" might have been exposed to illnesses through contact with other animals (this kitten had a raccoon-variant rabies infection).

Some vets will give reduced rates for rescued animals - call your local veterinarians to find out if they offer assistance or can recommend other services in your area. The American Animal Hospital Association, the accrediting group for animal hospitals in the US and Canada, has a directory of vets that you can search by zip code.

It's also a good reminder to spay/neuter pets that you don't plan to breed - the ASPCA has an online directory of low-cost providers for this service.

Variety post


Life has been very hectic lately - here are a few interesting things that have been lingering in my feed reader -

- Greenwood DC. Reliability of journal impact factor rankings. BMC Medical Research Methodology 2007, 7:48.

- PLoS Medicine blog: EQUATOR: a new site for reporting guidelines - cumulation of recommendations/standards for reporting the methods and results of clinical research.

- PLoS Publishing blog: Bringing peer review out of the shadows

- PLoS Medicine: The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies

- Institute of Medicine project: Conflict of interest in medical research, education, and practice

and finally, since it's Friday, Pinky and the Brain's musical tribute to neuroanatomy

More on heuristics


The cognitive psychology Thinker has a few great minitutorials that give examples illustrating some of the most common heuristics.

From the site overview:
A number of factors can affect how we go about making decisions, but it is unusual for us to make a decision completely objectively and rationally; rather we usually bring biases from our prior beliefs or experiences into the situation. As a result, we often use "rules of thumb," or heuristics, to help us. These heuristics allow us to have an idea about how to weigh our options, even though they might sometimes lead us astray. Likewise, sometimes the way our options are worded, or "framed," may lead us to think differently than we might otherwise. Finally, we often allow prior experience or outcomes to guide our approach to a decision, even though, again, that approach may not be the best way to go.

Representativeness bias


This week's AMNews, the newsletter of the American Medical Association, includes an excerpt from Dr. Jerome Groopman's book How Doctors Think ( book info). The excerpt discusses a case of missed diagnosis of cardiac disease in a healthy man and gives a great example of the representativeness heuristic in clinical decision-making.

Groopman notes of the case and how it illustrates this kind of bias:
The mistake Croskerry made is called a representativeness error: your
thinking is guided by a prototype, so you fail to consider possibilities that
contradict the prototype and thus attribute the symptoms to the wrong