Jambalaya

Our local hospital is updating its policy on the use of mobile phones on site. The existing policy is sensibly liberal and recognises that the evidence of harm resulting from electromagnetic interference (EMF) is remarkably thin, but that the consequences are potentially dangerous.

It seems that if you bring an active (i.e. switched-on) mobile phone within a couple of metres or so of an electronic medical ‘device’ (monitor, infusion pump, whatever), the device could malfunction. It probaly won’t malfunction, but it might: good territory for precautionary principle afficionados, perhaps. Nevertheless, our existing policy basically says, don’t use mobiles within a few feet of medical equipment attached to patients.

However, a few nut-heads seem to be fanatically opposed to mobile phones. Period. Official-looking (but actualy unofficial) notices have appeared all over the hospital stating that mobile phones must be switched off, and some individuals have been subjected to verbal abuse for using their mobiles in public areas of the hospital.

A revised policy then appeared in draft seeking to ban the use of mobiles completely in any of the hospital buildings, and recommending the installation of monitoring devices to detect their ‘illicit’ use. This produced a flood of objections, the more sensible of which drew attention the benefits of mobile phones for visitors as well as staff (especially since public phones are extremely scarce). Ironically, a couple of our cardiologists had only shortly before published a very balanced editorial in the British Medical Journal pointing out that mobiles are not as hazardous as believed and recommending that they should be allowed at least in non-clinical areas. Others have taken a contrary view: the South Tees NHS Trust has followed the precautionary principle and opted for an outright ban, whilst, policy-makers in Glasgow opted for creating several mobile friendly places where the nearest electromedical equipment was at least 5 m away.

A recent on-line review revisits the evidence, and again finds it largely unconvincing. The reviewer neatly turns the argument on its head and suggests that maybe the problem (if there is one) is not with mobile phones, but with malfunctioning medical equipment. Perhaps it is more to do with poor EMF shielding in just a few medical devices rather than a problem with all mobile phones.

Fortunately, the local policy-makers seem convinced, and the ban now proposed will not be total, but applied to a just few critical clinical areas. Not really much of a change after all, except that monitoring for illicit use is againthreatened: something else our cash-strapped hospital can ill afford.

Ben Toth has unearthed a few newsfeeds from NHS organizations. Not very many but, taken with his own newsfeed, the content is already enough to demonstrate the enormous potential of this medium for disseminating ideas and generating discussion within the NHS—and bringing in the public at large. As yet, of these only Ben’s site is an actual weblog with a comment facility. And, curiously, the news in the NHSIA’s feed bears no relationship to the news on its home page.

I wonder what software these NHS organizations are using? I bet won’t very often be MovableType, Radio Userland, or other mature weblog software. The NHSIA still seems to be pushing the rather hopeless Digerati product, which as far as I am aware does not have an RSS (or similar) newsfeed facility.

What is needed is a ‘killer’ site to publish (and advertise) a newsfeed. I have been working on the Health Service Journal (who so far have not returned my emails) and NICE (which I think is yet to be convinced).

Assays of the d-dimer fibrin degradation product in the circulation have become ‘indispensible’ in the evaluation of patients with suspected venous thromboembolism (VTE: deep venous thrombosis and/or pulmonary embolism). But how useful are they, and are they used wisely?

Like many diagnostic aids, the utility of d-dimer assays is influenced by the clinical setting (to be more precise, the a priori or ‘pre-test’ probability that the disease being tested for is present). Unfortunately, this is a test with a very low specificity, albeit a high sensitivity [1], and a significant problem for the diagnostician using this test is that d-dimers behave like ‘acute phase’ reactants and can be elevated in a wide range of situations associated with an acute phase response, such as inflammation, infection and malignancy. The trouble is that many of these feature in the differential diagnosis of presentations suggesting venous thromboembolism (e,g. pleuritic chest pain:pleurisy, shortness of breath/hypoxia:pneumonia, painful swollen leg:cellulitis). And, to cap it all, patients with malignant disease are at high risk of VTE, but may have elevated d-dimers for other reasons [2].

In practice, the d-dimer test is only useful if the result is not elevated and the clinical probability of VTE is low, when it adds confidence to a conclusion that VTE is not present and that further investigation with scanning is unnecessary. Diagnostic dilemmas arise commonly, however, when the clinical probability of VTE is low but the d-dimer result is elevated. An elevated CRP in this situation indicates an acute phase response and renders the d-dimer result virtually worthless. An elevated d-dimer with a normal CRP may be more significant, but I don’t think the utility of the d-dimer assay in that situation has yet been adequately studied. In general, it is best not to order a d-dimer test if there is a high clinical probability that it will be elevated anyway.

Similarly, if the clinical suspicion of VTE is anything but very low then don’t bother with a d-dimer assay, just get on and do the appropriate scans.

Farmers around us are growing large amounts of rape again this year. Not only do they get a hefty EC subsidy, but we get to look at acres of a not very pretty yellow landscape. In a couple of weeks or so, the pollen will come and with it—so some people believe—a spate of respiratory illness, coinciding in all probability with the Whitsun Bank Holiday weekend, when our local hospitals and healthcare systems will be least able to cope.

It's that time of year again!

Last weekend I cooked Thai food for friends. We had tom yam, green chicken curry, pad thai, beef salad, ca chien muoi xa (fish with lemongrass, from Alan Davidson’s Seafood of South East Asia [1]), and fragrant rice. The clear favourite was beef salad, for which I used a recipe from Jennifer Brennan’s excellent The Original Thai cookbook [2].

I adapted Jennifer’s recipe roughly as follows:

First, grill or barbeque a piece of beef. Fillet is best but sirloin (or New York strip) is fine: season it well with black pepper. I prefer to grill it on a very hot barbeque for a few minutes only each side (depending on size), pouring over some melted butter, creating a ‘flare up’ to give the beef a slightly blackened crust. However you do it, it should be very rare inside. Then allow to cool, wrap in tinfoil and refrigerate. This can be done well in advance.

Then prepare a platter with some salad leaves. Tear up some basil, mint and coriander leaves and sprinkle over the lettuce. Finely grate over this a stalk of lemongrass, and scatter over some thinly sliced red birdseye chilli. Now slice the beef thinly and lay over the salad bed: it will be easier to slice cold. I prefer to allow it then to come up to ambient temperature before dressing and serving, but others might prefer the whole thing chilled.

Make a dressing by pounding some green chilli and garlic in a mortar. Add fish sauce and lime juice in equal quantities and a teaspoon or so of sugar. Stir to mix well. Finely slice some red onion over the beef and then the dressing. Garnish with some fried onion and dried red chilli flakes, or whatever you fancy.

Obviously the quantities are determined by how many you plan to feed, and how hot you like it. Just use your imagination, experiment, or scale the proportions in Jennifer’s book. If you don’t have the book: buy it. Its not just a recipe book, but a comprehensive introduction to the origins and development of Thai cuisine.

I have only had half an eye on my incoming newsfeeds this week but one that did catch said that SixApart was barely making a miserable 50 cents a copy on MovableType. So when they announced a new pricing structure it was no surprise. It seems to have caught others by surprise, judging by the whingeing response from users. What is it with thse guys?

In one of his best posts for a while, Dave Winer reminds us that things cost money —“When you drive to the gas station, try whining at the attendant, and see how much gas you get. Do it enough and they’ll call the cops”—and that it is miserable for software developers when users take them for granted in this way. In many ways I find this a more depressing portent for our civilization than what the situation over Iraq.

I use a lot of great, free software—and lots more for which I pay a trivial amount. (There is of course, some essential stuff that costs an awful lot, but that’s another story.) Some developers accept donations and I am happy to give back something to those who have given me real value. Movable Type is one such: I planned to make a donation when I read the 50 cent story. Now I shall simply purchase a licence and still think myself lucky.