Shelved in the W's

Soaked up and squeezed out

2009-06-01T20:15:00.004-05:00

I act as a sponge. I soak it up and squeeze it out in ink every two weeks. ~ Janet Flanner, American journalist

Readers of Shelved in the W's may be interested to know that, after a year's silence in which I attended to a serious family illness while at the same time moving to a new job, I have decided to continue writing about health, libraries, the web, and anything else that I happen to soak up.

My new blog is called Gossypiboma - for no other reason than that I liked the word when I first encountered it, with its peculiar, continent-striding etymology, the tang of operating room antiseptic, and overtones of high-minded indiscretion. See my first post at the new blog site for a definition.

Do a search on gossypiboma in PubMed for the fun of it. You'll find a perfect example of how a relatively straightforward concept can become lost in a gauzy tangle of MeSH headings. All of the following terms have been used by PubMed indexers to categorize articles on gossypibomas:

Surgical Sponges (often with the subheading /adverse effects)
Foreign Bodies
Foreign-Body Migration
Foreign-Body Reaction
Granuloma, Foreign-Body
... and occasionally Bandages.

A gossypiboma may also be called a pseudotumo(u)r, a granuloma or (I like the poetic reverberation here) a textiloma. These troublesome little "retained" items are rare, but not that rare. Cases have been reported of patients who have carried their surgical souvenirs around for more than twenty years. Now that's retention.

I hope those of you who have been retentive readers will journey on with me as I set out in some new directions. There is so much information to explore. Let us absorb it together.

William Osler tells us in one of his aphorisms: "An old writer says that there are four sorts of readers: Sponges, which attract all without distinguishing; Howre-glasses, which receive and powre out as fast; Bagges, which retain the degrees of the spices and let the wine escape; and SIEVES, which retain the best only. A man wastes a great many years before he reaches the 'sieve' stage."

Reader, I am more Sponge than Sieve. But I will try to retain the best. And we all want to avoid becoming stuck at the Bagge stage.

Nostalgia for handwriting: it's love th@ m@ters

2008-05-07T15:14:00.008-05:00

Words are things, and a small drop of ink, falling like dew upon a thought, produces that which makes thousands, perhaps millions, think. ~ Byron

On a recent vacation, having deliberately divested myself of all digital devices, I experienced once again the pleasure of applying pen to paper and transposing the words in my head into the scrawled combinations of graphemes we call handwriting. There is no describing my satisfaction in filling a page with cursive script, nor the miracle of being able to read it back to myself, especially when about half of the content is in my own idiosyncratic shorthand. Why, then, am I writing about my little ink-stained indulgence in Google Docs, for ultimate posting to my blog?

The commanding presence of computers and their keyboards in my life has left little room for pen and pencil. It's so much easier to martial ideas and manipulate text using software. As it neatly telegraphs itself in German, "Laptop auf, Google an!" The computer facilitates the process of writing, and so much more besides. But like my attachment to printed books and paper manuscripts, the love of handwriting is still there, perhaps fostered by a childhood that knew no keyboarding — I first used a typewriter in high school, and a manual one at that. My school days were marked, and liberally spotted, by old-fashioned straight pens. I still remember the smell of the inkwell on my desk, the feel of my pen's stained cork hand-grip, and the distinctive rasping and scratching of many nibs as my classmates and I learned our ABCs.

Now my work compels me to interact with digital text and images for the better part of the day. Years of typing and mouse manipulation have wreaked predictable havoc on the tendons of my forearms. Writer's cramp was easier to deal with. At this point you are probably expecting a rant against the soulless reign of technology, but I shall have to disappoint. I actually enjoy most aspects of computing, especially the flexibility and maybe-I'll-try-that freedom of word and image processing in all its extraordinary variety. At the same time I have my fond memories of the dull pencils, nib-torn pages, smudges, leaky ballpoints, ink blots, and boo-boos of that older world of paper, not to mention the now antique art of typewriting. Underwoods really have had their day, but handwriting is indispensable it seems. Beyond the intrinsic appeal of calligraphic expression, I find it more practical for the recording of thoughts, the exchange of intimacies, note taking, appointment scheduling, grocery list making, and other obiter scripta. No electronic gadget has appealed much to me as a tool for this kind of task. And who, for instance, would feel truly comfortable emailing condolences to a friend whose parent has died? Whether a sonnet or a laundry list, a written document is a hand-produced, human thing. Writing is something handed down. It is part of our history and our most cherished invention after language itself: the perfect tool to record everything our wagging tongues could come up with, from gossip to the oracles of a god. You could say I have a nostalgia for handwriting.

As a counterpart to my computer use, I have tried for many years to order my life with a Palm handheld; but I've grown weary of fussing with it. I'm tired of flubbed Graffiti strokes and poorly aimed taps. There is the persistent mild anxiety caused by having to remember to sync or recharge the battery. I miss the old standard paper calendar books, not just for the ease of whipping them out and quickly scribbling the information I need to record in them, but also for the satisfaction of leafing through past editions, watching the history of my work life flow by as I turn the pages, reminding myself of important people, conversations, random thoughts, aperçus — all charmingly preserved on somewhat dog-eared paper.

A handheld's calendar cannot reproduce paper's tangible presence. Yes, software is efficient; screen resolution and storage are phenomenal; but my experience has been that, once past, events tend to slide inexorably into virtual oblivion. Months and years moulder into an indiscriminate bog of old data. What is lacking is the rich hermeneutical humus of varying inks or pencil types, pen pressures, private doodlings, coffee spills, annotations, underlinings, paper clip reminders, sticky attachments, crossings-out, etc. of a paper journal. Perhaps a future technology will make my complaint look petulant and uncool. I know that digital equivalents of all the above are available (well, perhaps not the coffee spills). But somehow a computer's clean, smooth surfaces act as barriers, depriving me of the all-important visual and tactile experience of paper. New developments in computer technology will doubtless bring better interfaces. When we get the optimum combination of microprocessor power and improved software, handwriting — although this time on a friendlier and ferociously sensitive digital medium — might become popular again. Who is to say where technological development will take us? It's becoming harder to follow the changes and hence to predict futures. As Wallace McLendon has written:

Ten years ago tracking technology was easier. A technology — like PDAs — flew solo, independent of other technologies, like a bird flying outside of a flock. Now technology is immersed in the flock and the flock moves as if each technology is connected. The pattern of a single technology is not as interesting or revealing as it used to be, even if we were able to extract it from the circuits and chips it shares. ... [F]uture technological innovations will be a flock of technology changes shifting and darting together over time continuous.

The demise of handwriting?
My reflections on handwriting give rise to the following questions: Has the computer led to the demise of handwriting? Is our cultural life diminished as a result? Will this loss also affect our language?

It's obvious that there has been a decline, as linguist David Crystal points out in a recent post, but "demise" is an exaggeration. Handwriting is going to be with us for some time to come. People attach great significance to handwritten documents: their "graphaesthetics" (writing style, paper choice, etc.), and what we can deduce from them about the writer's mood, personality, or status. Analyzing a writer's hand is also of vital importance to literary critics, teachers, historians, psychiatrists, forensic scientists, and the lovelorn.

There appears to be little danger to the English language from the millions of tapping fingers and thumbs out there, although anyone on the grumpy side of the Gr8 Db8 on "txting" may demur. I wrote about the phenomenon of Netspeak last October, quoting Martin Amis' very funny take on male genital insecurity and text messaging in his novel Yellow Dog:

... take my word 4 it, clint, u don't want a bloody great 2l. ... they're overr8ed! i h8 them! & what an un4tun8 effect it has on the ego: ... it's not size th@ m@ters, clint. it's love th@ m@ters.

There is no obvious connection between the loss of handwriting and the formal state of a language, as might manifest itself in such areas as vocabulary and grammar. The issues raised by the potential disappearance of handwriting seem to be more psychological and social than linguistic. The use of handwriting has indeed declined, but the language is alive and well, on our loose lips and on the web. Compared to the sinister euphemisms of Big Media, or the nerve-deadening sloganeering of corporate-speak, the lively twitter of real people is quite refreshing. Texting is often criticized, but is it really the bleak, bald, sad shorthand that some accuse it of being, masking dyslexia, poor spelling, and mental laziness? In fact, the evidence suggests the opposite. The texting system of conveying sounds and meaning goes back all the way to the origins of writing. Far from hindering literacy, texting may turn out to help it. Homo loquens at its best.

Could it also be that blogging as a technology is partially making up for the lack of a thoughtful, personalized graphic medium like the traditional diary? The popularity of blogging and other forms of individual expression online may have something to do with a certain nostalgia for paper and ink. While at present there is no substitute for the ease and comfort of typing (or even dictating) words into a computer, there will always be a place for handwriting. When the technology improves, I shall be happy to take up my stylus and handwrite my memoirs and my villanelles, even letters of condolence, onto a light, solid-state digital tablet. If writing is a labour of love, we shouldn't be too concerned about the tools employed. For it's love th@ m@ters.

In floods of rancid bile o'erflows: the poetry of medicine

2008-05-04T13:30:00.007-05:00

evoted to the mystic practice of healing, the priests of Aesculapius chanted their shamanistic verses long before scientific investigation was introduced into medicine. Over the ages poets good and bad (mostly bad) have communed with their medical muse and set down their deepest sentiments in the special language of symbol and metaphor. However halting or quirky their rhyme and metre, no matter the annihilating banality of their theme or the bottomless bathos of their bavardage, the poets of medicine have left their mark. The magic of poesy has cast its brilliant light on the unfairly neglected subjects of dissection and digestion, sanitation and elimination.

Medical librarians have been alert to these alternative interests of the physicians whose massive clinical texts accumulate on our library shelves. Whatever our own personal feelings may be regarding the poetic or other literary effusions of our patrons, we should not fail to add them to our collections. For example, Jack Coulehan, M.D., M.P.H., has recently published Primary Care (University of Iowa Press), a collection of poems written by physicians who reflect in verse on the uncertainty, pain, anger, sympathy, longing, skepticism, desperation, and love they observe in their patients and often experience themselves. Dr. Coulehan has also edited Blood and Bone: Poems by Physicians.

The thin line between good taste and travesty is easily crossed, however, when medicine is the muse. I have taken a particular interest in those poets, whether medically trained or not, who ostentatiously occupy the other side of that significant divide. In this post I have brought together an evocative collection of my favourites.

John Keats, sweet singer of the English Romantics, studied medicine and died young. In the short time he had to compose some of the greatest poems of the English language, Keats perhaps wisely avoided the daunting task of creating odes or sonnets on the spleen or the perils of gossypiboma. Yet he was no stranger to life's vicissitudes, for he watched his brother die slowly of consumption, and himself succumbed to the same illness a few years later:

Here, where men sit and hear each other groan;
Where palsy shakes a few, sad, last grey hairs,
Where youth grows pale, and spectre-thin, and dies. (Ode to a Nightingale)

For Keats, poetry and medicine could and did share many ideological threads, among them being his theory of "negative capability." It required a certain clinical detachment and strong powers of observation honed by hours of squinting at cadaver dissections to form the basis of that world view. But despite all his concerns about etiolated youth, alone and palely loitering in unhealthy fens and drafty towers, you will find none of Keats' verse below. His negative capability did not extend to meditations on chyle or sexually transmitted diseases. Nor is William Carlos Williams's work represented. Famous for the modernist minimalism so beautifully expressed in his The Red Wheelbarrow, Williams versified little of his experience as a physician. No red gurneys haunt our modern poetic sensibility.

No, the poets here gathered are special. Some were physicians, but most were mere human beings. What brings them together is their intemperate desire to write on medical subjects, an obsession matched only by their want of taste and utter lack of talent. They have experienced the world through the gimlet eye of the surgeon, the peculiar exudations of the funeral parlour, and the horrors of the dentist's chair. They have dropped dripping literary specimens into pails and left ample swatches of gauze after sewing up thoracic cavities. It takes special courage and determination to mount the heights of Parnassus with paeans to ditches, drains, embryos, bloody scalpels, and intestinal flora. Indeed, only the most sensitive of souls could write an elegy on a dissected puppy or a smothered child.

Drawing upon this rich and redolent tradition, the writing of medical poetry continues today. Not content with the themes and visual imagery of traditional English poetry, it challenges our inner eye and nostril with a singular corpus of verse, a very human afflatus that cuts like or can be cut with a knife. As Kathleen Béres Rogers reminds us:

Indeed, one could say that modern-day medical poets and patients repeat the traditionally conceived Romantic project, expressing a “spontaneous overflow” of “powerful emotion, recollected in tranquility”: after the diagnosis, the surgery, the recovery, or the death. Yet by writing their poems, medical poets—now and then—remind us that our bodies also exist as a part of the natural world, defined by both their sublimity and materiality. (Medical poems and the Romantic rise of disciplinarity. Thesis. University of North Carolina at Chapel Hil, 2007, p. 151.)

Each year the human body excretes its own weight in bacteria. Here is an earthy subject of a sublimity and materiality perfectly fitted to the imaginative powers of the poets gathered together in this little anthology. How sad that as yet no English poets have applied themselves to this formidable reality of human existence. We are the lesser for it.

The poems and fragments assembled below, spanning a period of many centuries, are arranged thematically. Readers are encouraged to be moderate in their perusal of the collection, for too rich a diet of this poetry of medicine could require the attentions of a physician.

Anatomy

A MOOD OF MADNESS

Two loves found refuge in my happy heart,
One for my bride, one for the healing art;
Each of my spirit claimed an equal part.

But, as my talent rose and waxed mature,
Love for my bride became more insecure,
Love for anatomy more deep and pure.

She was a subject to my eyes alone;
Not woman, forsooth, but so much flesh and bone,
Sinew, and blood, and skin, which were my own.

And I had lawful right, with foul intent,
I who for progress on this sphere was sent,
To use her body for experiment.

So in her wine I dropped consuming blight,
One moaning, shadow-haunted winter night,
And, watching, clutched my scalpel's handle tight.

Then, ere her eyes, that agony expressed,
Had closed forever, with impatient zest,
My hands were red dissecting her white breast.

Francis Saltus Saltus (1849-1889)

AN ELEGY TO A DISSECTED PUPPY

Sweet Dog! now cold and stiff in death,
What cruel hand enticed thee here?
Did toothsome crust of juicy bone
Allure to stretch on thy bier?

... ruthless hands of alien race
Are opening up thy quiet breast,
With prying eyes they peer within,
Explore the contents of thy chest.

Georgia Bailey Parrington (fl. 1907)

from THE COURSE OF TIME, Bk. VII

And as the anatomist, with all his band
Of rude disciples, o'er the subject hung,
And impolitely hewed his way, through bones
And muscles of the sacred human form,
Exposing barbarously to wanton gaze
The mysteries of nature, joint embraced
His kindred joint, the wounded flesh grew up,
And suddenly the injured man awoke
Among their hands, and stood arrayed complete
In immortality—forgiving scarce
The insult offered to his clay in death.

Robert Pollock (1798-1827)

MRI

In this image

Of your brain
I see each curve
In the corpus callosum,
Curlicues of gyri,
Folding of fissures,
Sinuous sulci,
Mammillary bodies,
Arcuate fasciculus,
Angular gyrus,
Tracts and nuclei,
Eyes and ears,
Tongue and phalanx.

But not even
A single syllable
Of one
Tiny
Poem

Vernon Rowe. In: Angela Belli and Jack Coulehan, eds. Blood and Bone: Poems by Physicians (Iowa City: University of Iowa Press, 1998), p. 102.

Dentistry

Stranger! Approach this spot with gravity!
John Brown is filling his last cavity.

Anonymous

MY LAST TOOTH

You have gone, old tooth,
Though hard to yield,
You have long stood alone,
Like a stub in the field.

Farewell, old tooth
That tainted my breath,
And tasted as smells
A woodpecker's nest

from THE DENTIAD

... her lips disclosed to view,
Those ruined arches, veiled in ebon hue,
Where love had thought to feast the ravished sight
On orient gems reflecting snowy light,
Hope, disappointed, silently retired,
Disgust triumphant came, and love expired!

When'er along the ivory disks, are seen,
The filthy footsteps of the dark gangrene;
When caries come, with stealthy pace to throw
Corrosive ink spots on those banks of snow—
Brook no delay, ye trembling, suffering Fair,
But fly for refuge to the Dentist's care.

Solyman Brown (1790-1876)

Dermatology

A PRETTY GIRL

On her beautiful face there are smiles of grace
That linger in beauty serene,
And there are no pimples encircling her dimples,
As ever, as yet, I have seen.

J. Gordon Coogler (1865-1901)

Emergency Medicine

from A TALE OF THE SEA

'Twas on the 8th April, on the afternoon of that day,
That the little village of Louisberg was thrown into a wild state of dismay,
And the villagers flew to the beach in a state of wild uproar,
And in a dory they found four men were cast ashore.

Then the villagers, in surprise, assembled about the dory,
And they found that the bottom of the boat was gory;
Then their hearts were seized with sudden dread,
When they discovered that two of the men were dead.

And the two survivors were exhausted from exposure, hunger, and cold,
Which caused the spectators to shudder when them they did behold ...

They were carried to a boarding-house without delay,
But those that were looking on were stricken with dismay,
When the remains of James and Angus M'Donald were found in the boat,
Likewise three pieces of flesh in a pool of blood afloat.

Angus M'Donald's right arm was missing from the elbow,
And the throat was cut in a sickening manner, which filled the villagers' hearts with woe,
Especially when they saw two pieces of flesh had been cut from each thigh,
'Twas then the kind-hearted villagers did murmur and sigh.

William McGonagall (1830-1902)

Epidemiology

ODE TO A DITCH

Oh, ditch of all ditches,
Death's store-house of riches,
Where wan disease slumbers mid festoons of slime!
Oh, dark foetid sewer
Where death is the brewer
And ail is the liquor he brews all the time!

Oh, hot-bed of fever,
That fatal bereaver
Whose fiery breath blights the blossom of life!
Oh, palace of miasm
Whose hall is a chasm
Where pestilence revels and poison is rife!
...

Oh, wonderful sewer,
Each year brings a newer
And ghostlier charm to they cavernous deeps!
More puppies and cats,
To say nothing of rats,
And offal and filth of all manner in heaps.

Anonymous. Originally appeared in the Fayetteville North Carolinian on February 21, 1857.

Gastroenterology

from THE ART OF PRESERVING HEALTH, BOOK II

The languid stomach curses e'en the pure
Delicious fat, and all the race of oil:
For more the oily aliments relax
Its feeble tone; and with the eager lymph
(Fond to incorporate with all it meets)
Coyly they mix, and shun with slipp'ry wiles
The woo'd embrace. Th'irresoluble oil,
So gentle late and blandishing, in floods
Of rancid bile o'erflows: what tumults hence,
What horrors rise, were nauseous to relate.
Choose leaner viands, ye whose jovial make
Too fast the gummy nutriment imbibes.

...

Half subtilis'd to chyle, the liquid food
Readiest obeys th'assimilating powers;
And soon the tender vegetable mass
Relents . . . .
The stomach, urged beyond its active tone,
Hardly to nutrimental chyle subdues
The softest food: unfinished and depraved,
The chyle, in all its future wand'rings, owns
Its turbid fountain; not by purer streams
So to be cleared, but foulness will remain.

John Armstrong (1709-1779)

Infectious Disease

from POOR LITTLE HEARTS

Poor little Ada Queetie has departed this life,
Never to be here no more,
No more to love, no more to speak.

Poor little Ada Queetie's last sickness and death,
Destroyed my health at an unknown rate,
With my heart breaking and weeping,
I kept the fire going night after night, to keep poor little dear warm,
Poor little heart, she was sick one week
With froth in her throat,
Then 10 days and grew worse, with dropsy in her stomach,
I kept getting up nights to see how she was.

She was coming 9 years of age, when she was taken away,
By all I found out, very certain true
Poor Sissy hatched her out her egg in Chilmark,
The reason she was taken away before poor Sissy,
Her constitution was as weak as weak could be.

Her complaint that caused her death,
Was just such a complaint as poor Sissy had
Only poor Sissy's complaint ended with dropsy in her stomach.

Nancy Luce (fl. 1860s)

Internal Medicine

from THE SPLEEN

I always choose the plainest food
To mend viscidity of blood.
Hail! water gruel, healing power,
Of easy access to the poor;
Thy help love's confessors implore,
And doctors secretly adore:
To thee I fly, by thee dilute—
Through veins my blood doth quicker shoot;
And by swift current throws off clean
Prolific particles of spleen.

Matthew Green (1697-1737)

Obstetrics

Gooing babies, helpless pygmies,
Who shall solve your Fate's enigmas?

from The Light-Bearer of Liberty, by J.W. Scholl (A pathetic attempt at rhyme by a very bad poet)

BETWEEN OUR FOLDING LIPS

Between our folding lips
God slips
An embryon life, and goes;
And this becomes your rose.
We love, God makes: in our sweet mirth
God spies occasion for a birth.
Then is it his, or is it ours?
I know not—He is fond of flowers.

T.E. Brown (1830-1897)

Ophthalmology

ONLY ONE EYE

Oh! she was a lovely girl,
So pretty and so fair,
With gentle, lovelit eyes,
And wavy, dark-brown hair.

I loved the gentle girl,
But oh! I heaved a sigh,
When first she told me she could see
Out of only one eye.

But soon I thought within myself,
I'd better save my tear and sigh,
To bestow upon some I know,
Who has more than one eye.

She is brave and intelligent,
Too she is witty and wise,
She'll accomplish more now, than many,
Who have two eyes.

Ah! you need not pity her,
She needs not your tear and sigh,
She makes good use, I tell you,
Of her one remaining eye.

Lillian E. Curtis (fl. 1870s)

Orthopedics

WOODEN LEG

Misfortune sometimes is a prize,
And is a blessing in disguise;
A man with a stout wooden leg,
Through town and country he can beg.
...

And when he only has one foot,
He needs to brush only one boot;
Through world he does jolly peg,
So cheerful with his wooden leg.

In mud or water he can stand
With his foot on the firm dry land,
For wet he doth not care a fig,
It never hurts his wooden leg.

No aches he has but on the toes
Of one foot, and but one gets froze;
He has many a jolly rig,
And oft enjoys his wooden leg.

James Macintyre (1827-1906). A Canadian noted for another immortal poem, Ode on the Mammoth Cheese.

Pediatrics (Psychiatry?)

HIS MOTHER DRINKS

Within a London hospital there lies,
Tucked in his cot,
A child with golden curls and big blue eyes.
The night is hot,
And though the windows in the long low ward
Are open wide,
No breath of air comes from the sun-baked yard
That lies outside.

A kindly nurse who sees his wistful smile,
To cheer him cries;
"The doctor says that in a little while
He'll let you rise,
And send you home again!" His eyes grow dim.
She little thinks
What since his father died home means to him—
His mother drinks!

TWO SMOTHERED CHILDREN

Theirs was not the peaceful death-bed,
Where affection's silent tears,
O'er the couch of pain fast falling,
Blend with deep responsive prayers;

Nay, their death was strangely fearful!
No fond parent closed their eyes,
And no voice of pity answer'd
To their feebly moaning cries!

Mrs. Marion Albina Bigelow (fl. 1850s)

Public Health

COME BACK CLEAN

This is the song for a soldier
To sing as he rides from home
To the fields afar where the battles are
Or over the ocean's foam:
"Whatever the dangers waiting
In the lands I have not seen,
If I do not fall—if I come back at all,
Then I will come back clean.

"I may lie in the mud of the trenches,
I may reek with blood and mire,
But I will control, by the God in my soul,
The might of my man's desire.
I will fight my foe in the open,
But my sword shall be sharp and keen
For the foe within who would lure me to sin,
And I will come back clean."

Ella Wheeler Wilcox (1850-1919)

LONDON

Magnificent, too, is the system of drains,
Exceeding the far-spoken wonders of old:
So lengthen'd and vast in its branches and chains,
That labyrinths pass like a tale that is told:
The sewers gigantic, like multiplied veins,
Beneath the whole city their windings unfold,
Disgorging the source of plagues, scourges, and pains,
Which visit those cities to cleanliness cold.
Well did the ancient proverb lay down this important text,
That cleanliness for human weal to godliness is next.

Samuel Carter (fl. 1848-1851)

Surgery

from THE SURGEON'S KNIFE

There are hearts—stout hearts,—that own no fear
At the whirling sword or the darting spear,—
that are ready alike to bleed in the dust,
'Neath the sabre's cut or the bayonet's thrust;
They heed not the blows that Fate may deal,
From the murderer's dirk or the soldier's steel:
But lips that laugh at the dagger of strife
Turn silent and white from the surgeon's knife.

It shines in the grasp—'tis no weapon for play,
A shudder betrays it is speeding its way;
While the quivering muscle and severing joint
Are gashed by the keen edge and probed by the point.
Dripping it comes from the cells of life,
While glazing eyes turn from the surgeon's knife.

Eliza Cook (1818-1889)

from THE AVENGER

[A brigand is overpowered in the act of attempting to molest a lady and requires medical care:]

So stunned, surrounded and beset,
The surgeon struggled hard to see
His patient, or at least to get
Some signs of his proximity:
At length they opened up a way
To where a man extended, lay,
Presenting an appalling sight
Seen dimly through the chequered light...
For swelling, high amid the clothes,
The body, like a mountain rose
That scarce the head was seen;
While from below the feet protrude
(Like Satan "stretching many a rood"
So giant-like I ween.) —
And on those large and naked feet
A pair of antique spurs were placed,
Which fastened o'er the instep meet,
With many-coloured latchets graced.

[The surgeon enquires later:]

"Since when he has," (replied the nurse,)
"Been going on from bad to worse."

Samuel Carter (fl. 1848-1851)

Physicians

ON DR. ISAAC LETSOME

When people's ill they comes to I,
I physics, bleeds, and sweats 'em.
Sometimes they live, sometimes they die;
What's that to I? I Letsome.

ON SIR JOHN HILL, M.D., PLAYWRIGHT

For physic and farces his equal there scarce is;
His farces are physic; his physic a farce is.

David Garrick

from ODE UPON DR. HARVEY

Coy Nature (which remain'd, though aged grown,
A beauteous virgin still, enjoy'd by none,
Nor seen unveil'd by any one),
When Harvey's violent passion she did see,
Began to tremble and to flee,
Took sanctuary, like Daphne, in a tree:
There Daphne's lover stopt, and thought it much
The very leaves of her to touch,
But Harvey, our Apollo, stopt not so,
Into the bark and root he after her did go.

Abraham Cowley (1618-1667)

In closing

And now, kind friends, what I have wrote,
I hope you will pass o'er,
And not criticize as some have done,
Hitherto herebefore.

Julia A. Moore (1847-1920) "The Sweet Singer of Michigan."

Injecting doubt: the rhetoric of harm reduction and the fate of Insite

2008-04-20T01:55:00.005-05:00

The debate over the future of Insite, the successful safe-injection and drug health centre in Vancouver's Downtown Eastside, grew more impassioned this month after the federal government's so-low-key-as-to-be-well-nigh-subsonic release of a report by a panel of experts tasked with assessing existing scientific research on the facility.

Perhaps the loudest squawk came from the authors of the report's most quoted studies: "This government may already have garnered a reputation for being the most antiscience government in Canadian history." In a sharply worded article published last week on Straight.com, Thomas Kerr and Evan Wood, research scientists at the British Columbia Centre for Excellence in HIV/AIDS, accuse the federal Conservatives of politicizing science in their straight-laced and passive-aggressive approach to Insite's work with injection drug users.

Doing exactly what it was set up to do
Kerr and Wood charge the government with attempting to "cloud science" and "manufacture uncertainty." In the Tories' get-tough, war-on-drugs strategy, they aver, there is no room for sound public health strategies like harm reduction — despite the wealth of scientific evidence to support these interventions, including 22 studies by the authors which appeared in major medical journals such as the New England Journal of Medicine, the Lancet, and the British Medical Journal. This plethora of research shows that Insite is doing exactly what it was set up to do:

contributing to reductions in the number of people injecting in public and the number of discarded syringes on city streets,
helping to reduce HIV-risk behaviour and saving lives that might otherwise have been lost to fatal overdose,
achieving a 30% increase in the use of detoxification programs among Insite users in the year after the site opened,
not increasing crime or leading others to take up injection-drug use.

Moreover, Insite appears to be cost-effective and is popular among the general public. Within the strict limits imposed on it, Insite just seems to work. Undeterred by mere facts, however, Prime Minister Stephen Harper, whose strong opposition to "deviant behaviour" is well known, claims to remain unconvinced. Neither the overwhelming scientific evidence nor Insite's articulate defenders — not even the largely positive conclusions of the government's own Expert Advisory Committee — seem to have swayed this staunch defender of prudence and propriety and his loyal supporters.

The most negative finding the Committee could come up with was that Insite did not show a record of addiction prevention. However, as the Canadian Medicine blog points out in an April 14 post, "it should come as no surprise that prevention hasn't improved. Perhaps the prevention of further harm and more death should be prevention enough, and we shouldn't expect one single intervention to solve the problem of drug addiction itself. After all, this is a 'harm reduction' project we are talking about — not harm prevention." However, as is the case with global warming, no amount of compounding detail is enough to disabuse the determined believer.

Ideological warfare
Given the significant disagreement on this issue, perhaps the very term "harm reduction" is the problem, as A.I. Leshner of the American Association for the Advancement of Science suggests [1]. The imprecise application of this term and its use as a euphemism for drug legalization have "sufficiently inflamed ... drug warriors that they cannot have a rational discussion of even the underlying concept, let alone how harm-reduction strategies might be implemented." Leshner advocates the avoidance of ideological intensity. "Let's get on with studying specific strategies to protect the public health and ensure social well-being and give up this term that only gets in the way, even if it does make sense." This well-meant and seemingly pragmatic dismissal of ideology, so characteristic of certain debates within American elites, is itself highly ideological. Excellent solutions are brought forward in print, and they stay securely in print. There are still no safe injection sites anywhere in the United States.

From a Canadian perspective, Bernadette Pauly of the University of Victoria reminds us that harm reduction, however well implemented, is only a partial solution [2]. Conceived within a broader social justice context, harm reduction strategies should be part of a comprehensive approach to reducing social inequities, providing accessible health care, and improving the health of those who are street-involved. Pauly is proposing to move from print to political project. All well and good, but then we confront the by-one's-own-bootstraps catechism of the dogged Harperites and their extraordinary ability to mobilize the fear and petty prejudices of Canadians in support of their retrograde policies.

The worst part of having success is trying to find someone who is happy for you, as Bette Midler once said. Insite's harm reduction achievements are being deliberately downplayed as time runs out on the facility's exemption from federal legislation that would otherwise see operators charged under federal drug laws. The current licence expires on June 30, when Health Minister Tony Clement must decide whether to grant another exemption to the Controlled Drugs and Substances Act or amend legislation that prohibits it. Battle lines are being drawn as two law suits challenging the federal government's jurisdiction over the matter head to the British Columbia Supreme Court, and experts like Thomas Kerr demand publicly that the Minister honour the findings of his own researchers and stop injecting doubt by his disingenuous questioning of Insite's raison d'être.

The only dope worth shooting is ...
On the other side of the ideological divide, the Vancouver Police Union issued a recent statement criticizing Insite, which operates near capacity, for serving only a tiny minority. That's like denouncing underfunded and understaffed day care centres in this country for serving only a small number of Canadian children. According to the Canadian Press, Chief Superintendent Derek Ogden, the RCMP's director general of drugs and organized crime, echoed his masters by stating he would like to see further research. "I absolutely cringe when I hear people talk of a safe injection site," he said in an interview from Ottawa. How about that for informed comment. The Chief Superintendent probably also cringes at the thought of certain sexual practices, religious rituals, or undergraduate film studies courses. It's comforting to know that federal law enforcement policies are being planned based on the cringe factor. Health Canada spokespersons ran for cover and would only respond to emailed questions from the media. Predictably, they intoned the mantra that the Minister was "examining" the Expert Advisory Committee's report.

Perhaps Ottawa's balmy spring weather is distracting Mr. Clement. But the question needs to be asked. What further research is really needed, and how much more examining must he do? The money spent on this lengthy and redundant investigation (no cost figures for the Committee's efforts seem to be readily available) could probably finance the start-up of another harm reduction program in, say, Toronto or Montreal. Insite remains the only safe injection site in North America.

The strange timing of the report's appearance has not gone unnoticed. The surreptitious nature of its release late on a Friday afternoon seemed designed to minimize media coverage. The ideological reasons for the health minster's coy and constrained behaviour are obvious. As David Eaves so aptly comments on his blog, "for what must be the first time in Health Canada’s history the department is trying to bury a study that highlights how one of its programs improves healthcare outcomes to Canada’s most marginalized citizens."

Scientific arguments are insufficient in themselves
In a brilliant commentary on the ideological warfare behind the war on drugs, two Canadian sociologists take on the sententious rhetoric that labels harm reduction advocates as "legalizers" in the guise of scientists and public health professionals [3]. Because the right-wing attack comes from either the intractably convinced or cleverly hypocritical stance that abstinence, prevention, and enforcement are the only acceptable and morally legitimate solutions, harm reduction's muted stance on morals, rights and values prevents proponents from engaging criticisms of this nature in terms other than the evidence or science.The case of Insite, the authors argue, demonstrates the value of asserting human rights claims that do not rest on evidence per se. Scientific arguments are insufficient in themselves to move beyond the status quo on drugs.

They conclude, "Without commitment to 'strong rights' and the sovereignty of users, harm reduction sentiments are easily subverted to a technocratic governance agenda. Against the accusation that we are really 'legalizers' harm reduction advocates need not dispute the label but rather the suggestion that opposition to the drug war is somehow irresponsible, dishonest, or immoral. Respect for human rights moves harm reduction past the confines of a scientific project — which has not been well respected outside academic circles — toward a generative programme for replacing prohibition with policies reflecting the costs and benefits of drug use and the costs and benefits of formal intervention."

Here, surely, is the way to proceed. Palaver and posturing should not get in the way of real progress, which will be measured in terms of real lives and the difference that intelligent and compassionate social programs can make. Noam Chomsky once said, "The sign of a truly totalitarian culture is that important truths simply lack cognitive meaning and are interpretable only at the level of 'Fuck You', so they can then elicit a perfectly predictable torrent of abuse in response." Let's hope that the continuing controversy over harm reduction and safe injection sites will not sink to that level.

References:

1. Leshner AI. By now, "harm reduction" harms both science and the public health. Clin Pharmacol Ther. 2008 Apr;83(4):513-14.

2. Pauly B. Harm reduction through a social justice lens. Int J Drug Policy. 2008 Feb;19(1):4-10.

3. Hathaway AD, Tousaw KI. Harm reduction headway and continuing resistance: insights from safe injection in the city of Vancouver. Int J Drug Policy. 2008 Feb;19(1):11-16.

A PDF version of the Expert Advisory Committee's report has been created by David Eaves (www.eaves.ca) and is available here.

And here are the reports from the independent researchers as provided by the Vancouver Sun: http://www.canada.com/vancouversun/pdf/FinalCost-BenefitAnalysis_.pdf http://www.canada.com/vancouversun/pdf/finalEnvironmentalScan-IDU.DOC http://www.canada.com/vancouversun/pdf/boydetalfinalsis.pdf

PubMed sends out a few new blooms: simplified web links

2008-04-14T14:29:00.011-05:00

As the snow melts under the tall spruces around my house and flocks of Canada geese honk in the skies overhead like roaring twenties traffic, the blooming bottle brush trees and ocotillos of Palm Springs occupy my dreams, disquietingly alien, like science fiction flora. The Day of the Triffids meets flip-flops and Ray-Bans. On a California oldies station a snatch of the opening number from The Rocky Horror Picture Show: "And I really got hot when I saw Janette Scott / Fight a triffid that spits poison and kills." Those lurid red blooms nodding in the desert breeze seem to be searching for something. My pale raw flesh perhaps? The desert is strangely alive with growing things.

Half a continent away from the riotous brittle bushes of Tahquitz Canyon, flowers are merely in potentia here as the earth slowly thaws and scatters the snow lice in my boreal soul. But spring has come. Like my labs, I'm blowing my coat after a snarling winter. Frisking red squirrels and fisking politicians are chattering away, the sun's warmth is infectious, and my thoughts turn towards spring cleaning, perennials, and ... PubMed updates.

A recent NLM Technical Bulletin informs us that the URL parameters used to generate web links to PubMed have been simplified. I hadn't realized they were excessively complicated, but I'm all for simplicity, and I suppose eliminating the tiresome "entrez" filler in PubMed URLs is progress. I never did see the point of it. Although you'd think it would have made more sense to dump "entrez" during the past francophobic furor, when victory fries were flung in the face of l'ennemi du jour, that nation of cheese-eating surrender monkeys.

Creating Simplified Web Links to PubMed
Nothing of earth-shattering importance here, but the Bulletin's terse summary is as digestible as human flesh to a triffid and saves trawling through the user guide. It gave me some ideas about how I might use these PubMed features more frequently.

1. Simplified URL The base URL to retrieve citations and search PubMed is http://www.ncbi.nlm.nih.gov/pubmed/. Just add the PMID. I would have liked it even better if they could have eliminated most of the alphabet soup. What prevented them from achieving a del.icio.us-like simplicity by allowing us to use http://pubmed.com? This very simple URL actually works, even with a PMID stuck on. Now that's spitting poison. Pubmed.com is resolved into an ncbi.nlm.nih.gov-type URL. But, curiously, not the new, "simplified" URL that is the subject of this announcement. If, for example, you enter

http://pubmed.com/1386390

it resolves to the following:

http://www.ncbi.nlm.nih.gov/sites/entrez/1386390

You get to the citation, but there's that annoying surrender monkey word in the non-simplified URL. Can anyone explain why this happens?

2. Retrieve one or multiple citations

Here's something that I haven't used much. You can separate PMIDs with a comma after the base URL to retrieve citations in the default AbstractPlus HTML format:

http://www.ncbi.nlm.nih.gov/pubmed/10742334,1386390

My staff use this trick regularly to call up multiple records in order to print articles for our patrons from written requests. I can see myself using it — along with the code to change the format to text (see below) — for producing quick, painless citations.

3. Change the format To change the format from html to text, use format=text:

http://www.ncbi.nlm.nih.gov/pubmed/1386390?format=text

I like the way this technique lets you create a quick-and-dirty citation, no matter which display you're working from. Go up to the URL, erase everything after the question mark, and enter the code "format=text." Remove the carriage returns from the resulting citation, erase the extraneous text, and you have a decently formatted citation. (It would be so nice if PubMed had a convenient button for each reference which would create a proper citation in one of the leading bibliographic formats and copy it to the clipboard for easy insertion into a document. But I'll make do with this.)

Wiswell TE. John K. Lattimer Lecture. Prepuce presence portends prevalence of potentially perilous periurethral pathogens. J Urol. 1992 Aug;148(2 Pt 2):739-42. No abstract available. PMID: 1386390 [PubMed - indexed for MEDLINE]

Of course, the easiest option is to find the reference in PubMed and select Text on the Send to pull-down menu. Send multiple references to the Clipboard first and then send to text. But make sure you're looking at the Summary display. If you send to text from the Abstract display, you're left with a fragmented citation full of blank lines, even more extraneous material to delete, and all the clicking-cutting-pasting that spells kluge.

Until we get that magic button, I'll continue to use this method for quick citations from PubMed. I know that a program like RefWorks will give me perfectly formatted citations, but all the required loading and clicking and waiting is too much effort just to produce a simple reference to insert into a blog post or an email.

4. Change the display To change the display, add the URL parameter ?report=display (where "display" is the name of the desired PubMed display format such as citation, MEDLINE, etc.).

5. Search strategy URLs: To search PubMed, use the URL parameter ?term=search (where "search" is the actual strategy):

http://www.ncbi.nlm.nih.gov/pubmed?term=tp53+cancer

Note that the + sign takes the place of spaces, which are not allowed in the URL. This looks less useful. It's the rare day that my searches are so simple.

My NCBI Collections added to PubMed Send To Menu
Finally! I think everyone will appreciate this small improvement. My NCBI Collections is now available as a selection under the PubMed results Send to menu. Sending results to a Collection was previously only available from the Clipboard. Works like a charm.

From critical care to comfort care: the sustaining value of humour

2008-04-11T16:58:00.002-05:00

He who has laughter on his side has no need of proof. ~ Theodor Adorno, Minima moralia

(Plagiarized from a UPI news item) A study by a Winnipeg researcher shows that humour can play an essential role in intensive or end-of-life care. Continuing research begun in her 2003 dissertation, Ruth Dean of the University of Manitoba Faculty of Nursing, with her colleague Joanne Major, a nurse at the Health Sciences Centre, spent hundreds of hours observing and carrying out interviews with staff, patients and families in an intensive care unit and a palliative care unit.

Their paper, published in the Journal of Clinical Nursing, demonstrates how health care staff use humour not only to reduce tension and express frustration, but to connect with patients, making them feel cared for as individuals and alleviating their embarrassment. They conclude that humour plays an essential role in promoting team relationships and adding a human dimension to the care and support of seriously ill patients and their families. "Our research suggests that nurses and other health care professionals don't need to suppress humour," Dean said in a statement.

The researchers found that staff used humour in a number of ways:

To cope with, and sometimes distance themselves, from difficult situations. As one person commented: "When you've had the most stressful day and you're ready to cry, sometimes it's easier to bring out humour and take it in the other direction instead of bawling on somebody's shoulder."

To connect with other health care professionals and provide mutual support. Shared laughter energized and nurtured a sense of community. "If you have those fun moments and that connectedness even the worst hell can happen," said one person who worked with terminally ill patients. "You sail through it as opposed to walking out really wounded."

To reduce tension when things don't go as well as they could do. A doctor who admitted he had been hasty suggesting that a terminally ill man give up his apartment so soon was greeted with the quip: "Shall I chart that you made a confession or that you made a mistake?"

To express frustration at life-prolonging measures that staff disagreed with. Staff in the intensive care unit told researchers how they paralleled what was happening to one patient by using an inflatable dinosaur called Dino and putting him through the same interventions. He became a symbol of their dissatisfaction with the situation.

To connect with patients and make them feel cared for as individuals. When a health care aide took a joke picture of a patient with a bubble bath helmet on his head to put him at ease, it became one of his prized possessions. He showed it to everyone who visited as evidence of the special treatment he was receiving. And when he died, it was displayed alongside important family photos.

To reduce patients' embarrassment with the indignity of needing help with toileting and other highly personal functions. When a patient suffered an episode of incontinence she reported that she found the nurse's matter-of-fact humour — "what goes in must come out" — made her feel less distressed.

It wasn't just the staff who used humour to alleviate difficult situations. One nurse recalled how a patient's monitor kept going off in the intensive care unit. "Don't worry, if I can hear it I'm still alive," the patient joked.

"Some people feel that humour is trivial and unprofessional in health care settings, but this study shows that it is neither," said Dr. Dean. "Despite major differences between the work of the intensive care and palliative care units, they are both areas where serious illness, high anxiety and patient and family distress are prevalent and staff are placed in emotionally demanding situations. Crises are frequent, death is close by, and emotions tend to run high."

The authors conclude that humour was very important in these stressful health care settings. "One member of staff referred to humour as the glue that holds human connections together, a statement that was clearly reinforced by our findings," said Dr. Dean. "Our research suggests that nurses and other health care professionals don't need to suppress humour. They should trust their instincts about when it is appropriate. Combined with scientific skill and compassion, humour offers a humanizing dimension in health care that is too valuable to be overlooked."

Reference:

Dean RA, Major J E. From critical care to comfort care: the sustaining value of humour. J Clin Nurs. 2008 Apr;17(8):1088-95.

"Flush tissue with stool": the problem of low health literacy in Canada

2008-03-22T19:38:00.008-05:00

All Canadians must have the tools to take responsibility for their own health and the health of their loved ones. This includes access to up-to-date and accurate health-related information as well as the tools required to understand and use this information. ~ How low literacy can affect your health (Canadian Council on Learning)

Last January I wrote about a particularly atrocious example of patient information, a poop test brochure, which, among other things, advised the reader to "flush tissue with stool." Have you ever tried flushing a toilet using a stool, let alone trying to repeat the step "on the next two subsequent bowel movements?" It's not easy, let me tell you.

Every time some hapless patient is forced to struggle through the opaque vocabulary and convoluted syntax of the Coloscreen brochure published by Helena Laboratories in Beaumont, Texas, you can almost see the illiteracy ratio and mortality rate starting to rise on the charts. Whoever wielded the applicator stick that smeared this rank prose specimen into print has a lot to answer for, as has the Winnipeg health clinic that decided it was appropriate to give to patients [1]. For we have become a country of the reading challenged, where even Robert Service's unpretentious, galumphing strophes, which my Grade 4 class once recited with pleasure, are becoming artifacts of another age. For school kids hooked on Halo and Twitter, The Cremation of Sam McGee will soon be as obscure as Horace's Alcaics; although I see that someone has posted a video of McGee on YouTube. Perhaps this will become a trend: literary works preserved for the print-allergic population as YouTube presentations — bardic recitation in the digital realm. An abomination like the poop test brochure is not the kind of challenge we really want. A health brochure's business is to communicate important facts that will help guide a person to make good health decisions. How did we reach such an impasse: that we can produce neither texts that communicate nor readers who comprehend them?

A vision for a health literate Canada
This month another study is bringing bad news about Canadians' ability to read. "Low health literacy is a serious and costly problem," says a recent report from the Canadian Public Health Association. A vision for a health literate Canada was released on March 3, 2008. A CPHA Expert Panel found that a majority (more than 55%) of Canadian adults do not have the skills to understand information about their own health or to make daily health-related decisions. The low levels of health literacy in Canada are "critical" and a countrywide strategy is needed to solve the problem.

The panel's findings were drawn from a 2003 analysis of 23,000 Canadians by the Canadian Council on Learning, which offers its own take on the problem in a March 6 report on its website, How low literacy can affect your health. See also another CCL report dated February 28, 2008, Health literacy in Canada: a healthy understanding.

Videosphere vs. Graphosphere
What is the nature of this literacy problem, which is certainly not unique to Canada? It seems likely that Fahrenheit 451's flame throwers will never be required. As young people's desire to read is assiduously burned off in what Régis Debray calls the era of the videosphere, and as cultural and political discourse becomes increasingly infused by and confused with the ruminant world of the cartoon or the video game, elites will not crease their linen worrying about proletarian revolution. In a typically quirky but thought-provoking essay published in the New Left Review [2], Debray laments the loss of the graphosphere, the era of printing that made possible the Enlightenment and progressive social change. In his schema this passing age is being replaced by the era of the image, the videosphere, in which the book is knocked off its pedestal and replaced by widescreen, gridlinked digital culture. Debray offers an arresting image of the possible political consequences of the drift from the printed word to digital prattle:

A practical example: to find out what is going on one has to watch TV, and so stay at home. A bourgeois house arrest, for beneath "a man’s home is his castle" there always lurks, "every man for himself." The demobilization of the citizen begins with the physical immobilization of the spectator.

Very much like Ray Bradbury's dystopia. And today's video-capable mobile devices could act like a digital equivalent of ankle bracelets to keep our minds virtually immobilized. According to Debray, the Internet, its access devices, and the jet plane are good for internationalization, but they are lethal for progressive politics and international solidarity. They enlarge the sphere of individual relations but privatize them at the same time; they particularize even as they globalize. And it is the isolated, atomized individual who makes the ideal consumer and the credulously passive subject of the state.

A digression: lexemes and publishing extremes
Strange, then, that even as some thinkers mourn the loss of literacy and the end of solidarity, consumers at all levels of the literacy scale are buying extraordinary amounts of reading material, some of it even subversive of the ruling order. I find it difficult to reconcile the massive size of the English-language publishing industry and the continuing problem of low literacy. To illustrate, a brief note by Daniel Soar in the London Review of Books for 7 Feb 2008 cites the annual turnover of the British publishing industry as £2.8 billion. That's 900,000 books flying off British bookshop shelves every day, or one book for every nine loaves of bread sold in the UK. A lot of bread, however you look at it. In Canada book sales are healthy as well. The overall value for Canadian consumer book sales for 2006 was $1.59 billion. The Association of American Publishers reported that U.S. publishers had net sales of $25 billion in 2007. Book sales were up 3.2% over 2006, with a compound growth rate of 2.5% per year since 2002.

The average person has never been so well educated. Look at the size of an adult's working vocabulary today. According to the linguist David Crystal [3] it's 50,000 words. That represents the average adult's active vocabulary in present-day Britain. The estimate of passive vocabulary (words that can be recognized but would not be used in speech or writing) is roughly 25 per cent larger. Modern vocabularies are simply enormous. There are approximately 400,000 lexemes (actually differing words, not including various forms of the same word) in the Oxford English Dictionary which make up Modern English vocabulary. A reasonably well-educated person with a working vocabulary of about 50,000 words is thus actively employing about 12 per cent of the word stock of the language. By comparison, Shakespeare was working with a word stock of 150,000 lexemes. The size of his vocabulary is approximately 20,000 lexemes. This means that Shakespeare was using something over 13 per cent of the total word stock available to him. That total was probably much higher than his contemporaries, and it was certainly well ahead of the linguistically conservative King James Bible, which has only 8,000 lexemes. But it's extraordinary to think that the average educated working person in most English-speaking countries has a larger active vocabulary than the Bard himself. Obviously social status plays an important role here, something that Crystal does not discuss. Those buyers of books and users of dictionaries are less likely to be from the low-income strata of society.

Health literacy facts
But let's get back to the facts about health literacy. Whatever we may think of Debray's lofty theorizing and the remarkable vocabularies of the average adult, the fact remains that four out of ten Canadians still struggle with low literacy. And we have solid research to show how this affects the health of Canadians. What do we now know about the state of health literacy in this country?

11.7 million working age residents of Canada (55%) are estimated to lack the minimum level of health literacy needed to effectively manage their health information needs. (CCL, 2007)
When seniors are added, an estimated 14.8 million may be without adequate health literacy skills. An estimated 88% of respondents 65+ fell below Level 3 on the Health Literacy Scale, which is considered the minimum level of proficiency required to meet the demands of modern day life including those posed by health information. (CCL, 2007).

Canadians aged 16 to 65 who rate their health as excellent or very good have the highest levels of proficiency in health literacy. People who rate their health as fair or poor have the lowest levels of proficiency. People with the lowest health literacy skills are more than three times as likely to report fair or poor health. (Outcomes from the National Symposium on Health Literacy, CPHA, 2008)

A recent American study examined mortality rates of a group of 3,260 adults over age 56 in four metropolitan areas and found that those with inadequate and marginal health literacy levels had a 50% higher mortality rate over a five-year period than those with adequate skills. Low health literacy was the top predictor of mortality after smoking, and was a more powerful variable than both income and years of education. (Outcomes from the National Symposium on Health Literacy, CPHA, 2008)

Dr. Irving Rootman, chair of CCL's Health and Learning Knowledge Centre and co-chair of the expert panel, provides the following grim statistics in his PowerPoint presentation: Health Literacy and Public Health [PPT]:

Over 800 studies have found that health-related material for patient education far exceeds the reading levels of the average adult.

A recent study of health information websites in Canada, the U.K. and Australia found that the content of all sites was written at a higher level than recommended by literacy organizations. The lowest level was grade 11.
Low health literacy is a barrier to effective self-management of chronic disease. A review of randomized control trial studies found that 62% of patients with lower reading skill levels were unable or unwilling to engage in self-management.

Gimcrackery
Despite the excellent work of CPHA and CCL, I'm afraid I don't have much hope that our literacy rates will greatly improve without serious social change. After all, quickly sending their own clear message about the depth of their commitment to such change, the Conservative government wasted no time in cutting nearly $20 million from adult literacy programs back in 2006. The unerringly empathetic John Baird, the minister overseeing the cut, explained at the time: "I think if we're spending $20 million and we have one out of seven folks in the country that are functionally illiterate, we've got to fix the ground floor problem and not be trying to do repair work after the fact." Funny, but I thought doing gimcrack repairs was the government's answer to most of Canada's social problems — either that or just cutting costs and programs outright, at least the type that don't get noticed at a G8 summit. One of Harper and Co.'s bright ideas for fixing the ground floor problem of health literacy has been to cut the Canadian Health Network website, which specializes in plain-language consumer health information. By the way, CHN has a good article on Canadian health literacy: Beyond words: the health-literacy connection. But you'd better look now, because whether you can read or not, it won't be available from CHN come April Fool's Day.

The role of the media
The media aren't much help either. For all their health beats, ambulance chasing, and obesity scares, by excluding or marginalizing other perspectives — notably, a more explicitly political analysis of the origins of illness — the media play a significant part in actually narrowing public debate about health, illness and medicine, and they are not helping to fix Mr. Baird's ground floor problem either. A Social Science and Medicine article [4] that looks specifically at Canadian newspapers goes on to conclude:

The absence of any discussion about social gradients in health indicates that newspapers do not find the central observation driving the population health perspective in public policy newsworthy. Even the stories that we have classified as being concerned with the social environment largely fail to discuss broad issues of the welfare state in relation to health—housing and housing policy, child development and related issues of education and child care, the social relations of work environments (as opposed to exposures to physical hazards), community design and urban infrastructure, etc. Implicit in the obsession with issues of health care is the notion that this aspect of the welfare state is singularly important to maintaining and improving human health. Debates as to whether investments in the health care sector come at the expense of investments elsewhere within the welfare state (in education, housing, income supplementation, etc.) rarely appear in Canadian newspapers. Newspapers appear to do little to advance levels of critical health literacy on broad determinants of health in Canada.

A tissue of equivocations
If we are to avoid the bourgeois house arrest of Régis Debray's isolated, passive consumers of the videosphere, we must not approach the issue of health literacy in passive isolation. It is well known that the determinants of literacy include: education, early childhood development, aging, living and working conditions, personal capacity/genetics, gender and culture [5]. These are basically the same as the social determinants of health. Literacy should be framed within an empowering paradigm that highlights opportunities and choices for people. Unfortunately, the way the media deal with the issue has been devoid of empowerment. The blatant fostering of disease-laden imagery (e.g., “stamping out the epidemic of illiteracy”) is one such counterproductive example. It is not helpful either when literacy is promoted — wittingly or unwittingly — as the predominant solution to Canada’s economic woes. What the public often gets from journalists and politicians is a tissue of equivocations.

Literacy or the lack of it should not be separated off from its social context. Nor can the solution to poor literacy be found in some bureaucratic, gimcrack program. Perhaps John Baird was right. We should stop throwing money into programs that are not truly connected to broader efforts to change the determinants of health. But he is wrong to think that anything will change without a radical program to reduce social and economic inequity in Canada.

Like the problem of homelessness in Canada, the baleful reality of illiteracy has been studied very thoroughly. As many experts familiar with the facts will admit, we have known for years what the reports are telling us over and over again. Is it any surprise, for example, to be told that "daily reading appears to be a strong determinant of health literacy?" Good heavens, Francis Bacon was saying that "reading maketh a full man" four centuries ago.

The recommendations of the most recent report are what one might expect: we need a comprehensive, coordinated, cooperative, and integrated pan-Canadian strategy on health literacy, involving all levels of government. We also need educators, bureaucrats, and health professionals who are able to communicate in plain language [6]. And, as always, more research is required. There is nothing new here. Rather than more paper, Canadians need leadership that is truly responsive to people's needs, with the political will to increase social inclusion, reduce income disparities, and uphold everyone's right to equitable health care, housing, education, and employment opportunity. As the Expert Panel conclude, "The question is: are we willing as a country to make the investment that is required to create a health literate Canada?"

Test your health literacy (from the Canadian Council on Learning website)

Can you correctly answer this example question?

Imagine your child is 11 years old and weighs 85 pounds. According to the chart below, how many 80 mg tablets of Tempra can you administer to your child in a 24-hour period and in what dosage?

References:

1. Rootman I. Health literacy: where are the Canadian doctors? CMAJ. 2006 Sep 12;175(6):606.

2. Debray R. Socialism: a life-cycle. New Left Review. 2007 Jul-Aug;46:5-28.

3. Crystal D. The stories of English. London: Penguin; 2004.

4. Hayes M, Ross IE, Gasher M, Gutstein D, Dunn JR, Hackett RA. Telling stories: news media, health literacy and public policy in Canada. Soc Sci Med. 2007 May;64(9):1842-52.

5. Rootman I, Ronson B. Literacy and health research in Canada: where have we been and where should we go? Can J Public Health. 2005 Mar-Apr;96 Suppl 2:S62-77.

6. Stableford S, Mettger W. Plain language: a strategic response to the health literacy challenge. J Public Health Policy. 2007;28(1):71-93.

Health literacy reports

Canadian Council on Learning.

Health literacy in Canada: A healthy understanding, February 2008. This report reveals that daily reading outside of work is associated with higher health literacy scores.

Health Literacy in Canada: Initial Results from the International Adult Literacy and Skills Survey (IALSS), September 2007. Provides Canadians with a country-wide snapshot of health literacy.

Canadian Public Health Association.

A Vision for a Health Literate Canada, February 2008. The CPHA Expert Panel on Health Literacy found a majority of Canadian adults do not have the skills needed to respond to daily health information demands. Low health literacy is associated with poor health and the Panel estimates that the situation in Canada is critical.

The Ontario Health Promotion E-Bulletin of 20 March 2008 provides an excellent list of Canadian resources on health literacy.

Recent articles in mainstream media on health literacy
The Toronto Star, March 4, 2008 Alarm raised on health literacy, by Meghan Ogilvie, http://www.thestar.com/living/article/309115

CBC March 4, 2008 Canadians illiterate about health, report says, http://www.cbc.ca/health/story/2008/03/04/health-literate.html

I like to think that when I fall,
A rain-drop in Death's shoreless sea,
This shelf of books along the wall,
Beside my bed, will mourn for me.

Robert Service, Bookshelf

Storm and strife as the Canadian Health Network approaches the chopping block

2008-03-16T19:57:00.001-05:00

It is not in the storm nor in the strife
We feel benumb'd, and wish to be no more,
But in the after-silence on the shore,
When all is lost, except a little life.

Lord Byron, On hearing Lady Byron was ill

With a pair of sqawkingly incongruous dangling participles, the Canadian Health Network (CHN) has announced its own demise and its absorption by another government website:

Beginning April 1, 2008, Canadians will be able to access timely, trusted and credible public health information through a single source — the Public Health Agency of Canada’s Web site at www.publichealth.gc.ca. Accessed by over 10 million visitors a year, we invite you to bookmark this Web site as a valuable and unique source for information on healthy living, disease and injury prevention.

In their haste to liquidate this last vestige of independent, community-based health information from the government's official web presence, some faceless committee also succeeded in mutilating the English language as part of their dirty work. As if that wasn't depressing enough, there is now little doubt that the voices of nearly 4,000 Canadians who have signed a petition pleading for the CHN's preservation will be ignored. But we can still shout up a storm until the end of March, when, the Friends of CHN website informs us, Liberal Health Critic Robert Thibault will present the petition to the House of Commons, requesting that Parliament rescind the funding cut and immediately restore full, stable funding for the Canadian Health Network.

Much more fluid in its syntax was the succinct form letter I received from Tony Clement, the Minister of Health, with its admission that the decision to "terminate" the Canadian Health Network was "difficult, and was by no means arrived at without thoughtful consideration." But, as always, there are "other equally important health priorities that require government funding." Yes, like the one billion dollars a year that our military adventure in Afghanistan is costing us and the frightful, ongoing costs of caring for all the Canadian wounded, of whom we hear remarkably little in the media. The Minister likes the idea of providing health information through "a single, consolidated website." Somehow that is supposed to ensure that "more Canadians will have access to quality and trusted health information." I would very much like to know how dumping the CHN is going to provide more people with information.

And as the Social Justice Librarian justly pointed out in a recent post, "it’s one thing to take away a really great consumer health resource. It’s another to take it away and leave a pointer referring people to another resource that is virtually useless for the same type of information seeking!" A query of both the Public Health Agency of Canada and the Health Canada websites provided no comprehensible results to a question she and a student posed concerning the relationship between abortion and breast cancer. By contrast, when CHN and MedlinePlus were consulted, they offered reliable, consumer-friendly information when searched with the same key words.

The quality of that service does not seem to have been of great concern to my MP, James Bezan (Selkirk-Interlake). In his response to my complaint about the axing of CHN he pleaded lack of funds. "The Conservative Government has had to make decisions as a result of cuts to spending made in the previous government's ... budgets." That's it. Blame it on the Liberals. Mr. Bezan assures me that "moving from three sites to two will result in saving $7 million per year" — enough to keep the Afghanistan "mission" going for about two days. I am to "rest assured that PHAC will work with CHN in the transfer of information ... wherever possible." The last two weasel words, of course, mean that exactly nothing is promised.

Nothing in Mr. Bezan's letter makes me feel rested or assured. In closing he respectfully counsels me once again to "rest assured that Canadians will continue to have access to the important healthcare information they need." The importance and the need, we can all rest assured, will be determined solely by our wise leaders in Ottawa, whose "thoughtful consideration" has burdened the country with an $18-billion defence budget, the highest level of military spending in inflation-adjusted dollars since the Second World War.

Even if you're feeling benumbed, please sign the Save the CHN petition and write to the Minister of Health and your Member of Parliament.

Augustus was sensible that mankind is governed by names; nor was he deceived in his expectation, that the senate and people would submit to slavery, provided they were respectfully assured that they still enjoyed their ancient freedom.

Edward Gibbon, The decline and fall of the Roman empire, Chapt. 3.

Oh Brother: the Ontario health minister joins the Soggy Bottom Boys

2008-03-10T16:05:00.002-05:00

... nearly blowed us into shivers and smithers. ~ Charles Dickens, Our Mutual Friend, Bk. 4, Chapt. 13

Ontario's health minister, George Smitherman, was singing his own version of Man of Constant Sorrow last month. He made a bad mess worse when he responded to criticism of the treatment of the elderly in the province's nursing homes by blurting out that he was prepared to don an adult diaper — and use it — to justify his government's policies. Not surprisingly, this singular outburst didn't sit well with an outraged public. Advocates for the improvement of personal care homes have complained for years that standards are poor, that homes are understaffed, and that private companies such as Extendicare endanger patients by pressuring their employees to cut costs.

The Ontario Association of Non-Profit Homes and Services for Seniors says seniors in nursing homes should be getting at least three hours of personal care; it says the average in the province is now about 2.5 hours a day. The Canadian Union of Public Employees (CUPE), which represents many nursing home workers, says the standard should be 3.5 hours. Many studies have shown that without proper staffing and adequate standards the quality of care plummets. Front-line nursing home staff in Ontario report that residents are sitting in deplorable conditions. Incontinence products are often kept under lock and key, and many homes are directing staff to change residents only when the product is 75% soiled.

On February 27, two long-term care workers used four bottles of water to fill an adult diaper at a CUPE press conference in Toronto. They wanted to show how much urine had to be in a diaper before care aides were allowed to change it under current legislation. With stunning insensitivity Smitherman said in response that he was ready to test out an adult diaper to show criticism was unfounded. “I’ve got one of these incontinence products — albeit a new one, not the ones that tend to appear at committee — on my desk and I’m really giving this matter very serious contemplation,” Smitherman said. It wasn't only critics of the Liberal government who were angry. There were loud calls for the minister's resignation, even within his own caucus.

Wags and cynics sharpened their quills. March 1st's National Post published an imaginary Smitherman diary entry, with entries like this:

TUESDAY
Major confession, diary. I tried out an incontinence diaper today. It was so ... freeing. I had three large coffees ... and then I sat through a three-hour meeting with a bunch of bureaucrats. No pee breaks! It was so much more efficient. Made a bit of a stumble at lunch, though, by having the side dish of asparagus. Won't make that mistake again! I think this will really help in my discussion with the nurses' union. Five hours seems to be the limit before things get a little soggy. I think I'll publicly float the idea tomorrow. Right after I shoot up an eight-ball of smack to get a better feel for drug addiction.

Of course, an apology followed immediately. "I wasn't trivializing the matter," Smitherman said. "I take it really, really seriously." Not surprisingly, the minister couldn't be reached for comment afterwards; but his "diary" entry gives us some insight into why:

FRIDAY
After I came in from my night on the streets yesterday morning, Dalton [Premier Dalton McGuinty] called and ordered me to apologize for the diaper "stunt." I explained that I only thought it would gain a better understanding of the issue, but he wouldn't listen. "Also, George," he said, "please tell me you weren't wearing one in my office the other day. Because I thought it smelled like asparagus, if you catch my drift." I told him my cellphone was cutting out and I hung up.

Sam Solomon, writing in his blog Canadian Medicine, adds that this isn't the first time that "Furious George" has run off at the mouth:

Speaking about new building plans suggested by some hospital boards in Ontario, Mr Smitherman dismissively referred to the expensive proposed upgraded facilities as "Taj Ma-hospitals."

His most famous outburst was featured on Stephen Colbert's American parody politics talk show in 2005. Talking to none other than an assemblage of the Ontario Association of Optometrists, Mr Smitherman called optometrists "a bunch of terrorists, and I don't negotiate with terrorists." "Bravo, sir," Mr Colbert said. "Optometrists are a menace. You have to be careful with a group that gets their kicks blowing air into our eyeballs."

Smitherman’s bizarre antics were dismissed by Sid Ryan, president of CUPE's Ontario chapter, who said the minister completely missed the point. The problem isn’t the products, but the cruel reality that residents in long-term care facilities are forced to wear soiled diapers through the night and sometimes up until noon the next day. “If the minister wants to play silly games, well then, let him put on a diaper and sleep in it all night long and come into the legislature and wear it up until 12 o’clock,” Ryan told the Canadian Press.

Could the problems so clumsily dealt with by Ontario's health minister be related to the fact that in Ontario 60% of all publicly funded long-term care beds are in for-profit institutions, as compared with 15% in Manitoba [1]? There is ample research to show that public investment in not-for-profit, rather than for-profit, delivery of long-term care results in more staffing and improved care outcomes for residents [1,2]. Instead of experimenting with adult diapers, perhaps Mr. Smitherman should try absorbing some of these important statistics. There are a lot of excellent health libraries within throwing distance of the Ontario legislature.

References:

1. McGrail KM, McGregor MJ, Cohen M, Tate RB, Ronald LA. For-profit versus not-for-profit delivery of long-term care. CMAJ. 2007 Jan 2;176(1):57-8.

2. McGregor MJ, Cohen M, McGrail K, Broemeling AM, Adler RN, Schulzer M, Ronald L, Cvitkovich Y, Beck M. Staffing levels in not-for-profit and for-profit long-term care facilities: does type of ownership matter? CMAJ. 2005 Mar 1;172(5):645-9.

Misconstrual of the month: naked librarians and involving buns

2008-03-06T13:26:00.005-06:00

There must be a copy editor job vacancy at the office of Library review. How else to explain the driving sleet of slips, flubs, gaffes, muffs, typos, punctuation misfirings, and hair-raising solecisms in an article that appears in the most recent issue? With an effusive application of that endearing élan and derring-do of the "librarians rule" school to my professional bailiwick, two South Africans work up a mighty sweat as they trample hard over the conventions of English prose and punctuation in their contribution, The naked librarian: health librarians in the modern era [1].

Little more than a collection of boilerplate truisms and trite exhortations, this essay is a roll-up-your-sleeves call to action, a perky if not always entirely coherent ramble through the usual library science banalities, starting with that most hackneyed of clichés from the last couple of decades. Care to guess what it is? A phrase so familiar that we now hear it being solemnly intoned by bakers, candlestick makers and undertakers: "The only constant is change."

That, of course, is the famous quotation from Isaac Asimov. Nothing to misconstrue there. But back to our scantily attired article. For the next five pages we are marched out into the cold courtyard and put through a vigorous drill of platitudes and commonplaces:

Health information professionals have to envision the future and plan from there. We have to get rid of outdated ideas and revolutionize our way of thinking. Shrugging off the old coat of the stereotypical librarian, we must start off in our envisioned future, as 'naked librarians' turning into brand new and constantly evolving [sic].

After a laundry list of the challenges and obstacles, most of them "huge," facing health libraries in the "modern era," we are exhorted to "use the digital age" and "proactively anticipate the future implications." Once we have done all that "we will be educated in the latest technical lingo and sound just like computer scientists." (Now I know why I became a librarian.) But look at what else our naked chefs are cooking up: "One of the less mined (as yet) areas for us to explore and conquer, is how to make raw data available to everyone." Not even half-baked? Instead of worrying about a post-Google world we are exhorted in a memorably mixed metaphor to "step up to the plate, accept these challenges and go with the flow."

Now perhaps I'm being overly critical when I say that we librarians have really had enough of this. As Candy Hillenbrand wrote in her take on librarianship in the 21st century, "Desperate to slough off the old limiting stereotypes of the stern bespectacled cardigan-clad shushing controller of books, librarians are clamouring to convince themselves, each other and the wider community that there is far more to the humble librarian than meets the casual eye" [2]. Are we so hankering for attention that only disrobing ourselves in public will suffice?

Just what is this fixation on ripping off our tweedy garments and emerging unclad into the light, like Blake's Glad Day? Is some kind of mass psychosis making us want to run through the streets in puris naturalibus? I saw a sign the other day advertising evening classes in pole dancing. Is this part of some larger social pathology? Or have librarians been infected by the myriads of spores invisibly rising from the piles of discarded print materials in our denuded workplaces? What next? When the clothes are gone should we move on to trichotillomania? Please, let us put a stop to this depilatory process, expose the abuse, and doff this tired metaphor once and for all.

But back to the rapidly unravelling Steyn and de Wee. In the last section of their article they offer what I'm sure is meant to be an edifying quote from a newspaper column by Shelley Howells [3] that appeared five years ago in the New Zealand Herald. All very cute and fluffy in a condescending way, Howells' piece is an example of what has become a standard mass-media treatment of librarians. We are secret nonconformists, wise as serpents and clever as foxes. We are wily, rebellious and twee — not a stitch left of our old encumbrances. Here is Howells' opening sentence, as quoted by Steyn and de Wee:

Librarians rock. That reputation that they have involving buns, sensible shoes and shushing people is merely a cunning ruse, developed over centuries, to conceal their real lives as radicals, subversives and providers of extreme helpfulness.

At this point, having ploughed my way dutifully through the entire article, I had become accustomed to its many textual difficulties. I was beginning to understand the challenges faced by the squinting exegetes of the Dead Sea Scrolls. For here I was, rubbing my eyes in confusion. There was something very wrong with the passage. How to figure out the thats? What exactly were those buns? And how did involving buns relate to naked librarians? Flushed with curiosity, I decided to check the original newspaper article, hoping its text had not disappeared into the Internet Gehenna of 404 not-found error pages. I was lucky this time and found it. Here is what Shelley Howells actually wrote:

Librarians rock. That reputation they have involving buns, sensible shoes and shushing people is merely a cunning ruse, developed over centuries, to conceal their real lives as radicals, subversives and providers of extreme helpfulness.

The sharp-eyed among us will note immediately that in the original text there is no that after reputation. Oh what a difference one word can make! When I first read the sentence, Steyn and de Wee's slipshod insertion of the extraneous that in their quotation had thrown me off completely. It put a spanner in the syntactical works, so to speak, leading this innocent reader to think librarians' buns were being described in the same way as their shoes — with an adjective. The extra that altered the sentence's focus and led me to think impure thoughts. Was involving a typo for involuted? What would such buns look like? But then I was brought up short by the non-tensed verb phrase shushing people. It didn't seem to fit with the two previous attributes which I thought I was being told librarians possessed.

My apologies to those of you who aren't grammar buffs, but I have to get technical here. After seeng Howell's original text I was finally able to parse the sentence to my satisfaction. Buns is the object of the gerund involving, which may also be described as a non-tensed verb phrase with -ing participle. Buns is not the object of the verb have. Involving is the first word of a participial defining relative clause which tells us that which the reputation of librarians involves. It is not a participial adjective, as in these examples: dangling participles, burning buns, flaming idiots. For more information on all things participial, see the Cambridge grammar of English [4].

Confused by now? I certainly was. Dangled enough participles for today? I'm ready to hit the showers.

But Steyn and de Wee aren't finished yet. Feel the goosebumps rise as you thrill to their final rallying cry: "Let us shrug off our 'clothes' and get into the new gear of the future! ... From naked librarian to formidable information force."

Oh dear. It's -25 outside and I don't want to dangle for long. This radical subversive and provider of extreme helpfulness would much rather stay indoors and fully clothed, thank you.

References:

1. Steyn C, de Wee JA. The naked librarian: health librarians in the modern era. Library review. 2007;56(9):797-802.

2. Hillenbrand C. Librarianship in the 21st century - crisis or transformation? Australian library journal [serial on the Internet]. 2005 [cited 2008 Mar 4];54(2):[about 5 p.]. Available from: http://www.alia.org.au/publishing/alj/54.2/full.text/hillenbrand.html

3. Howells S. The secret life of tattooed and belly-dancing librarians. New Zealand herald [serial on the Internet]. 2003 Nov 28 [cited 2008 Mar 4]. Available from: http://www.nzherald.co.nz/section/story.cfm?c_id=5&objectid=3536464

4. Carter M, McCarthy M. Cambridge grammar of English: a comprehensive guide. Cambridge: Cambridge University Press; 2006.

Missing the obvious, Part 2: slapdash database grocery lists masquerading as articles in medical journals

2008-03-03T15:06:00.004-06:00

Six months after a "research letter" entitled World Databases of Summaries of Articles in the Biomedical Fields was published by Falagas et al. in the Archives of Internal Medicine, a politely-worded demolition of that pretentious excresence has appeared in the same journal's issue of 14 Jan 2008. I vented much less diplomatically about Falagas et al. last July, shortly after it had been published. What was it that raised my hackles and got my goat? Without even nodding in the direction of a library, Dr. Falagas and his team (it actually took more than one person?) sat around a computer one day, scribbled a straggly list of a few databases "based on our previous knowledge" and a few they happened to come across in Google, and by some unattested miracle got their sophomoric effort published in one of the world's most important medical journals. Imagine Will Ferrell and Jon Heder doffing their figure skates and heading for the Moulin Rouge.

I groused at some length about how this inept and unscientific approach not only missed the obvious but apparently escaped any intelligent peer review. I made reference to the well-known Murphy's Law definition of an expert as a person who avoids the small errors while sweeping on to the grand fallacy. Unfortunately, in Falagas' farrago even the small errors were hopelessly compounded, and he swept irreversibly on to something approaching Grand Guignol.

With their letter subtitled "Getting the whole picture," Dr. Isobel C. Hoskins of CAB International and her two co-authors shine some welcome light on this Carnaval des spectres. With laudable courtesy and restraint — something I wouldn't be capable of under any circumstances — they list "some important omissions" from Falagas' shabby compendium of health databases: Global Health, CINAHL and PsycINFO, to name a few. They tactfully correct one of the grossest errors: "Readers should also be aware that the published list of additional databases includes hosts for databases such as Dialog and EBSCO rather than the databases themselves." As if his dilettantish approach wasn't bad enough, even Falagas' mistakes have errors. His misbegotten enumeration of database hosts omits OVID, for example. Hoskins et al. conclude by finally attempting the right thing and pointing to a health library website. They could have done better than supply a list of public health databases (CINAHL is not included), but in this weak suggestion Hoskins et al. are at least providing a hint to the readers of the Archives that it's all right to go beyond the input of colleagues and the Google prompt when looking for medical resources on the web.

In his two-paragraph reply, festooned with no less than four self-referential footnotes, Dr. Falagas welcomes the valuable input of "our colleagues." In a tone approaching that of a pronouncement from the Holy See he asserts his strong belief "that the availability of lists of databases ... is useful to researchers, clinicians, and other health care professionals." And he's not just whistling Gaieté parisienne. He goes on to puff more of his grocery lists, all of them published in major medical journals. And there are others he hasn't cited. This bloke pumps out more research than kicks at a cancan show (I count 298 PubMed citations to date). An extraordinary accomplishment considering that he seems not to have do-si-doed across the threshold of a library in his entire career. My question is: why doesn't he leave the choreography of knowledge-based information resources to those who know how to dance?

Before I get my petticoats into a real knot, I will briefly mention another of Falagas et al's forays into the world of databases and search engines — this time in a paper unaccountably published in FASEB Journal — comparing PubMed, Scopus, Web of Science, and Google Scholar. Did anyone at FASEB edit this article or even look at the contents? A reading of the first clause of its first sentence is not encouraging: "The development along with the spread of the World Wide Web (WWW) represents an informational [sic] revolution ..." There is much more where this comes from as the article develops and spreads. "In conclusion, scientific databases of biomedical information are frequently used by both clinicians and researches [sic]. In this article, we compared the content and various practical aspects in [sic] the utility of the main databases of biomedical scientific information. We found that PubMed remains an important source for clinicians and researchers ..." And on they go in this manner for five densely printed pages without a single original thought, spinning in all directions, legs lifted and twirling. Zoot alors! Kick. Kick. Kick.

A new wheeze tease: tobacco ads return to Canadian magazines

2008-02-21T12:02:00.004-06:00

I should have been better prepared to have my flabber gasted, but I don't know what confounded me the most: learning that cigarettes are once again being peddled in Canadian magazines or the jarring use of the word "anyways" in the Canadian Medical Association Journal report that brought this depressing news to my attention [1]. Of course, the smelly reality of tobacco hawking gets a higher ranking in the shocked-and-appalled section of my catalogue of outrage. Vocabulary concerns aside, I am forced to reflect on the putrid fact that, like zot skunque de terriblay odeur, tobacco ads are back. I feel like poor Penelope Pussycat, squirming madly to escape the foul embrace of a love-struck Pepé Le Pew. L'amour toujours.

Having squandered my youth on the "fuliginous moyste vapours which trouble the harte and strike up into the head" [2], I can say I was duly formed (and possibly stunted) by cigarette culture. Surrounded by the floating signifiers of its advertising — and the choking fumes of its products — I coughed my way through the cloudy expanses of Marlboro country, trying every filter, flavour and flip-top box on offer. Now in my winded late middle age I can breathe a sigh of relief that I parted ways with the sacred herb years ago, and that my loved ones and I are no longer subjected to the throaty blandishments of cigarette commercials in smoke-filled rooms. At least, that's what I thought until I received this week's My NCBI update with the latest from CMAJ.

Le mew? Le purrrrr? Non, c'est le terriblay skunque fatale!
The otherwise grammatical CMAJ article informs us that, without fanfare and with little controversy, one of the Canadian tobacco industry's "big 3," JTI-Macdonald Corp. (the other two are Imperial Tobacco Canada Ltd. and Rothmans, Benson and Hedges Inc.) recently opened a new front in the ongoing tar wars. The makers of my former favourite wheeze tease are launching new products by advertising them in entertainment magazines such as Montreal's Mirror and Vancouver's Georgia Straight, and in the less-entertaining Canuck edition of Time. Yes, Canadian mags are rolling their own again. The smell of dollar bills and tobacco leaves has always made a good blend. Roger Collier, the journalist responsible for the CMAJ article, first reported last December on this new phase of tobacco shilling in the Ottawa Citizen.

I read with a creeping sense of unease about the new Mirage brand of smokes now being offered for our delight and delectation. Armed with their Exocets of nicotine and carbon monoxide, these new-fangled cigarettes are supposedly scented with vanilla so that they emit a "less lingering tobacco smell in an enclosed area." Through one of those grotesque coinages of the advertising industry this celebrated feature is termed "unique Less Smoke Smell (LSS) Technology." The only thing I smell here is a skunk. I submit that LSS will turn out to be about as effective at dispersing stinky cigarette smoke as my past practice of spraying Lysol and furiously swiping an open palm back and forth in the boys' room. You might as well try dousing Pepé Le Pew with Chanel No. 5.

Scent-imental over you
Way back in the wild and primitive days of my shaggy-haired youth, when Keith Richards could walk — and Elton John could pass for — straight, I also made liberal use of incense in my bedroom to hide the stench of my two smoking habits, and, like Elton, fooling nobody. How I and my friends must have reeked at our happenings, sit-ins, be-ins, and in-ins, daubed with patchouli oil, chewing Chicklets, and flourishing our trendy Gauloises. I confess to a certain nostalgia for that time. We would-be intellectuals frequented smoky coffee shops to gesticulate with glowing ash, listen to sitar music and talk about poetry, pointillism and proletarian revolution. Nowadays, it seems young people frequent fume-free coffee shops to listen to their mobile devices and talk about — coffee.

An aside. In a recent Lancet article [3] on the social commentary implicit in Dickens' Little Dorrit, James Horton too betrays a certain nostalgia for pipe and plume:

Little Dorrit is also Dickens' striking tribute to tobacco, his great smoking novel. From the opening pages, tobacco is rolled, lit, inhaled, smoked down to the fingers, stuffed into English and Eastern pipes, presented as cigars, traded in "snug" businesses, and used as refreshment and as an idle accompaniment to long journeys. Smoking, or rather ceasing to smoke, is the one means by which [Amy Dorrit's] father signals, even celebrates, the freedom of his new life after leaving the Marshalsea [debtor's prison].

Who scent you?
But that was then, and this is now. Physicians for a Smoke-Free Canada would like to stick it to Japan Tobacco and have called upon Health Canada and Health Minister Tony Clement to end JTI's advertising campaign, claiming that it is misleading and contravenes the 1997 Tobacco Act. In this country it is against the law to promote tobacco products by means "that are likely to create an erroneous impression about the characteristics, health effects or health hazards of the tobacco product or its emissions." Erroneous doesn't even begin to describe the breathtaking mendacity of the Mirage campaign. Tobacco ads are so offensive to good taste and common sense, they should be banned for that reason alone. Kel terriblay odeur!

Past perfumance
In June of last year the Supreme Court of Canada upheld the legal restrictions on tobacco advertising, dismissing an expensive, decade-long court battle which argued that such laws violate the right to freedom of expression. However, the court did admit that there is still a window of legitimate advertising in this country, through which the tobacco companies have now nimbly climbed with their glossy adverts and website bromides, after a long silence. For a decade big Canadian tobacco refrained from huckstering in mass-market publications, arguing that the restrictions were so limiting as to constitute a ban. Until 2003 they confined their efforts to "lifestyle" marketing through sponsorship of music festivals, car races and the like, until that route was closed off when a general prohibition on such stealth advertising came into effect. The Tobacco Act actually allows cigarette promotions that are "information advertising or brand-preference advertising," directed at adults in various ways, in "a publication that has an adult readership of not less than eighty-five per cent." Now that the Supreme Court has settled matters, the tobacco companies seem to have decided to exploit whatever opportunities are left to them. Hence the magazine advertising campaign. The three mags mentioned in the CMAJ article have a relatively large circulation. I'm not sure how it is determined that a particular publication's audience consists mostly of adults; although there would probably be general agreement that Time is not exactly at the top of a teenager's list of must-reads. Regardless, there is no doubt that tobacco's new ad offensive will increase the likelihood that kids will start to smoke [4] or (eww!) chew [5]. We can expect more clever and costly promo campaigns in the future. Come viz me to ze Cats-bah!

The ultimate target. "Eet ees possible to be too attractive, no?"
In the past ten years that the Tobacco Act has been in force, smoking prevalence in Canada has dropped from about 30% to 18% for Canadians 15 years of age and older. That's far too many clean sets of adolescent lungs to be endured. Air pollution can't finish the job properly. Something has to be done. Perhaps LSS "technology" will be the prime coolness factor, the lure that brings more lips to butts. As the insidious infiltration of tobacco advertising continues (see my post of 30 Dec 2007) my six young nephews are a pretty easy target. Alert to every nano-variation of current coolness, they have been firmly indoctrinated in the principles of our feckless, thoughtless, throw-away society. Critical thinking is still a great effort, so they prefer to let media dictate their needs. Like many males their age they are stolid, taciturn, twitchy with misfiring hormones, occasionally surly, mostly funny, optimistic, absurdly affectionate, and hopelessly normal. Their heads full of turbid, TV-fed fantasies of sex, slugs and pelf, they are paradigmatically unaware of the civilizing effects of etiquette, self-discipline and soap — I love them dearly. The three oldest are smokers, the other three probably will stay tobacco-free. But their luck so far in avoiding those nicotine-fuelled Exocets will start to run out as more ads for Camel, Craven A and Mirage start popping up like love-sick skunks around them. Whether for smoking or expectorating, tobacco products are ultimately designed for and promoted to youth. That's because adult users have the unfortunate habit of dying off. Here's hoping that as a member of WHO'S Framework Convention on Tobacco Control, Canada will follow Australia's example and ban all tobacco product peddling by 2010. Otherwise we'll all be singing Louvre come back to me.

For those who follow this sort of thing, over at the Scientific Misconduct Blog there is an interesting post on another kind of questionable magazine advertising, this time in the venerable British Medical Journal. In the 16 Feb 2008 issue 88.4% of ads are by pharmaceutical companies. Kel terriblay odeur, indeed.

Zugszwang
Now that they have begun to deploy their substantial forces, CMAJ's report concludes, keeping Canadian tobacco companies out of the ad game won't be easy. Richard Pollay, a University of British Columbia marketing professor who has followed tobacco marketing for twenty years, provides the closing remark: "The industry is endlessly creative, not only adapting to new legislation or changing public sentiment, but anticipating them. They're playing chess when everyone else is playing checkers." The next move is up to us.

Chess is as elaborate a waste of human intelligence as you can find outside an advertising agency. ~ Raymond Chandler

References:

1. Collier R. Cigarette ads return to Canadian magazines. CMAJ. 2008 Feb 12;178(4):384-5. PMID: 18268258

2. Gratarolo G, Newton T. A direction for the health of magistrates and studentes, namely suche as bee in their consistent age, or neere thereunto: drawen as well out of sundry good and commendable authours, as also upon reason and faithfull experience otherwise certaynely grounded. London: Imprinted by William How for Abraham Veale; 1574

3. Horton R. The resistance of Little Dorrit. Lancet. 2008 Feb 9;371(9611):468-9. PMID: 18271080

4. Lovato C, Linn G, Stead LF, Best A. Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD003439. DOI: 10.1002/14651858.CD003439

5. Morrison MA, Krugman DM, Park P. Under the radar: smokeless tobacco advertising in magazines with substantial youth readership. Am J Public Health. 2008 Jan 30. PMID: 17600263

Are shy people mentally ill?: the DSM and SAD

2008-02-11T17:02:00.001-06:00

... because I'm good enough, smart enough, and — doggone it — people like me! ~ Stuart Smalley

I was born the year they first published the Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its fourth edition as DSM-IV. I was a shy little boy. In fact, I was so shy, instead of wishing the ground would open up and swallow me, I dug my own little foxhole and crouched there for most of my childhood. Little did I know that the majestic architects of the DSM's careful categories and checklists would some day cast concerned looks at trembling little me in my hiding place and see another instance of a treatable social anxiety disorder. Nor could I have imagined how one day pharmaceutical companies would promote the idea that things like diffidence and embarrassment are ameliorable through drug therapy, that by swallowing a little green and white pill I could feel as if I had just aced the Endtime and placed my conquering toe upon the Mount of Olives.

What pill would they prescribe for the timid and empty-headed Georgiana Podsnap of Our Mutual Friend, who is so painfully shy she squeals like a panicky toddler at the prospect of being introduced to strangers?

Oh there's Ma speaking to the man at the piano! Oh there's Ma going up to somebody! Oh I know she's going to bring him to me! Oh please don't, please don't, please don't! Oh keep away, keep away, keep away!' These pious ejaculations Miss Podsnap uttered with her eyes closed, and her head leaning back against the wall. ... 'Oh there's Ma being awful with somebody with a glass in his eye! Oh I know she's going to bring him here! Oh don't bring him, don't bring him! Oh he'll be my partner with his glass in his eye! Oh what shall I do!' This time Georgiana accompanied her ejaculations with taps of her feet upon the floor, and was altogether in quite a desperate condition. (Charles Dickens, Our Mutual Friend, Chapt. 11, Podsnappery)

What about the terribly bashful Edward Ferrars in Sense and Sensibility, with his awkward silences and stiff politesse? What if he were popping Zoloft to make it through high tea with his formidable relations?

Edward Ferrars was not recommended to their good opinion by any peculiar graces of person or address. He was not handsome, and his manners required intimacy to make them pleasing. He was too diffident to do justice to himself; but when his natural shyness was overcome, his behaviour gave every indication of an open, affectionate heart. His understanding was good, and his education had given it solid improvement. But he was neither fitted by abilities nor disposition to answer the wishes of his mother and sister, who longed to see him distinguished - as - they hardly knew what. They wanted him to make a fine figure in the world in some manner or other. His mother wished to interest him in political concerns, to get him into parliament, or to see him connected with some of the great men of the day. Mrs. John Dashwood wished it likewise; but in the mean while, till one of these superior blessings could be attained, it would have quieted her ambition to see him driving a barouche. But Edward had no turn for great men or barouches. All his wishes centred in domestic comfort and the quiet of private life. Fortunately he had a younger brother who was more promising. (Jane Austen, Sense and Sensibility, Chapt. 3)

Fewer Eeyores, more Tiggers

Would we say that Georgiana and Edward, with all their social faults, were mentally ill and in need of medication? For those of us who have no turn for great men or barouches — who would rather stay home with the cat and The Cask of Amontillado than kiss cheeks at a cocktail party — our shyness may be limiting at times. It may be, as some say, merely egotism out of its depth; but it doesn't feel like a disorder. It's more like the way being myopic keeps one from taking up skeet shooting, or being dyslexic makes reading The Faerie Queene an exercise in futility. Life goes on, even if you're not a hotshot Spenser scholar.

Like many other normal human imperfections — stretch marks, baldness, flat feet — shyness is a fact of life you accept, if not embrace. Just as there are many bumptious bigwigs conquering the world on white horses and donning their crowns of laurel, there are also all the little shy people who are modestly content to pluck their bouquets of wallflowers and violets. Of course, introversion can occasionally get in the way of things; but we introverts have our various means of coping: bathroom mirror self-assertion, transcendental meditation, unlisted numbers, pimple cream, tequila.

But it appears that some DSMmers out there would claim I was mentally ill until, somewhere in the dirty bottom of the 1970s, I left my mirror, emerged into the sunshine, and realized that — doggone it — people liked me. Eeyore had turned into Tigger.

Toastmasters or Paxil?

Brian Cox holds a Canada Research Chair in mood and anxiety disorders at the University of Manitoba, so he is probably as qualified as anyone to comment on the health of the timid and insecure. In his review of Christopher Lane's new book, Shyness: how normal behavior became a sickness [1], which appeared in the January 31 issue of the NEJM [2], Cox agrees with Lane that psychiatrists should stop pathologizing and medicating shy children:

I find it interesting that the term "social phobia" has increasingly been replaced by the term "social anxiety disorder" in the official nomenclature. I don't believe that this is purely coincidental. Rather, it seems to me that if a general physician sees someone with a social phobia, the physician may recommend that the patient see a psychologist for behavior therapy, participate in Toastmasters, or use another self-help resource. However, if the same person receives a diagnosis of social anxiety disorder, a term that sounds far more serious, the physician might recommend more aggressive medical attention such as pharmacotherapy.

Shyness is not a "sickness" or a psychopathology, argues Cox, who conducted a study [3] a few years ago which found that many with extreme childhood shyness didn't meet the criteria to be diagnosed with an anxiety or mood disorder. Conversely, half the adults with severe social phobia did not view themselves as very shy when growing up. In his NEJM review, Cox states his conviction that it is important not to view shyness in young people as a form of mental disease requiring medical intervention, thereby potentially damaging their self-esteem and self-confidence. In other words, the kids are all right.

"Is she just shy? Or is it Social Anxiety Disorder?" (Advertisement for Zoloft in The American Journal of Psychiatry, August 2003)

The day I ran across Cox's book review I happened to be reading the 6 December 2007 New York Review of Books, which contains a beautifully written article, Talking back to Prozac [4], by the irreverent Frederick Crews, Professor Emeritus of English, UC Berkeley, and author of The Pooh perplex. Crews discusses three books that are critical of the mental health establishment and its relations with Big Pharma, one of them being Lane's Shyness. Also reviewed are Horwitz and Wakefield's The loss of sadness [5], and the release in paperback of David Healy's well known Let them eat Prozac [6], first published in 2004.

Crews begins with a fascinating anecdote about the 2002 appearance of star football player Ricky Williams on The Oprah Winfry Show. The brawny athlete went before the cameras to spill in a major way. He revealed that he suffered from social anxiety syndrome. Very touching. What didn't show up in the credits, however, was that Williams was a paid shill for Glaxo-SmithKline — not to do anything so flagrant as to tout its own product, Paxil, but simply to do a little "condition branding" by persuading Oprah's gullible glued eyeballs to believe that being "a shy person" could actually be a disorder requiring antidepressant medication.

Crews launches into an acerbic critique of the happy-drug industry. His verdict: "[O]ne thing is certain: the antidepressant makers have exploited our gullibility, obfuscated known risks, and treated the victims of their recklessness with contempt." As for the mental health industry, Crews wants a DSM that is "scientifically respectable; its users, instead of regarding disadvantaged classes as infested with mental illness, will gain an appreciation of socioeconomic reasons for unhappiness; and a brake will be placed on the expensive middle-class hypochondria that the drug companies have so assiduously encouraged and exploited."

These three books point us, as Crews asserts, "toward some uncomfortable insights about American psychiatry and its role within a far from rational health care system." He goes on to suggest the deeper significance of psychiatry's inability to settle on a discrete list of disorders that can remain impervious to fads and fashions. In a perfect storm of hypocrisy, for bureaucratized psychological treatment, and for the pharmaceutical industry that is now deeply enmeshed in it, confusion has its uses.

Now, I understand that there are some who suffer from debilitating fear of social situations and who may need to seek medical help, including drugs that moderate their symptoms. However, the tendency towards untrammelled use of expensive glamour drugs to medicate away what is simply an aspect of the human condition — that looks like the devil's bargain.

Long before Ricky Williams made his public confession on Oprah, an article appeared in The New York Times which made mention of Williams' "shyness syndrome," adding interesting details like the fact that he kept his helmet on during rookie-year media interviews. No indication yet of the money flowing from the stealth marketing Paxil pushers into the football player's bank account. But we are offered this shrewd comment: "[I]t is much easier to turn on the spigots of empathy and attention these days when you can cite a diagnosed imbalance in brain chemistry rather than an eccentricity, a character flaw or an economic disadvantage." Much easier as well to market your designer drug. Successfully hyped by socially anxious celebrities like Williams, Donny Osmond and David Beckham, social anxiety disorder has become a widely recognized "condition." Those who have the money can now buy happiness. Shyness is for losers.

The company accountant is shy and retiring. He's shy a quarter of a million dollars. That's why he's retiring. ~ Milton Berle

References:

1. Lane C. Shyness: how normal behavior became a sickness. New Haven: Yale University Press; 2007.

2. Cox BJ. Shyness: how normal behavior became a sickness [book review]. N Engl J Med. 2008 Jan 31;358(5):539-540.

3. Cox BJ, MacPherson PS, Enns MW. Psychiatric correlates of childhood shyness in a nationally representative sample. Behav Res Ther. 2005 Aug;43(8):1019-27. PMID: 15967173

4. Crews F. Talking back to Prozac. The New York Review of Books. 2008 Dec 6;54(19):10-14.

5. Horwitz AV, Wakefield JC. The loss of sadness: how psychiatry transformed normal sorrow into depressive disorder. Oxford: Oxford University Press; 2007.

6. Healy D. Let them eat Prozac: the unhealthy relationship between the pharmaceutical industry and depression. New York: New York University Press; 2004.

Revised research on Iraq casualty statistics

2008-02-05T06:24:00.000-06:00

ORB (Opinion Research Business), the independent UK-based polling agency, has produced more research on deaths in Iraq:

Following responses to ORB’s earlier work, which was based on survey work undertaken in primarily urban locations, we have conducted almost 600 additional interviews in rural communities. By and large the results are in line with the 'urban results' and we now estimate that the death toll between March 2003 and August 2007 is likely to have been of the order of 1,033,000. If one takes into account the margin of error associated with survey data of this nature then the estimated range is between 946,000 and 1,120,000.

The ORB survey makes no claim to be as rigorous as the two Johns Hopkins studies, Lancet 1 (2004) and Lancet 2 (2006) [1,2]. In contrast to the recent absurdly low mortality figures compiled by the Iraqi Ministry of Health and published in the NEJM [3], which I discussed in a recent post, the ORB statistics look like the best available until another thorough Lancet-style epidemiological survey is carried out.

The press release [DOC] of 28 January 2008 gives a more intimate perspective on these ghastly numbers:

Among the over 2,160 respondents who answered the question 20% said that there had been at least one death in their household as a result of the conflict which started in 2003. Within these households the average number of deaths was 1.26 people.

The data tables found in the New Casualty Tabs [PDF] break down the sources of death in a fashion approximately similar to Lancet 2 [PDF]. The responses to Question 2 ("How were they [members of the household] killed?") are interesting. They are divided into nine categories:

Gunshot	40%
Car bomb	21%
Other blast/ordnance	8%
Aerial bombardment	8%
Accident	6%
Sectarian violence	4%
Kidnapping and killing	1%
Other	2%
Don't know/refused	9%

Note the separate category for sectarian violence to which 4% of violent deaths are attributed. It is difficult to see why this was included. One is led to question the method by which the figures were derived. How is a "sectarian" death by gunshot separable from an "ordinary" death by gunshot? It is necessary to distinguish between the means of killing and the mode of killing. Otherwise there should be categories for "Killed by coalition forces," "Killed by mercenaries," "Killed by police," etc. The presence of sectarian violence as a category on this list is confusing and invites criticism.

After gunfire (40%), the largest number of deaths is attributed to car bombings (21%). That amounts to roughly 200,000 deaths resulting from this grisly tactic. The use of what the Pentagon refers to as "Vehicle Borne Improvised Explosive Devices" draws more attention than other forms of death. In Iraq we see it applied in the deadliest, most spectacular way. As Mike Davis tells us in his recent book Buda's Wagon: A Brief History of the Car Bomb [3], it is a technology that has proliferated incredibly since its first deployment in 1920 when a horse-drawn wagon was exploded by the anarchist Mario Buda near New York's Wall Street. No continent, save Antarctica, has been spared the car bomb's devastation. Davis describes it as a weapon whose use is "guaranteed to leave its perpetrators awash in the blood of innocents," a "categorical censure" that applies "even more forcefully to the mass terror against civilian populations routinely inflicted by the air forces and armies of so-called 'democracies'."

ORB, a non-government-funded group founded in 1994, conducts research for the private, public and volunteer sectors. According to a 30 Jan 2008 Reuters report, the director of the group, Allan Hyde, said it had no objective other than to record as accurately as possible the number of deaths among the Iraqi population as a result of the invasion and ensuing conflict. And the numbers are staggering. So far, most of the mainstream media continue to ignore this objective attempt at a just accounting of mass death in Iraq.

References:

1. Roberts L, Lafta R, Garfield R, Khudhairi J, Burnham G. Mortality before and after the 2003 invasion of Iraq: cluster sample survey. Lancet. 2004 Nov 20-26;364(9448):1857-64.

2. Burnham G, Lafta R, Doocy S, Roberts L. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Lancet. 2006 Oct 21;368(9545):1421-8.

3. Davis, Mike. Buda's wagon : a brief history of the car bomb. London : Verso; 2007

"Like snapping at flies": the rubber librarian hears from the condom makers

2008-02-03T19:50:00.000-06:00

Once again Winnipeg is experiencing that most rigorous of winter's many onslaughts, a cold snap. It's so cold there's an air of conspiracy about it, because it doesn't seem real. On the other side of my frosted-up window it's as cold as a campground privy on the dark side of Pluto. Lip-crinkling, flesh-withering, molecule-slowing winds that seem to have blown across the vacuum of space before reaching us, testing the lower depths of the Kelvin scale. With weather like this it is perhaps appropriate to return to the troubling question that has concerned the public health authorities here. What effect does Winnipeg's cold weather have on latex condoms?

I have an update to my two previous posts about this issue. In my last post I reported on the initial response from the condom manufacturer to the question whether condoms can be stored safely in the cold.

Here is that first reply that came to public health officials:

Latex condoms are made of natural polyisoprene, 99+%, with trace amounts of residual vulcanization chemicals. This is a stable organic polymer and contains no water. As well, there are no mixtures or emulsions. As such, there is nothing in a latex condom to be affected by cold temperatures. Indeed, a sealed, opaque packaged condom place [sic] in a cold environment may well be preserved.

Problems may occur in the thawing process if extra heat is added. Should condoms freeze, they must be left to thaw gradually at room temperature.

A follow-up email was sent to the company asking why, if this is the case, cartons of condoms purchased in bulk bear printed instructions not to store their contents in extreme heat or cold. The carton warning reads: "Store at room temperature. Protect latex condoms against prolonged periods of exposure to: extreme low or high temperatures, moisture, direct sunlight, fluorescent light."

There certainly is sufficient research to support all the other warnings. But the fruitless search I did for the Healthy Sexuality and Harm Reduction department of the Winnipeg Regional Health Authority showed that the risk of extreme cold to the physical integrity of the condoms is still unknown. Yet we have a printed warning about exposure to extreme cold printed on every box of condoms manufactured in a southern American state where cold normally means how you like your tea. The cryogenic frigidity of a Prairie winter is not even conceivable where these condoms are made. One begins to juggle with the questions that pop up. What, then, would warrant the printed warning on the condom packages? What exactly is the nature of the risk so obliquely referred to. Is it a risk to the plastic wrap or the condom lubricant? What rationale, we must ask the manufacturers, is there for this warning?

Perhaps this left them with too many balls in the air, for it was only after a considerable delay that a reply was finally received from a spokesperson:

Please forgive the delay in responding to your inquiry but I took the time to review it with the regulatory officials in case anything had changed since my last investigation into this matter.

The warning against prolonged cold is just a precaution. There is nothing about cold that will harm the latex as long as the condoms are thawed before use. Extreme cold can make latex hard and brittle, just as it does many items. We have no literature references immediately at hand for you on this subject, but we have tested frozen condoms in the past and we have laboratory data to sustain this claim [data not supplied].

The warning against prolonged heat and light exposure is NOT just a precaution. Both will shorten the life of condoms and ultimately destroy them. Heat is used in accelerated aging protocols. A [sic] opened condom exposed to light will be compromised in a [sic] little as a week. As you mentioned, there is literature available to sustain this claim.

The moisture warning is for the boxes and film only as moisture has no impact on the condom itself. The box, however must remain intact to help protect against light and temperature fluctuation.

Plastic wrap for condoms is fine for the shelf life of condoms, as long as the seals are intact. There is absolutely no cause for concern regarding the plastic film.

Films and especially seems [sic] can suffer water damage. Condoms that have been flooded could be compromised if the seems [sic] of the films or foils are not intact or have been damaged and water may have infiltrated. Again, we have no literature references immediately at hand for you on this subject but such incidences have occurred.

I regret that I am unable to provide the literature you were hoping to receive. Until Health Canada mandates manufacturers to test for these specific issues, I doubt that any such literature will be made available.

Speaking out of both sides of their mouth and saving both their faces, the condom manufacturers claim to have "tested frozen condoms in the past." But at present they "have no literature references immediately at hand" on this subject. At the same time, they do have "laboratory data to sustain this claim." However, they are unable "to provide the literature you were hoping to receive." The warning against prolonged cold is "just a precaution" they tell us. (Against what?) And they will take no steps to release existing data, conduct any further research, or answer any more questions about this matter unless forced to by government regulators.

As a society we place a great deal of trust in manufacturers of products designed to keep us and our children safe. One would think that a respected condom manufacturer would have resorted to keeping fewer balls in the air and taken slightly more time and effort to respond to an honest question from a public health official. Why not condescend to show some interest in what is after all an interesting and challenging query? To start with, why not share the so-called laboratory data? Who are the "regulatory officials" who were consulted? Why no promise of cooperation in referring the question to Health Canada? Trying to get a decent answer from Condoms & Co. is like snapping at flies. The answer we finally get leaves such a bad taste, it's like we actually swallowed one.

Note: The opinions stated in this post are entirely my own and do not necessarily represent those of the Winnipeg Regional Health Authority.

The Scarers in Print: analyzing a poop test brochure for readability

2008-01-28T12:25:00.000-06:00

Now, it's too late for me to begin shovelling and sifting at alphabeds and grammar-books. I'm getting to be a old bird, and I want to take it easy. But I want some reading—some fine bold reading, some splendid book in a gorging Lord-Mayor's-Show of wollumes. ~ Charles Dickens, Our Mutual Friend, Chapt. 5

Those of us who take our ability to read for granted, who live and breathe letters as dogs do feces and effluvia, are sometimes forgetful of the difficulties experienced by so many in the face of nothing more formidable than the back of a cereal box, let alone a "chapter book." In Our Mutual Friend the illiterate dustman Mr. Boffin hires that "ligneous sharper," the peg-legged Silas Wegg, to read to him his newly acquired and highly treasured book Decline-And-Fall-Off-The
-Rooshan-Empire ("Eight wollumes. Red and gold. Purple ribbon in every wollume, to keep the place where you leave off.") Because all print is shut to them, he and Mrs. Boffin are willing to endure night after night of Mr. Wegg's garbled delivery of Gibbon's prose, just for the feeling of participating in what they consider proper culture. They want some fine bold reading, in some splendid book. Instead they have to put up with the malapropisms, mispronunciations and petulant malingering of the scheming Silas Wegg.

In 21st century Canada there are still many Mr. and Mrs. Boffins. According to ABC Canada:

Four out of 10 adults, age 16 to 65 — representing 9 million Canadians — struggle with low literacy. (Adult Literacy and Life Skills (ALL) Survey, Statistics Canada and the Organization for Economic Co-operation and Development, 2005)
Nearly 15 per cent of Canadians can't understand the writing on simple medicine labels such as on an Aspirin bottle.
An additional 27 per cent can't figure out simple information like the warnings on a hazardous materials sheet.
In total, 42 per cent of Canadians are semi-illiterate. The proportion is even worse for those in middle age. And even when new immigrants are excluded, the numbers remain pretty much the same.

The statistics for our neighbours to the south are roughly the same, nor has there has been much improvement over the last generation in either country. This surprises me, for reading is ostensibly such a popular pastime and a prominent feature of our popular culture — certainly much more so than in that now distant, pre-postmodern period when there were few book clubs, no lit blogs, no Chapters-Indigo, no Amazon, no Oprah, no Harry Potter. In the United States, a 2004 NEA report on Reading at Risk lamented the sharp decline in the reading of books of "literature." Some hapless bloke's complaint is recorded there for posterity: "I just get sleepy when I read." To which Ursula Le Guin, in a feature article in the February Harper's, replies resignedly, yes, but there are actually many people who read wide awake. Le Guin thinks books are here to stay. "It’s just that not all that many people ever did read them. Why should we think everybody ought to now?" (Warning: the Harper's website only provides a teaser version of the article to non-subscribers.)

I have to agree. Books are not a threatened species. However, when it comes to health information, the large ranks of the functionally illiterate, possessing a merely nodding acquaintance with the printed word, face a very real threat. In English-speaking North America, as more than 300 studies indicate, health-related materials cannot be understood by most of the intended audience [1]. Now that two thirds to three quarters of our populations are seeking out consumer health information on the Internet, one wonders how this massive group of so-so readers is dealing with the often challenging vocabulary and syntax to be found on sites like MedlinePlus and the Canadian Health Network, not to mention the huckstering puffery of Health 2.0.

'Why, truly, sir,' Mr Wegg admitted, with modesty; 'I believe you couldn't show me the piece of English print, that I wouldn't be equal to collaring and throwing.' 'On the spot?' said Mr Boffin. 'On the spot.' 'I know'd it! Then consider this. Here am I, a man without a wooden leg, and yet all print is shut to me.'

Trying to digest the ColoScreen brochure
My own recent experience with "patient information" has convinced me that the literate need to learn how to write as badly as the illiterate need to learn how to read. Not long ago I had occasion to do some stooping and scooping — for my own, not my Retriever's. A lab test was required, and for the first time in my life I was introduced to the mysteries of ColoScreen. My doctor gave me a package including a special envelope, three sample collection areas with fold-over flaps, and three small wooden "applicator sticks" with which to provide "specimen" smears. The ColoScreen kit came with a 600-word set of instructions: everything I needed to know about the poop test. To this extraordinary work they give the title ColoScreen: a test for fecal occult blood. Now there was some fine bold reading!

Talk about occult. Here is a representative selection of the kind of prose some committee probably laboured over for hours in order to ensure I would make no error in carrying out what any two-year-old can do with the greatest of ease all over the nursery wallpaper:

Two days prior to, and including the test period, a red-meat free, high-residue diet should be followed ... Do not ingest high doses of aspirin or other anti-inflammatory drugs, for 7 days prior to and during testing ... However, consult a medical professional before discontinuing any prescribed medication ... Discontinue the use of toilet tank/bowl cleaners or deodorizers throughout the test period to avoid interference ... Flush tissue with stool, and discard stick in waste container ... On the next two subsequent bowel movements, repeat above steps ...

What possible excuse could there be for this laughable effort? Precision? There certainly is lots of that. Ass-covering? No one can say they weren't told in excessive detail how to scrape their own excrement into an envelope. Just who was this written for? The patients, their health care professionals, the government, or the lawyers? The strenuous, stilted syntax, the jargon, the Latinisms, the pathological avoidance of common idiom — all this adds up in my mind to a truly deplorable effort at communication. What were the authors thinking? Half their potential readership is left to puzzle at expressions like "discontinuing any prescribed medication" and "subsequent bowel movements." And couldn't they have found a simpler way to say "waste container?" Do any of us use such language in our daily lives? "That's alright, Junior. Just make sure you throw any of Fido's subsequent evacuations into the waste container."

Helena Laboratories in Beaumont, Texas, is the manufacturer of the fecal occult blood test package, and, I assume, responsible for the accompanying patient instruction. Their website advertises a number of educational brochures, and I shudder to think of the squinting and squirming and cocking of heads going on right at this moment as millions of helpless Boffins decline and fall under these heavy catapults of English prose.

Different versions of the ColoScreen brochure may be found on the Helena.com website. I checked to see how they compare to the print version I received. Sad to say, they are even more prolix and impenetrable. Here is a not untypical excerpt (perhaps it reads more easily in the Spanish version):

Because of the nonhomogeneity of the stool, it is recommended that the test be performed on three (3) consecutive evacuations, or as close together as possible.

Testing for readability
In the face of such a frontal assault one can do little else but evacuate the wounded and regroup. I wanted to find out just how bad the ColoScreen brochure really was. I needed to see some data that would allow me to compare it against a benchmark. So I resolved to analyze the text using a number of standard readability measures: Coleman Liau, Flesch Kincaid, ARI, SMOG, Gunning Fog, and Lexile. Microsoft Word does a basic readability test as part of its word count feature, and I started there.

According to Word's word count my printed ColoScreen brochure scored 57.2 in the Flesch Reading Ease measure, and 8.8 in the Flesch-Kincaid Grade Level. Not satisfied to rely on a single test, I used a number of freely available online readability analyzers. The sites I used are stored under my readability tag on del.icio.us.

Running my brochure through these online tools produced slightly varying readability results, but they averaged out at roughly Grade 9 or higher. Testing against the Lexile measure returned a Grade 10 (1100L to 1200L). By way of comparison, the Harry Potter series measure between 880L and 950L; Don Quixote (in English translation presumably) rates a fairly high 1410L.

The scores were much too high. For consumer health information, the literature is full of admonitions to employ plain language at the fifth grade level or lower to accommodate differing literacy levels [2,3,4]. The ColoScreen instructions fail to inform patients in an appropriate manner. Not only is this preposterous brochure well-nigh impenetrable to the semi-literate, it is prudish and officious to boot. In fact, it stinks.

Everyone advocates health literacy. Library shelves sag with literature on the subject and the web does the same digitally. Barbara Nail-Chiwetalu reviews the issue of health literacy in a way I found useful [5]:

Health literacy may be defined as the ability to obtain, read, comprehend, and use health information to make appropriate health decisions. The development of appropriate and effective health communication is an initiative recognized in Healthy People 2010. To this end, improving health communication may call for use of a variety of approaches, which may include:

• Improving the accessibility of appropriate health materials in communities [6]
• Emphasizing readability and comprehension of health communication materials (e.g., pamphlets, instruction guides, package inserts, books, Web sites) by
o acquiring materials that are written in conversational style (active voice) [2]
o using short sentences of ten to fifteen words [2]
o translating complex medical terms [3]
o using plain language at the fifth grade level or lower to accommodate differing literacy levels [3]
o using caution with medical textbooks written for physicians or other health professions with consumer due to the high readability level and comprehension of terms [2]
o considering use of nonwritten materials (e.g., charts, diagrams, photographs , picture books, videotapes, audiotapes, multimedia presentations) with persons having limited literacy [3,4]
• Showing sensitivity to language and cultural needs by
o providing materials that are culturally relevant [3]
o translating materials into different languages [3]
o using interpreter services to provide direct translations of what is said [4]
• Adjusting oral communication of health information by
o slowing down the rate of speech when delivering health information [3]
o using a “teach back” or “show me” approach to ensure understanding [3]
o including important family members or close friends in discussions including “surrogate” readers [3]

I don't claim expertise in health literacy, and I realize that simple readability scores are not the last word in assessing the quality of consumer health information [7,8,9]. A recent study by Rosemblat et al. [10] enlightened me as to the importance of the "main point" for readability measurement, while at the same time admitting the difficulty of measuring it:

Only two features, "Vocabulary" and "Main Point," significantly predict whether the annotators rated consumer health texts as readable for general audiences. Traditional readability formulas incorporate syntactic (words per sentence) and semantic (vocabulary) features to predict readability. While the annotators verified familiarity with vocabulary as a predictor, they also found that effective communication of the main point is a significant attribute. These results may contribute to understanding consumer seeking and browsing health information online. For example, eye-tracking studies indicate that users typically scan a Web page for the "take-home" message and move on to another page if not found in a few seconds. However, "ability to communicate the main point" is difficult to define operationally and measure.

So with all this theory and the outstanding efforts of experts and advocates, how did I end up with the ColoScreen atrocity? What applicator stick smeared this rank specimen of English prose onto my slide? Here is the take-home message I extract from my experience. We all must work a little harder at communicating to the system that it must serve real people by promoting reading and assisting the non-readers among us. That is a professional and a political commitment. If the main goals of a system of public health are to increase quality and years of health life and to eliminate health disparities, then we health librarians must re-dedicate ourselves to the dissemination of health information and the promotion of healthy lifestyles, not just for the educated and comfortable, but for everyone who would not be able to read this sentence. More simply put, let's get rid of the Scarers in Print.

'... upon-my-soul to a old bird like myself these are scarers. And even now that Commodious is strangled, I don't see a way to our bettering ourselves. ... I didn't think this morning there was half so many Scarers in Print. But I'm in for it now!' ~ Mr. Boffin, after an evening of "declining and falling" with Mr. Wegg (Our Mutual Friend, Chap. 5)

References:

1. Nielsen-Bohlman L, Panzer AM, Kindig DA, editors. Health literacy: a prescription to end confusion. Washington: National Academies Press; 2004.

2. Baker LM, Gollop CJ. Medical textbooks: can lay people read and understand them? Library trends. 2004;53(2):336-347.

3. Parker R, Kreps GL. Library outreach: overcoming health literacy challenges. J Med Lib Assoc. 2005;93(Suppl. 4):S81-S85.

4. Allen M, Matthew S, Boland MJ. Working with immigrant and refugee populations: issues and Hmong case study. Library trends. 2004;53(2): 301-328.

5. Nail-Chiwetalu, B. Libraries meeting community health needs: trends and issues (Revised January 18, 2006) [monograph on the Internet]. Washington: NCLIS, 2006 [cited 2008 Jan 24]. Available from: http://www.nclis.gov/award/NCLIS-TrendsinLibrariesReport.pdf

6. Burnham E, Peterson EB. Health information literacy: a library case study. Library trends. 2005;53(3):422-433.

7. Gemoets D, Rosemblat G, Tse T, Logan R. Assessing readability of consumer health information: an exploratory study. Medinfo. 2004;11(Pt 2):869-73.

8. Keselman A, Tse T, Crowell J, Browne A, Ngo L, Zeng, Q. Assessing consumer health vocabulary familiarity: an exploratory study. J Med Internet Res 2007;9(1):e5. doi:10.2196/jmir.9.1.e5

9. Wang, Y. Automatic recognition of text difficulty from consumers health information. 19th IEEE International Symposium on Computer-Based Medical Systems (CBMS '06). 2006:131 - 36. doi:10.1109/CBMS.2006.58

10. Rosemblat G, Logan R, Tse T, Graham L. How do text features affect readability?: expert evaluations on consumer health web site text [article on the Internet]. Mednet Congress 2006 [cited 2008 Jan 24]. Available from: http://www.mednetcongress.org/fullpapers/MEDNET-192_RosemblatGracielaA_e.pdf

Medline copycats found out

2008-01-24T15:32:00.000-06:00

Nature News (published online 23 January 2008 | doi:10.1038/news.2008.520) has revealed that as many as 200,000 of the 17 million articles in the Medline database might be duplicates, either plagiarized or republished by the same author in different journals. The full article is available here (Errami M, Garner H. A tale of two citations. Nature 2008 Jan 24;451:397-399.)

Analysis with text-matching software produced estimates that 0.04% of a random sample of 62,000 articles might be plagiarized, and 1.35% might be duplicates with the same author. Employing a clever shortcut, the researchers examined more than 7 million Medline abstracts with listed related articles, running their algorithm against just the original abstract and its "most related" abstract. This method revealed 70,000 potential duplicates, which have been loaded onto a publicly accessible database called Déjà vu. It is likely that tools such as Déjà vu and text-comparison software will act as future deterrents to plagiarism.

Publishers are already taking part in tests of anti-plagiarism tools. One of these, CrossCheck, compares new manuscripts against already published materials in its database. CrossCheck searches for similar or identical parts of manuscripts, and when it detects questionable text, it highlights those sections for a suspicious editor to scrutinize.

iParadigm, in Overland Park, Kansas, is working with the IEEE and the other publishers to develop CrossCheck. This is the same company that developed Turnitin.com, an online resource that helps university educators detect plagiarism in student papers. The program has been very successful as a deterrent, although not without stirring up controversy. CrossCheck is expected to be its equivalent

As Oliver Obst (from whom this post was plagiarized), comments in his blog medinfo, this kind of text mining would be easier and more useful generally if all articles were Open Access. It would then be possible to compare more than abstracts, which are brief and not as textually significant; plagiarism could also be determined at the syntax level of an article's full text — truly an alarming scenario for the cribber.

Shout with the largest: violent disagreement about Iraqi mortality rates

2008-01-20T17:46:00.000-06:00

'It's always best on these occasions to do what the mob do.' 'But suppose there are two mobs?' suggested Mr. Snodgrass. 'Shout with the largest,' replied Mr. Pickwick. ~ Charles Dickens, The Pickwick Papers, Chapt. 13

An article in the New England Journal of Medicine was published on January 9, 2008 with new mortality statistics compiled by the Iraqi Ministry of Health under the sponsorship of the World Health Organization [1]. The study, by the innocuously named Iraq Family Health Survey Study Group (IFHSSG), concludes that 151,000 Iraqis suffered violent deaths between March 2003 and June 2006. A previous estimate, the highly controversial study published in the Lancet in October 2006 [2], suggested a much higher number: more than 600,000 deaths.

Les Roberts, a co-author of the Lancet survey (and an earlier one in 2004 [3]), has offered his response on Tim Lambert's Deltoid blog, which generated an enormous number of comments. The entire post reflects very well the politically charged controversy surrounding the issue of Iraqi mortality since the American-led invasion in March 2003. Roberts claims that there is more in common in the results than appears at first glance, and he continues to defend the conclusions of the two Lancet studies.

In an angry attack on the NEJM study in Counterpunch [4], Andrew Cockburn notes how their final tally of "only" 151,000 deaths has been greeted with respectful attention in US press reports, along with swipes at the Lancet effort for having, as the New York Times reminded readers, "come under criticism for its methodology." Cockburn argues forcefully that the IFHSSG study is guilty of sloppy methodology and tendentious reporting. He criticizes the NEJM for "lending its imprimatur to this farrago."

On September 14, 2007, ORB (Opinion Research Business), an independent UK-based polling agency, published a startling estimate of the total casualties of the Iraq war that has received little mention in the mainstream press. The figure suggested by ORB, which was based on survey responses from 1,499 adults, stands at more than 1.2 million deaths. The horrifying figures tallied by ORB — although its survey was conducted independently, using a different polling methodology — are consistent with the Lancet findings. One of the shocking results of the ORB analysis was that almost one in two households in Baghdad have lost a family member, significantly higher than in any other area of the country. The governorates of Diyala (42%) and Ninewa (35%) were next.

The reaction to the ORB report in the US political and media establishment was virtual silence. There was no comment from the Bush White House, the Pentagon, or the State Department; not a single Republican or Democratic presidential candidate or congressional leader made an issue of it; nor was the subject raised on the Sunday morning TV talk shows. Perhaps their attention was diverted by events in Iraq itself, for it was at this same time that eight civilians were reported killed by private US "security contractors" in a ghastly Baghdad shootout. That story was heavily covered by all the media for days afterward.

At the other end of the Iraq mortality scale, the Iraq Body Count website, which has strongly criticized the Lancet studies, estimates the death toll by violence at between 80,000 and 88,000. IBC's results are based on English-language media reports only, and are accurate as far as they go. They do not even attempt to estimate the number of deaths resulting from the dreadful conditions prevailing in Iraq.

As Stalin is said to have observed: A single death is a tragedy; a million deaths is a statistic. Aside from moral considerations and the ideological wars well documented in various sources [5-8], the difficulty with Iraq mortality numbers seems to involve methodological differences with regard to non-violent death. The Lancet studies and the ORB poll include estimates of mortality occasioned by other means than bombs or bullets. Hence the enormous casualty rates reported in those surveys. The problem with this month's NEJM study is that only violent deaths "count," as if people dying from poverty, lamentable public health conditions, poor nutrition, or terrible health care are somehow less dead, or as if the increase in their numbers is any less attributable to the invasion.

Illustrative of how the Iraq mortality debate has become a touchstone for broad ideological differences is that the media reaction to the Lancet studies is even being used by statistics teachers to highlight the role of politics in the framing of statistical findings. Les Roberts himself has commented on the controversy surrounding his research: "It is odd that the logic of epidemiology embraced by the press every day regarding new drugs or health risks somehow changes when the mechanism of death is their armed forces" [5]. De Maio [9] discusses how class discussions can be based around this quotation to explore the complex interplay between hierarchies of credibility, claims of scientific precision, and political standpoints. It is interesting to note the contrasting receptions given in the media to Robert's Iraq surveys and a study that Roberts led in the Congo using a very similar methodology [7]. The conclusions of the latter were accepted unquestioningly by the press and political leaders alike [6].

What exactly the intentions of the authors of the NEJM article were when they undertook their survey is a matter for debate. While to some their results will look like a whitewash, it does not appear that their work was dishonest or deliberate propaganda. Unfortunately, it has entered public discourse primarily in terms of its disapprobation of the Lancet survey (the ORB report is still under the radar). That is the way it is going to be used, and almost all the attention given to the problems and complications pointed out by Roberts and others will be confined to a small number of commentators and scholars. Lenin's Tomb commented: "Whatever the intentions of the ministry of health workers who carried out this study, its findings are now out of their hands. It is now a weapon for neutralising the findings of the Lancet survey."

Counterspin on the Lancet studies is still in full swing. Witness the oddball critique just published in the National journal [10], which goes so far as to suggest that The Lancet was a victim of "wartime fraud." The article's author, Neil Munro, also claims that jihadists "used this research as a justification for killing Americans." (In 2001 Munro looked forward to the destruction of Iraq in an enthusiastic opinion piece for the right-wing National review online entitled "The Iraqi opportunity: Berlin '45. Tokyo '45. Baghdad '02." He was off by a year.)

Meanwhile, in numbers that still remain undetermined — but that everyone agrees are horribly excessive — Iraqis continue to die. Kieran Healy at Crooked Timber has nicely summed up the disagreements among epidemiologists, politicians, statisticians, ideologues, intellectuals, and wing-nuts:

The main challenge facing those doing this sort of research is that there is a war going on, and wars kill a lot of people, bring about the dissolution of households, and compel very large numbers of people to flee the region. All of this makes the machinery of statistical science rather difficult to apply. None of the available numbers look any good, both on their own and given what they imply about what’s happening in Iraqi society. If you find yourself really delighted that a war of choice has resulted in the deaths of a population the size of Jersey City, or maybe Oakland, instead of one the size of Baltimore, you probably need to rethink your priorities.

References:

1. Iraq Family Health Survey Study Group. Violence-related mortality in Iraq from 2002 to 2006. N Engl J Med. [Internet]. 2008 Jan 9 [cited 2008 Jan 20]. Available from: http://content.nejm.org/cgi/content/full/NEJMsa0707782

2. Burnham G, Lafta R, Doocy S, Roberts L. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Lancet. 2006 Oct 21;368(9545):1421-8.

3. Roberts L, Lafta R, Garfield R, Khudhairi J, Burnham G. Mortality before and after the 2003 invasion of Iraq: cluster sample survey. Lancet. 2004 Nov 20-26;364(9448):1857-64.

4. Cockburn A. Gross distortions, sloppy methodology and tendentious reporting: how the New England Journal Of Medicine undercounted Iraqi civilian deaths. Counterpunch [serial on the Internet]. 2008 Jan 12/13. [cited 2008 Jan 20]. Available from: http://www.counterpunch.org/andrew01122008.html

5. Medialens. Burying the Lancet – Part 1. [blog on the Internet] 2005 Sep 5 [cited 2008 Jan 20]. Available from: http://www.medialens.org/alerts/05/050905_burying_the_lancet_part1.php.

6. Medialens. Burying the Lancet – Part 2. [blog on the Internet] 2005 Sep 6 [cited 2008 Jan 20]. Available from: http://www.medialens.org/alerts/05/050906_burying_the_lancet_part2.php

7. Guterman L. Researchers who rushed into print a study of Iraqi civilian deaths now wonder why it was ignored. The Chronicle of Higher Education. 2005 Jan 27. [cited 2008 Jan 20]. Available from: http://chronicle.com/free/2005/01/2005012701n.htm.

8. Wikipedia. Lancet surveys of Iraq War casualities. [Internet]. [cited 2008 Jan 20]. Available from:
http://en.wikipedia.org/wiki/Lancet_surveys_of_casualties_of_the_Iraq_War

9. De Maio F. Statistics in the news: estimating mortality in war-time Iraq: a controversial survey with important lessons for students. Teaching statistics. 2007 Jun;29(2):34-7.

10. Munro N, Cannon CM. Data bomb. National journal [serial on the Internet]. 2008 Jan 4 [cited 2008 Jan 20]. Available from: http://news.nationaljournal.com/articles/databomb/index.htm

Stiffening in the cold: more on condoms in the Canadian winter

2008-01-13T22:24:00.001-06:00

"The elastomers—natural rubber and polychloroprene— ... are susceptible to crystallization during prolonged exposure to low temperatures. This leads to a gradual long-term stiffening. ... Stress–strain measurements have confirmed the extremely large increase (up to 100-fold) in the initial stiffness that crystallization produces." (Fuller KNG, et al. The effect of low-temperature crystallization on the mechanical behavior of rubber. Journal of polymer science: Part B: Polymer physics. 2004;42:2181-90.)

The rubber librarian has been at it again, straining hard to stretch a bit more evidence over a vast gap in the condom literature. Last month I posted on my failure to find any scientific literature on the effect of extreme cold on latex condoms. But the thrust of my investigation didn't stop there. Not trusting my own abilities to probe the strange literature of latex, I consulted with a colleague in the Sciences and Technology Library who knows well the ins and outs of the relevant databases, just to make sure that I hadn't missed anything vital. After a prolonged search he found a number of seminal papers on the influence of low-temperature crystallization on the tensile elastic modulus of natural rubber. My enthusiasm for the subject momentarily bounced back, until I realized that once again the condom was getting no respect. All that rubber research and not one mention of condoms. Undeflated however, I carried on. Here is a brief survey of the science of gelid latex, and anything useful pertaining to condoms that can be extracted from this small body of knowledge. A full bibliography with abstracts is given below as an appendage.

To get any insight into what "tensile elastic modulus" exactly means, think stretchability or "elongatability." Modulus is a mathematical term that was appropriated by the British scientist Thomas Young in the 18th century to express the physical measure of stiffness, equalling the ratio of applied load (stress) to the resultant deformation of the material, such as elasticity or shear. (A high modulus indicates a stiff material.) Having thus stretched my high school chemistry to the snapping point by reading through a torrent of exceedingly dull prose, I finally reached a partial understanding of inspissation and cold crystallization and their effect on tensile elastic modulus. To avoid undue rigidity of language, let us translate this jargon-splotched no-man's-land of technolinguistic barbed wire and chevaux-de-frises into a more flexible dube-ological vernacular (kondomswissenschaftliche Umgangssprache). The upshot of seventy years of low-temperature rubber research is that it gets hard in the cold. The non-scientific majority of humanity must be truly grateful for this remarkable advance in rubber research.

What does this all mean for the hardy condom user? Because cold tends to "crystallize" rubber, this leads to a progressive increase in density, gradual long-term stiffening, and a doubling of tensile elastic modulus ... of the condom, not its wearer. None of the literature discovered by my research actually concerns itself with the common condom, but all the science points to a Canadian winter's ability to make rubbers slightly brittle, which could possibly — and I emphasize possibly — lead to leaking or breakage. Not to elongate this explanation more than the kinetic measurements allow, it seems clear that the effect of arctic air on a condom's stress-strain characteristics, in reverse proportion to its effect on the body part for which the condom is designed, is one of stiffening and tensile swelling. Furthermore, as Natarajan cogently reminds us [6], free radicals formed during tensile testing at low temperatures are stable below the glass transition temperature of the material. (These radicals arise from main-chain fracture occurring during yielding of the material — and too-frequent reading of Bakunin in unheated garrets. Natarajan also suggests that yielding of the material which gives rise to these characteristics occurs by crazing of the material — reading Bakunin in an unheated garret during a Winnipeg winter.)

The existing research suggests that public health officials might consider ensuring that condoms for distribution by clinics and street health workers are not stored at extreme winter temperatures. Individuals should not keep their condoms in glove compartments, unheated back porches, or hidden behind the snow blower in the garage. Most package directions already recommend a normal range of acceptable temperatures for safe storage. Maybe they are right.

A condom manufacturing company with whom my local health authority has dealings responded by email to an official request for their position on condom storage. The company's reply stated that in their opinion there is no risk in storing condoms in extreme cold, as long as they are not thawed out with the application of high heat, but are allowed to come gradually to a normal temperature. A follow-up email was sent to the company asking why, this being the case, large boxes bought at wholesale containing hundreds of condoms have printed instructions not to store their contents in extreme heat or cold. To date no reply has been received. This anecdote is no proof that condom manufacturers have no answers, but it does demonstrate how the lack of research on this issue means that the concerns of public health departments cannot be resolved by resorting to corporate public relations offices.

Other questions come to mind. Even if the storage of condoms in extremely cold environments, caeteris paribus, has no effect on their integrity, what guarantee is there that the cold would never contribute to damage caused by the often imperfect conditions that pertain in warehouses? What if, for example, a large box full of condoms were dropped from a truck or a fork lift at a temperature well below zero, or were otherwise jostled, jounced or dented? Might the cold, having stiffened the latex, not contribute further to any resulting damage to individual condoms? Is it possible that the increased modulus and crystallization of the latex might contribute to minute tears that could cause leakage or breakage when the condom is eventually used? What is the effect of extremely low humidity and excessive cold on condom integrity? Could this combination further contribute to damage from being bumped or dropped in storage?

This will have to be our last word for now on condoms and low temperatures, until a free radical bounces upon the scene to answer all our questions, electrify the rubber world, and warm the hearts of Canadian street health workers with a path-breaking, definitive study.

Flecte quod est rigidum,
Fove quod est frigidum,
Rege quod est devium.

Bend what is stiff,
Warm what is cold,
Guide what goes off the road.

Archbishop Stephen Langton, d. 1228

References:

1. Specifying elastomers for low temperature service. Materials and methods. 1953 Nov;38(5):114-8.
Changes occurring in rubbers as result of exposure to low temperature; how common elastomers differ in their low temperature behavior; improvements in low temperature flexibility obtained by use of certain types of plasticizers in compound; chart shows minimum temperatures at which various elastomers are useful.

2. Chenal JM, Chazeau L, Bomal Y, Gauthier C. New insights into the cold crystallization of filled natural rubber. Journal of Polymer Science, Part B: Polymer Physics. 2007 Apr;45(8):955-62.
This article is devoted to the cold crystallization of filled natural rubber with different types of filler such as carbon black, silica, and grafted silica. A large set of differential scanning calorimetry data is presented with various scanning rates, times, and temperatures of isothermal crystallization to display the factors affecting natural rubber (NR) crystallization. The crystallization kinetic measurements suggest that fillers can create a region with perturbed mobility where the kinetics of nucleation and/or growth are slowed down, the rest of the matrix being unperturbed. And, the final crystallization level indicates the existence of an excluded region for crystallization close to the filler surface. Furthermore, the presence of fillers appears less unfavorable to NR crystallization than chemical crosslinking.

3. Douglas WD. Mechanical properties of rubber in compression at low temperature. India rubber journal. 1930 Dec;80(25):9-11.
Investigation on effect of low temperatures on stress-strain characteristics of rubber in compression; tests were made upon half-inch cubes of black rubber of specific gravity 1.3 cut from single molded ring, such as might be used in springing of aircraft tail skids.

4. Fuller KNG, Gough J, Thomas AG. The effect of low-temperature crystallization on the mechanical behavior of rubber. Journal of polymer science: Part B: Polymer physics. 2004;42:2181-90.
In cold climates the correct performance of rubber components such as seismic isolators depends on them maintaining their elastic properties when exposed to prolonged periods at low temperatures. The high damping compounds developed for seismic isolation are normally especially prone to crystallization when exposed to subzero temperatures for periods of a few weeks. The effect of low-temperature crystallization on the mechanical stiffening of natural rubber is evaluated. The relationship between the shear modulus and amount of crystallization is measured using a technique in which the dimensional change and stiffness are monitored simultaneously. The relationship is found to be approximately independent of the crosslink density and the temperature of crystallization. It appears not to be realistically modeled by considering the crystals to behave as rigid filler particles but good qualitative agreement with experiment was obtained by modeling the crystals as a network of threads. Partially crystalline rubbers are found to yield under the application of a large stress like other partially crystalline polymers. Mechanisms for suppressing crystallization in rubber are discussed and the low-temperature stiffening of specially formulated rubber compounds for seismic isolation is presented. These results show that carefully formulated high damping natural rubber compounds can give adequate performance at low temperatures.

5. Ho CC, Khew MC. Low glass transition temperature (Tg) rubber latex film formation studied by atomic force microscopy. Langmuir. 2000;16(6):2436-49.
Latex with very low glass transition temperature (Tg) polymers forms a continuous film on drying. The physical and mechanical properties of the film are dependent on the extent the latex particles are able to coalesce and fuse into each other. Any hindrance to the film formation process would result in a poorly formed film and a drop in performance. The film formation process of natural rubbert (Tg approx. -65C) latexes and synthetic latexes with low Tg are monitored as a function of time using atomic force microscopy (AFM). The influence of the leaching method of the film, the presence of additives (some added after preparation) and nonrubber materials [specific for natural rubber (NR) latex only], and gel content on film morphology and flattening of the particles in the film is studied. The influence of the leaching procedure on the effectiveness of nonrubber removal from NR latex films and their effect on film formation is highlighted. The effects of nonrubbers and high gel content of NR latex in slowing down the NR film formation is discussed and contrasted with the synthetic polyisoprene and chloroprene latexes. The change of the surface mean roughness, Ra, with time provides a convenient means of comparing the rate of flattening of the polydisperse particles in these films.

6. Natarajan R, Reed PE. Molecular fracture in natural rubber during tensile testing at low temperatures. Journal of Polymer Science, Macromolecular Reviews. 1972 Apr;10(4):585-98. Sulfur-cured natural rubber and other elastomers subjected to tensile tests at low temperatures and low strain rates are found to swell and left double quote foam right double quote after testing when brought to room temperature. Free radicals formed during tensile testing are studied by (ESR) techniques. It is found that the free radicals observed at the low temperatures are stable below the glass transition temperature of the material, and it is suggested that these radicals arise from main-chain fracture occurring during yielding of the material. It is also suggested that yielding of the material which gives rise to these characteristics occurs by crazing of the material.

7. Spanos P. Cure system effect on low temperature dynamic shear modulus of natural rubber. Rubber world. 2003 Nov;229(2):22-7.
The effects of cure system on low temperature properties of natural rubber are discussed. High crosslink density cure systems were used for minimizing the crystallization induced shear modulus increase at low temperatures. Modulus measurements were made using dual lap shear samples on a servohydraulic dynamic test machine. The results show that the most pronounced changes in modulus occurred with the lowest sulfur formulation. All of the modified cure systems showed a much smaller change in modulus with decreasing temperature.

8. Stevenson A. Crystallization stiffening of rubber vulcanizates at low environmental temperatures. Kautschuk und Gummi Kunststoffe. 1984 Feb;37(2):105-9.
In environments with low ambient temperatures, several types of rubber vulcanizate can stiffen due to the formation of a crystallite structure in the rubber. The elastic modulus can increase by up to two orders of magnitude. The paper discusses the relevance of the stiffness changes to the performance of various rubber engineering components in cold environments - e. g. bridge bearings, helicopter rotor bearings and offshore mooring bearings. The stiffening of several natural rubber and polychloroprene vulcanizates, specified for engineering applications, has been studied at temperatures from minus 40 degree C to plus 5 degree C, using direct measurements of elastic modulus. The paper also reports on the correlation between changes in elastic modulus and results from the existing standard (ISO) tests - low temperature compression set and low temperature hardness.

9. Stevenson A. Influence of low-temperature crystallization on the tensile elastic modulus of natural rubber. Journal of Polymer Science, Polymer Physics Edition. 1983 Apr;21(4):553-72.
Data are presented which show that when natural rubber crystallizes at low temperatures, there is an increase in elastic modulus of up to two orders of magnitude. This phenomenon has beens studied at various temperatures in the range 0 to minus 55 degree C for samples held at tensile strains of up to 500%. There is an induction period associated with the nucleation of crystallites, before any increase in modulus is observed. The induction period increases with decreasing strain and passes through a minimum with increasing temperature at minus 25 degree C. The growth rate subsequent to nucleation is successfully described in terms of Avrami-type rate relationships. The Avrami rate coefficient is independent of temperature and follows a simple exponential function of strain. The equilibrium extent of the modulus incease has also been studied by means of experiments of up to three months' duration. The equilibrium modulus increases with decreasing temperature - as predicted by Flory's thermodynamic theory.

10. Yu HQ, Liu, XH. [Study on shear properties of low-temperature modified nature rubber]. Guti Huojian Jishu/Journal of Solid Rocket Technology. 2006 Jun;29(3):222-4. Chinese.
Compared with the relationship between shear strength and strain of nature rubber, the shear properties of the low-temperature modified nature rubber at -30-50C. was investigated. The analysis results show that the shear modulus of the low-temperature modified nature rubber kept for 6 hours at -30C or 50C is close to shear modulus at room-temperature when the shear stress is up to 343 N. Furthermore, the adhesive quality of the modified nature rubber with metals and other composite materials is very good, which can meet the adhesive strength demand of component in the temperature range -30-50C.

"Filter, flavor, flip-top box": getting PubMed filters to work good and draw easy

2008-01-10T17:01:00.000-06:00

While attempting to assist a medical resident with a difficult search, I was trying out the Cochrane filter (revised strategy) as discussed in an article by Robinson & Dickersin in the International Journal of Epidemiology [1]. They present a highly sensitive search strategy to retrieve reports of controlled trials using PubMed. In short, you get a lot to like. Excellent for use in systematic review searching, the authors' filter creates a subset much larger than what you would get from clicking on the various clinical trial check boxes in the Limits menu.

This is the search string in all its wonky glory:

(randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized controlled trials[mh] OR random allocation[mh] OR double-blind method[mh] OR single-blind method[mh] OR clinical trial[pt] OR clinical trials[mh] OR ("clinical trial"[tw]) OR ((singl*[tw] OR doubl*[tw] OR trebl*[tw] OR tripl*[tw]) AND (mask*[tw] OR blind*[tw])) OR ("latin square"[tw]) OR placebos[mh] OR placebo*[tw] OR random*[tw] OR research design[mh:noexp] OR comparative study[mh] OR evaluation studies[mh] OR follow-up studies[mh] OR prospective studies[mh] OR cross-over studies[mh] OR control*[tw] OR prospectiv*[tw] OR volunteer*[tw]) NOT (animal[mh] NOT human[mh])

I have been saving this article for years, but never got round to trying the filter out. Upon entering the strategy directly into the PubMed search box I was alerted by a pink-banded message telling me that the two descriptors highlighted above were not found. Of the two problems, the first is an error in the search strategy itself (I found no correction in the literature). The second is the result of a recent "major change" in PubMed.

This was more filter flavour than I had counted on. Now I was really huffing and puffing as I inhaled a man-size portion of PubMed technical detail in order to discover what had gone wrong with my peer-reviewed, much treasured filter in the flip-top box of my knowledge base. Here is what I found:

1. "Comparative Study" is used only as a publication type. The field delimiter or tag [mh] must be replaced with [pt]. This appears to be an error on the part of the creators of the filter. Comparative Study has only ever been a publication type since 1966. (An aside: this term has never found its way into the PubMed Help list of publication types. However, it does show up on the official NLM Publication Characteristics (Publication Types) - Scope Notes web page.)

2. "Evaluation Studies" was once a MeSH heading but is now a publication type. The tag must be changed to [pt] or PubMed gets tetchy. More on this change below.

Here is a corrected version of the filter (it works in PubMed without error reports):

(randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized controlled trials[mh] OR random allocation[mh] OR double-blind method[mh] OR single-blind method[mh] OR clinical trial[pt] OR clinical trials[mh] OR ("clinical trial"[tw]) OR ((singl*[tw] OR doubl*[tw] OR trebl*[tw] OR tripl*[tw]) AND (mask*[tw] OR blind*[tw])) OR ("latin square"[tw]) OR placebos[mh] OR placebo*[tw] OR random*[tw] OR research design[mh:noexp] OR comparative study[pt] OR evaluation studies[pt] OR follow-up studies[mh] OR prospective studies[mh] OR cross-over studies[mh] OR control*[tw] OR prospectiv*[tw] OR volunteer*[tw]) NOT (animal[mh] NOT human[mh])

So I had stubbed out the problem filter and made my corrections, but what had happened to require the change to Evaluation Studies?

Not that many of us took much notice in the annual yuletide neuronal storm, but the National Library of Medicine announced a major revision of publication types and corresponding subject descriptors in a Technical bulletin dated 26 Nov 2007 (final update 13 Dec 2007). These were bundled with the usual announcements of new MeSH headings. You know the type: score-settlings amongst the specialists (Coronary Occlusion — not to be confused with Coronary Stenosis); the exotic and somewhat frightening (Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative; Shiga-Toxigenic Escherichia coli; Weapons of Mass Destruction); and the when-would-I-ever-use-this? puzzlers: Pollination; Muscle, Striated).

PubMed now distinguishes between articles ABOUT evaluative studies and articles that ARE actually evaluative studies. For the former you must use the brand new MeSH heading Evaluation Studies as Topic. For the latter you use the publication type delimiter: Evaluation Studies [pt]. A useful distinction. Makes sense when you think about it. Direct from NLM's last Technical bulletin, here is a list of the new MeSH Headings that correspond to the Publication Types used for journal article indexing:

Bibliography as Topic
Biography as Topic
Clinical Trials as Topic
Clinical Trials, Phase I as Topic
Clinical Trials, Phase II as Topic
Clinical Trials, Phase III as Topic
Clinical Trials, Phase IV as Topic
Congresses as Topic
Consensus Development Conferences as Topic
Consensus Development Conferences, NIH as Topic
Controlled Clinical Trials as Topic
Correspondence as Topic
Dictionaries as Topic
Directories as Topic
Duplicate Publication as Topic
Evaluation Studies as Topic
Government Publications as Topic
Guidelines as Topic
Interviews as Topic
Legislation as Topic
Meta-Analysis as Topic
Multicenter Studies as Topic
Patient Education as Topic
Practice Guidelines as Topic
Randomized Controlled Trials as Topic
Retraction of Publication as Topic
Review Literature as Topic
Twin Studies as Topic
Validation Studies as Topic (New for 2008)

In what looks like a gaff or an oversight, the indexers at NLM did not see fit to create a MeSH heading Comparative Study as Topic, nor have they come up with rationalizations for the following: Follow-up Studies and Prospective Studies. Nor have they resolved the singular/plural confusion in headings of this type. Perhaps they wish to spare us too much excitement at once. Leave room in your Xmas stocking next December.

If you enter the revised Cochrane filter for controlled trials into PubMed, the database puffs out more than 3,450,000 hits. This creates a nice subset of the PubMed database consisting of controlled trials (or, more precisely, consisting of articles that at least contain terms that would lead one to suspect that they might be controlled trials of some sort). It works good and draws easy. You'd expect it to cost more, but it doesn't.

As Robinson and Dickersin state in concluding their article, "To continue to be an effective and efficient strategy, the revised strategy should be examined periodically to take into account new features available on PubMed, as well as developments in indexing by the National Library of Medicine." I can vouch for that. Pass me that flip-top box.

References:

1. Robinson KA, Dickersin K. Development of a highly sensitive search strategy for the retrieval of reports of controlled trials using PubMed. Int J Epidemiol. 2002 Feb;31(1):150-3

Why can't del.icio.us do A to Z?

2008-01-06T12:41:00.003-06:00

I struggled through the alphabet as if it had been a bramble-bush; getting considerably worried and scratched by every letter. After that, I fell among those thieves, the nine figures, who seemed every evening to do something new to disguise themselves and baffle recognition. But, at last I began, in a purblind groping way, to read, write, and cipher, on the very smallest scale. ~ Charles Dickens, Great Expectations, Chapter 7

My alphabet starts with this letter called yuzz. It's the letter I use to spell yuzz-a-ma-tuzz. You'll be sort of surprised what there is to be found once you go beyond 'Z' and start poking around! ~ Dr. Seuss, On Beyond Zebra

Librarians are perhaps overly given to the love of alphabetical order, and many of us have a hard time with today's casual lack of concern about whether McTavish should precede or follow Macdonald, or whether St. Boniface should interfile with Saint Boniface. We still cringe internally when we watch an analphabetic patron fumbling through a dictionary or encyclopedia. Anti-alphabeticists like Mortimer Adler have complained that resorting to the alphabet is an evasion of intellectual responsibility. In his new book, Everything is miscellaneous, David Weinberg fondly recollects Adler's pique in his description of the digitized and "miscellanized" third order of information, in which alphabetization is quickly going the way of Ptolemaic cosmography.

Everyone still likes a good list, and the fact remains that many lists are easier to use when they are alphabetized, like the phone book (despite its making a hash of initialisms), or Wikipedia's List of countries, or Google Reader's list of subscriptions. For the users of these tools it is second nature to find items according to the arbitrary order of our alphabet. del.icio.us itself recognizes this archaic institution, by default providing its users with its famous alphabetical array of tags. The mega-cool tag cloud is fundamentally alphabetical. Finding a tag is much simpler when you can do it at a glance rather than typing blindly into a search box. That is why I find so irksome the complete inability of del.icio.us to alpha sort links within tags or without. When del.icio.us was being coded it was decided that the list default would be reverse chronological order, with no alternatives allowed. It's absolutely crazy-making. Alphabetical sorting is on most users' wish lists, and it has been promised by the folks at del.icio.us. Perhaps 2008 will see the release of the new Delicious 2.0.

What to do in the meantime? I have a simple need. I want to be able to sort a list of blogs by student nurses that I have gathered under the tag blogs.nurschool. There are about 50 items that I would like to list alphabetically by blog title. A simple matter it seems, but impossible for del.icio.us. I could copy the chronological list I get when I click on the tab and do the sort manually. But that's silly. Surely there is some other way, I thought; and I set out to find it.

A Greasemonkey approach to sorting del.icio.us bookmarks: Del.icio.us alpha sort

As a user of the Firefox add-on Greasemonkey, I immediately started searching for a script that might do the job. Greasemonkey allows users to install scripts that add new functionality to web pages. (If scripts are not your thing, move on the next section.) I quickly found one called Del.icio.us alpha sort, which places a control at the top of the page permitting the user to toggle between alphabetical and chronological sorting of links — something del.icio.us programmers should have added in the first place. The problem is that it doesn't work properly. When I tried the script it would do the alphabetical sort only for one page — which works up to a point, that is, if you have 25 items or less in that tag. But, in all fairness, should the user be required continually to adjust the number of items appearing on a del.icio.us page to accommodate for this programming deficiency? The maximum number of bookmarks on one page is one hundred. What if you have more than one hundred bookmarks to be sent to a list? I quickly uninstalled Del.icio.us alpha sort without experimenting further. This script is not ready for prime time (it also slows down del.icio.us) and I don't have the hacking ability to improve on it. It really is time for del.icio.us programmers to incorporate alphabetical sorting into their code.

It occurred to me later that Del.icio.us alpha sort might conflict with Pagerization, my favourite Greasemonkey script, which turns a website's page-by-page results into an unbroken scrolling list with no annoying "next page" links needing to be clicked in order to proceed. Some of the sites that can be "pagerized" are Google (Search, Image, News, Group, Video), Yahoo, Wikipedia, YouTube, del.icio.us, Twitter, and digg. Sadly, PubMed does not allow itself to be pagerized. For my tenosynovitic forearm's sake I would never give up Pagerization. This extraordinary bit of code is worth the small effort of installing Greasemonkey. I did try Del.icio.us alpha sort with Pagerization disabled; but it still failed to alphabetize more than the first page. Having wasted an hour or two on this futile experiment, I moved on.

Turning to the del.icio.us Help pages

I went to the Developer section of del.icio.us Help. There we are promised the ability to "access data and build cool stuff." I must say, in most cases the del.icio.us help pages truly are helpful. Sure enough, under the HTML section I found something I could work with.

A simple URL with a few added "arguments" creates a reasonably attractive bulleted list in reverse chronological order of your most recent del.icio.us bookmarks. In the following simply replace USERNAME with your del.icio.us identity, and replace XXX with the number of links you want to list:

http://del.icio.us/html/USERNAME/?count=XXX&extended=body&extendeddiv=yes
&tags=no&rssbutton=no&bullet=bull

The count is limited by default to 15. To list more items add the appropriate number after "?count=".

I used these arguments to refine my results:

&extended=body : includes the full descriptive note for each bookmark
&extendeddiv=yes : starts the note on a separate line under the bookmark link &rssbutton=no : removes the default orange RSS button at the bottom of the bookmark list
&bullet=bull : adds a standard round bullet before each bookmark link (I prefer this to the del.icio.us help site's suggestion of "&bullet=raquo", which produces a right-pointing quotation mark or guillemet (»))

Using the above URL you get a result that looks like this:

• BioMed Central | Abstract | 1471-2105-8-487 | Userscripts for the Life Sciences

Discusses userscripts that aggregate information from web resources. Examples of enriching web pages from other resources, and how information from web pages can be used to link to, search, and process information in other resources.

• 2008 Web Predictions - ReadWriteWeb

Like, yeah! "People engaged in the new web will do some really awesome stuff that we'll all be in awe of."

• M A B - Mozilla Amazon Browser

Can now be run as a remote application. http://www.faser.net/mab/chrome/content/mab.xul

• Partners in a pandemic - www.universityaffairs.ca

May 2005. Medical researchers from Winnipeg helped discover how the AIDS virus is transmitted in Kenya because they were in the right place at the right time.

• Top 10 Medical Breakthroughs - 50 Top 10 Lists of 2007 - TIME

University of Manitoba researchers involved in the #1 medical breakthrough. Circumcized men in Africa 50% less likely to be infected by HIV.

• MedlinePlus: Health Literacy

"... the ability to understand health information and to use that information to make good decisions about your health and medical care."

• Show me the data -- Rossner et al. -- The Journal of Cell Biology 17 Dec 2007

Critique of impact factors. "We hope this account will convince some scientists and funding organizations to revoke their acceptance of impact factors as an accurate representation of the quality—or impact—of a paper published in a given journal."

• Web 3.0 and medicine -- Giustini 335 (7633): 1273 -- BMJ

Logically, web 3.0 should bring order to the 21st century web in the same way that Dr John Shaw Billings’s Index Medicus brought order to medical research back in the 19th century.

If you want to a list of bookmarks for a particular tag, then simply add the tag name after your user name:

http://del.icio.us/html/USERNAME/TAGNAME?count=XXX
&extended=body&extendeddiv=yes&tags=no&rssbutton=no&bullet=bull

This hack allowed me to gather all 50 or so nursing school blogs together in an unalphabetized list. Not bad, but still offensive to my instinctive need for this list to be alphabetized.

No help from del.icio.us Export (but good for a complete backup)
Another way to get a list of links is the standard export procedure found in del.icio.us Settings. Unfortunately, you can only create an enormous list of all your bookmarks, and there is no option as to their order, which is reverse chronological. This feature is useful if you ever want a good backup of your bookmarks, however, or if you want to import them back into a browser (heaven forbid). Go to Settings, and click on "export/backup" under the Bookmarks heading. You are given the option of including your tags and notes. del.icio.us will generate an HTML file of all your bookmarks that you can save to your computer. Eminently simple, but frustrating for my purposes.

Finally getting an alphabetical list (but is it worth the trouble?)

The URL for producing a bulleted list was helpful, but del.icio.us provided no method for getting my list in alphabetical order. I remarked above how in our "miscellanized" world alphabetical order is terribly passé. I can only continue to demur. I live by the English alphabet, and could not tolerate the loss of the time-honoured sequence of its 26 letters. I cannot fathom why the del.icio.us designers left out the alpha sort. Of course, I can alphabetize any list manually, including the tag-delimited list that del.icio.us provides. But what if I had hundreds of items, instead of fifty? Surely there is some way out of the tedious omnium-gatherum of just-one-damn-link-after-another.

After considerable effort, here is one method I found to get a set of my del.icio.us bookmarks into a usable alphabetical list. This goes beyond the hobbled and unavailing alphabetical listings for tags allowed by the new del.icio.us Firefox extension.

In del.icio.us Help, under the section for Developers, click on API, then click on posts. This section is marked by a rather ascetic and elitist assumption that the intrepid enquirer who has ventured this far needs no further condescending explanations or instructions. We are sternly informed that del.icio.us APIs are done over https and require HTTP-Auth. Furthermore, "this document and the APIs herein are subject to change at any time." Accepting my subordinate status and having informed myself a bit better about APIs, I persisted and found something I could use.

The first https URL in the posts section allows you to "get" all the bookmarks for a certain tag. (At least I assume it gets all of them. There is another URL that also returns all your bookmarks, but which can be filtered by tag. I used both and the results were the same for my selected tag. However, each URL returns information in a slightly different order. The "get" URL works better for my purposes, which I will explain below.)

Use this URL to create an XML file for your specified tag, adding your chosen tag name after the equals sign:

https://api.del.icio.us/v1/posts/get?&tag=TAGNAME

Type the URL into your browser. After you press Enter you will be prompted to enter your del.icio.us ID and password. The next step is to save the resulting XML file to your hard disk and then import it into Excel. (I used my old home-computer version of Excel XP for this experiment, but any version of Excel will do the job.) Using the Data|Import External Data|Import Data command, I brought the contents of the XML file, correctly separated into columns for each data field, into a spreadsheet.

Once the title of each bookmark is in an Excel cell, it is a simple matter to use Excel's Sort command to alphabetize the list. Delete columns with extraneous material. I chose only three columns to use: bookmark title, URL, and accompanying note.

Highlight the data and copy it to the Clipboard. You can then paste the spreadsheet data into most word processors. In Microsoft Word use Paste Special to copy the data into a formatted table. A little more fussing will be required, but at least the list is alphabetical. The downside is that your bookmark titles are no longer hyperlinked, but have their URL hived off into a separate cell. To get anything like the bulleted list illustrated above, you must now highlight each bookmark title and manually create the link by pasting in the appropriate URL.

That seems like a lot of trouble. In fact, it's hardly worth the effort, and actually makes manual alphabetization of the HTML output start to look attractive. With all my best efforts exhausted, I found I really hadn't come very far. For all its benefits, del.icio.us makes it extremely difficult to create alphabetized link lists. If I have missed a glaringly obvious hack or a deus ex machina solution, will some kind reader let me know? Otherwise, I shall just have to wait until del.icio.us delivers on its promise to include alphabetical sorting in its long awaited new user interface.

Ten enhancements on my del.icio.us wish list

It has been four months since the new version of Delicious (finally dumping the trendy but annoying internal punctuation) was announced. Alphabetical sorting was promised and is eagerly awaited by the faithful. Here is my wish list for ten more improvements to what has become an indispensable tool. Do you have any others to add?

1. Increase the character limit on descriptive notes. They are never quite long enough to hold the text I want to include. I have to waste time trimming and editing. And fix the bugs, please. My cursor occasionally disappears in a note field.

2. Number all pages instead of only including 'earlier' and 'later', which forces us to click through every page. In the alphabetical sort, provide a clickable alphabet selection list for quick navigation.

3. Allow unfettered scrolling through all bookmarks, with no page divisions.

4. On-the-fly bundle creation and allocation. Call them categories instead. We're grown up now.

5. We should be permitted to set a permanent or session-defined defaults. Example, a setting for not sharing as well as sharing our links. Sometimes I want to bookmark a series of daily-use links that would be of no use or interest to anyone else. It's tiresome to be forced to click the do not share checkbox for each. In the same way, we should be able to set permanent or session-only default tags that are applied to each new bookmark.

6. Deleting items should be easier. Allow users to delete with only one click, or with a keyboard shortcut. (In the meantime I am using an excellent Greasemonkey script called del.icio.us delete now.) Highly recommended if you are the type who likes to clean house from time to time.

7. Importing any del.icio.us list into a spreadsheet or word processor should be simplified.

8. Allow users to set desired text, background and highlighting colours.

9. Let's see contextual search implemented in the new version. If I don't specify what I want, del.icio.us should search whatever I am currently looking at — my own bookmarks, bookmarks from my network, or all bookmarks.

10. Reduce the amount of clicking required by introducing a range of keyboard shortcuts for searching, bundle creation, tag renaming, easy deletion, etc.

Clover learnt the whole alphabet, but could not put words together. Boxer could not get beyond the letter D. He would trace out A, B, C, D, in the dust with his great hoof, and then would stand staring at the letters with his ears back, sometimes shaking his forelock, trying with all his might to remember what came next and never succeeding. On several occasions, indeed, he did learn E, F, G, H, but by the time he knew them, it was always discovered that he had forgotten A, B, C, and D. Finally he decided to be content with the first four letters, and used to write them out once or twice every day to refresh his memory. Mollie refused to learn any but the six letters which spelt her own name. She would form these very neatly out of pieces of twig, and would then decorate them with a flower or two and walk round them admiring them. None of the other animals on the farm could get further than the letter A. George Orwell, Animal farm. Chapt. 3. Penguin Books; 1968.

Pushing tobacco on the web: is YouTube telling or selling you something?

2007-12-30T18:26:00.000-06:00

"Lung cancer becomes a STD. Nice."

A fascinating study by Australian researchers [4] investigates the prevalence of smoking-related videos on YouTube. One of the study's authors and a global authority on tobacco marketing, Professor Simon Chapman of the School of Public Health at Sydney University [2,3,4,5], has been quoted in the media as accusing tobacco manufacturers of hijacking YouTube by flooding it with videos of glamorous, smoking teens. YouTube and other popular social sites like Facebook and MySpace are running riot with pro-smoking messages which appear to have the fingerprints of tobacco companies all over them. In November 2006, when the authors conducted the research for their study, the use of the search term "smoking" returned 29,325 videos. For an Australian blogger's reaction, see Melissa's Blog.

Chapman says that tobacco companies are probably responsible for some of the most sophisticated online video promotions, with clips ranging from pro-smoking propaganda to images of celebrity smokers and seductive women smoking cigarettes. Smoking fetish videos are strangely popular. A video mentioned in the study depicts two women blowing smoke into each other's mouths. It had 221,033 views and 142 comments. The majority of feedback was positive (e.g., "Smokin’ HOT HOT HOT. Loved it"). Others were less impressed (e.g., "Lung cancer becomes a STD. Nice.") My attempt to follow the link provided by the authors led to a dead end. Some of the smoking fetish videos are restricted to those over the age of 18, and require registration. Interested readers can go to www.smoking-models.com for abundant examples of the genre.

The invasion of YouTube would be in line with the increasing use of "below the line" forms of viral cigarette marketing, such as promotions at dance parties, disguising market research as sampling promotions, and themed nights in bars and at music festivals. Just as tobacco-company marketers have a presence on youth-friendly venues, it is quite conceivable that they also have a presence on youth-friendly websites. Here is another quote from Simon Chapman: "If I was a tobacco marketer I'd be saying, 'It's not illegal; it's an international market and it's unregulated,' and it goes right to the heart of what I believe will be the future of tobacco marketing."

Although it is devilishly difficult to prove, it seems clear that young people are being encouraged to take up smoking through pro-tobacco stealth marketing on YouTube. According to the Word of Mouth Marketing Association (WOMMA), stealth marketing is any practice designed to deceive people about the involvement of marketers in a communication. Of course, from the tobacco biz there are only denials and claims that they are clear about their responsibilities to society and their obligations under the tobacco control laws of the countries in which they operate. They admit to the use of buzz marketing techniques, which are to be distinguished from stealth marketing by being, well, less stealthy.

The tobacco companies could never be criticized for slack performance [1]. Despite overall decreases in youth smoking, thousands of children under the age of 18 still start smoking every day, especially in developing countries. To increase demand among these groups, new, more targeted marketing strategies are being developed. Flavoured cigarettes, with alluring names like Dark Mint, Cool Myst, Midnight Berry and Mocha Taboo, have been successfully flogged in the United States. Complemented by stylish and colourful packaging, these candied cancer sticks contain invisible flavour delivery pellets inside their filters. Fortunately, many states have agreed on an outright ban of such confections, and the American Lung Association is advocating a total ban. As far as I know, they are not permitted in Canada. Whatever happens, the hawkers of halitosis will continue to take advantage of any opportunities, including Web 2.0 innovations, to bring lips to butts.

The good news is that YouTube and the like are obvious vehicles for the dissemination of anti-smoking messages. Health Canada has placed their latest anti-smoking ad on YouTube, and some of the brilliant thetruth.com ads can also be found on the site. Particularly striking is a Marlboro Man spoof entitled You don't always die from tobacco.

The authors conclude their article with some suggestions:

1. YouTube could be lobbied to broaden its definitions of unacceptable material to include those that depict smoking.

2. YouTube could be urged to adopt a rating system for smoking in videos.

3. YouTube is an obvious vehicle for the dissemination of anti-smoking messages. Smoking cessation organizations will need to avoid the corporate marketing pitfall of hiring actors and being deceitful about the origins of the video content. Working with real people who are actually quitting smoking and producing inexpensive video blogs is another possible way for tobacco control to maximize this new form of media.

While the world wide web is being used extensively to sell cigarettes, its largely unregulated status holds much potential as a vehicle for the promotion of both smoking and non-smoking. The web has become a battleground for the lungs of our adolescents, says Professor Chapman.

Is Big Tobacco Stealth Marketing to YouTubers? By usmedstudent (Added to YouTube: 10 May 2007)

A Harvard medical student discusses the implications of the study by Chapman and Freeman.

"I was stunned to learn that Youtube videos containing smoking imagery may be paid for by tobacco companies. Some of these videos with smoking imagery include anywhere from vlogs to movie clips. It's sad, but in hindsight, given the tobacco industry's track record, I shouldn't have been surprised..."

Other videos on buzz marketing and stealth marketing:

Tobacco's stealth marketing

http://www.youtube.com/watch?v=jevfwAwgAc4

Youtube Members In Stealth Marketing Scam

http://www.youtube.com/watch?v=tCQ5XPUkRl0

As One Gatherings : The Future Of Stealth Marketing

http://www.youtube.com/watch?v=qltsWjnVY6I

Allan Brandt - Health Research and the Tobacco Industry

http://video.aol.com/video-detail/allan-brandt-health-research-and-the-tobacco-industry/4101659155

Complete video at: http://fora.tv/fora/showthread.php?t=810
Medical historian Allan Brandt discusses the history of conflict between health researchers and the American tobacco industry. Allan Brandt researched "The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America," and after doing so for twenty years, he has become one of the top expert witnesses for tobacco-related state and federal cases. In 2004 Brandt took the stand as an expert witness for two full days of cross-examination in the case of U.S. vs. Phillip Morris. The judge's opinion referenced Brandt's testimony nearly 200 times and for the first time ever tobacco companies were found to be in violation of Federal racketeering statutes. Now, in "The Cigarette Century," Brandt presents the definitive history of the cigarette, both as the ultimate cultural icon and as the produce that shaped US agriculture, big business, medicine, and regulatory policies in the 20th century. Making extensive use of previously secret corporate documents which became available in the last decade as a result of litigation, Brandt offers critical analysis of the cigarette controversy and how the industry used sophisticated public relations to invent a modern "disinformation" campaign. -- Allan Brandt is the Amalie Moses Kass Professor of the History of Medicine at Harvard Medical School, and holds a joint appointment in the Department of the History of Science at Harvard University.

References:

1. Brandt AM. The cigarette century: the rise, fall, and deadly persistence of the product that defined America. Basic Books; 2006.

2. Chapman S. Falling smoking prevalence: how low can we go? Tobacco Control 2007;16:145-7.
Large public awareness campaigns to inform and motivate millions of smokers about quitting seem destined to remain a feature of everyday life in wealthier nations. However, very few poorer nations can afford to even get to the starting line with such campaigns and try in vain to inform their communities via valiant, low-budget efforts at publicity on World No Tobacco Day. A sustained international initiative to fund major public awareness campaigns in nations that could never afford to run such campaigns would make a huge difference to nations in which such awareness remains rudimentary. The profligacy of some areas of tobacco control expenditure in some industrialised nations is embarrassing when there are now many more smokers and deaths caused by smoking in less developed nations.

3. Chapman S. Public health advocacy and tobacco control: making smoking history. Wiley-Blackwell; 2007.
A major new book on advocacy and smoking prevention from the editor of Tobacco Control.

4. Freeman B, Chapman S. Is YouTube telling or selling you something? Tobacco content on the YouTube video sharing website. Tobacco Control 2007;16:207-10
Smoking imagery is prolific and accessible on YouTube. The effectiveness of overt tobacco advertising and sponsorship bans is well established. The industry has responded to these bans by implementing "buzz" or "viral" marketing techniques, such as nightclub and dance party promotions. This paper analyses possible tobacco industry content on the burgeoning consumer-generated media website, YouTube. Tobacco control efforts need to embrace this new medium, in order to counter pro-smoking messages and maximize media advocacy opportunities.

5. Gartner CE, Hall WD, Chapman S, Freeman B. Should the health community promote smokeless tobacco (snus) as a harm reduction measure? PLoS Medicine 2007;4(7)e185 doi:10.1371/journal.pmed.0040185 [you can listen here to a Radio 6PR Perth interview of Coral Gartner (11.12mins & 10.2mb) & Simon Chapman (11.06mins & 10.1mb) discussing this paper]
Smokeless tobacco [low nitrosamine oral snuff, or Swedish "snus"] has low appeal for the overwhelming majority of the world’s smokers. There are profound risks in letting tobacco industry tigers off their leash to use snus to subvert the hard-won provisions of the Framework Convention on Tobacco Control—provisions that include a ban on all tobacco advertising. Such a ban has already been achieved in some nations, but not in the US, from where much of the enthusiasm for snus now comes.

Circumcision and HIV prevention: Manitoba researchers make a medical breakthrough

2007-12-24T15:19:00.000-06:00

An HIV study led by the University of Manitoba's Dr. Stephen Moses has been named the year's top medical breakthrough by Time magazine. Dr. Moses was one of the principal investigators in research that found male circumcision can reduce the risk of HIV infection in men who have heterosexual sex.

Collaborating with researchers from universities in the U.S. and Nairobi, Dr. Moses conducted clinical trials in Kenya and Uganda, following thousands of HIV-negative men over a number of years to determine what effect circumcision would have on the spread of HIV. Their results show that circumcised men were roughly 50 per cent less likely than uncircumcised men to acquire HIV during sex with women. The trials were halted a year ago after early data showed high levels of success, and the results were published in the The Lancet earlier this year.

"It’s nice that the issue has got this kind of recognition in the popular press," Dr. Moses told the Winnipeg Free Press. The notion that circumcision can protect against HIV transmission has been accepted in the scientific community, and increasingly in the world health community. Dr. Moses predicts that "circumcision is going to start to be taken up more widely as a public-health measure to protect against HIV." While circumcision is no magic bullet against HIV, it can help reduce the spread of infection along with safer-sex practices and improved screening and treatment of sexually transmitted infections.

Dr. Moses is now working with the government of India and state governments to try to mitigate the impact of HIV in India, and prevent the spread of the virus. His work is largely based in the southern state of Karnataka, where the aim is to enhance care for people living with HIV.

Time.com currently lists the HIV study as the biggest breakthrough of 2007, followed by the development of a test for metastatic breast cancer and a human vaccine against avian flu.

Does circumcision help men who have sex with men?
Dr. Allan Ronald, an infectious disease specialist in Winnipeg who has also done important work in African HIV research, added some perspective in an interview with CBC Radio One last week. He stated that, although the results of Dr. Moses' research are convincing, they are not likely to have the same relevance for North America. Referring to recent research, Dr. Ronald cautioned that circumcision is not as effective in reducing the rate of HIV infection among men who have sex with men (MSM). He was referring to an article by researchers with the Centers for Disease Control in Atlanta, which was published in PLoS Medicine this month [4], which reported: "Most sexual transmission of HIV in the US [and Canada] occurs through male–male sex, most often infecting the receptive partner in penile–anal intercourse. The results from the African trials demonstrated that circumcision was protective for men who were the insertive partner in vaginal intercourse, suggesting that the utility of male circumcision in preventing HIV transmission among MSM may be limited." Another study published this month reinforces this statement, concluding that "there was no evidence that being circumcised was protective against HIV infection among black MSM or Latino MSM" in the United States [1].

Circumcision certainly has a role in the prevention of HIV transmission. However, because of the many differences between the underlying HIV epidemics in Africa and the developed world, differences in the prevalence of male circumcision, and the considerable gaps in knowledge that exist regarding the potential impact of circumcision on HIV transmission by male–male sex, the extent of this role on a population basis is unknown.The PLoS article calls for more discussion of the benefits and risks of circumcision before any recommendations are drafted. Among the issues to be considered are gaps in the research (for example, differences in shedding of HIV by rectal versus vaginal mucosa), barriers and facilitators to acceptance of adult male circumcision, buy-in from the at-risk communities, cultural and ethical questions, cost benefits, and insurance.

A contentious issue
Male circumcision is a contentious issue still. It has its vocal opponents and strong defenders on the web, while the published literature is generally favourable [2,3,4,6]. Canadian statistics show fewer infant sons being circumcised. Infant circumcision rates dropped to 9.2% in 2005. The rate of male circumcision in the United States is high by comparison: about 57% nationwide. Roughly 3% of male children in the UK are being circumcised. Owing to the sometimes intensely partisan positions taken by opponents of circumcision, librarians and researchers should be cautious when searching the web for information.

Non-heterosexual and injection drug HIV transmission must be considered
Although circumcision is a very important issue, it should not be forgotten that, for example, it is estimated that just under half of all people living with HIV in China in 2006 were infected while injecting drugs with contaminated equipment, and drug use remains the main mode (66%) of HIV transmission in the Russian Federation [5]. In the United States 18% of HIV infections occurred among injecting drug users, and more than half of all newly diagnosed HIV infections (53%) in 2005 were among men who have sex with men [5]. Canadian statistics are similar: 19% injection drug users and 43.2% MSM. Circumcision must always be regarded as one more method to reduce the HIV infection rate. In those parts of the world where heterosexually acquired infections account for the largest proportion of new HIV diagnoses, circumcision will be effective as part of a comprehensive prevention program.

Condoms first
Condoms are still the most effective means of HIV prevention. Because high rates of sexually transmitted infections (STIs) are an important contributing factor to the spread of HIV, it is also vital that STIs be controlled [3]. Free STI testing would be an extremely useful weapon in the anti-HIV arsenal. Taking into account regional variations and the special needs of affected populations, health authorities and community-based organizations should promote a global expansion of STI treatment and male circumcision programs as vital components in the prevention of HIV infection.

References:

1. Millett GA, Ding H, Lauby J, Flores S, Stueve A, Bingham T, Carballo-Dieguez A, Murrill C, Liu KL, Wheeler D, Liau A, Marks G. Circumcision Status and HIV Infection Among Black and Latino Men Who Have Sex With Men in 3 US Cities. J Acquir Immune Defic Syndr. 2007 Dec 15;46(5):643-650.

2. Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays. 2007 Nov;29(11):1147-58.

3. Sahasrabuddhe VV, Vermund SH. The future of HIV prevention: control of sexually transmitted infections and circumcision interventions. Infect Dis Clin North Am. 2007 Mar;21(1):241-57, xi.

4. Sullivan PS, Kilmarx PH, Peterman TA, Taylor AW, Nakashima AK, Kamb ML, Warner L, Mastro TD. Male circumcision for prevention of HIV transmission: what the new data mean for HIV prevention in the United States. PLoS Med. 2007 Jul 24;4(7):e223.

5. UNAIDS. AIDS epidemic update : December 2007 [Internet]. “UNAIDS/07.27E / JC1322E”. Geneva: UNAIDS; 2007. [cited 2007 Dec 24]. 50 p. Available from: http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf

6. Vardi Y, Sadeghi-Nejad H, Pollack S, Aisuodionoe-Shadrach OI, Sharlip ID. Male circumcision and HIV prevention. J Sex Med. 2007 Jul;4(4 Pt 1):838-43.

Grotty cravats and microbial stats: taking aim at "functionless clothing items" in British hospitals

2007-12-19T16:26:00.000-06:00

No one has ever had an idea in a dress suit. ~ Sir Frederick G. Banting

His vesture was dabbled in blood — and his broad brow, with all the features of the face, was besprinkled with the scarlet horror. ~ Edgar Allan Poe, The Masque of the Red Death

Nowadays the word "cravat" starts with C. difficile. Undoing centuries of tradition and male privilege, British hospitals are banning neckties (4). Scarcely a civil word can be heard in their defence. In 2006 the British Medical Association called them "functionless clothing items." The BMA went on to say: "Ties are rarely laundered but worn daily, commonly outside the healthcare environment. Ties perform no beneficial function in patient care and have been shown to be colonised by pathogens." Take that, Beau Brummel. Now, along with long sleeves and jewelry, this male fashion staple, first introduced to the court of Louis XIV by Croat mercenaries, will become suddenly highly unfashionable as the UK's National Health Service continues its efforts to stop the spread of deadly hospital-borne infections. Even the hallowed white coat will disappear. Its cuffs can become heavily contaminated (1,10). Acute care hospitals are expected to go "bare below the elbows" by January 2008, according to last September's announcement by Health Secretary Alan Johnson.

A "guidance" document issued by the UK Department of Health, also in September, provides examples of good and poor dress practice for health professionals, expending special reserves of contumely and guile on unwashed coats and cravats. Cascading hair, false nails, open-toed shoes, wristwatches and other hand adornments (22) are also suspect. As a convenient reminder that complete rationality is rarely achieved in bureaucracies, tattoos are to be covered, not because they are a contamination risk, but because tattoo modesty is required to "maintain a professional appearance." Many hospitals have already changed their regulations in accordance with the new guidelines. Bedford Hospital, for example, launched its "bow-tie, no tie" policy in November.

"We think ties only give the baby boys something to take aim at."
Now that the common tie has become the sartorial equivalent of Typhoid Mary, other countries may soon follow Britain's example. Doctors Kei Lui and Danny Challis, from the Royal Women's Hospital at Randwick, Australia, have a wealth of excuses for not wearing neckties and are happy to add another to their list. "It's always too hot in our nurseries for a tie," says Dr Lui, the hospital's director of newborn care. "No tie is more comfortable. I'd only need to take it off when bending down and, most of all, we think ties only give the baby boys something to take aim at." Male pediatricians often wear ties with cartoon themes to entertain their young patients. They may want to think twice about that, now that we know it's more likely the ties that are taking aim at the patients.

Since at least 1972 there has been evidence that things doctors wear or carry around with them, like stethoscopes, may harbour infection (7,21). Computer keyboards also house germs. Studies done in 2000 and 2002 (6,16) demonstrated that neckties were vectors for nosocomial infection. But it wasn't until 2004 that the media picked up on a conference presentation by a medical student which reported on necktie nosology found at a New York teaching hospital (13). Nearly half (47.6%) of neckties worn by medical personnel in that institution were pullulating colonies of dangerous bacteria. Steven Nurkin and his team reported their findings at the 104th General Meeting of the American Society for Microbiology, and the media loved it. Once it was clear that the heraldic regalia of the well-dressed plutocrat had come under attack, every news organization picked up the story. Research on the germ-carrying potential of other types of hospital garb, including white coats, has been given less prominence (1,10,14,15,17,18,23). It was the grotty knotted cravat that attracted popular attention.

Offered his fifteen minutes, Steven Nurkin gave interviews. The IEQ review quoted him as saying, "I watched the doctors come over for a physical exam or procedure and saw the neckties would swing in front of the patient's face, or patients would cough on them. . . . The necktie is important for the doctor-patient relationship, but it's also there on the front lines — dangling in front of patients as the doctor makes his rounds. . . . Almost everything a doctor carries has bacteria — from a cell phone to a stethoscope. You can get to the point where the doctor is completely naked, but then the skin is covered with bacteria too."

Having lived and worked in Israel, where most doctors go about in shirtsleeves, Nurkin had good reason to question the rather stiff dress codes in North America. "This study brings into question whether wearing a necktie is in the best interest of our patients," commented Nurkin. "Being well dressed adds to an aura of professionalism and has been correlated with higher patient confidence. Senior physicians and hospital administrators often encourage staff to wear neckties in order to help promote this valuable relationship; but in so doing, they may also be facilitating the spread of infectious organisms." Nurkin added: "While there is no direct evidence to implicate neckties in the transmission of infection to patients, the link between contaminated neckties and the potential for transmission must be considered."

On this side of the Atlantic?
With a new year about to begin, we now see just how influential Nurkin's research has been. While British clinicians prepare to bare their necks, infection control societies in the U.S. and Canada are not yet recommending similar dress restrictions. Although there have been serious outbreaks of drug-resistant pathogens in North American hospitals, they have not yet reached the state of Prince Prospero's castellated abbey in Poe's The Masque of the Red Death, doomed by pestilence despite the lofty wall that girdles it in. A search of the AMA and CMA websites found no evidence of serious consideration. But it is probably just a matter of time before clothing policies change. As just a small sample of what can be found on the topic of infection control practice, the Canadian Patient Safety Institute has recently announced its Hand Hygiene campaign, aimed at those who are neglectful of soap and hot water. Ontario has produced a best practice manual for C. difficile. The Manitoba Guidelines for the Prevention and Control of Antibiotic Resistant Organisms contain excellent advice on hand hygiene, and mention that false nails and hand jewelry are not acceptable. But so far, no restrictions that I could find on neckties or coat sleeves. However, there is general agreement that doctors and nurses who don't adequately wash their hands pose a serious risk to patients and that hand-washing should be the focus of infection control efforts in hospitals (search PubMed under Handwashing[MAJR]).

Are lanyards as guilty as ties?
According to a 17 Sept 2007 report in Macleans, Dr. Dick Zoutman, physician director on the board of the Community and Hospital Infection Control Association - Canada, says the British decision on neckties has real merit, and Canadians should take a good look at it. Dr. Allison McGeer, director of infection control at Toronto's Mount Sinai Hospital, says she doesn't see many ties in parts of the hospital where patients are cared for. "It's not about ties; it's about things you don't clean," says McGeer. Common items like lanyards, mobile phones and handhelds that medical staff wear or carry with them can spread germs. (One BMJ rapid responder last September — Are lanyards as guilty as ties? — felt that the former were more of a hazard because they are in direct contact with the user’s skin where their tunic has no collar and are unlikely ever to be washed.) "The reason people are picking on ties is they tend not to go into the laundry. If you took them home and washed them the way you do your shirt, there wouldn't be any problem." (Obviously Dr. McGeer has not seen what happens to a pure silk jacquard weave Charvet cravat after being thrown into a washing machine.) It is not clear if anyone has the authority to ban ties from Canadian hospitals. Dr. Zoutman said that CHICA, an organization that represents about 1,200 infection control practitioners in Canada, needs to discuss the developments in Britain.

The controversy has certainly generated interest (4,5,8,11,12,14,15,17,23). Will anyone miss the necktie? As Oscar Wilde observed, "A well-tied tie is the first serious step in life." As an emblem of accomplishment for the upper-class professional male, it will not go quietly. Half of all neckties are purchased by women, according to a Forbes report. So both sexes are responsible for the persistence of this centuries-old carotid constrictor. But after the Beau Brummels and the four-in-hands of the last two hundred years, the belly-warmers and palm-bestrewed horrors of the 1940s, the shagadelic eyesores of the 1960s and 70s, surely the time has come for cravat harm reduction. This seemingly innocent rag has already been shown to contribute to intracranial pressure and glaucoma (2,9,19,20). Now we know that the necktie is a disease carrier too. The current fashion for ties that are long, pink and extremely bloated reflects either very bad taste or unsavoury phallic fixation. There is now a website that sells The Tie Thing, a washable tie restraint that the vendor claims will "keep potentially infectious ties from falling into places they should not." The SafetyTie is an anitmicrobial, stain-resistant necktie for use in the clinical setting. Can we expect to see condoms for ties in the near future?

Quoth the raven, 'Nevermore.'
It is unlikely that its suppression in a few hospitals will affect the universal domination of the Western cravat. However one looks at it, there is no denying its extraordinary endurance and proliferation around the world. This I would attribute not to some intrinsic beauty or comfort, but rather to its close association with power, particularly male power, in our culture. The symbolic significance of the necktie cannot be overstated. Not unlike the barbaric display of clan colours, it is at once a mark of personal style and a sign of belonging to — or at least aspiring to membership in — the ruling class.

Bakunin foresaw that attaining universal suffrage without an accompanying social revolution prevented ordinary people from achieving their freedom. Instead it forced the ruling elites to make their own depravity universal. The theme is pursued by Theodor Adorno in his Minima moralia: "This is the state to which the ruling consciousness has come — the shameless avowals of the pursuit of extravagant waste and champagne-sipping good times, which were previously the preserve of bemedalled attachés in Hungarian operettas, are now elevated in deadly earnest to a maxim of right living." Hence our tawdry universe of easy money and bored, vicious distraction: voodoo mortgages, video addiction, ridiculous spectacle, mall-formation, and manipulable political apathy. Hence also the snobbery and pitiless conformism of tight cravats and high heels, lavish vacations, real estate, oenophilia, food fads, and, worst of all, liposuction.

The discomfort of the necktie, or the girdle, as a form of attire, is its very significance. As with snaffle bits and hackamores, light but continuous pressure is applied to a region of the body — a constant reminder of your place in the social hierarchy. Are not such functionless clothing items really just tired symbols that are better undone? The cravat when your luck is good: the slipknot when luck runs out. Perhaps we can hope that the hospital ban on the necktie might be extended to other areas, like the increasing restrictions on smoking. We have had great success undermining the noisome reign of tobacco; and gone are the awful stays, bustles and petticoats once imposed on women. Will the cravat's mystique finally be unravelled? Now there's something to take aim at.

Clothes make the man. Naked people have little or no influence on society. ~ Mark Twain

Dress is at all times a frivolous distinction, and excessive solicitude about it often destroys its own aim. ~ Jane Austen

REFERENCES:

1. The traditional white coat: goodbye, or au revoir? Lancet 2007 Sep 29;370(9593):1102.

2. Tight neckties may increase risk of glaucoma. Geriatr. Aging 2003;6(8):11.

3. Candlin J, Stark S. Plastic apron wear during direct patient care. Nurs.Stand. 2005 Sep 21-27;20(2):41-46

AIM: To identify factors that influence nurses' practice in apron use during direct patient care. METHOD: A small-scale documentary analysis of a purposive sample of 15 journal articles relating to nurses' apron use during patient care was undertaken. The analysis sought to address what factors affect nurses' decisions in relation to apron use. FINDINGS: Nurses' decisions regarding apron use during patient care tend to be ritualistic rather than evidence-based. Their knowledge of infection control is limited. CONCLUSION: Although there is current literature available on infection control, as well as health and safety regulations, if local policy regarding apron use in nursing care is scant this can result in inconsistent and, perhaps, less desirable practices.

4. Day M. Doctors are told to ditch "disease spreading" neckties. BMJ 2006;332(7539):442.

5. Ditchburn I. Should doctors wear ties? J.Hosp.Infect. 2006 Jun;63(2):227-228.

6. Dixon M. Neck ties as vectors for nosocomial infection. Intensive Care Med. 2000 Feb;26(2):250.

This study assessed whether neck ties worn by doctors at an intensive care unit were potential vectors for infection. Heavy growths of coagulase negative staphylococcus on 2/5 ties tested suggest this is possible. Neck ties should be considered a significant potential source of infection. Although this risk can be lessened by wearing plastic aprons when we come into contact with patients maybe we should do without neck ties altogether in critical care areas.

7. Gerken A, Cavanagh S,Winner HI. Infection hazard from stethoscopes in hospital. Lancet. 1972 1/2 i:1214-1215.

8. Jameson M. Dirty ties. Br.J.Perioper.Nurs. 2004 Aug;14(8):332.

9. Jonas JB, Theelen T, Meulendijks CFM. Tight necktie, intraocular pressure, and intracranial pressure [19] (multiple letters). Br. J. Ophthalmol. 2005;89(6):786-787.

10. Loh W, Ng VV, Holton J. Bacterial flora on the white coats of medical students. J.Hosp.Infect. 2000 May;45(1):65-68

This study has demonstrated that the white coats of medical students are more likely to be bacteriologically contaminated at points of frequent contact, such as the sleeve and pocket. The organisms identified were principally skin commensals including Staphylococcus aureus. The cleanliness of the coat as perceived by the student was correlated with bacteriological contamination, yet despite this, a significant proportion of students only laundered their coats occassionally. This study supports the view that the students' white coat is a potential source of cross infection on the ward and its design should be modified in order to facilitate hand washing. Hospitals training medical students should consider taking on the burden of providing freshly laundered white coats for the students.

11. Lomas C. Is your uniform harbouring infection? Nurs.Times 2007 Oct 9-15;103(41):20-21.

12. Magos A, Maclean A, Baker D, Goddard N, Ogunbiyi O. Bare below the elbows: A cheap soundbite. BMJ 2007 Oct 6;335(7622):684.

13. Nurkin S. Is the clinician's necktie a potential fomite for hospital acquired infections? 104th General Meeting of the American Society for Microbiology 2004.

14. Nye KJ, Leggett VA, Watterson L. Provision and decontamination of uniforms in the NHS. Nurs.Stand. 2005 Apr 27-May 3;19(33):41-45

AIM: To ascertain the provision and decontamination of uniforms within a cross-section of NHS trusts in the UK and to compare policies regarding their use. METHOD: A questionnaire was circulated to 170 NHS trust infection control teams in the UK. Eighty-six (51 per cent) responses were received, which represented 101 NHS trusts. RESULTS: Less than half of the trusts (47 per cent) provide adequate numbers of uniforms to allow a clean uniform per shift. Only 26 per cent had adequate on-site staff changing facilities and 65 per cent did not launder uniforms. The majority of nursing staff (91 per cent) were compelled, by a combination of these factors, to launder their uniforms at home. Few were provided with any guidance on how to do this safely. CONCLUSION: There is an urgent need for minimum standards to be set for the provision of uniforms, laundering and changing facilities, to minimise the potential for spread of healthcare-associated infections.

15. Shintani H, Hayashi F, Sakakibara Y, Kurosu S, Miki A, Furukawa T. Relationship between the contamination of the nurse's caps and their period of use in terms of microorganism numbers. Biocontrol Sci. 2006 Mar;11(1):11-16

Nosocomial infections are a great problem in the health care facilities. The white uniforms of nurses are often washed to keep them clean, but the nurse's caps are not washed as frequently in comparison. It could be that the importance of these caps is being overlooked. If these caps are providing a residence for microorganisms causing nosocomial infection in the health care facility, then they should be washed as frequently as the uniforms. So far, the relationship between the contamination of the nurse's caps and nosocomial infection has not yet been studied. Therefore, this study was conducted to confirm if relationships exist among factors regarding the number of microorganisms on the nurse's caps, the period in which caps were used without being washed, and the individual characteristics of nurse wearing the caps. Results showed that the degree of contamination of the nurse's caps depended on individual characteristics and the period of use. Finally, results led to the conclusion that the nurse's caps should not be worn if their only purpose is to symbolize female workers in the health care facilities because, in actually, they provide a resistance for microorganisms causing nosocomial infections.

16. Steinlechner C, Wilding G, Cumberland N. Microbes on ties: do they correlate with wound infection? Ann R Coll Surg Eng 2002, (Suppl) 84(9):307-9.

Many measures are taken to reduce the spread of pathogenic micro-organisms within hospitals, particularly MRSA. It is known that they are transferred by direct contact and that simple measures such as hand washing are highly effective in reducing spread. Many woven fabric items within hospitals have been shown to carry pathogens; the possibility of resultant wound infections cannot be ignored and unnecessary potential vectors should be eliminated. Infection in orthopaedic patients is a disaster which may lead to implant removal and multiple surgical procedures. We tested the ties of our orthopaedic department for pathogenic organism carriage and found that all ties were colonised by bacteria that are frequently cultured from swabs taken from discharging wounds of orthopaedic patients.

17. Sundeep S, Allen KD. An audit of the dress code for hospital medical staff. J.Hosp.Infect. 2006 Sep;64(1):92-93.

18. Takashima M, Shirai F, Sageshima M, Ikeda N, Okamoto Y, Dohi Y. Distinctive bacteria-binding property of cloth materials. Am.J.Infect.Control 2004 Feb;32(1):27-30

BACKGROUND: Nosocomial infections may be caused by pathogens that are transmitted from the hands or clothes of hospital personnel. Handwashing has been evaluated as effective against the spread of pathogens, but transmission through clothes has been little investigated. Evaluation of bacterial adherence to clothes is difficult because of the nonuniform amount of water absorbance by cloth. Therefore, we measured binding of bacteria to cloth fibers made of cotton, nylon, polyester, acrylic, or sheep's wool and tried to characterize bacterial binding to cloth. METHODS: We chose to study the opportunistic pathogens Staphylococcus aureus and Pseudomonas aeruginosa. Cloth fibers were incubated with bacterial suspensions in silicone-coated tubes. We evaluated the reduction of numbers of bacteria in solutions incubated with the fibers and calculated binding ratios of bacteria to the fibers. RESULTS: Polyester or acrylic fibers bound S aureus and P aeruginosa at high ratios (>80%), but cotton fibers bound them at low ratios (<10%). Nylon fibers bound S aureus at low ratios, but P aeruginosa at intermediate ratios. CONCLUSION: The results suggested that polyester, acrylic, or wool clothes could be good carriers of S aureus and P aeruginosa and thus should be covered with cotton clothes to minimize the spread of the pathogens.

19. Tally P, O'Brien PD. Does extended wear of a tight necktie cause raised intraocular pressure? J. Glaucoma 2005;14(6):508-510

20. Teng C, Gurses-Ozden R, Liebmann JM, Tello C, Ritch R. Effect of a tight necktie on intraocular pressure. Br. J. Ophthalmol. 2003;87(8):946-948

21. Waghorn DJ. Stethoscopes: a study of contamination and the effectiveness of disinfection procedures. British Journal of Infection Control. 2005;6(1):15-17

Stethoscopes are universally used by healthcare professionals. They can come into contact with numerous patients and may harbour organisms that can be transferred between individuals. Wycombe hospital has a policy that stethoscopes should be disinfected with a 70% isopropyl alcohol swab after each patient use. A study was undertaken to assess the degree of stethoscope contamination and the effectiveness of the disinfection procedure. A randomly chosen group of healthcare professionals submitted their stethoscopes for microbiological analysis. A selection of ward-based stethoscopes were also tested. Personal stethoscopes were then disinfected with an alcohol wipe and re-sampled. All stethoscopes showed bacterial contamination before disinfection, the highest concentration of organisms being seen on doctors' stethoscopes. Skin flora was grown from all samples and 12% grew Staphylococcus aureus. Following decontamination, bacterial levels were greatly reduced, but three contaminated stethoscopes remained heavily colonised even after the disinfection procedure. Staff need to be made more aware of the need to routinely disinfect stethoscopes correctly between each patient use. The increased placement of bed- or ward-specific stethoscopes needs to be considered.

22. Ward DJ. Hand adornment and infection control. Br.J.Nurs. 2007 Jun 14-27;16(11):654-656

Studies have shown that despite infection control guidelines recommending that false fingernails, nail varnish, stoned rings and wrist watches not be worn by clinical staff, a large proportion of them continue to do so. Hand jewellery and false finger nails should be kept short, clean and free from nail polish. This article discusses the bacterial carriage, contributions to outbreaks of infection and interference with proper hand hygiene practices, thereby explaining why these recommendations are made in infection control policies and guidelines.

23. Wilson JA, Loveday HP, Hoffman PN, Pratt RJ. Uniform: an evidence review of the microbiological significance of uniforms and uniform policy in the prevention and control of healthcare-associated infections. Report to the Department of Health (England). J.Hosp.Infect. 2007 Aug;66(4):301-307

A systematic search and quality assessment of published literature was conducted to establish current knowledge on the role of healthcare workers uniforms' as vehicles for the transfer of healthcare-associated infections. This review comprised a systematic search of national and international guidance, published literature and data on recent advances in laundry technology and processes. We found only a small number of relevant studies that provided limited evidence directly related to the decontamination of uniforms. Studies concerning domestic laundry processes are small scale and largely observational. Current practice and guidance for laundering uniforms is extrapolated from studies of industrial hospital linen processing. Healthcare workers' uniforms, including white coats, become progressively contaminated in use with bacteria of low pathogenicity from the wearer and of mixed pathogenicity from the clinical environment and patients. The hypothesis that uniforms/clothing could be a vehicle for the transmission of infections is not supported by existing evidence. All components of the laundering process contribute to the removal or killing of micro-organisms on fabric. There is no robust evidence of a difference in efficacy of decontamination of uniforms/clothing between industrial and domestic laundry processes, or that the home laundering of uniforms provides inadequate decontamination.

RNAO defends the Canadian Health Network

2007-12-12T14:19:00.000-06:00

The Registered Nurses' Association of Ontario has issued a strong statement criticizing the federal government for its announced closure this March of the Canadian Health Network.

In its undated "Action Alert" the RNAO states:

[The CHN] is a trusted service that Ontarians use daily to help navigate an overwhelming amount of conflicting opinion and marketing on the web to get to evidence to inform health and health-care decisions.

Health professionals make up 39 per cent of visitors, with nurses compromising the largest segment of health professional users at 14 per cent. The closure of CHN will mean the loss of a health education tool that nurses find invaluable for our nursing practice.

At a more systemic level, we find it unfathomable that the federal government would decimate a trusted resource that has taken eight years to build up in order to save $7 million just as the final surplus for the 2006-2007 fiscal year was $13.8 billion.

RNAO has sent an open letter to the Minister of Health and urges nurses and everyone concerned to do the same, providing a sample letter for the public, which can be sent via the RNAO website.

Go nurses!