And while we're talking about patient privacy...

Today Pulse reports that pharmaceutical companies are directly approaching NHS staff to try to get their grubby paws on patient-identifiable data. The story reports that "two staff members had been approached by a pharmaceutical company while at a conference in London, given access to a website and asked to upload patient-identifiable data".

A spokesperson for Poole Hospital NHS Foundation Trust went on to say: "For some time the trust has been concerned about the lengths to which pharmaceutical companies, or companies working on their behalf, will go to seemingly bypass the research governance route and encourage staff to release person-identifiable data onto third-party databases. A number of attempts have been thwarted by the trust." So it seems that for some time pharmaceutical companies have been trying to weasel patient information out of NHS employees.

Hospital employees fired for posting photos of patients on MySpace

I recently wrote a post about how patient privacy can be threatened in blogs written by doctors. Now a new case illustrates another way that healthcare professionals can violate patient privacy online.

Yesterday the Associated Press reported that two hospital workers in New Mexico had been fired for taking pictures with their mobile phone cameras of patients being treated. Even worse, these pictures - "mainly close-ups of injuries being treated in the Albuquerque hospital's emergency room over the past few months" - were posted online on MySpace. This all happened despite the fact that hospital employees were banned from taking mobile phones int patient areas.

Unbelievably, this incident doesn't represent the first time this sort of thing has happened. In May last year the Tri-City Hospital in San Diego confirmed that medical workers in the hospital had been taking photos of patients with their mobile phones, and the Associated Press reports that there have also been similar violations in Arizona and South Dakota. Also, UCLA banned mobile phones and laptops earlier this year after a patient posted group photos of other patients on a social networking website, although I feel this instance is a slightly different issue.

This issue was picked up in the blogosphere (WSJ Health Blog, Kevin, M.D. and Scalpel or Sword to name a few) as bloggers were horrified that hospital employees could do something so stupid. Posting photos of patients online, particularly patients in an emergency room who are may well be unconscious and totally unaware that they are being photographed, is an unbelievable violation of patient privacy. Let's hope this is the last time this sort of thing happens.

Digging for the best healthcare information on the internet

You may have noticed that 'Vote' buttons have appeared at the bottom of my blog posts. Clicking on one of these buttons will submit the particular blog entry to Healthcare Today, a new website where users proffer and vote for the best healthcare news and blogs on the internet.

The majority of information for doctors and other healthcare professionals comes from traditional outlets like journals, but this route is a slow and very formal way of getting stuff out there. In comparison, the internet is far more immediate, but information online is liable to be poorly written, filled with inaccuracies, penned by crackpots, or hopelessly biased, and that's just for starters.

Healthcare Today aims to unearth good medical news and blogs online and highlight the most interesting stories. But as Shane, a creator of the site, says, "instead of being a reflection of some editor’s (possibly biased) perception, it’s the professionals in healthcare who decide what’s interesting and how interesting it is by submitting links and adding their votes."

Healthcare Today works in a similar way to the website Digg, in that users are invited to submit news articles, journal papers or blog posts that they discover on the net and then vote on links they find interesting. The front page of the site contains the most popular links, representing an essentially peer reviewed overview of the best medical information online.

The site is aimed at healthcare professionals - i.e. doctors, nurses and the like - so a lot of the links on Healthcare Today are to blog posts that discuss the day to day trials and tribulations of these groups. There are also plenty of links to medical or medicine-related news stories; for example, the most popular link at this exact moment is time is from ABC News: 'Grey's Anatomy' lesson? TV ups awareness, a story about a new study that has quantitatively shown that audiences of TV shows such as Grey's Anatomy absorb health messages in the programmes.

At the moment links only need about 4-5 votes in order to make it onto the front page, but hopefully as the number of users and of submitted links continues to grow Healthcare Today will come to truly represent the most up to minute source of healthcare information on the net.
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And here comes the shameless self promotion - if you think a post of mine is good and other people interested in medicine might want to read it, give the old vote button a click and submit the entry to Healthcare Today!

Do common pain medications mask signs of prostate cancer?

A study recently published in the journal Cancer has suggested that common painkillers such as paracetamol and aspirin might affect blood levels of a marker commonly used to diagnose prostate cancer.

In this study, Singer et al. examined levels of prostate specific antigen (PSA) in the bloodstream of 1,319 men aged over 40 years. PSA is a protein produced in the prostate gland. Blood levels of PSA will be minuscule in healthy men, but raised levels often indicate the presence of prostate cancer. If a simple blood test detects serum levels of PSA higher than a specific threshold (4 ng/ml to be exact), your doctor will be booking you in for a digital rectal examination with a prostate cancer specialist faster than you can say "He wants to stick his finger where?!"

In addition, study participants were asked how often they took analgesic drugs classed as non-steroidal anti-inflammatory drugs (NSAIDs) - common types being aspirin and ibuprofen - or the drug acetaminophen, which you'll probably be familiar with as paracetamol. NSAIDs and acetaminophen act as painkillers by reducing inflammation. Given that inflammation in the prostate has been implicated in the development of prostate cancer, the authors of this study wanted to find out whether NSAIDs or acetaminophen affected the risk of prostate cancer in men who took these drugs.

The results of this study showed that serum levels of PSA in men who took NSAIDs or acetaminophen "nearly every day" were considerably lower than levels in men who did not take either drug. Seeing as this study didn't then follow these men for several years to find out whether there were fewer instances of prostate cancer in the men who took these analgesics than in those who didn't, it is not clear whether this decrease in PSA levels means that the drugs reduce the risk of cancer. In fact, it it possible that NSAIDs and acetaminophen may reduce serum levels of PSA despite suspicious goings on in the prostate and thus cause doctors to miss cases of prostate cancer, which would otherwise be flagged by raised PSA levels.

So what are the implications of the study? Should men chew down aspirin every day to prevent prostate cancer, or would they make detection of the malignancy more difficult for their doctor by doing so? Dr Eric Singer, one of the authors of this study, told Reuters news, "If you're a guy who's close to the upper limit of normal [in PSA levels] or would have been over the upper limit and now you're under it because of [these drugs], that could certainly change whether or not you would be referred for a biopsy [to check for a tumor]". He also emphasizes that these findings are preliminary and shouldn't prompt men to change their behaviour.

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Eric A. Singer, Ganesh S. Palapattu, Edwin van Wijngaarden (2008). Prostate-specific antigen levels in relation to consumption of nonsteroidal anti-inflammatory drugs and acetaminophen Cancer DOI: 10.1002/cncr.23806

Music, memories and the mind

Yesterday I went down (no, make that up - up a very steep hill, on my bike) to Jackson's Lane in Highgate for some neurology theatre - not of the surgical kind but a performance of the play Reminiscence.

Inspired by a case study published by the neurologist Oliver Sacks, the play tells the story of elderly Mrs O'Connor, who, following a stroke, experiences temporal lobe seizures accompanied vivid auditory hallucinations. Although she recognises the songs she hears, Mrs O'Connor can't put her finger on where she knows the melodies from. Through these seemingly familiar "experiential hallucinations", she re-lives events that she believes are buried memories from her distant past.

As far as I was concerned, a key aspect of the play was how Theatre DaCapo approached a dry medical case study and transformed it into an engaging piece of theatre. Instead of depicting the story of Mrs O'Connor through the objective view of the neurologist, the whole case study is portrayed from the perspective of the patient, bringing an altogether more human angle to the case study.

Thus, the onus was on the theatre group to represent effectively the subjective, difficult-to-quantify experiences of a neurology patient. In order to do this, the five-man group of actors used clever staging and a myriad of props and visuals.

In scenes such as the one shown here, actors popped out from between the folds of a giant white backdrop, portraying in this instance the characters Mrs O'Connor begins to see as her hallucinations gather more sensory components. In another scene, the actors, posing as doctors, appeared in the windows within the backdrop and bounced neurological terms off each other, depicting Mrs O'Connor's disorientation at the mass of medical information she was being bombarded with.

Folk songs - reworked in a classical style and performed by the actors - and the pitching and swaying of the scenery indicated when Mrs O'Connor was experiencing a seizure.

I was also interested in how the play was going to depict the neurology that underlines the case study. In the scene shown here, a dish of jelly was used to represent the brain and the affected region scooped out with gusto to demonstrate how the seizures and hallucinations could be cured by surgical removal of the damaged part of the brain.

One of the issues raised by the play is whether the hallucinations Mrs O'Connor experiences actually reflect real memories, or are false and are in fact the result of Mrs O'Connor's psychological motivation to come to terms with her past. This issue was one of many debated in a a panel discussion after the play in which the audience quizzed the director Michael Callahan, clinical psychologist and Mind Hacks blogger Dr Vaughan Bell, and actors Ian Harris and Katie Pattison. During the discussion, we touched on whether the verity or not of our memories is important - although they may be revised through telling at different points in our life, they still represent an important part of our identity.

It was a refreshing change to learn about a clinical case study through such an imaginative and well-realised play rather than from a journal paper.

• Reminiscence will be performed at 8pm at Jackson's Lane theatre until Saturday 20th September (matinee 2pm Wednesday 17th September). For tickets, contact the box office on 0208 341 4421 or buy online at jacksonslane.org.uk
  

(Thanks to Theatre-DaCapo.co.uk for the photos)

Blogging and doctoring: a hazardous mix

Medical blogs, in particular those written by doctors, have come into the spotlight thanks to a study of 271 medical blogs published recently in the Journal of General Internal Medicine, titled 'Content of Weblogs Written by Health Professional'.

The study found that over half of the medical blogs examined contained enough information to identify the doctor writing the blog. In addition, 42% described individual patients, and 16% included enough information for users to figure out the identity of the doctor or patient. (The Pharmalot blog helpfully has a PDF of the full text version if you want to peruse the data yourself) Granted, this study was looking at blogs that published in 2006, so the conclusions may well not reflect the level of professionalism among doctors who blog today, but it raises some important issues about patient privacy.

Of course, the study got the media frothing about whether blogs written by doctors compromise patient confidentiality and prompted the American Medical Association ethics committee to discuss the issue.

Most doctors and medical bodies seem to agree that medical blogs have an important role in providing medical information and demystifying the medical profession. However, the issue of unguarded blogging and patient privacy is real, and there are many instances of doctors' blog posts coming back to bite them.

Canadian Medicine describes the case of pediatrician Robert Lindeman, who blogged anonymously about the death of a patient and the subsequent malpractice trial under the pseudonym "Flea". As the Boston Globe reported: "Unexpectedly, during cross-examination, the prosecutor asked Dr Lindeman if he was 'Flea'. The case was lost, his lawyers realized immediately. They settled the next day." Dr Lindeman used his blog - and his anonymity - to say on permanent record things that he would not otherwise have said in the open. He lost his case and his professional reputation was trampled on.

The main point of the Journal of General Internal Medicine study and the case of Flea seems to be that, anonymous or not, doctors who blog should always remember that the internet is a public space and write about patients with this fact in mind. Of course, this concept brings up questions of free speech, but inappropriate blogs could comprise the trust that forms the foundation of the patient-doctor relationship and undermine the authority of the medical profession.

However, as Canadian Medicine points out: "Whatever the subject, blogging is a positive development in medicine and something that doctors should not and must not abandon because of some medical association analysts’ largely unfounded fears"

• The Clinical Cases and Images blog recommends guidelines for doctors who blog, which includes complying with the somewhat outdated Health Insurance Portability and Accountability Act (HIPAA).

Hadrian's heart trouble

Today I went to see the Hadrian: Empire and Conflict exhibition at the British Museum, which "explores the life, love and legacy of Rome’s most enigmatic emperor". The exhibition was fascinating, providing all sorts of detail about how the Roman empire was run and some fascinating perspectives on ancient culture.

One particularly interesting poster noted that the detailed and naturalistic statues of Hadrian in the exhibition always feature a diagonal crease in both earlobes - a tell-tale sign that the great emperor might have suffered from coronary artery disease.


For over 20 years, researchers have noted an association between bilateral diagonal earlobe creases and coronary artery disease. There is controversy, however, as to whether the presence of these creases genuinely reflects a higher risk of heart disease.

A recent study in the journal Atherosclerosis found that the presence of diagonal earlobe creases correlated with the thickness of the intimal and medial layers that line blood vessels. Intima-media thickness reflects the build up of plaques in arteries, which causes 'furring' and narrowing of vessels and increases the risk of heart attack. In addition, a 2006 study that examined 520 cadavers undergoing forensic autopsy and a 2004 study of 415 patients both found that diagonal earlobe creases correlated with coronary artery disease.

On the other hand, Jorde et al. found that the prevalence of various risk factors associated with heart disease was the same in individuals with earlobe creases and in those without, although the authors noted that the creases were more common in older individuals. Similarly, Brady et al. concluded that the association between earlobe creases and coronary artery disease was down to the fact that the prevalence of both conditions increases with age.

Despite these studies, the majority of the literature on this subject does seem to agree that earlobe creases are a sign of heart disease.

Thanks to modern research, this otherwise innocuous detail recorded by the dedicated sculptors of ancient Rome is able to give us fascinating insight into the physical health of Hadrian, and also suggests that humans living thousands of years ago suffered the same illnesses as we do now. As the poster in the British Museum points out, we may never know whether Hadrian had coronary artery disease, but the intricate craftsmanship in the statues of this great emperor provide a tantalizing hint of what might have finally seen him off.

Weird medical stories vol 1

When searching eTOCs or browsing the web, I can't help but be drawn to slightly strange or bizarre medical cases. Not the 'Pregnant man gives birth to a baby girl' genre of stories, although I will confess to a morbid fascination, but also disgust, at 'Urgh look at this freak' tales.

Given that I'm generally looking at clinical websites or the websites of journals I instead tend to pick out intriguing sounding case studies or clinical trials that have unexpected outcomes. This week's weird medical story was brought to my attention by the British Medical Journal, which highlighted a case study that suggests that peanut allergy could be be transferred by lung transplantation.

The case, published in the Journal of Heart and Lung Transplantation, is of a middle-aged woman who developed peanut allergy following a lung transplant from a donor who had died of anaphylactic shock after eating a peanut-related food. Although the transplant recipient did not previously have any allergy to peanuts, following the transplant she experienced anaphylactic shock herself and had to steer well clear of nuts.

Interestingly, transfer of food allergies from donor to recipient has been seen in liver transplantation. The phenomenon is thought to be due to either the transfer of IgE antibodies bound to cells within the donor liver or to relate to post-transplant use of the immunosuppressant agent tacrolimus. An instance of allergy transfer following bone marrow transplant also suggests that transfer of IgE antibodies or immunosuppression might be to blame.

The report in the Journal of Heart and Lung transplantation is the first instance of allergy being transferred by lung transplantation, however. As the study authors say, "This case emphasizes the importance of considering donor allergy transfer when caring for all solid-organ transplant recipients." I wonder if similar cases will start to appear in kidney transplant recipients and so on. Certainly this case could mean that finding an organ donor match could become more complicated, as it seems that potential donors with allergies might need to be struck off the list.