Bugs in the redesigned PubMed? Trouble with Auto Suggest and Title searching

On Friday my colleague Tania Gottschalk and I were looking forward to the pleasurable task of introducing a group of library staff to the new, improved PubMed. These are people we know well and work with every day. So they were in a tolerant mood as we began to stumble about the new PubMed interface, trying to point out the most important features and to differentiate the substantial from the merely cosmetic changes.

What we thought would be a breeze turned out very differently. After my experience in that lab I’m ready to put on my old T-shirt from the 90s, with the slogan “Smash Forehead on Keyboard to Continue.”

Preliminary philosophical reflections
Now, I’m an easy-going type, and the continental drift that has randomly rearranged PubMed’s major menu items is no big deal. Think of all the wrists around the planet getting more exercise as cursors are sent on expeditions to rediscover vital menus and links scattered across the vast white sea of the introductory PubMed page.

One could argue that the apparent complexity and randomness – I would not go so far as to say capriciousness – of the PubMed redesign must have emerged in a way that did not depend on finely-tuned details of the system: variable parameters appear to have changed spontaneously without affecting the underlying programming code, in a sort of self-organized criticality. In short, little is where it used to be, which wouldn’t necessarily be a bad thing if one had a sense of the fundamental rationale.

Why, for example, are the tutorials separated from the FAQs? Why are Clinical Queries and Single Citation Matcher called a “resource” in Advanced Search and a “tool” on the main page? Why have the ready-to-hand tabs been replaced with the scattered remnants of their algorithmic detonation?

Philosophers have argued for centuries on what constitutes the quiddity or “whatness” of a thing as opposed to its haecceity or “thisness.” Librarians, equally inclined to make much of a muchness, cannot help but quibble about a drop-down menu here or a radio button there, a menu before or a link after, this option or that feature. Nor can we stop ourselves from applying our hermeneutic of suspicion to the new PubMed.

But it is not my purpose in this post to vent on what I dislike about the changes to my favourite database. There is also a great deal that I like. Let me return to Friday’s lab session on the PubMed redesign. Brief and informal as it was, our little demo gone demonic gave rise to two apparent bugs in PubMed’s programming, something more substantial than its desultory interface tweaks.

Auto Suggest
Our first difficulty came to light with Auto Suggest. This feature, I would suggest, is not all that it should be. In our little training demo we were working with the search terms “low carbohydrate diet” and “carbohydrate restricted diet.” In our prep for the session, we noticed that after typing the former, PubMed auto-suggested the latter with “or.” What a handy way to show how PubMed could help the novice search aided by suggestions about alternative search terms. As luck would have it, when we had PubMed up on the big screen during our lab session, this happy combination failed. No “or” appeared after Tania typed the first phrase. Not even after multiple attempts.

Oh well, it gave us our first opportunity to use that time-honoured escape clause of the harried presenter: “Moving right along …” I have tried to repeat the same thing again today, but Auto Suggest seems to be working again.

Is this a real bug in the PubMed code, or could it have had something to do with the congested entrails of our proxy server? I’m not sure about this one. But when my turn came to discuss field searching in Advanced Search, a truly nasty surprise was waiting.

Advanced Search: Search by Author, Journal, Publication Date, and more
This function of Advanced Search looks like a great way to introduce casual users of PubMed to searching within fields. I wanted to compare a simple, across-the-board two-word search to looking for each of the terms in the title field only. I often use the latter method (using the [TI] delimiter in the command line) just to reconnoitre unfamiliar terrain, as a quick-and-dirty way to find some relevant articles. I had never tried this method before.

My chosen example was a search employing the two keywords “doctors” and “torture.” The basic, unadvanced search “doctors torture” yields 353 results and produces the following details log:

(“physicians”[MeSH Terms] OR “physicians”[All Fields] OR “doctors”[All Fields]) AND (“torture”[MeSH Terms] OR “torture”[All Fields])

No surprises there. Before using any Advanced Search procedure I tried my standard method of adding the Title field tag to each term just to make sure that PubMed would produce some results. There were 70 hits with this search (the field tags prevent any mapping):

doctors[Title] AND torture[Title]

Then (as illustrated above) I attempted the same search using Search by Author, Journal, Publication Date, and more in Advanced Search. I selected the Title field for each of the first two search boxes. I made sure “All of these (AND)” is selected. I entered my two terms in their respective locations.

Result? Fail.

Error #1: PubMed ignores the first term, takes only the second term (in this case, “torture”), and puts into a search box with “[Title]” directly appended.

Error #2: In doing so, PubMed leaves Advanced Search and displays the orphan term in the search box on its main search page.

Error #3: Having reverted pointlessly to the main page, PubMed fails even to perform the search for the one term it has placed in the search box there, leaving the user marooned.

Error #4: For no obvious reason except perhaps Schadenfreude, PubMed adds a peculiar message below the search box: “If you are trying to search, please enter a term.”

A true bug?
Since Friday’s embarrassment, I have been able to reproduce this error consistently, using a variety of terms: “men” and “women,” “blood” and “pressure,” “aerobic” and “non-aerobic.”

I have employed various methods to ensure that other factors are not interfering, such as clearing the entire history, clearing any previous search terms, and even clearing my browser cache and restarting PubMed. Nothing will make this feature work with the Title field.

Here is another annoyance. If have performed a previous search and have not cleared everything out of the search box, searching Search by Author, etc. as above adds that orphaned second term to my existing search statement – without warning.

After my embarassing experience with advanced field searching, I felt like the guy in Hell who doesn’t know where to tell someone to go.

Other field searches work
As I investigated further into field searching in Advanced Search, I did not encounter the same errors ANDing together two Author names (e.g., Smith & Jones), or two terms as Text Word. Even as implausible a search as entering “English” and “French” into the Language fields causes the database to cough up 11,855 bilingual articles.

As far as I can determine, this PubMed bug is confined to the Title search.

Needless to say, there was much tittering around the lab as my colleague and I “moved right along” from that bit of pother. I’m curious to know if the PubMed people are aware of this bug, and if so, whether that is one of the causes of the seeming delay in transitioning to the redesigned interface. It will be interesting to see if others have endured the same sort of PubMed redesign tribulations.

Photo credit: cc licensed flickr photo by TaranRampersad: (flickr.com/photos/knowprose/101872870/)

Frankly, we do give a dam: differentiating between dental dams and sex dams

An alert public health official in Winnipeg pointed out that my post on oral sex barriers failed to distinguish between dental dams and sex dams. I freely admit to having been vague on the distinction between the two, this not being an area of expertise for me. So I delved a little more deeply into what the web could offer. Because the primary literature is so focused on condoms (male or female), the web is often the only resort for the safer sex researcher. When you consider the popularity of oral sex in the general population and the clear documentation on disease transmission by means of oral-genital or oral-anal contact, it is surprising and distressing to see so little research.

Try a search in Scopus, for example, on “sex dams.” 15,000 journals and not a single mention. One fares a little better with the search term “dental dams,” until it becomes clear that all the serious research strictly involves their use in dental practice.

Differentiating the dams

In my defence I should say that the term “dental dam” is frequently used to refer to any patch of latex, polyurethane or polyethylene used for oral stimulation during sex. Many safer sex web pages use the phrase exclusively, without mentioning sex dams. It is not surprising that this leads to some terminological confusion. Yet there is a notable difference between the two types of dams, and I hope that the following will be a useful clarification.

A dental dam is a small latex patch, normally 5 or 6 inches square, used in dental procedures. A sex dam is a delicate latex sheet, usually 10 by 6 inches, specially designed for oral sex. It is larger and much thinner than a standard dental dam and frequently comes in various colours and flavours. Polyurethane sex dams are also available commercially, but again, don’t expect to find terminological exactitude or you may miss the Hot Dam Banana Flavored Polyurethane Dental Dam when you do a Google search.

Sex dam benefits

The major factors that differentiate the dams are size, look and feel, taste and smell, thickness, and transparency. Sex products need to be “fun,” a basic requirement often forgotten by those whose main concern is to get the science right.

1. A good sex dam should be large enough to fit over the entire genital or anal area. Normal dental dams or cut-up condoms are really too small for cunnilingus and anilingus, however “approved” they may be as a barrier.
2. Some condoms have a powdery surface that is not suitable for oral contact, and dental dams are too rubbery and clinical. The tactile sensation involved in using a dam for pleasurable stimulation is important, for the giver as well as the receiver.
3. Sex dams are usually scented to hide the turn-off latex stench, and flavoured to please the tongue.
4. Sex dams are also very thin and delicate. They are designed to give pleasure. A good thing, since there is very little pleasure in trying to find and purchase them on the web or in shops. It goes without saying that a thick, podgy slab of latex has all the sex appeal of a placemat.
5. Finally, the transparency of a dam is an important motivator. We’re talking sex here, after all, not wrapping cutlets for the freezer. One of the reasons that plastic wrap is used at all is that it allows both sexual partners to see the erogenous terrain, as it were. This is a definite plus when it comes to sexual pleasure. A well-designed sex dam should have this characteristic of transparency or at least translucency.

Alternatives to dams

As I explained in my previous post, most of us who might benefit from them do not have easy access to good sex dams. That is why efforts have been made to suggest safe alternatives, even in the face of the overwhelming lack of good evidence as to their efficacy.

SexualityandU.ca, a Canadian safer sex website, has a good definition of the use of what it terms “dental dams” for oral sex, and it has the most reasonable advice I have been able to find for anyone thinking about using plastic wrap as an alternative barrier:

Some people also use non-microwaveable plastic wrap (Saran Wrap®) as dental dams. This has not been studied in depth yet, but there is evidence that non-microwaveable plastic wrap can stop virus-sized particles, which could mean it can prevent STIs. Until this has been studied in more detail, sticking with latex dams or condoms (or even a cut-open latex glove) is probably your safest bet.  However, plastic wrap is certainly better than nothing, as it does provide at least some level of protection against STIs.

CDC would have done well simply to borrow this balanced and objective plain-language explanation for its revised pronouncement of last June on oral sex and HIV risk.

The SexInfoOnline website, maintained by students from the University of California, Santa Barbara, offers well-illustrated instructions on how to make an oral sex barrier using a standard condom. The final photograph shows revealingly just how small a cut-up condom actually is. Although somewhat chaotically organized, SexInfoOnline is an excellent resource. For example, I learned the meaning of “queefing,” a spicy new addition to my vocabulary.

Compare the cut-up condom photo to this illustration of a sex dam found at Sheer Glyde Dams, a U.S. commercial website that is known to ship product to Canada and Australia. The difference is considerable. A dental dam, the kind used by your dentist, is somewhat larger than a sliced condom, but not as large as the typical sex dam produced for sale at sex shops, on commercial websites, and very occasionally at pharmacies.

The best instructions I have seen for constructing an alternative dam from a condom or latex glove can be found at the website of Agence de la santé et des services sociaux de Montréal. The information is available in English and French accompanied by detailed colour photographs. With predictable Canadian reserve, the instructions, thorough as they are, do not show the practical application of these improvised barriers in situ.

Another good general resource on oral sex and HIV prevention is thebody.com.

Dams around the world: Lecktücher, digues dentaires, fazzoletti di lattice

In German the thick latex sheet used by dentists is called der Kofferdamm. For sex dams the Germans employ the more sexually suggestive word das Lecktuch (lick sheet), which for no apparent reason is in the neuter gender. The plural form is Lecktücher. One occasionally finds the more sedate term Latextuch, but it’s not as popular.

The French language is content to settle for a single term for the dental/sex dam. It is the (appropriately) feminine la digue dentaire. Digue is also the French word for dike.

The Italians use the term il fazzoletto di lattice (literally, latex hanky), whereas the Russians simply transliterate the technical German term: коффердам.

Be wary of Wikipedia entries

Wikipedia’s article on dental dams is adequate for a simple explanation of their use by dentists. But it is very disappointing for the sex researcher, devoting all of two sentences to the subject of their sexual use. You will have to go to the entry on cunnilingus to get more on the safer sex angle. As we have seen, there are far better sources on the web for this kind of information.

The German Wikipedia has a lengthier article, whose only reference, curiously, is to the Canadian site sexualityandU’s page on dams.

The French Wikipedia entry falls somewhere between the English and the German coverage. Its single reference is to a poorly illustrated, bare-bones instruction page on a French AIDS prevention website. Come on, francophone colleagues. Get snapping.

The Italian Wikipedia entry provides only very general information, like the French. But the Italian entry at least has a reference to a relatively decent PDF on lesbian health issues.

The Russian Wikipedia entry is all business, i.e., dentistry only. The sexual use of коффердам (a transliteration of the German term) is as far from view as Lenin in his tomb.

Plastic wrap around the world

It’s a relief to see that, despite the lack of adequate research support, there is general agreement in many countries that the clear, scritching, clingy stuff we use to keep old pizza slices in the fridge is not the best means of warding off a serious sexually transmitted infection.

In French the term for plastic wrap is film alimentaire. Browsing through various French websites I saw general consensus that le film alimentaire n’est pas du tout recommandé (because it’s porous).

The Italians concur: la plastica alimentare è un mezzo poco sicuro (plastic wrap is a less secure method).

German safer sex sites also consider die Haushaltsfolie (lit. “household foil”) as less than ideal, to be used nur im Notfall (only in a pinch).

Saran wrap is a wonderful invention. It’s irresistible for pranksters and goofballs too. The Urban Dictionary defines it thus:

saran wrap: the original (1950s, early 1960’s ?) clear foodwrap that teens used when they were too scared to go buy condoms. “I’m a saran wrap baby.”

Beneath the humour, however, is the sticky reality that plastic wrap is commonly being used for purposes for which it was never designed. In light of the significant concern about the risks of using plastic wrap for any kind of sexual encounter, it is inexcusable that science has not given it the kind of attention that has been lavished on condoms, gloves, masks and other barriers to infection. It is not stretching a point to assert once again that more research is urgently needed.

A note on kissing and STIs
My contact in public health also expressed concern that I had linked kissing with transmission of the human papillomavirus. I believe there is adequate support in the literature for this position [1,2]. In short, along with things like the common cold, mononucleosis, influenza and meningitis, kissing can also pass on some sexually transmitted infections: HPV, herpes simplex, and syphilis.

References

1. Slots J. Oral viral infections of adults. Periodontology 2000. 2009 Feb;49(1):60-86.

2. Kreimer AR. Oral sexual behaviors and the prevalence of oral human papillomavirus infection. J Infect Dis. 2009 May 1;199(9):1253-4.

Oral sex and plastic wrap: the CDC sandwiched between a riddle and an enigma

Every year we make enough plastic film to shrink-wrap the state of Texas. ~ EcoSection.com. Tweeted 31 Mar 2009. http://twitter.com/ecosection

Two years ago, with tongue occasionally in cheek, I wrote a lengthy discussion about my efforts to find information on the effectiveness of plastic wrap (a.k.a. cling film, sandwich wrap, shrink wrap, Saran Wrap) as a safe barrier for oral sex. At that time I found this cautious admonition offered by the Centers for Disease Control and Prevention (HIV/AIDS among women who have sex with women, June 2006): “Plastic wrap may offer some protection from contact with body fluids during oral sex and thus may reduce the possibility of HIV transmission” [1].

Well, we can put our rolls of Saran wrap back in the kitchen drawer. It appears that the CDC is shrinking from even that heavily qualified recommendation. In a fact sheet released last June, Oral Sex and HIV Risk, the CDC emphasizes the risk of oral transmission of a number of diseases and continues to advocate the use of physical barriers such as condoms and dental dams. However, on the issue of plastic wrap the CDC has changed its tune:

At least one scientific article has suggested that plastic food wrap may be used as a barrier to protect against herpes simplex virus during oral-vaginal or oral-anal sex. However, there are no data regarding the effectiveness of plastic food wrap in decreasing transmission of HIV and other STDs in this manner and it is not manufactured or approved by the FDA for this purpose [2].

As I found in doing the research for my previous post, the CDC is right to be cautious about plastic wrap. Simply put, there is no research that tests the effectiveness of ordinary sandwich wrap as a barrier between lips and tongue and what they seek to titillate sexually. Whether it is sheer squeamishness on the part of the scientific community, or sex-phobic avoidance, or merely benign neglect, the fact remains that after many years of shilly-shallying about oral sex barriers, a major U.S. health agency has admitted that its own recommendations have not been based on the evidence. While the CDC’s statement makes no admission of its responsibility to the many thousands who have struggled with this humble oral sex accessory based on its past recommendations, at least in publishing it the CDC shows its willingness to face the evidence gap while implicitly challenging the research community to put their money where their mouth is. So to speak.

Characteristically, Canadian public health officials cling to their formulas and soft-pedal the issue. The Canadian Public Health Association mentions only dental dams or condoms cut lengthwise as appropriate barriers for cunnilingus, ignoring altogether what to use for anilingus, or rimming. Not in Canada, eh? It is more surprising that the Canadian AIDS Society also leaves this issue alone in its web page on safer sex. Yet in its official guidelines on HIV transmission risk, CAS has this to say about plastic wrap:

Plastic wrap has also been advocated by some AIDS educators as a risk-reduction tool for cunnilingus and anilingus. Only one brand, Glad®, has been tested in the laboratory. It was found to be effective for preventing transmission of the herpes simplex virus. It has not been tested as a barrier for HIV. Plastic wrap is not subject to the quality control testing for filtering viruses and micro-organisms that condoms require. It is not as elastic as latex, but it is cheap, accessible and easy to use. However, plastic wrap marketed as “microwavable” is more porous than the conventional plastic wrap; it is not recommended for use during sexual activity [3].

Perhaps the CPHA and CAS should compare notes. As far as I can determine, neither organization is aware of the CDC statement of June 3, 2009.

Who is listening to the CDC?

Despite the considerable uncertainty concerning the use of plastic wrap barriers of any kind in oral sex, many organizations continue to support their use.

The Australian Federation of AIDS Organisations is still recommending plastic wrap along with latex dental dams. “Glad Wrap” is suggested for use during cunnilingus and rimming, although there is an admission that the recommendation is not based on any significant evidence beyond that of other AIDS prevention organizations. Without citing scientific evidence, AFAC launches into an odd discussion about microwaveable versus non-microwaveable wrap:

The peculiar debate about the effectiveness of microwaveable as compared to non-microwaveable cling wrap is difficult to evaluate. Many commentators have suggested that microwaveable wrap should not be used. The concerns about microwaveable wrap are understood to relate to the presence of pores in the wrap, which are designed to open at high temperatures, thereby releasing trapped steam. While the concerns sound reasonable, it seems unlikely that even the most passionate of sexual individuals will reach the temperatures of a microwave oven.

Trapped steam indeed. This lame attempt at humour does not disguise the fact that on this matter the Australians are talking out of their assertive derrieres.

Some websites encourage “creative uses” of plastic wrap. One dash-challenged example will suffice. Consensual Text put out by Planned Parenthood of Northern New England’s Education Department:

Using plastic wrap will protect you against HIV when engaging in anal sex – and it should be used during oral sex as well. Although vaginal and anal sex can pass HIV more easily – engaging in oral sex is not a safe practice. Use a barrier like shrink wrap whenever you have anal or oral sex. Have fun with plastic – wrap it up!

Less chirrupy, but no less odd in its own way, is a peer-reviewed continuing education document for dentists, which offers a recommendation on preventing disease transmission from operatory surfaces. The author includes plastic wrap in a list of effective protective barriers including “bags, sheets, tubing, and plastic-backed paper or other materials impervious to moisture. Their utilization on surfaces and equipment can prevent contamination of clinical contact surfaces” [4].

The need for more research

When it comes to plastic wrap not enough attention is being paid to the evidence – or the lack thereof. But, as I mentioned in my previous post, the paucity of sufficient research on the quality of plastic wrap as a barrier to infectious agents is no laughing matter. For some groups, there is no other choice.

The difficulty of obtaining condoms and the virtual impossibility of finding something like a dental dam in many prisons for men, means that a (possibly reused) sheet of Saran wrap is often all that comes between those engaged in oral or even penetrative sex. That consensual sex between men is not unusual in prisons is common knowledge. A study published this year shows that in the U.S. the estimated prevalence of HIV is more than five times higher among state prison inmates than among the general population. Many men seroconvert while incarcerated, some from injection drug use or tattooing, but the majority from unprotected sex [5]. I should mention again a poster prepared by the Project START Study Group, Sexual behavior and substance use during incarceration (2004), where we learn that 12% of incarcerated men in the United States are using Saran wrap and other plastic substances as a means of protection during consensual sex.

In another recent study of the Georgia state prison system it was found that of 43 inmates reporting consensual sex, 30% said they used condoms or other improvised barrier methods (e.g., rubber gloves or plastic wrap). This study does not always specify actual numbers of those using plastic wrap, but in one group 21% reported using improvised barrier methods only [6].

The HIV infection rate is increasing among women in general and among female prison inmates specifically. Incarcerated women report participation in unprotected consensual sex [7]. In a study of safer sex methods among women (not in prison) who have sex with women, 36 out of 92 respondents had used dental dams or plastic wrap as a barrier during oral sex [8].

Latex dental dams, of course, provide the same protection as a condom. However, although occasionally available for free from public health agencies, dams are not as easy to find as condoms and cost considerably more per square inch of latex. They can be purchased from commercial websites such as Safe Sex Canada, but it is not clear that many are doing so, especially teenagers or people on low incomes. Cut-open condoms will do the same job, but the resulting surface area is not as large as that provided by a dam. This could lead to “errors” when these improvised barriers are used for cunnilingus or rimming.

Although the CDC is declaring that there is insufficient evidence that plastic wrap is suitable for safer sex, a number of studies done in the past six years indicate that plastic wrap does afford protection from a number of infectious agents, even prions [9,10,11]. But there is no research that analyzes the safety of plastic wrap for sexual purposes, and not a word about its effectiveness as a barrier to HIV infection.

Facts about oral sex

Fact number one. There is lots of it going on – in most age groups, and in growing numbers among the young. There is no question of the increase in popularity of oral and anal sex among the heterosexual population. It is estimated that one-third of American men and women have experienced anal sex, and three-quarters have had oral sex. Annoyingly, it is not always clear in a research study how these types of sexual activity are experienced. For example, the common assumption appears to be that heterosexual men are only giving, not getting anal sex. Condom use during oral or anal sex is still relatively uncommon [12].

Oral sex among the young
There are no large-scale published studies assessing the prevalence of oral sex among younger Canadian teens. The sexualityandU.ca website gives a good overview of the situation in Canada. According to the Canadian Youth, Sexual Health and HIV/AIDS Study (Boyce et al., 2003), Canadian teenagers are more likely than in the past to engage in oral sex. Results from studies done in the United States contain inconsistent data about who is giving oral sex to whom, but all the data agree that a sizeable proportion of both male and female teenagers, ranging from 39% to 51%, reports giving or receiving oral sex.

One in four Canadian teenagers are sexually active at a mean age of 15 years. The mean age at first oral sex was also 15 years. Condom use is common, but 17% do not know that STIs can be transmitted through oral sex. Many teens are engaging in sexual behaviours that may threaten their health. Casual sex is reported by 38%. The most prevalent STIs in Canadian teens are HPV, chlamydia, and less commonly, genital herpes and gonorrhea. However, when questioned adolescents identify much less common infections as the most frequent (e.g., HIV and hepatitis B). The gaps in STI knowledge and some of the sexual behaviours of teens may explain, in part, the increasing prevalence of STIs in Canada [13].

With respect to oral sex, it is important to remember that over the last 30 to 40 years fellatio and cunnilingus have become a normative aspect of the adult sexual script and this trend has been followed by youth. Studies conducted on adolescent populations in the United States and Canada during and since the 1970s consistently show that oral sex is about as common as sexual intercourse, is most typically initiated at about the same time as intercourse, but precedes first coital activity for 15-25% of adolescents [14].

A study of more than 11,000 youth aged 12-25 years old attending a Baltimore clinic over a 10-year period concluded that oral sex and, to a lesser degree, anal sex, appear to be increasing among teenagers and young adults. The odds of reporting oral sex were approximately three times higher in 2004 than in 1994; odds of anal sex were twice as high [15].

Oral sex considered less risky and frequently not even “sex”
Many young teenagers consider oral sex more acceptable and less risky than vaginal intercourse [16]. In a recent study of California ninth graders more participants reported having had oral sex (19.6%) than vaginal sex (13.5%), and more participants intended to have oral sex in the next 6 months (31.5%) than vaginal sex (26.3%). Adolescents evaluated oral sex as significantly less risky than vaginal sex on health, social, and emotional consequences. Adolescents also believed that oral sex is more acceptable than vaginal sex for adolescents their own age in both dating and nondating situations, oral sex is less of a threat to their values and beliefs, and more of their peers will have oral sex than vaginal sex in the near future [17].

The CDC fact sheet on the risk of oral sex states: “some data suggest that many adolescents who engage in oral sex do not consider it to be ’sex;’ therefore they may use oral sex as an option to experience sex while still, in their minds, remaining abstinent.”

Risk of transmission during oral sex and the need for a good barrier
Finally, the inescapable fact about oral sex is that there is ample proof that it can transmit various infections, including HIV, syphilis, gonorrhea, chlamydia, herpes simplex, and hepatitis [18,19,20,21]. Even kissing is implicated in the transmission of oral HPV. While the evidence for oral HIV infection is still debated, organizations such as the Public Health Agency of Canada, strongly maintain that people engaging in oral sex should use a barrier. The Canadian AIDS Society emphasizes that the risk of transmission of HIV (or other STIs) from any kinds of oral intercourse can be effectively reduced by the proper use of a latex barrier (condom or dental dam), and thus advocates the avoidance of unprotected orogenital or oro-anal contact. Neither organization advocates the use of plastic wrap in any public statement on oral sex.

“How do you use Saran products?”

The evidence shows a growing number of people of all ages engaging in oral sex play, often with little or no protection and with even less good information from reliable sources. This begs the question: why is there so little research being done on oral sex barriers, including plastic wrap?

I concluded my previous review with my take on why I thought researchers have failed to confront this important issue. It is still disturbing that, given the near universal recommendation by community organizations of this alternative barrier, that the large dose of cold water thrown by the CDC on their assertions has not flushed away the erroneous information they produce for public consumption. What is being advocated about the virtues of stretch-and-seal wrap as a barrier for oral sex is not supported by any credible evidence. These assertions are full of holes. I also suggested that the continuing drought of decent research on polyethylene as a sex accessory may be fuelled by sex-phobic and/or homophobic avoidance of a distasteful issue. After all, the manufacturer of Saran Wrap, SC Johnson & Son, calls itself a “family company.”

Nor is there much evidence that this is a promising area of research for ambitious scientists competing for government or corporate grants. At a time when enough polyethylene is being produced to shrink-wrap Texas or Turkmenistan, surely someone must be out there who can do the necessary science on density, porosity, permeability, and microwaveability to make the next update I do on this topic a little less onerous. But all the potential funders, even Bill and Melinda Gates, are clinging to their wallets and keeping their intentions under wraps.

Finally, what are the Centers for Disease Control going to do about this? They waited three years for research to appear to back their cautious recommendation of plastic wrap, only to admit in the end that nothing had resulted from their doing nothing. My question is, rather than waiting another three years as infections continue to increase, why don’t they find someone to fund a research project? Would the cost be that prohibitive? When you see the absurd things that do get published (have a look at the wildly funny blog NCBI ROFL for ample evidence of this), surely a decent study on the effectiveness or otherwise of plastic wrap as an oral sex barrier is in order.

References

1. Centers for Disease Control and Prevention. Divisions of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. HIV/AIDS among women who have sex with women. 2006 Jun. Available from: http://www.cdc.gov/hiv/topics/women/resources/factsheets/wsw.htm

2. Centers for Disease Control and Prevention. Divisions of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Oral Sex Is Not Risk Free. 2009 3 Jun. Available from: http://www.cdc.gov/hiv/resources/factsheets/oralsex.htm. The article referred to in this quote is probably: Garland SM, Newman DM, De Crespigny Ch. L. Plastic wrap for ultrasound transducers. herpes simplex virus transmission. Journal of Ultrasound in Medicine. 1989;8(12):661-3.

3. Canadian AIDS Society. HIV transmission: guidelines for assessing risk. 5th ed. Ottawa: CAS; 2004. Available from:  http://www.cdnaids.ca/web/repguide.nsf/Pages/45A115EBBCBA2586852570210054FC3E/$file/HIV%20TRANSMISSION%20Guidelines%20for%20assessing%20risk.pdf. The unreferenced article mentioned here is likely Garland, et al. (1989) as above.

4. DePaola LG. Preventing disease transmission from operatory surfaces. Academy of Dental Therapeutics and Stomatology; 2008.  Available from: http://www.ineedce.com/coursereview.aspx?url=1557%2fPDF%2fPreventingDiseaseTrans.pdf&scid=13875

5. 5. Jafa K, McElroy P, Fitzpatrick L, Borkowf CB, Macgowan R, Margolis A, Robbins K, Youngpairoj AS, Stratford D, Greenberg A, Taussig J, Shouse RL, Lamarre M, McLellan-Lemal E, Heneine W, Sullivan PS. HIV transmission in a state prison system, 1988-2005. PLoS One. 2009;4(5):e5416. Epub 2009 May 1. PubMed PMID: 19412547; PubMed Central PMCID: PMC2672174.

6. Centers for Disease Control and Prevention (CDC). HIV transmission among male inmates in a state prison system–Georgia, 1992-2005. MMWR Morb Mortal Wkly Rep. 2006 Apr 21;55(15):421-6. PubMed PMID: 16628181.

7. Knudsen HK, Leukefeld C, Havens JR, Duvall JL, Oser CB, Staton-Tindall M, Mooney J, Clarke JG, Frisman L, Surratt HL, Inciardi JA. Partner relationships and HIV risk behaviors among women offenders. J Psychoactive Drugs. 2008 Dec;40(4):471-81. PubMed PMID: 19283951; PubMed Central PMCID: PMC2746431.

8. Allen AA. Barriers: an analysis of the user of safer sex methods in the queer community. Thesis. Bachelor of Arts, Women’s Studies. University of Washington. June 2004. Available from: https://dlib.lib.washington.edu/dspace/bitstream/handle/1773/2057/Allen04.pdf?sequence=2

9. Makinde ON, Aremo BT, Aremo B, Akinkunmi EO, Balogun FA, Osinkolu GO, Siyanbola WO. Re-usable low density polyethylene arm glove for puerperal intrauterine exploration. East Afr Med J. 2008 Jul;85(7):355-61. PubMed PMID: 19133425.

10. Davies LN, Bartlett HE, Dunne MC. Cling film as a barrier against CJD in Goldmann-type applanation tonometry. Ophthalmic Physiol Opt. 2004 Jan;24(1):27-34. PubMed PMID: 14687198.

11. Rani A, Dunne MC, Barnes DA. Cling film as a barrier against CJD in corneal contact A-scan ultrasonography. Ophthalmic Physiol Opt. 2003 Jan;23(1):9-12. PubMed PMID: 12535051.

12. Leichliter JS, Chandra A, Liddon N, Fenton KA, Aral SO. Prevalence and correlates of heterosexual anal and oral sex in adolescents and adults in the United States. J Infect Dis. 2007 Dec 15;196(12):1852-9. PubMed PMID: 18190267.

13. Frappier JY, Kaufman M, Baltzer F, Elliott A, Lane M, Pinzon J, McDuff P. Sex and sexual health: A survey of Canadian youth and mothers. Paediatr Child Health. 2008 Jan;13(1):25-30. PubMed PMID: 19119349; PubMed Central PMCID: PMC2528827.

14. Maticka-Tyndale E.. Sexuality and sexual health of Canadian adolescents: yesterday, today and tomorrow. The Canadian Journal of Human Sexuality. 2008 Jul 1;17(3):  85-95. Document ID: 1623790231.

15. Gindi RM, Ghanem KG, Erbelding EJ. Increases in oral and anal sexual exposure among youth attending sexually transmitted diseases clinics in Baltimore,
Maryland. J Adolesc Health. 2008 Mar;42(3):307-8. Epub 2007 Dec 21. PubMed PMID: 18295140; PubMed Central PMCID: PMC2350224.

16. Hollander D. Many young teenagers consider oral sex more acceptable and less risky than vaginal intercourse. Perspectives on sexual and reproductive health. 2005 Sep;37(3):155.

17. Halpern-Felsher BL, Cornell JL, Kropp RY, Tschann JM. Oral versus vaginal sex among adolescents: perceptions, attitudes, and behavior. Pediatrics. 2005 Apr;115(4):845-51. PubMed PMID: 15805354.

18. Leber A, MacPherson P, Lee BC. Epidemiology of infectious syphilis in Ottawa. Recurring themes revisited. Can J Public Health. 2008 Sep-Oct;99(5):401-5. PubMed PMID: 19009926.

19. Groves MJ. Transmission of herpes simplex virus via oral sex. Am Fam Physician. 2006 Apr 1;73(7):1153; discussion 1153. PubMed PMID: 16623201.

20. Oral sex more risky. AIDS Patient Care STDS. 2000 Apr;14(4):227. PubMed PMID: 10806652.

21. D’Souza G, Agrawal Y, Halpern J, Bodison S, Gillison ML. Oral sexual behaviors associated with prevalent oral human papillomavirus infection. J Infect Dis. 2009 May 1;199(9):1263-9. PubMed PMID: 19320589.

Photo credit: Wrap – the photo, by mariogirl. 18 Oct 2006.

Dudley Doright on drugs: the RCMP Drug Identification Chart should be tied to the tracks

Medical librarians have welcomed the announcement of the National Library of Medicine’s Pillbox as a useful addition to our arsenal of drug ID tools. Both e-CPS in Canada and Lexi-Comp Online, for example, have fine indentification modules for pharmaceuticals.

But where can we find photo collections of drugs not normally dispensed at the local pharmacy? Pharmacists and health providers are interested in all drugs that people are consuming. There should be reputable resources doing the same job for street drugs that compendia do for discreet drugs, i.e. any legitimate pharmaceuticals allowed to occupy clean dispensary shelves by bureaucrats and politicians. Aside from obvious sources like High Times and Hollywood films, what guides and directories are out there and how good are they?

A pharmacist colleague of mine alerted me to the Royal Canadian Mounted Police’s Drug Identification Chart, which describes itself as “a reference tool for identifying illicit drugs and their harmful effects.” This shoddy effort (supported by the Sûreté  du Québec, the Canadian Association of Chiefs of Police, and Health Canada, no less) is flagrant proof that there has never been a situation so dismal that Dudley Doright couldn’t make it worse.

As a directory of illicit drugs the whole thing is risibly inadequate. Clearly, dope comes in many forms, and it would be hard to catalogue them all visually; but this looks more like an elementary school project than a police web page. It’s rife with bad grammar and spelling, poor quality images, and clumsy design. Hashish, for example, comes in many colours and forms. From the RCMP photograph it’s impossible to get a sense of perspective on what is being depicted. Is it thick as a brick, or a size that can be more discreetly concealed in a cigarette pack? Is it possibly a piece of burnt toast, or a map of Oregon made out of Play-Doh? It’s hard to tell from the single tiny picture displayed.

It’s almost as if the Mounties were somehow embarrassed to include better photographs and more explicit detail, similar perhaps to the reluctance of Catholic catechisms to elucidate more fully the Seven Deadly Sins, whilst revelling in descriptions of the Seven Cardinal Virtues.

And why is it that the combined efforts of three police organizations and the Canadian government could not figure out the proper spelling of marijuana? The photograph of “marihuana” shows a greenish pile of something that resembles a green hedgehog. How is this supposed to help new recruits in the war against drugs? This website is supposed to be an official resource for police officers, but it has the distinct look and feel of something thrown together for appearance’s sake. Look at the treatment of Canada’s favourite illegal pastime (along with tax evasion and cigarette smuggling). What about showing an actual leaf from the marijuana plant, just for starters? Or a grow-op specimen? Last I heard, when raiding a drug den it’s rare to find weed spread in convenient piles all over the kitchen table. Is it not more usually found in pockets or backpacks in small plastic bags or rolled into joints? But in this official directory you would look in vain for such a photograph. It’s like explaining all the forms of tobacco use by showing large brown leaves hung to dry in a barn or a pinch of snuff.

Surely from their vast reserves of confiscated drugs and drug paraphernalia the Mounties could have done something better than this farrago. I could go on, and I’m certainly no expert. Canadian police forces need to consult someone with professional or street experience of these drugs and come up with a decent range of samples. How can a ten-year-old find a pusher any time and the cops can’t?

Not only are the RCMP’s photographs of dubious value, the text of the Drug Identification Chart needs to be revised, badly. Here is how LSD is categorized:

Perception-distorting (Substance that alters sensory perception. It causes changes in user’s mood, thoughts and consciousness)

The Chablis chilling in my fridge fits this description quite well.

This being a police directory, advice is given on detection of drug users. To this end, in an odd mix of nouns and adjectives, the LSD user is described as exhibiting the following symptoms:

Hilarity, hallucinations, excitable, wild-eyed, dilated pupils

Yes officer, I cannot tell a lie. My Labrador Retriever frequently chases imaginary squirrels.

For some more helpful information on recreational drugs, I recommend the following:

U.S. Drug Enforcement Administration. Multi-Media Library (more great spelling from our law enforcement organizations)Police-Information.co.uk. Drug Identification Guide

Sushine Coast Health Centre (B.C.) Drugs of Abuse: An Identification Guide [PDF]

And remember what Abbey Hoffman said: Avoid all needle drugs – the only dope worth shooting is Richard Nixon.

When H1N1 visits food banks and shelters, what then? We need a plan

Coughs and sneezes spread diseases. Trap the germs in your handkerchief.  ~  World War 2 health slogan

Charities and non-profits provide critical services to communities across Canada. What if they are not adequately prepared for an H1N1 outbreak? asks Marcel Lauzière, head of Imagine Canada, a national program to promote public and corporate giving, volunteering and support to the community.

In an opinion piece that appeared in a number of Canadian newspapers this week, including the Winnipeg Free Press, Lauzière attempts to bring to public attention the potential impact of the H1N1 pandemic on Canada’s charitable and non-profit organizations. From the blank looks and long pauses over the phone he says he has been experiencing when he starts talking about it, it is apparent that this issue is still languishing at lower levels in the nation’s health bureaucracies.

The focus of most official attention is on hospitals, schools, businesses, First Nations reserves, and vulnerable individuals like pregnant women. There is a lively and useful public debate about how prepared we are, and how prepared we should be, for a major outbreak. But charities and non-profits are too often not part of the discussion. Left out of the picture is the fact that charities and non-profit organizations deliver critical services to Canadians. If the H1N1 epidemic is severe, what will happen if charitable organizations lose up to a third of their staff and volunteers to illness?

What if food banks start closing? How will desperate families feed their kids? What if meals are no longer prepared and delivered to elderly people who can’t get out and who have no friends or relatives nearby to help them? What about Canadians needing dialysis or chemotherapy but who can’t get to the hospital because there are no volunteers to drive them? What about the thousands of children and their families who rely on local sports and recreation and arts and cultural organizations for their weekly activities? What if the homeless shelters shut their doors in the middle of winter?

As a third pillar of Canadian society alongside governments and business, charities and non-profit organizations are part of an intricate system of societal supports that significantly improve the quality of life in Canada. They are also a significant part of our economy. “The sector generates more than $87 billion annually, a contribution of almost seven per cent to Canada’s GDP. It employs more than 1.5 million Canadians (full-time equivalents)and mobilizes 12.5 million volunteers in Canada.”

Lauzière refers to the importance of “business continuity” during an outbreak and the plans that government and major corporations are putting in place. Everyone agrees that the economy must keep on working. That is precisely why we cannot forget charities and non-profits.

[They] are part of our economy too, as well as being major contributors to our quality of life… The demand many of them face is already greater given the impact of the recession and now they must prepare for the possibility of an H1N1 outbreak. What if they are not adequately prepared?

We will need them more than ever at a time of crisis. This is no time for blank looks. As a country, we need to figure out how we can help them be prepared for whatever this influenza season brings.

Lauzière’s argument is lucid and important, but he has put the focus largely on continuity of vital services to the disadvantaged. Yes, if H1N1 cripples charities the results could be, according to the Halifax Chronicle Herald’s melodramatic headline, “catastrophic.” But where are the plans to prevent H1N1 transmission among people these charities serve? This, it seems to me, is an issue that should be higher up the priority list of public health authorities. Toronto has a working document, the Toronto pandemic influenza plan: a planning guide for homeless and housing service providers [PDF]. Other Canadian agencies seem to be a little slow on the uptake.

Rather than focusing almost entirely on business continuity, it makes sense to intensify efforts to slow the spread of the virus among disadvantaged and equity seeking groups who make use of charitable services such as food banks and shelters. These are environments in which disease can spread quickly. Sleeping and eating in close quarters, the homeless are even more vulnerable to infection by H1N1, many of them already being immune compromised, poorly nourished, and suffering addiction and chronic illness.

While Marcel Lauzière’s plea for a plan to maintain services should not go unheard, it is also important that our public health authorities act now to slow the spread of H1N1 among the many vulnerable users of charitable services until the vaccine is ready. Or we may find down the road that we have adequately prepared service organizations with no one left to serve.

Pharmaceutical flimflam: drug advertising in medical journals is a global issue

Advertising may be described as the science of arresting human intelligence long enough to get money from it.  ~  Stephen Leacock, Garden of Folly (1924) ‘The Perfect Salesman’

A recent systematic review in PLoS One demonstrates quite effectively something that shouldn’t surprise any intelligent high school student: pharmaceutical advertising in medical journals often provides “poor quality information.” This strikes me as the authors’ excessively polite way of saying that drug ads, even those that appear in authoritative periodicals widely read by physicians, are unregulated, manipulative, meretricious and mendacious. Selling the latest SSRI is not really different from shilling shampoo, with the difference, of course, that there is superior evidence of shampoo’s efficacy.

Othman N, Vitry A, Roughead EE. Quality of pharmaceutical advertisements in medical journals: a systematic review. PLoS One. 2009 Jul 22;4(7):e6350. PubMed PMID: 19623259; PubMed Central PMCID: PMC2709919.

The article, buffed to a high scholarly polish with any hint of libellous language or ethical disdain well suppressed, warrants close reading. Here are some highlights:

Advertising in medical journals is one of the techniques used by pharmaceutical companies to promote their products to medical doctors. During the first four years of a new medicine on the market, pharmaceutical companies may gain approximately US $2.43 for each dollar spent on medical journal advertisements for a medicine. The return on investment has been reported to increase to more than US $4 after that period.

We found that pharmaceutical advertisements in medical journals usually provided brand and generic name and indication. Other essential information required for rational prescribing including contraindications, interactions, side effects, warnings and precautions were less commonly provided. The majority of references cited to support pharmaceutical claims were journal articles. However, less than two-third [sic] of the claims were supported [emphasis mine] by a systematic review or a meta-analysis (110/1375, 8%) and randomised control trial (455/1500, 30%).

This review noted that references used to support pharmaceutical claims were often of low quality. The inappropriate use of references in journal advertising suggests that the availability of references does not always guarantee the quality of claims.

Information on medicines is essential to help doctors ensure the optimal use of medicines. However, studies show that doctors who use journal advertisements as a source of information may prescribe less appropriately. In addition, reliance on journal advertising for information is associated with increased costs of prescribing. Even doctors who think that they obtain their knowledge from the scientific literature can be influenced by promotional sources without being aware of it. As information provided in journal advertising has the potential to change doctors’ prescribing behaviour, our review indicates that ongoing efforts including complaints and recommendations by researchers, health professionals and policy makers to improve the quality of advertisements in medical journals are crucial.

Governments may need to take more proactive action such as engaging independent experts to help in designing regulation for journal advertising where self regulatory codes are limited. In addition to that, effective regulatory system may complement pharmaceutical litigation to ensure accuracy and reliability of information in journal advertising.

Our review found that the low quality of journal advertising was a global issue. Poor quality advertising has been observed in developing countries and post-Soviet Russia where controls might be weak and limited as well as in developed countries which have stricter regulations.

Globally, pharmaceutical advertising in medical journals often provides poor quality information. The impact of this problem on doctors’ prescribing behaviour might be even greater in developing countries and post-Soviet Russia where access to industry-free medicine information is limited. The results from our review suggest the need for a global pro-active and effective regulatory system to ensure that information provided in medical journal advertising is supporting the quality use of medicines.

It is the most extraordinary thing, but I never read a patent medicine advertisement without being impelled to the conclusion that I am suffering from the particular disease therein dealt with in its most virulent form.  ~  Jerome K. Jerome, Three Men in a Boat (1889)

Slow death by rubber duck: how the toxic chemistry of everyday life affects our health

“When I see a bird that walks like a duck and swims like a duck and quacks like a duck, I call that bird a duck.”  ~ James Whitcomb Riley

We consume hundreds of toxic chemicals from the things we use day to day to keep ourselves sheltered, fed, clothed and healthy. So say authors Rick Smith and Bruce Lourie in their recent book Slow death by rubber duck: how the toxic chemistry of everyday life affects our health (Knopf Canada, 323 pages, $32). But they are hopeful that things can change for the better, noting a recent European ban on noxious flame-retardant chemicals in television sets, Canadian legislative changes to end toxic baby bottles, and a new U.S. law to restrict hormone-mimicking ingredients in the plastic of children’s toys.

Almost everything we use, recline on, sleep in, eat off, wash with, or rub into our skin is a source of pollution. “For most people belching smokestacks, sewer outfalls, and car exhaust are the first images that come to mind when the word ‘pollution’ is mentioned,” the authors observe. Pollution is still seen as “an external concern, something floating around in the air or in the nearest lake. Something that can still be avoided.” But research makes it clear that pollution is so pervasive “it has become a marinade in which we bathe every day.”

Pollution is actually inside us all. It’s seeped into our bodies. And in many cases, once in, it is impossible to get out.

Toxic chemicals are now found at low levels in countless appliances, in everything from personal care products and cooking pots and pans to electronics, furniture clothing, building materials, and children’s toys. They make their way into our bodies through our food, air, and water.

From the moment we get up from a good night’s sleep under wrinkle-resistant sheets (which are treated with the known carcinogen formaldehyde), to the moment we go to bed at night after a snack of microwave popcorn (the interior of the bag being coated with an indestructible chemical that builds up in our bodies), pollution surrounds us … It has been estimated that, by the time the average woman grabs her coffee, she has applied 126 different chemicals in 12 different products to her body.

The authors advise readers on which products to choose in order to avoid the ones that are most dangerously polluting. But these are only short-term solutions. “For the long-term fix,” they warn, “only improved government regulation and oversight of toxic chemicals is the answer. It’s critical that we address this problem, not only as consumers, but also as engaged citizens demanding better of their governments.”

Rick Smith, one of Canada’s leading environmentalists, is director of Environmental Defence, a non-profit organization known for its innovative work on environmental issues.

Bruce Lourie started one of Canada’s largest environmental consultancies. He works closely with governments, businesses, foundations, and non-profit organizations. He is president of the Richard Ivey Foundation, which supports environmental and other beneficial projects.

This is a modified version of a review by Roy LaBerge which appeared in the September 2009 issue of The CCPA Monitor.

For academic librarians what’s hard to reach is time for research

These be the stops that hinder study quite
And train our intellects to vain delight.

Love’s Labour’s Lost, 1.1

Who has the time for research? Very few of us, unless it is somehow part of our work day. Our teaching faculty colleagues do not teach from 9 to 5, Monday to Friday, nor are they always required to be in their offices when not in front of a class, especially between June and August. But academic librarians, it seems, can never have their cake and eat it too. We are expected to be on the job, at the workplace, every day, summer included, unless we are on vacation or on ventilation. And, with some variations, from the midst of this perpetual motion machine we are also expected to produce viable, publishable, imperishable research.

At the University of Manitoba we librarians take our research obligations seriously. We enjoy academic status and are members of the University of Manitoba Faculty Association (UMFA). We have senior management who by and large recognize the value of research and support our pursuit of it. We now also have new language in our Collective Agreement that guarantees us academic freedom and twelve paid days a year to devote entirely to scholarly pursuits. During our last protracted contract negotiations, obtaining recognition from the University that, as part of our academic status, librarians needed time to do the research required of them was a hard-fought battle.

Articles 17 and 20 of the UMFA Collective Agreement, not to mention our own promotion guidelines, more than adequately define both research and the purpose of the working time entitlement for librarians (in particular 17.A.2.5; and see also the Research, Scholarly and Other Creative Works section, 20.B.1.2.2, of the Promotion article). But lately there has been talk amongst my colleagues of establishing “guidelines” to determine the suitability or otherwise of someone’s research and whether a request for time away from other duties to pursue research should be granted.

My generous nature interprets this development as arising from good intentions, but I have to ask: why establish a set of guidelines separate from what has already been well defined in the contract, as well as in a detailed document on guidelines and criteria for the promotion of librarians through the ranks? As I see it, the subject of a librarian’s research is a matter of professional judgement in an atmosphere of academic freedom and collegiality. Our Collective Agreement wisely includes its own warning that librarians’ academic work must be undertaken responsibly: “Academic freedom carries with it the responsibility to use that freedom in a manner consistent with the scholarly obligation to base research, teaching and the collection, dissemination and structure of knowledge in a search for truth.” (17.A.1) Must we form yet another committee to encode and encapsulate what “responsibly” means?

Here is the controversial addition to our contract that seems to stick in some people’s craw. As I mentioned, Article 17 (Academic Librarians) was revised in 2007 to include language on so-called “research days”:

Academic librarians holding probationary and continuing appointments are entitled to twelve (12) working days on full salary in each academic year for research and scholarly activities relating to library science or an academic subject within their expertise, subject to notifying the department head of their proposed work and arranging a mutually agreeable schedule.  (17.A.2.5)

Article 20 on Promotion defines the nature of librarians’ research, scholarly work and other creative activities:

Factors that may be considered include:  the publication of books, monographs, and contributions to edited books; papers in both refereed and nonrefereed journals; papers delivered at professional meetings; participation in panels; both supported and nonsupported unpublished research including current work in progress; editorial and refereeing duties; creative works and performances; and scholarship as evidenced by the candidate’s advanced study and research in library and information science and/or a subject specialization, his/her depth and breadth of knowledge and general contributions to the research of the University. (20.B.1.2.2)

Here, in clear and unequivocal language, the UMFA Collective Agreement spells out what is considered research by librarians and carves out a bit of unencumbered space in which such research can be performed. Some have complained that the twelve days are no more than “automatic days off.” To argue so, I would reply, is misguided in the same way that it would be foolish to maintain that sick days should not be provided because they might, heaven forfend, actually be taken. Should the remote possibility that one of us might abuse a provision of the Collective Agreement be used as a pretext to reshape or subvert what is already appropriately defined in that document? Life is too short for us to start composing intricate commentaries on reasonably comprehensible contractual language. I think what Calvin Trillin once said is appropriate: if law school is so hard to get through, how come there are so many lawyers?

It might be argued that establishing more rigorous guidelines for librarians’ research activities would provide clarity and  improve equity across the library system. My response is that the existing contractual provisions for librarians’ research are entirely sufficient for this purpose. If all librarians read, understand and abide by it, the Collective Agreement itself is the best assurance of equity and should be the primary authority on this issue. It is only when the Collective Agreement specifically calls for the creation of guidelines that we are obligated to go beyond its provisions, as is the case with hiring and promotion at this university.

It is the responsibility of an academic library to foster librarians’ research and to organize the work of the academic staff in such a manner as to accommodate time away from other duties for that purpose. This is in the spirit of the Collective Agreement. If a manager disagrees with a librarian about his or her request for time to pursue research, that is an academic matter which should be resolved between the two of them. If no resolution is possible at that level, there are agreed-upon steps that individual can take. Under the terms of the UMFA Collective Agreement, extended postponement or denial of research time could lead to a grievance. Moreover, any attempt further to enumerate and codify what should or should not be the nature of a librarian’s research – beyond the very detailed provisions already cited above – could be interpreted as an infringement upon his or her academic freedom.

It is unfortunate that we have become accustomed to use the term “research days” – which, by the way, is not to be found in the Collective Agreement – as a convenient but demeaning moniker for what that document calls “twelve working days on full salary in each academic year for research and scholarly activities relating to library science or an academic subject within [a librarian's] expertise.” (17.A.2.5) The entry of this term into common usage has contributed to a general perception that Article 17’s provision for time given over to research is somehow an add-on, accessory or perquisite, when in fact research is an essential component of our work. This is precisely the attitude that our hard-won provision for research time was meant to dispel.

As I see it – and I speak solely from my Canadian experience – some academic libraries have not yet developed or have not fully developed a culture of research. That goal can only be achieved by creating work environments and job expectations that are not so demanding as to discourage librarians from considering research and creative scholarly contributions, or from thinking that such pursuits could be an integral part of their “regular” working day. A strong faculty association and a Collective Agreement with guts are two other important factors in furthering librarians’ participation in academic research.

I have often heard from librarians at this and other universities that they are too busy just coping with their job even to contemplate doing research. That is why I think it vital to focus on fostering research rather than devising methods to contain or curtail it. It is part of moving away from what I call the “No” school of librarianship, the kind of passive-aggressive impasse where – I speak figuratively – it is illegal to make liquor privately or water publicly. If any more guidelines are to be written for us librarians, let them elaborate on how we can open up the taps of creativity, improve our working conditions, provide better service, and be more rounded scholars and professionals.

Hard-to-reach, hard to research

From a public health perspective, who are the hard-to-reach and how can we find research articles about them?

I was asked this question by a manager in the Winnipeg Regional Health Authority. He was looking for research specifically on immunization programs for the hard-to-reach as part of the WRHA’s ongoing preparation for the expected H1N1 epidemic. In order to assist my client, how was I to construct a search strategy in PubMed and other databases that would gather disparate materials together without a comprehensive catch-all subject heading?

Finding appropriate literature is just one of many challenges associated with conducting research on hard-to-reach populations. In the first place, how do we identify and sample certain groups of individuals for health research? Undoubtedly some populations are particularly vulnerable and difficult to contact. Other populations may be defined by characteristics such as ethnicity or sexual preference that are not recorded in routinely available data sources. Yet while the need for research on the hard-to-reach is pressing, a comprehensive definition of this population is lacking, and hence it is difficult to get one’s bearings.

Before creating my search strategy, I had to do some research of my own in order to get a handle on exactly the groups that I would be investigating.

Defining the hard-to-reach

What exactly is meant by ‘hard-to-reach’ is a matter of some debate. The term is inconsistently applied. It will sometimes be used to refer to minority groups, such as immigrants, LGBT people, or the homeless; it can be used to refer to ‘hidden populations’, groups of people who do not wish to be found or contacted, such as illegal drug users or gang members; at other times it may refer to broader segments of the population, such as the elderly, or young people, or people with disabilities. In the service context, hard-to-reach often refers to the underserved, certain minority groups, those slipping through the social safety net, and those who are deemed to be ’service resistant’.

Yet another term used in this context is ‘hidden populations’, meaning those who are hidden from the point of view of research sampling. Hidden populations may also actively seek to conceal their group identity, as for example in the case of sniffers, injection drug users, LGBT people who are in the closet, sexually active teens, etc.

The hard-to-reach are also called the ’seldom heard’. The use of this term indicates that these are people who do not have a collective voice and are often under-represented in consultation and involvement activities about developing services. ‘Hard-to-reach’ suggests that there is something that prevents their engagement with services. ‘Seldom heard’ emphasizes the responsibility of agencies to reach out to excluded people, ensuring that they have access to social care services and that their voices can be heard.

One of the chief difficulties in defining the hard-to-reach is the unintentional imputation of a homogeneity among distinct groups that does not necessarily exist. Or it may imply that the problem is one within the group itself and not within the approach. Attempts at categorization can have a stigmatizing effect. Hard-to-reach audiences have, with varying degrees of prejudice, been called obstinate, recalcitrant, chronically uninformed, disadvantaged, have-not, illiterate, dysfunctional, and information poor.

Associative and Nonassociative

In addition to these various ways to categorize the hard-to-reach, we can distinguish between ‘associative’ hard-to-reach populations, such as people at risk of AIDS, and ‘nonassociative’ hard-to-reach populations: those whose members do not normally have contact with other members.

Nonassociative populations share two primary characteristics. The first is demographic. There is no effective centralized information about them, and a large proportion of their members do not know each other. The second is that their members share characteristics or attributes that make it important for health and human services to have information about them to inform service planning, policy, and delivery. In addition to these features, they are often low-frequency populations, and they might be subject to stigma of various kinds.

There has been a large amount of research on associative hard-to-reach populations, those whose members are socially networked with each other and form a community (with literally thousands of studies being done on populations at risk of HIV and AIDS, such as injection drug users) – but there have been very few rigorous studies of nonassociative populations, particularly those that are less in the public eye, such as shut-ins.

The central focus of my search strategy was to gather together information precisely on these nonassociative populations. I was looking for groups defined by individual attributes (such as health or social status) where there is often no overriding reason for within-population socializing and where a substantial proportion of population members do not have strong social links with other members and, indeed, might even resist such contact. These hard-to-reach groups must be taken into account in immunization planning. No effective H1N1 prevention strategy can exclude them.

After much effort I decided to include the following in my search strategy:

1. The homeless, the marginally housed, street people, and sex trade workers
2. Shelter residents (including women and youth)
3. Inmates in the correctional system (the incarcerated, parolees, the recently released, and those in half-way homes)
4. Persons with serious and persistent mental health issues, including dementia or addiction
5. Housebound persons (cystic fibrosis, arthritis), shut-ins, and the disabled
6. The linguistically isolated (people with communication impairments, recent immigrants who are not fluent in English or French)
7. Selected recipients of Family Services and Housing (employment income assistance, government housing, children in care)
8. Miscellaneous nonassociative groups (transients, the uninsured, the socially isolated)

PubMed Search Strategy

Here, finally, is the strategy I employed for my PubMed search:

(“Immunization”[MAJR] OR vaccinat*[TI] OR immuniz*[TI] OR immunis*[TI] OR “Immunization Programs”[MAJR] OR “Immunization Schedule”[MAJR] OR “Influenza, Human/prevention and control”[MAJR] OR “unvaccinated population”)

AND

(hard-to-reach OR “seldom heard” OR “hidden population” OR “hidden populations” OR homeless OR homelessness OR  “Homeless Persons”[MAJR] OR “Transients and Migrants”[MAJR] OR “Housing”[MAJR] OR “Prostitution”[MAJR] OR “sex trade workers” OR migrant OR vagrants OR “street worker” OR “street workers” OR “street people” OR “street youth” OR “street kids” OR “street children” OR “street involved” OR “unstable housing” OR shelters OR “shelter residents” OR (marginally[TIAB] AND housed[TIAB]) OR under-housed OR “marginalized population” OR “marginalized populations”

OR “Emigrants and Immigrants”[MAJR] OR “Refugees”[MAJR] OR “recent immigrants” OR “recent immigrant” OR “undocumented immigrant” OR “undocumented immigrants” OR “illegal immigrant” OR “illegal immigrants” OR emigres

OR “Vulnerable Populations”[MAJR] OR “Poverty”[MAJR] OR “Poverty Areas”[MH] OR “Social Class”[MH] OR “Socioeconomic Factors”[MH] OR “Urban Population”[MH] OR welfare OR underserved OR “underserved areas” OR “high-risk inner-city” OR socially-at-risk OR “at-risk population” OR “at-risk populations” OR slum OR slums OR ghetto OR ghettos OR favela OR favelas OR “low-socio-economic” OR disadvantaged OR low-income OR impoverished OR uninsured OR underinsured

OR “Prisoners”[MAJR] OR “Prisons”[MAJR] OR incarcerated OR incarceration OR “corrections facility” OR “correctional facilities” OR  “correctional population” OR prisoners OR probation OR probationers OR probationary OR parole OR parolees OR inmates OR “half-way house” OR “half-way houses”

OR “Drug Users”[MAJR] OR “Substance Abuse, Intravenous/psychology”[MAJR] OR “drug users” OR addicts OR addicted OR “drug addicts” OR “substance abuser” OR “substance abusers”

OR deaf[TIAB] OR “Hearing Impaired Persons”[MAJR] OR “Social Isolation”[MAJR] OR “low literacy” OR “language isolated” OR (linguistically[TIAB] AND isolated[TIAB]) OR homebound OR shut-in OR shut-ins OR “disabled persons”[MH]

OR “Mentally Ill Persons”[MAJR] OR “mentally ill”)

References

1. Brackertz N. Who is hard to reach and why? ISR working paper 2007. SISRQ/EL 06.07Institute for Social Research (Australia) [online]. Available from: www.sisr.net/publications/0701brackertz.pdf

2. Southern DA, Lewis S, Maxwell CJ, Dunn JR, Noseworthy TW, Corbett G, Thomas K, Ghali WA. Sampling ‘hard-to-reach’ populations in health research: yield from a study targeting Americans living in Canada. BMC Med Res Methodol. 2008 Aug 18;8:57. PubMed PMID: 18710574

3. Stewart M, Makwarimba E, Barnfather A, Letourneau N, Neufeld A. Researching reducing health disparities: mixed-methods approaches. Soc Sci Med. 2008 Mar;66(6):1406-17. Epub 2008 Jan 14. PubMed PMID: 18248867.

4. Thompson S, Phillips D. Reaching and engaging hard-to-reach populations with a high proportion of nonassociative members. Qual Health Res. 2007 Nov;17(9):1292-303. PubMed PMID: 17968045.

Would Nietzsche have taken Prozac?

My existence is a dreadful burden: I would have rejected it long ago, had I not been making the most instructive experiments in the intellectual and moral domain in just this condition of suffering and almost complete renunciation — this joyous mood, avid for knowledge, raised me to heights where I triumphed over every torture and all despair.  On the whole, I am happier now than I have ever been in my life. And yet, continual pain; for many hours of the day, a sensation closely akin to seasickness, a semi-paralysis that makes it difficult to speak, alternating with furious attacks (the last one made me vomit for three days and three nights; I longed for death!). F. Nietzsche, Letter to Dr. O. Eiser, January 1880

Would Nietzsche have taken Prozac? The intensity and frequency of his migraine attacks would certainly make him a candidate for modern preventive therapy. [1] Virgina Woolf, Miguel de Cervantes, Lewis Carroll, and Peter Tchaikovsky might also be given the nod. According to a review article published in the May 2009 Mayo Clinic Proceedings [2] preventive therapies are commonly underused in patients who may be appropriate candidates and who may benefit from treatment. The American Migraine Prevalence and Prevention survey states that 38.8% of migraineurs “should be considered for preventative treatment.” However, the Mayo Clinic article makes no mention whatsoever of Prozac and goes on to praise the anticonvulsant topiramate for headache prevention.

There seems to be a great deal of confusion about the best preventive medications for migraine. Prozac (fluoxetine) is just one of many drugs that have been and are being tried on suffering patients, everything from feverfew to ergotomine to botulinum toxin. Research is ongoing, of course. But despite gaps in the literature and promising evidence for some of the competition, Prozac is commonly prescribed for migraine prophylaxis. [14] A little casual investigation reveals that hard evidence to support its use is, in fact, lacking. Moreover, what evidence there is comes from a few studies done more than a decade ago.

The two most relevant Cochrane reviews are inconclusive. Cipriani, et al. (2005) found statistically significant differences in terms of efficacy and tolerability between fluoxetine and certain other antidepressants, but concluded that the clinical meaning of these differences was uncertain and that no definitive implications for clinical practice could be drawn from them. [3] Moja, et al. (2005) found that selective serotonin re-uptake inhibitors (SSRIs) like Prozac were no better than placebo for preventing migraine. [4]

One of the leading headache textbooks, the aptly named Wolff’s Headache, takes no heed of the Cochrane information and confidently asserts the prophylactic efficacy of Prozac. The studies it cites are from the early 1990s. [5,6,7] Curiously, in its own review of Prozac for migraine prevention, the US Headache Consortium cites completely different studies from the same decade. [9,10] The Consortium’s guideline [8] cautiously approves the use of Prozac based on some favourable outcomes from the cited studies.

Borkum’s Chronic Headaches (2007) barely mentions fluoxetine prophylaxis. [11] Another text, Migraine and Other Headache Disorders (2006) merely nods in the direction of SSRIs, [12] admitting that the mechanism by which antidepressants work to prevent headache is uncertain (p. 319). The editors of The Headaches (2006) also make a brief mention of the 1994 Saper study [7] which “found fluoxetine 20 to 40 mg/d more effective than placebo in the last month of a 3-month study.” [13] In his chapter on chronic migraine in Advanced Therapy of Headache (2005) Silberstein asserts that Prozac is “coming into wider use for daily headaches” (p. 104). [14]

But here is the summary from BMJ Clinical Evidence:

Compared with placebo SSRI antidepressants may be no more effective at reducing headache symptoms (very low-quality evidence).

Compared with amitriptyline We don’t know whether SSRI antidepressants are more effective at reducing headache duration (very low-quality evidence).

I could go on …

So why is Prozac being prescribed to thousands for relief of their migraine headaches? Beats me. Especially when harms associated with the use of Prozac are well described. (See the alerts published on the FDA website.) What would Nietzsche do?

David Healy’s warning is still relevant:

Since the development of anesthesia, physicians have been prepared to do harm to a few patients in order to benefit a majority of patients. The de facto Hippocratic Oath has always been: Do no harm to a majority of your patients. In the case of the SSRIs, the clinical trial evidence indicates that we may benefit some patients. None of this evidence shows us what proportion of patients benefit from SSRI treatment and what proportion are harmed by it. In the case of anesthesia, much less than 1% of takers are at risk. In the case of the SSRIs, there is a serious risk to far more than 1% of takers, but neither society nor the psychiatric profession has expressed a view as to what constitutes an acceptable minority of harmed patients. [15]

References

1. Hemelsoet D, Hemelsoet K, Devreese D. The neurological illness of Friedrich Nietzsche. Acta Neurol Belg. 2008 Mar;108(1):9-16.

2. Buse DC, Rupnow MF, Lipton RB. Assessing and managing all aspects of migraine: migraine attacks, migraine-related functional impairment, common comorbidities, and quality of life. Mayo Clin Proc. 2009 May;84(5):422-35.

3. Cipriani A, Brambilla P, Furukawa T, Geddes J, Gregis M, Hotopf M, Malvini L, Barbui C. Fluoxetine versus other types of pharmacotherapy for depression. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004185.

4. Moja L, Cusi C, Sterzi R, Canepari C. Selective serotonin re-uptake inhibitors (SSRIs) for preventing migraine and tension-type headaches. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD002919.

5. Silberstein SD, Lipton RB, Dodick DW. Wolff’s headache and other head pain. 8th ed. New York: Oxford; 2008. p.353.

6. Bussone G, Sandrini G, Patruno G, et al. Effectiveness of fluoxetine on pain and depression in chronic headache disorders. In Headache and depression: serotonin pathways as a common clue (G Nappi, G Bono, G Sandrini, et al., eds), pp. 265-272. New York, Raven Press;1991.

7. Saper JR, Silberstein SD, Lake AE, et al. Double-blind trial of fluoxetine: chronic daily headache and migraine. Headache 1994;34:497-502.

8. Ramadan NM, et al. Evidence-based guidelines for migraine headache in the primary care setting: pharmacological management for prevention of migraine. US Headache Consortium. Available from: http://www.aan.com/professionals/practice/pdfs/gl0090.pdf

9. Adly C, Straumanis J, Chesson A. Fluoxetine prophylaxis of migraine. Headache. 1992;32(2):101-104.

10. Steiner TJ, Ahmed F, Findley LJ, MacGregor EA, Wilkinson M. S-fluoxetine in the prophylaxis of migraine: a phase II double-blind randomized placebo-controlled study. Cephalalgia. 1998;18(5):283-286.

11. Borkum JM. Chronic headaches: biology, psychology, and behavioral treatment. Mahwah NJ: Lawrence Erlbaum; 2007.

12. Lipton RB, Bigal ME. Migraine and other headache disorders. New York: Informa Healthcare; 2006.

13. Olesen J, Goadsby PJ, Ramadan NM, Tfelt-Hansen P, Welch KMA. The headaches. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2006.

14. Silberstein SD. Chronic migraine without medication overuse. In, Purdy RA, Sheftell FD, Rapoport AM, Tepper SJ. Advanced therapy of headache. 2nd ed. Hamilton ON: BC Decker; 2005.

15. Healy D. Let them eat Prozac. Toronto: James Lorimer; 2003. p. 380