Can text messages be used to monitor health?

text-messageMobile phones are possibly one of the most ubiquitous pieces of technology in the 21st century.  In 2003 the Office of National Statistics reported that 75% of all adults in the UK owned or used a mobile phone, and Wikipedia estimates that the UK now has more mobile phones than people.

Text messaging has been the surprise success of mobile phones – who would have thought that people would prefer to write out a message to their friends rather than simply give them a quick call?  The latest statistics record that 4.7 million messages are being sent every hour in Britain, with 72% of women and 70% of men texting regularly.  These days, however, text messages are being put to much worthier use than simply catching up on last night’s gossip.

Earlier this month the BMJ reported that the ability to send a text message was a sure sign of recovery from a faint or a panic attack.  The authors of the study had spent several years working for the charity Festival Medical Services, helping out in the first aid tents at large British music festivals.  They noticed that teenagers who were brought in for medical attention would send a text message to their friends as soon as they were feeling better.  Given that sending a text message requires “a Glasgow coma scale score of 15 (fully conscious), an adequately functioning ‘executive system’ in the frontal lobes, and a high degree of manual dexterity and psychomotor coordination”, they concluded that this ability was reasonable grounds for discharge and successfully employed ‘the text test’ during busy times at this year’s Reading Festival.

Text messages have also been employed by heathcare trusts to monitor the medical status of patients.  Oxfordshire and Buckinghamshire Mental Health and Oxford University’s Department of Psychiatry have been using a daily text message to monitor the mood of mental health patients.  Patients receive a text message every morning and  respond with a letter in the range of A to E, which corresponds with mood on a scale from depression and euphoria.  This technique allows doctors to to plot mood swings in real time, monitor medication efficacy and assess whether a face-to-face appointment is needed, and removes the need for unreliable retrospective assessments.  The system is current being used with 150 patients and is due to be rolled out across Oxfordshire and Buckinghamshire in the new year.

In a similar vein, London’s Hammersmith & Fulham Primary Care Trust has been using text messages to establish the current smoking status of patients and, accordingly, their risk of developing cardiovascular disease.  As many as 49% of patients responded to texts enquiring whether they were active smokers, a much higher response rate than other methods of communication previously used.  Doctors were then able to quickly and efficiently update medical records.  The system that the Trust used, iPlato, began as a means of reducing missed GP appointments within the NHS and has now been adopted across 40 NHS organisations, including 36 Primary Care Trusts.  As well as monitoring smoking status, iPlato also uses text messages to establish methadone compliance, keep tabs on patients on weight management plans and helps patients stay up to date with prescriptions.

And it’s not just in the UK that healthcare providers are exploiting text messages to monitor patients.  The Infectious Disease Clinic at the University of Virginia is piloting a text messaging system to improve contact with HIV patients living in rural parts of the state. In the programme, patients are given a mobile phone that only receives texts about medication regimens and pending medical appointments, and can only call emergency and medical contacts.  Organizers hope that this initiative will help patients adhere to their treatment for longer than 6 months, the current drop off point.

Stanford University in California and the Centers for Disease Control and Prevention even held a conference on text messages and healthcare in February this year – Texting 4 Health.  The event “showcased applications, ideas, and insights on using mobile text messaging to improve personal and public health”.  Speakers from as far afield as Denmark and Scotland presented the text messaging strategies that are currently in use in their regions – HandyMentor for asthma self management and SweetTalk for diabetes reminders if you’re wondering – and techniques to provide health information and instigate healthy lifestyles via text messaging were presented (the full conference program and slides can be found here).

Given the widespread use of mobile phones, text messages could certainly be a cheap and far reaching way to monitor patients and disseminate public health information.  What do you think?  Are text messages the future of health management?  Are text messaging programmes going to be widely adopted for public health purposes in 2009?  Or are text messages good only for personal affairs and not for important medical information?

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Busting the fake online pharmacies

which-is-realAn orchestrated raid in ten countries has led to the arrest of several individuals behind online pharmacies that illegally sell unlicensed or prescription-only medicines.  Dozens of residential and commercial addresses in Australia, Canada, Germany, Ireland, Israel, New Zealand, Singapore, Switzerland, the UK and the USA were searched by investigators and countless counterfeit drugs were seized, including those purported to treat conditions such as diabetes, impotency, obesity, hair loss and the side effects of steroid abuse.

The operation, codenamed Pangea, was undertaken by the international police agency Interpol, the World Health Organisation’s (WHO) International Medical Products Anti-Counterfeiting Taskforce (IMPACT), and the Permanent Forum on International Pharmaceutical Crime.

Federal agencies in the US conducted an intensive one-day inspection of international mail in Dallas, Chicago, Seattle and New York.  In total approximately 635 international mail parcels were examined and 18 containing counterfeit Viagra, Cialis, steroids and Xanax were seized.

In the UK, the Medicines and Healthcare products Regulatory Agency visited 12 residential and commercial addresses relating to seven websites thought to be selling unlicensed agents or prescription-only medicines.  Over a thousand packs of pharmaceuticals were seized, as well as several computers and reams of documentation.

Over 50% of medicines bought from illegal websites that conceal their physical address are counterfeit – i.e. they are deliberately mislabelled with respect to their identity or source. The quality of such drugs is unpredictable, as many contain the wrong amount of active ingredients, wrong ingredients or no active ingredients at all.

Jean-Michel Louboutin, Executive Director of Interpol’s Police Services, said, “Buying medicines from illegal and unregulated websites poses significant risks, not least that the buyer is putting their health in danger by taking drugs which have no guarantee of safety, quality or effectiveness”.

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Drinkers don’t take their medications often enough

alcoholA recent study by Bryson et al. has found that moderate to severe alcohol misuse increases the likelihood that patients won’t take their medication properly.

Many patients do not take their medications as often as they should – i.e. on at least 80% of the days they are supposed to.  In fact, a recent study found that over the space of a year, 40% of patients taking cardiovascular or diabetes medications didn’t take their medications often enough.  Such ‘medication nonadherence’ is associated with worsening of disease, increased health care costs, and even death.

Bryson et al. looked at more than 20,000 patients who were receiving treatment for high blood pressure, high cholesterol levels, or diabetes.  All participants undertook a three-point questionnaire to evaluate their alcohol use on the basis of frequency and typical quantity of drinking during the past year, and the frequency of heavy episodic drinking (at least 6 drinks per occasion).  Medication adherence over the space of a year was measured by how often patients went back to their pharmacy for a refill.

Among patients taking medication for high blood pressure or high cholesterol levels, nonadherence increased as the severity of alcohol misuse increased.  Compared with patients who did not drink, the proportion of patients who did not stick to their cardiovascular medications was significantly higher among those who moderately or severely misused alcohol.  Interestingly, there was no difference in adherence to diabetes medications between diabetic patients who did not drink and those who did.

This research might seem like it’s straight from the department of the obvious: “Of course people with alcohol problems don’t take their medications properly!”  There are a couple of key findings that are important to bear in mind though.  For one, the authors were able to assess alcohol consumption with a brief questionnaire , unlike previous studies on this subject that used lengthy, time consuming interviews.  Thus the approach used in this study could be used easily in clinical practice.

In addition, a fair few studies have examined the problem of medication nonadherence, but most have found that the factors responsible for nonadherence are ones that would be very difficult to modify, such as older age (over 80 years old) or low socioeconomic status.  The study by Bryson et al. is important because it identifies a modifiable factor responsible for medication nonadherence.  Counsel a patient to cut their drinking and, in theory, they should be more likely to take their medication properly, which would keep their condition in check and enable them to get on with their life unhindered.

Bryson CL et al. (2008) Alcohol screening scores and medication nonadherence. Ann Intern Med 149 (11): 795-803. PMID: 19047026

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More than 20% of English primary school children are obese or overweight

obesechild460One in four 4-5 year old children and one in three 10-11 year olds in England are obese or overweight, according to data from the 2007/08 National Child Measurement Program published by the NHS Information Centre.  The North East, the West Midlands and London are particular obesity blackspots, and boys are more likely to be obese than girls.

The National Child Measurement Program, established in 2005, weighs and measures school children in Reception (3-4 years old) and Year 6 (10-11 years old) to assess the level of overweight and obesity among kids in England. Almost a million primary school children were measured in the 2007/08 survey, representing 88% of those eligible.

The 2007/08 survey found that 22.6% of 3-4 year old children and 32.6% of 10-11 year olds were overweight or obese.  Almost twice as many Year 6 children were obese compared with Reception-age kids (18.3% vs 9.6%), and boys were significantly more likely to be obese than were girls.

The prevalence of obesity among primary school kids in both age groups was significantly higher than the national average in the North East, West Midlands and London.  In addition, there was a high prevalence of obesity in Reception-age children in the North West and Year 6 children in Yorkshire and Humber.  The South East Coast, South Central, South West and East Midlands regions, on the other hand, had lower-than-average rates of obesity among schoolchildren.

Obesity rates in 2007/08 seem similar to those in the 2006/07 survey (9.9% among Reception-age children and 17.5% in Year 6 children); however, the National Child Measurement Program report cautions that the prevalence of obesity among Year 6 children might have been underestimated by as much as 1.3% in 2006/07 due to children opting out of being measured.

The British Heart Foundation responded to these results by calling for several measures to tackle childhood obesity, including tighter regulation of junk food marketing, consistent and simple food labelling, and more funding to help children get involved in physical activities.  Saranjit Sihota, Head of Public Policy at Diabetes UK, likewise called for more action to tackle the epidemic – remarking that “This new data confirms the shocking state of children’s health in this country” – and pointed out that said that there is a clear link between obesity and Type 2 diabetes.

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Festive funnies in the BMJ Christmas issue

Christmas treeEvery year the British Medical Journal team get in the festive spirit with their Christmas issue, publishing zany or amusing research.  This year is no exception, with a host of genuine research papers and rigorous scientific analyses guaranteed to make you giggle.

Research articles in this week’s issue of BMJ include:

  • Head bangers: stuck between rock and a hard bass
  • Head banging to heavy metal is a popular dance form, but it increases the risk of head and neck injury. The effects may be lessened with reduced head and neck motion, head banging to lower tempo songs or to every second beat, and using protective equipment such as neck braces, say Australian researchers Declan Patton and Andrew McIntosh.

  • Rugby (the religion of Wales) and its influence on the Catholic church: should Pope Benedict XVI be worried?
  • Researcher Gareth Payne and his two colleagues from Cardiff investigate whether there is any substance to the intriguing urban legend that has arisen in Wales in recent times: “Every time Wales win the rugby grand slam, a Pope dies, except for 1978 when Wales were really good, and two Popes died.” Wales won the Grand Slam in 2008 – so should Pope Benedict XVI be worried?

  • Frankincense: systematic review
  • Edzard Ernst, the UK’s only professor of complementary medicine, systematically reviews the evidence on frankincense – a tree resin that was one of the first ever Christmas presents and is now a popular complementary remedy. He concludes that, although frankincense does not bestow supernatural instant youth or eternal life as many claims would have it, it has encouraging anti-inflammatory properties.

In the comment section, Deborah J Anderson, an author of the IgNobel-winning research on the use of coca cola as a spermicide, advises against this approach to contraception, while MA Buchanan and colleagues discuss whether modern golf clubs can cause hearing damage.

The Christmas issue also traditionally subjects prevalent medical myths to critical appraisal.  Last year Rachel Vreeman and Aaron Carroll showed that reading in low light does not damage eyesight and that turkey is not to blame for drowsiness after Christmas dinner.  This year they turn their attention to whether sugar causes hyperactivity in children and if wearing a hat reduces heat loss in cold weather, thoroughly debunking these popular beliefs.

The whole BMJ Christmas issue can be found online at  I hope you enjoy it as much as I did!

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NEJM vs the South Dakota abortion script

gavelIn the recent US election, several pieces of legislation that aimed to limit reproductive rights were voted down.  Colorado said no to the Definition of a person initiative that would have given fertilized eggs the same rights as humans, and California rejected a proposition that would have required parents to be notified when a patient under 18 has an abortion. Importantly, in South Dakota Measure 11 – which sought to ban abortion in all cases bar incest, rape and danger to the the health or life of the mother – was narrowly defeated.

Despite all this good news, one hefty piece of reproductive rights legislation slipped through the net this year.  In July, following the Planned Parenthood Minnesota vs Rounds court case, statute 34-23A-10.1 was passed.  This measure states that the physician performing an abortion must inform the pregnant mother that “the abortion will terminate the life of a whole, separate, unique, living human being”, that she “has an existing relationship with that unborn human being “, and that she is, supposedly, at “increased risk of suicide ideation and suicide”.

The New England Journal of Medicine has taken up the case of the ‘South Dakota abortion script’, which seems to have been largely ignored by the media.

The Perspective article ‘South Dakota’s Abortion Script — Threatening the Physician–Patient Relationship‘, published in November, outlines the small print of the legislation and issues at stake.  The authors write:

The law requires that doctors give pregnant women a description of medical and “statistically significant” risks of abortion, among which it includes depression and other psychological distress, suicide, danger to subsequent pregnancies, and death. Physicians must tell women the approximate gestational age of the fetus and describe its state of development … The physician must answer all the woman’s questions in writing and enter them into her medical record … Physicians who do not satisfy the statute are subject to license suspension or revocation and may be charged with a class 2 misdemeanor.

In addition, the authors state that the increased risks of psychological distress, depression, and suicide included in the script are not supported by the bulk of the scientific literature, and that the legislation should be viewed in the context of South Dakota’s repeated attempts to outlaw abortion outright, not least in 2005 and 2008.

The article also points out that in forcing doctors to parrot the state’s message as if it were their own opinion, the law violates physicians’ First Amendment rights.  The December 4 Editorial ‘Physicians and the First Amendment‘ picks up on this issue of the right of the physician to freedom of speech.  The “ideological speech” included in the script is clearly in breach of the First Amendment, which enshrines “both the right to speak freely and the right to refrain from speaking at all.”  If the state is able to dictate that doctors give emotive and partisan information about abortions, there is a precedent for the state determine the medical advice given on other contentious issues such as contraception.  The authors of the editorial call for prompt overturning of the law and boldly state:

The South Dakota ‘script law’ is an affront to the First Amendment rights of physicians and an embarrassment to the people of South Dakota.

The New England Journal of Medicine certainly has a lot of clout in the medical community and beyond, but whether they will succeed in overturning law is another matter. What is needed is for the journal and the physician community to mobilize behind this issue and either as a body or via a proxy patient take on South Dakota law the way that the landmark Roe vs Wade case took on the state of Texas. Let’s hope that this issue gets some wider publicity and that someone is willing to take on the state to protect the reproductive and constitutional rights of the people of North Dakota.

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Are researchers fudging clinical trial statistics?

Before a clinical trial can commence a protocol – a plan of exactly how a trial will be conducted – will be formulated.  As part of the planning, the individuals undertaking the trial will calculate approximately how many patients need to take part for the results to be meaningful (the ‘sample size’) and prespecify which statistical tests they will perform on the data once the trial is complete.

A new study of published clinical trials, however, has found that many do not report these crucial sample-size calculations and that authors often do not mention if they have changed their mind as to which statistical test they are going to use.  About half of the trials studied by Chan et al. did not include sample-size calculations or mention whether the statistical tests actually used on the data differed from those provided in the trial protocol.

It is important that people conducting clinical trials stick to the statistical methods outlined in their protocol, as different types of statistical test can produce different outcomes for the same set of raw data.  If trial authors plan to use a particular test then change their mind and use a different test once they have seen the data, the results can be inadvertently biased – or directly manipulated – so they appear much more positive.

In the recent BMJ study, Chan et al. compared the published papers of 70 Danish randomized clinical trials with the corresponding protocols, which had been submitted to the local ethics committees for approval before the trials commenced.

Only 11 trials fully and consistently described sample-size calculations in both the protocol and the published paper. There were unacknowledged discrepancies between the calculations in the protocol and those in the published paper in 53% of cases.

Most protocols and publications specified which statistical tests would be used on the trial data; however, in 60-100% of cases the tests listed in the published paper differed from those in the protocol.

So it seems that in many cases sample size calculations and statistical methods are not prespecified in trial protocols or are poorly reported.  If they are prespecified, authors don’t tend to acknowledge instances when the statistical methods used differ from those in the protocol.  These two practices can easily introduce bias into the analysis of clinical trials and, ultimately, lead to misinterpretation of study results.

All this is bad news for everyone – if trial results aren’t reported honestly and transparently then it will be impossible to tell which trials, and therefore treatments, will genuinely help patients.  Hopefully initiatives such as SPIRIT (Standard Protocol Items for Randomised Trials), launched by Chan et al., and CONSORT (Consolidated Standards of Reporting Trials) will improve the accuracy of clinical trial reporting, but always remember: “There are three kinds of lies: lies, damned lies, and statistics”.

Chan AW et al. (2008) Discrepancies in sample size calculations and data analyses reported in randomised trials: comparison of publications with protocols BMJ 337 (4 Dec 2008) DOI: 10.1136/bmj.a2299

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Welcome to the new look blog!

In sickness and in health has now moved from my old Blogger site to a spangly new WordPress site that forms part of my shiny personal website,

The blog should work pretty much the same as the old site and the RSS feed is still the same, so all you need to do is update your favourites.  I hope you enjoy having a good rummage around, and please feel free to contact me if you have any comments or questions about the new blog or indeed the whole website.

On a similar note, I am also in the process of physically moving to France – I’ve been pretty busy undertaking this relocation so apologies that things have been a bit quiet on the blogging front.  Normal service will resume shortly…

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World AIDS Day roundup

Today December 1st is World AIDS Day. As many as 33 million people worldwide are living with HIV, and there are 80,000 people with HIV in the UK. The aim of World AIDS Day is to raise awareness of the challenges and consequences of the epidemic – ultimately halting the spread of the HIV virus and improving the lives of people living with infection.

The UK theme for World AIDS Day 2008 is “Respect & Protect“. Many people living with HIV face discrimination – this year’s campaign hopes to highlight the responsibility everyone has to transform attitudes to HIV and encourage actions that stop its spread. You can show your support for the campaign by wearing a red ribbon, which you can get your hands on in Gap, H&M, Selfridges and Levi’s stores around the UK, as well as in Red Cross charity shops.

There is a whole selection of events and promotions worldwide to mark World AIDS day. For example, this weekend a flash mob descended on Glasgow town centre, “freezing” while handing each another red ribbons and condoms in the event organized by the British Red Cross.

South Africa is poised to grind to a halt for 15 minutes to talk about AIDS. This weekend the country received £15 million worth of support from the UK to tackle the HIV epidemic. In South Africa, 20–30% of the population is HIV positive and as many as 365,000 people have died unnecessarily thanks to the AIDS denialism of former president Thabo Mbeki.

Online, has launched the “Facing AIDS for World AIDS Day” campaign. Participants are invited to take a photo of themselves wearing a red ribbon and, on World AIDS Day, put the photo on their social networking site, blog, Twitter page, or website. There is also a Flickr group and a Facebook group where supporters can upload their pictures.

Digital magazine (RED)Wire by Product (RED), the charity run by Bono to engage the private sector in AIDS programmes, launched today. For a monthly subscription fee of £4, half of which will go to the Global Fund to help people in Africa with HIV and AIDS, users can get world premieres of exclusive tracks from the likes of Elton John, Jay-Z and Coldplay.

Bloggers Unite, a movement that aims to “harness the power of the blogosphere to make the world a better place”, has invited bloggers to dedicate their blog posts today to issues related to HIV/AIDS, with the aim of reminding people that HIV/AIDS is still a critical issue and to promote HIV testing. You can follow World AIDS day on Twitter with the tag #WAD08.

There is also a World AIDS day Musical Festival in Second Life, which will feature HIV/AIDS presentations and displays, tours, writing workshops, and virtual red ribbons and t-shirts.

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