Quest for oldest NHS waiting room magazine.

Clearly anything pre-1948 would attract serious bonus points ... and any private clinic found to be not wasting money on expensive 'update your waiting room magazines' services (e.g. DLT as recommended by my dentist (Mrs J)) will attract bonus sarcasm.

It all started with a tweet ...

Friend waiting 4 Dad in local OPD found: Practical Classics & Car Restorer Mag July 1987. He says crossword not completed #bonus #beatthat?
— Anne Cooper (@anniecoops) October 1, 2013

Post photographic evidence of publishing heritage on Twitter along with a brief overview of the particular venue.

I wonder what characteristics the 'winning' clinic would have? High regard by patients, welcoming staff, long waits, rationing, northern, southern, rural, urban, primary, secondary, Tredegar?

Encrypted messaging

Secure messaging for sensitive information - such as that used in healthcare - would be very useful. Who writes things on pieces of paper these days or sees so few people that they can remember it all! It is important for us in the health business to understand more about the underlying technologies so we can be wary of circumstances where data, entrusted to us, may be snooped on by others.

We do not want patients to lose trust in the health system because their confidential information is stored electronically. We believe that electronic is more secure than paper. The news of the intelligence services routinely storing communications and particularly the accusation that they have even manipulated cryptography standards is alarming.

There is a claim that if more of us routinely used encrypted email it would make the work of those who want to snoop on communications a whole load harder.

Whether you support that notion or not it doesn't really seem to make sense at the moment since so few want to use encrypted email. Why send a message in a complicated way making it hard for someone else to decode when all you're talking about is daily trivia anyhow? I posted a public key for over a year and nobody sent me anything. (Probably because I'm not very popular). An old friend dared others on Facebook to send him an encrypted email and, even though he's got lots of techie friends, hardly any did.

I was one of them ... and have posted a new public OpenPGP key.

So here goes. Anyone use encrypted email? Mailvelope has an easy to use browser plugin. Send me something.

The big problem however, is that really confidential encrypted email is not so vulnerable in transit. It is when it is un-encrypted at each end (the endpoints), or the private keys are not secured properly.

Also, there's useful advice on would be secrecy from Bruce Schneier in the Guardian last week.

"Diabetes Apps"

This systematic review from researchers in Dakota looked at applications in the Apple Store and all publications between 1995 and 2012 on mobile technologies for people with diabetes.

"Research into the adoption and use of user-centered and sociotechnical design principles is needed to improve usability, perceived usefulness, and, ultimately, adoption of the technology. Proliferation and efficacy of interventions involving mobile applications will benefit from a holistic approach that takes into account patients' expectations and providers' needs." (1)

It is a good (but not thorough) update of the current status of supportive technologies for people with Type 1 and Type 2 diabetes. They cautiously conclude that these applications improve attitudes towards diabetes and may therefore improve outcomes.

Integrating with electronic health records could be a key benefit of future developments. It is the level of engagement for the person with the diabetes and the people who help support their care that I feel is where the efficacy is - not the 'technology' per se.


1. El-Gayar O, Timsina P, Nawar N, Eid W. Mobile applications for diabetes self-management: status and potential. J Diabetes Sci Technol 2013;7(1):247–262. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23439183

Enhancing the quality of life of carers (CCG OIS)

NICE has announced topics for the Clinical Commissioning Group Outcome Indicator Set (CCG OIS). Cancer, stroke and enhancing the quality of life for carers are among the topics covered.

Topics for latest CCG Outcomes Indicator Set announced (http://www.nice.org.uk/newsroom/news/TopicsLatestCCGOutcomesIndicatorSetAnnounced.jsp) 

"Professor Danny Keenan, the chair of the Advisory Committee for the Clinical Commissioning Groups Outcome Indicator Set, said:

"We're delighted to recommend this robust set of indicators for potential inclusion in the 2014/15 indicator set.

"We hope they will help the new CCGs to commission NHS services that will improve the quality of people's lives."

The CCG OIS forms part of NHS England's approach to promoting quality improvement. It will provide information on the quality of health services and outcomes provided by each CCG, which can then be accessed by patients and the public.

The set includes indicators from the NHS Outcomes Framework that can be broken down at CCG level, as well as additional indicators that can help to deliver improvements in quality.

A full list of indicators is now available following public consultation and testing carried out by NICE and the Health and Social Care Information Centre earlier in the year.

The final indicators in the CCG OIS will be agreed by NHS England, and may include indicators above and beyond those recommended by NICE"

The indicators potentially include identifying carers on practice registers and recording whether information has been given to them. This is practice to be encouraged of course - but how the growing number of 'tick boxes' is actually handled in any one consultation and whether it risks detracting from the important task of medical management needs to be addressed. Time for technological and process innovation perhaps.

NHS Friends and Family Test

The NHS England's 'Board to Ward' patient feedback system with public transparency has gone public.

You can see the results for every Trust down to ward level on the Gov.UK website.

The calculation of the Friends and Family Test and guidance on how the results should be shared with staff and the public is also available. When trying to calculate the scores remember that the 'likely' response is included in the denominator but the 'don't know' is not.

The calculation is based on a net promoter mechanism (a customer satisfaction measure) popular in business but not without its criticism including for variability even in the industries where it is sometimes claimed to be superior to more robust survey methods.

"Managers have widely embraced and adopted the Net Promoter metric, which noted loyalty consultant Frederick Reichheld advocates as the single most reliable indicator of firm growth compared with other loyalty metrics, such as customer satisfaction and retention. ... the research fails to replicate his assertions regarding the 'clear superiority' of Net Promoter" http://journals.ama.org/doi/abs/10.1509/jmkg.71.3.39

Having said that, it is quite a simple tool and arguably more practical for patients and relatives to complete on NHS wards. More importantly, it is what we currently have and it is here to stay. It is among the mandatory central information for Monitor. It was announced by Prime Minister David Cameron last year to identify the 'best performing hospitals'. If it has a use it is possibly better for detecting change and stress within a clinical area rather than comparing between clinical or geographical areas. A short stay on intensive care where your life is saved is very different to a long stay on a stroke rehabilitation ward where you are being urged to be as physically independent as you can when you are not used to being told what to do.

What has been the reaction in the first month of national publication of the figures?

99 per cent are happy with NHS hospital care (in a survey where only 10 per cent actually responded). Usefulness of data from post-Stafford research already called into question. Independent

Family and Friends test 'at best meaningless'. The Government's family and friends test for NHS hospitals has been condemned as "at best meaningless, at worst misleading" as critics warned the system is "open to gaming".  The Telegraph

Are you listening, Andy Burnham? NHS patients have been given a voice. The Friends and Family test improves transparency in the health service – and it's patients who will benefit the most. The Telegraph

PM: 1st ever #NHS friends & family stats out, giving patients far greater voice in NHS & putting a spotlight on care standards #NHSFFT
— UK Prime Minister (@Number10gov) July 30, 2013

Very strong believer in Friends and Family test because clinicians already using it to improve care. Tdy is big step on NHS journey #NHSFFT
— Tim Kelsey (@tkelsey1) July 30, 2013

I fear the gaming. Managers in NHS Trusts will put their own PR polish on their national results and not simply refer patients (and staff) to the transparent figures. They may add another layer of interpretation to the scores where none may exist. They may also try to shift the scores without making structural changes to the clinical areas themselves.

For example, a Trust may trumpet scores of 100 when the respondent numbers are very low, but then criticise a ward with scores nearer 50 when the respondent numbers are equally low. Low respondent numbers mean uncertain figures. Scores that conveniently support a particular Trust Board narrative may be selected for action in preference to others. Wards with low scores this month may have circulars to 'explain' the survey to patients and relatives so that 'the score can better reflect the true performance of the ward'.

Talk of ward scores should be responsibly done. I've been calculating the variance and margin of error on the ward scores using a discrete random variable approach. It gives an average margin of error of +/- 11.4 (range 1.1 to 43.8) for the Friends and Family score (based on the 68% of wards where variance can be estimated - the others are meaningless as numbers too small). [I've put the modified spreadsheet here ... column AA in the 'IP ward' sheet has the margin of error estimations where they are valid.]

Learning analytics - need to do more

I've been thinking about learning analytics again lately and how to do more of it in the projects I'm involved in. OnExamination.com has always been powered by analysis of activity - sequencing test items based on prior performance. However, not all learners are so fully engaged as they are when they are running through mock questions for a high-stakes exam. Although I had a great time helping to design the learning analytics for exam preparation, most learning is not so intensely focussed. It is more work-based, opportunistic and social.

In clinical medicine learning analytics would most benefit from objective measures of personal performance to help make recommendations and present the data. These outcomes are hard to capture and, even if you do, they are hard to analyse since there is so much variability. The easy things to measure aren't necessarily the most important to observe.

Using electronic health records would be good. Case mix, common diagnoses, common prescriptions, common investigations and findings, would be an ideal way to automatically design a syllabus. Heuristics could be defined to spot quality issues. But how to get in on that gig? Could work more with BMJ Informatica to link individual GP performance to bespoke learning I suppose. My background is secondary care however, and last time I tried asking to look at and explore solutions for individual physician performance at my local NHS Trust I hit a dead end.

I've worked with the background design of a learning tool tblable.com which represents knowledge. Looking at patterns of errors with the quiz tools that can be created from this may help identify areas for focus for individuals, and areas for novices or experts to start. Have a look at this example tblable on MODY. I think this is too niche at the moment though. Too narrow a cognitive tool. I've got over a number of hurdles but it is a solution without a defined problem.

I also analysed millions of Tweets using tools in the GrabChat idea via the different Twitter APIs but not managed to glean anything particularly inspiring. There's a lot of guff about sentiment analysis of tweets (e.g. how it bombed in stock picking) but it does not transfer from anything other than the binary of emotionally positive or negative in particular communities and topics. Analysing tweets is great for finding interesting links and people but it still needs human filtering and a lot of spam gets in there. Nowhere near a tool that would be useful for learning analytics.

So, in all, I'm feeling a bit of a frustrated skunk worker. Will have to experiment some more.

Tatoo biosensor for lactate to enable extreme sporting performance

Obviously you have to put years of training in and be a pretty unique (and sporty) sort of individual to benefit from such a biosensor tatoo. This sensor detects lactate levels which climb with increasing intensity of exercise until the athlete 'hits the wall', or 'bonks'. Having been there and done that myself all judgement and rational thought have long disappeared before the moment occurs. (Also I'm not that sporty either).

So this biosensor could be the solution!

"The sensor can be applied to the human skin like a temporary tattoo that stays on and flexes with body movements.

In ACS' journal Analytical Chemistry, Joseph Wang and colleagues describe the first human tests of the sensor, which also could help soldiers and others who engage in intense exercise — and their trainers — monitor stamina and fitness." Source: Tatoo biosensor warns when athletes are about to 'hit the wall' (Kurzweil AI)

I worked for a while in Waikato Hospital and remember at the City Gym, in Hamilton, New Zealand, there were some crazy rowers who every now and then brought a portable lactate measuring machine into their training sessions. They would plot their heart rate against their lactate levels with a progressive exercise programme that took them basically to oblivion. They then knew what heart rate level and exercise they could maintain without hitting the wall. They used this for extreme performance in rowing and iron man competitions.

This method of anaerobic threshold training dates from work in the 1980s by Conconi and others [1] and it has enabled a generation of athletes to push the boundaries of their sport.


1. Conconi F, Ferrari M, Ziglio PG, Droghetti P, Codeca L. Determination of the anaerobic threshold by a noninvasive field test in runners. J Appl Physiol 1982 Apr;52(4):869–873. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7085420

Mortality rates, averages and the media

Now that it seems a 'mystery rise' of 600 people a week are dying more than average in the UK

http://www.bbc.co.uk/news/health-23447683

there is a great opportunity for the media to start talking nonsense about things like excess deaths, older people more likely to die, why do we always seem to be above average half of the time, and why being above average is something to worry about. Maybe we'll get some daft MPs diving in too.

Hopefully, some sensible analysis will come out. It looks like Public Health England is considering whether it is a spike in respiratory illnesses earlier in the year. Of course it could just represent the nature of the real world where observed numbers tend to differ from those that were expected.

5 Ways the NHS has changed this week

Interesting piece from Nick Triggle BBC's Health Correspondent.

http://www.bbc.co.uk/news/health-23354789

The gloves are off with the politics of the NHS, the care of the elderly matter, the new inspector of hospitals has a tough job, death rates and special measures are here to stay.

The NHS is certainly becoming a key election issue. Facts such as decreasing mortality in all NHS hospitals over the past 10 years also being conveniently not mentioned by some.

Pioglitazone ban in India

Pioglitazone has been banned in India and has caused considerable debate among prescribers there.

"Banning pioglitazone in 2013 is wrong timing because there is no new evidence to show its ill effects. On the contrary the USFDA had called back an earlier drug – doziglitazone last month and it will be commercially available in India in a few months."
http://health.india.com/diseases-conditions/is-the-ban-of-pioglitazone-justified-expert-interview/

"Some doctors also refute the basis of ban. They say that the diabetic drug (Pioglitazone) is effective, and can cause adverse effects in sustained use of 40 mg in older patients. The option should be about the use of a lower dosage because alternatives such as DPP-4-inhibitors or gliptins are more expensive."
http://www.keralanext.com/news/2013/06/27/article159.asp

"While insulin sensitiser pioglitazone has been barred due to health risks, experts say the danger arises only if used in larger doses."
http://www.mumbaimirror.com/mumbai/others/Docs-surprised-with-ban-on-anti-diabetic-drug/articleshow/20807473.cms

Diabetes Day with BMJ Informatica

On Wednesday this week there was a Diabetes Day at BMA House hosted by BMJ Informatica.

I've just blogged about it on the BMJ Diabetes Blog.

http://blogs.bmj.com/diabetes/2013/06/27/bmj-diabetes-day/

The theme of using data to improve services was fascinating and made for a stimulating discussion among the commissioners of diabetes care who attended.

Hospital Weekend Mortality and the FFS analysis technique.

Where did all this nonsense about "excessive deaths at the weekend in hospitals is because they don't run a 24/7 service like supermarkets" come from?

'The NHS is not Tesco', say Doctors. Telegraph June 2013

BMA calls round-the-clock 'Tesco NHS' plan ridiculous. Independent June 2013

Tesco-style NHS plan 'ridiculous'. BBC June 2013

Sunday hospital admissions 'a bigger risk'. NHS Choices February 2012

Press Release: New report finds higher death rates at hospitals with fewer doctors at evenings and weekends. Dr Foster November 2011

The rhetoric in the UK seems to assume some miraculous recent discovery of data analysis in this area and somehow peculiar to the NHS and explained by factors such as European Working Time Directive, patient choice, out-of-hours GP contract, MRSA, unions, lack of regulators, too much regulation, weak colleges, the wrong type of teabag. However, 12 years ago in Canada they looked at nearly 4 million hospital admissions and found:

"Patients with some serious medical conditions [ruptured abdominal aortic aneurysms, acute epiglottitis, pulmonary embolism] are more likely to die [compared with 3 control conditions MI, intracerebral haemorrhage, acute hip fracture] in the hospital if they are admitted on a weekend than if they are admitted on a weekday." [1]

So, some conditions - that can present in a challenging way and require senior input into their correct diagnosis and management - seem to be associated with excess mortality. This seems to make sense, especially as it is controlled against conditions that, on the whole, present in an unequivocal way and require management as per an easily recognised protocol.

This is the medical evidence dialogue that has been lost in the low rigour, non-peer reviewed, middle-management led, headline grabbing, trawling of evidence - what I'd refer to as the Fifth Form Spreadsheet (FFS) technique. The FFS technique is where you gather whatever data you can, commenting on but largely ignoring any form of potential bias, go fishing for differences and correlations, and release a press release saying there is a 'signal of evidence' leaving an open goal for whatever political commentator wants to score their own prejudice.

Careful consideration of the case mix and cautious interpretation of the results may show otherwise. [2]

Can we have some more rigorous analysis of what the possible case for causation is between our spreadsheet 'big' data before diverting resources into 24 hour care? Those who present at weekends are likely to be different to those who present in the week because of the different social norms and interpretation of vague symptoms. More staff and services in a hospital won't necessarily help with challenging presentations but could be very beneficial for certain types of admission.

How about focussing resources where there is evidence that it would help and not over-interpret whatever data we can analyse FFS.


1. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N. Engl. J. Med. 2001 Aug;345(9):663–668. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11547721

2. McShane P, Draper ES, McKinney PA, McFadzean J, Parslow RC, Paediatric Intensive Care Audit Network (PICANet). Effects of Out-of-Hours and Winter Admissions and Number of Patients per Unit on Mortality in Pediatric Intensive Care. J. Pediatr. 2013 Apr; Available from: http://www.ncbi.nlm.nih.gov/pubmed/23623513

e-learning trends for 2013

Good infographic on the hottest trends for 2013 from KnowledgeOne

http://knowledgeone.ca/blog/post/2013-e-learning-trends.aspx

I particularly liked the increased serious gaming graphic demonstrating the likely rise in revenues. We seriously all need to be into gaming.

We used to "have to be on mobile" but that should be taken for granted ... now we "really need to be gaming".

The serious subject of medicine actually lends itself very well to gaming. After all, diagnosis has all the challenge of a quiz, and prevention and management is all about battling disease with various weapons.

African MOOCs

"... MOOCs are a godsend for Africa. Free, they have the potential to reach vast audiences who stand no chance of getting anywhere near higher education as we know it in the developed world. On the other hand, as the Namibian President wisely said at E-learning Africa this month, let’s not make the mistake of following an overly academic approach at the expense of Africa’s vocational needs, what he called the 'spectacle of hallucination'. African MOOCs will have to be more relevant to Africa’s vocational needs, such as agriculture, healthcare and entrepreneurship. A third view, is that Africa needs to produce as well as consume MOOCs."

Great article by Donald Clark "African MOOCs: unlocking a billion more brains".

http://donaldclarkplanb.blogspot.co.uk/2013/06/african-moocs-unlocking-billion-more.html

He also inks to the enthusiastic Africamooc

which offers to host free courses for free.

Case report involving cycling, diabetes and a rare genetic disorder

Just blogged about Tom Staniford's genetic form of Type 2 Diabetes which has been widely reported in the media following a publication by Prof Andrew Hattersley's team in Exeter.

http://blogs.bmj.com/case-reports/2013/06/18/a-very-unique-cyclist/

Tin Can API

Tin Can API is a specification for collecting information about learning experiences and seems to be emerging as fashionable and more mature technology.

Tin Can is "a brand new specification for learning technology that makes it possible to collect data about the wide range of experiences a person has (online and offline). This API captures data in a consistent format about a person or group’s activities from many technologies. Very different systems are able to securely communicate by capturing and sharing this stream of activities using Tin Can’s simple vocabulary."

Whether this system will have an effect in medicine remains to be seen. There are a number of registration / CPD / learning portfolio systems already available to health care professionals including my College's (Royal College of Physicians) CPD diary and BMJ Learning Portfolio. For larger learning experiences we will always have the request of "can you put that in a PDF for my portfolio?" but for smaller experiences perhaps an industry-standard API might be the way to make our collections a little more compatible with each other.

Tin Can API is certainly worth investigating.

Pick your own consultant

University Hospital of South Manchester Trust is the first to release individual consultant data starting with cardiologists and cardiac surgeons.

http://m.bbc.co.uk/news/uk-england-manchester-22878990

This is good but it must be introduced with care.

Single organ specialists and procedure-based practices might be more easily measured. Tackling the multiple morbidities in general medicine and geriatrics will be more of a challenge.

Whilst transparency is valuable the need to correct the figures for the different case mix and clinical risks will require ongoing research.
With suitable measurements will patients be able to make sensible choices and pick their own consultant?

Patents on human DNA? No thanks.

"U.S. top court says extracted human DNA cannot be patented" 

http://uk.mobile.reuters.com/article/idUKBRE95C0PW20130613?irpc=932

Seems like a sensible decision and would allow more rapid development of the market by preventing a throttling land grab. It is the techniques for investigation, the knowledge of the interactions of genes, and the new treatments that could be developed that are important (and of value) not the genetic sequences of naturally occurring DNA themselves.

"The ruling means that some of Myriad's [the company involved in the lawsuit] patents concerning synthetic molecules called cDNA, will likely survive, although the parties disagree on that point."

Eltrombopag for chronic immune (idiopathic) thrombocytopenic purpura

NICE publishes final draft guidance for eltrombopag (Revolade, GlaxoSmithKline) an option in ITP.

http://www.nice.org.uk/newsroom/pressreleases/NICEGivesGreenLightToBloodDisorderTreatmentInFinalDraftGuidance.jsp

Eltrombopag is a thrombopoietin-receptor agonist [1]. It has been used in ITP [2] and also in Hepatitis C infection where patients with thrombocytopenia would otherwise be excluded from treatment with Interferon [3].


1. Basciano PA, Bussel JB. Thrombopoietin-receptor agonists. Curr. Opin. Hematol. 2012 Sep;19(5):392–398. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22872157

2. Bussel JB, Cheng G, Saleh MN, Psaila B, Kovaleva L, Meddeb B, Kloczko J, Hassani H, Mayer B, Stone NL, Arning M, Provan D, Jenkins JM. Eltrombopag for the treatment of chronic idiopathic thrombocytopenic purpura. N. Engl. J. Med. 2007 Nov;357(22):2237–2247. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18046028

3. McHutchison JG, Dusheiko G, Shiffman ML, Rodriguez-Torres M, Sigal S, Bourliere M, Berg T, Gordon SC, Campbell FM, Theodore D, Blackman N, Jenkins J, Afdhal NH, TPL102357 Study Group. Eltrombopag for thrombocytopenia in patients with cirrhosis associated with hepatitis C. N. Engl. J. Med. 2007 Nov;357(22):2227–2236. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18046027

When do you move your social media world?

So, this morning I spent time sending messages on Snapchat (dean.jenkins) (an instant photo/video chat tool) and Zorpia (DeanJenkins) (one of the few social media sites allowed in China). I've not really used either before for exchanging information but have done now. I've also even gone back to look at Google+ ... but now have three accounts +Dean(main), +Dean(work),  +Dean(not at all) and so have a circle that only includes my other selves.

The question is, when do you switch and how readily should you experiment? Clearly someone you know well invites you into these new communities but at several points you make a judgement on the value of any new tool. I think I'll continue to have a low threshold to trying new technologies out.

Diabetes bankrupting the NHS?

Looking forward to a day of discussion at BMA House with colleagues at BMJ Informatica and invited speakers. If you are commissioning diabetes care in the NHS then consider joining the discussion.

We'll be using the hashtag #BMJdiabetes on the day for remote participation as well.

http://informatica.bmj.com/company/events/how-can-we-prevent-diabetes-bankrupting-nhs

Invasive strategy for non-ST elevation ACS in diabetes

A meta-analysis of trials that included a total of nearly 10,000 patients looked at the risk reduction for invasive cardiovascular intervention versus conservative approaches in people with diabetes presenting with non-ST segment elevation acute coronary syndromes.

The group well-regarded TIMI group found that:

"An early invasive strategy yielded similar RR reductions in overall cardiovascular events in diabetic and nondiabetic patients. However, an invasive strategy appeared to reduce recurrent nonfatal MI to a greater extent in diabetic patients. These data support the updated guidelines that recommend an invasive strategy for patients with diabetes mellitus and non-ST-segment elevation acute coronary syndromes." [1]

The absolute risk reduction of non-fatal MI is given in the paper as 3.7% which would mean (I calculate) that 28 people would have to undergo invasive cardiovascular intervention (angioplasty / coronary artery bypass graft) to prevent one non-fatal MI and its consequent risks of heart failure and shortened life-expectancy.



1. O’Donoghue ML, Vaidya A, Afsal R, Alfredsson J, Boden WE, Braunwald E, Cannon CP, Clayton TC, de Winter RJ, Fox KAA, Lagerqvist B, McCullough PA, Murphy SA, Spacek R, Swahn E, Windhausen F, Sabatine MS. An invasive or conservative strategy in patients with diabetes mellitus and non-ST-segment elevation acute coronary syndromes: a collaborative meta-analysis of randomized trials. J. Am. Coll. Cardiol. 2012 Jul;60(2):106–111. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22766336

Type 2 Diabetes in the young

Just blogged about one of our course director's talks at the BMJ / University of Leicester Diabetes Diploma course this weekend.

Professor Melanie Davies talked about the alarming issue of Type 2 Diabetes in the young and how they present with dangerous complications of diabetes.

http://blogs.bmj.com/diabetes/2013/04/23/type-2-diabetes-in-the-young/

insulinforall.org

This weekend has been a bit of a diabetes hack.

Started a project to try and "crowdsource" data on insulin prices across the world. Despite being invented nearly 100 years ago, and the team who discovered it handing over their rights to the University of Toronto so that insulin could be available to all who needed it, 'lack of access to insulin' is the leading cause of death globally for children with Type 1 Diabetes.

The reasons for this are complex and involve different priorities across national health systems, the global market for insulin development and supply chains, and individual choices of healthcare. However, it is the poorest children who develop diabetes that suffer. If their family cannot get them insulin then, literally, their treatment goes back 100 years. We can do better than this.

I felt strongly that since I was well connected to people with an interest in diabetes across the world we might be able to gather data and make it transparent what the variations are. Only when the variations are known can the barriers be addressed.

Please visit insulinforall.org for more information, share the links, and complete the survey.

Thanks to Laurie for making a most excellent video!

Tapping the Twitter brain

So I've set up a Twitter Streaming API client on a server and started consuming the large amounts of data that comes into it.

It feels a bit like that famous (to medics at least) Gary Larson cartoon with the mosquito who has hit an artery.

It is clearly possible to run some fancy types of analysis on Twitter data such as for collecting the top twitter posters and URLs for a particular hashtag e.g. GrabChat's #NICE2012, or the more recent text analysis of Diabetes UK's #dpc13.

The output from the streaming API though is another order of magnitude and will be promising for identifying, literally, 'trending' resources or individuals within a particular topic. I've just run 48 hours of the keyword 'diabetes' and got nearly 40,000 Tweets.

Tapping into the global discussion of diabetes is one thing but filtering out the good stuff is another challenge. I have a few competing algorithms that are running on the data to see which is best.

I've been filtering tweets for some time, sharing them with followers and relaying them through to our diabetes diploma course but this promises a whole new level - a more systematic approach. What's surprising is the enormous amount of spam and re-tweeting of low-level health and nutrition material that goes on. Thankfully, through the normal interfaces of Twitter, these are tweets you do not see. Hidden among them are useful ones and the trick is to filter them out.

Visualising Twitter Chats

Been experimenting with different ways of visualising text analysis of Twitter hashtags. Got GrabChat to use document clustering and display the results with HTML 5 allowing it to be read on mobile devices.

Run an example using a recent #CMEchat by doing the usual GrabChat of the hashtag but then included the text analysis.

Here's a screen shot of the text analysis output. Each of the cells are clickable and they send you back to Twitter to see more discussions through specific (and therefore deeper) searches.

This is an interesting way of archiving and analysing hashtags on Twitter. It's more than trawling through all the tweets or just numbers of hits and tweeters. I think it is probably most useful for 'feeling the pulse' of a big meeting - as it is progressing - or capturing the key concepts quickly and easily from a typical Twitter chat.

Here's another of #ACC13. Click on the image to go to the GrabChat text analysis and then click on the topics that take your interest.

As an idea this has come a long way from the semantics and homophily I talked about last year. Well, for the semantics anyhow. Must look more at the homophily.

Why do some computerised decision support systems fail?

A meta-analysis of studies on decision support in health care from a Canadian team published in the BMJ.

http://www.bmj.com/content/346/bmj.f657

"We identified several factors that could partially explain why some systems succeed and others fail. Presenting decision support within electronic charting or order entry systems are associated with failure compared with other ways of delivering advice. Odds of success were greater for systems that required practitioners to provide reasons when over-riding advice than for systems that did not."

So, a system that automatically offers opinion - like the challenging vision of artificial intelligence of the future - seems to fail, whereas one that asks you to think and document (your valued) exceptions seems to succeed.

I think this makes sense. Perception of the machine alters how it is used.

I imagined being on a ward round or in a clinic with a colleague who blurted out evidence and guidelines citations. Some of what they would say would be correct obviously but perhaps a lot would be irrelevant or cover areas that I had considered, would love to explain, but weren't directly relevant to the case in front of us. I'd probably have a hard time and need coffee earlier than usual. However, if I had a constructive colleague who asked open questions such as 'so why did you do that instead of the usual' I think I would have a more enjoyable time and engage in some meaningful thought and discussion.

Maybe we need more workplace psychologists involved in human interface design. What is cool to a developer or a priority to management might not be the best way of solving the problem of getting health professionals to interact with IT systems.

Dogs and Diabetes ... then and now.

Just wrote on the BMJ Diabetes blog about the exciting work from Barcelona on gene transfer treatment for Type 1 Diabetes in dogs.

http://blogs.bmj.com/diabetes/2013/02/16/gene-transfer-for-type-1-diabetes-proof-of-concept-works-in-dogs/

What's interesting that the authors point out in the first paragraph of their discussion is that this work has historical links with Banting and Best's work in 1922 and recent gene transfer success to humans following work in dogs in other conditions.

I thought I'd post the pictures of the dogs.

Banting and Best in 1922. (University of Toronto Archives, Frederick Grant Banting and Charles H. Best, A1978-0041/001(53).)

Lead researcher Fatima Bosch with team and dogs. (Universitat Autònoma de Barcelona. 2013)

BMI = 1.3*kg/m**2.5

"millions of short people think they are thinner than they are, and millions of tall people think they are fatter"

Just blogged about a suggestion for a revised Body Mass Index formula on the BMJ Diabetes Blog.

http://blogs.bmj.com/diabetes/2013/01/24/new-formula-suggested-for-bmi/

Breast Cancer prevention - age, history, genetics

The National Institute for Health and Clinical Excellence (NICE) have issued a consultation on the updated draft of its guidance on familial breast cancer due for publication in June 2013.

Widely reported in the news today is the proposed recommendation for tamoxifen or raloxifine at high risk of breast cancer. The news, as far as I can see doesn't highlight that this recommendation is for post-menopausal women. The BBC (Breast cancer drug tamoxifen recommended for 'high risk' women) seem to simplify the whole thing by only talking about tamoxifen and not mentioning the age issue except to say "Most cases occur by chance and with increasing age."

The full draft guidance says:

"Offer tamoxifen or raloxifene for 5 years to post-menopausal women at high risk of breast cancer unless they have a past history of thromboembolic disease or endometrial cancer."

The debate about genetic testing is discussed in the evidence review. There are three genes known to cause susceptibility BRCA1 BRCA2 and TP53 but they cause a minority of cases (5% or so). NICE favour family history over widespread genetic testing but I just wonder what the future will bring? If better genetic risks are identified then the complex computer algorithms and detailed family history checking to quantify risk might give away to more objective test.

Go paperless in 2013

If you haven't already then perhaps 2013 is the year to go paperless using tools like Google Drive and Expensify.

“It’s finally fast and simple to complete paperwork and expense reports, to manage accounting, pay bills and invoice others. The paperless office is here — we just need to use it.”

http://www.kurzweilai.net/why-you-should-go-paperless-in-2013

Just think of all that paper you'll save and you'll never be a mug again buying a cheap printer with expensive ink.

Hillary Clinton's 'blood clot'

Just blogged about Hillary Clinton's transverse sinus venous thrombosis on BMJ Case Reports Blog.

It was interesting following the story and the speculation over where the clot was - which was probably only of interest to physicians. Why was she kept in hospital? What sort of routine scan did she have that prompted all this? What would it be like to be that prominent in politics and get unwelcome news from your doctors?