Grand Rounds

Grand rounds are one of the more esoteric bits of medical education, often involving some sort of free lunch and maybe a case presentation or a journal article.

In blog terms ground rounds is "a weekly rotating carnival of the best of the blogosphere." Each Tuesday a different health-related blogger gathers together other health-related blogs and gives a brief description and a link for each of them. A recent grand round was held on the Path Talk blog. The blogs are written by health workers, and the target audience is "educated but non-medical readers". The purpose is introducing people to the world of medical blogs. As with many things, the focus is American, but if you're looking for a blog on health topics, Blogborygmi (don't ask - I don't know) and Grand Rounds is the place to start.

If you've ever wondered why doctors blog, you're not alone. In fact, a quick Google search shows that nurses, physiotherapists and pretty much everyone else is at it too. Even patients are in on the act. Is this a good thing? Some doctors are concerned that it's not helpful for parents, for example, to include in their blog details of medical care and decisions around care received by their children. But blogs can be a good way to find out how people feel about their treatment and how they experience illness. That can be helpful for those providing care, and for others experiencing the same illness. Whether you've got cancer, hypochondria or a passion for knitting, if you've got internet access you'll never be alone.

(c) creative commons attributed

What's the magic word?

It's a pain, isn't it? You sit down of an evening, or a Sunday afternoon, thinking you'll do a literature search to find some papers to keep you up to date, support patient care, help with writing that essay or guideline. You're all settled, cup of tea by your side, maybe a chocolate biscuit or two. You go to the website and you think OH NO!!! I've forgotten my Athens password! Who you gonna call? Well, the library staff aren't there...so that means you just have to do something else, wait until the library opens, call, get a new password...and by then you've probably gone off the whole idea.

Fret not - there is another way. You can now go to My Athens, click on the "login help" link below where you would enter your username and password, click on "reset your Athens Password" under "forgotten passwords" then enter your username and email address.

Your username is the one that starts nhs, includes your initial and surname, and ends with some numbers. If you've forgotten that then you will need to contact us for a reminder.

The email is the one you put on the form when you registered. This is the address to which an email will be sent with instructions for changing your password. It will not work, therefore, if you registered with an email address that you have since abandoned. Nor will it work if you were sloppy in your typing of the email address, or if you typed in the wrong address. I've seen various versions of Essex Rivers email addresses - essexrivers.co.uk, essexhospital.nhs.uk, essex.nhs.uk, essa.essexrivers...and that's without the typing errors, the last name before the first name, first name appearing as an initial only... If you work for Essex Rivers your email looks like this - firstname.lastname@essexrivers.nhs.uk

If your email address is correct you will be emailed a link and be able to submit a new password. If you think your email address may be wrong then go to My Athens , click on My Account and fill in the boxes to change your email address. Go on - do it now, before you forget your password!

(c) creative commons attributed

Tea for two

Two is the number of the moment. It started with web 2.0. Roughly this is the idea that moved us from programmes and functions that were bought (expensively) and installed on a particular physical PC to things that can be obtained freely, shared and accessed at whichever PC you are sitting at. The buzzwords are "social" and "personal" - social because you can share your bookmarks, pictures or thoughts, personal because you can personalise everything to suit you.

After web 2.0 came library 2.0. Despite the bun, tweeds and pearls image that librarians angst about so much there is a sizeable part of the library community that is really rather techie. Libraries were early on the bandwagon of websites, intranets, blogs and wikis. The point f library 2.0 is meeting those we serve (that's you!) in the spaces where you like to hang out - it's about being customer-centred.

Now we're awaiting the coming of search 2.0. This will be the new way to search from the National Library for Health. It will mean all your Athens resources in one handy place.

So the first question is WHY? You've probably spent ages growing used to Dialog Datastar (the current "front end" for Medline, Cinahl et al) so why are we asking you to use something new?

The idea is that the suppliers of databases and search technology change from time to time as contracts expire. Future contracts will be with firms who will work with search 2.0. So search 2.0 will change, evolve, improve, make use of new technology as it comes along, but will remain fairly stable in the way it looks because it wont have to present the corporate face of Ovid or Dialog or whichever other supplier is used. Books and journals will be included in the search, and local resources as well as national ones.

The other big benefit should be that because it is partly "in house" plenty of notice should be taken of what librarians want from the search - and that means us passing on what you, the user, wants. So if you have a bright idea or a gripe or a niggle, let us know. After all, search 2.0 is all about you.

(c) creative commons attributed

The proof of the pudding

The Lancet today reports that a "collaborative reanalysis" of epidemiological studies "shows beyond doubt that ovarian cancer can be prevented by the long term use of different generations of oral contraceptives." (Full text free with your Athens password!) In simple terms this means that if you take an oral contraceptive pill you are less likely to get ovarian cancer.

The point that interests me here is the way in which this conclusion was reached - not by doing any trials or studies, but by reading existing studies. The authors looked at epidemiological studies that included over 100 women. They defined what was meant by "ovarian cancer" and "oral contraceptive use". They looked at the figures they had and used them to come to wider conclusions than could be reached from any one study alone. Their findings are expressed using confidence intervals and there is an awful lot of statistics in the paper.

In health research there are levels of evidence. These range from (at the bottom) "expert opinion" to "systematic reviews". A systematic review is the gold standard of evidence. Like the Lancet paper it gathers together a number of studies - Randomised Controlled Trials - selects those that fall within defined limits, and using a "meta analysis" of the data attempts to draw wider conclusions than can be drawn from one trial alone.

If this is confusing, don't despair. There is plenty of help available, starting with a veritable mountain of books. One of the best for a straightforward accessible read, covering all the types of evidence and how to look for them and assess them, is Trisha Greenhalgh's How to Read a Paper, now in its third edition.

There are very specific books: Chalmer's Systematic Reviews, Systematic Reviews in Healthcare by Glasziou, and Systematic Reviews to Support Evidence-Based Medicine from the Royal Society of Medicine Press.

There are general books on understanding research: Studying a Study and Testing a Test, Reading Research, Bandolier's Little Book of Making Sense of the Medical Evidence.

There are endless titles on reading and understanding statistics, and evidence-based practice. Your local NHS library is, of course, the best place to start looking.

Online, CASP has tools to help you appraise a systematic review and randomised controlled trials. The Centre for Evidence-Based Medicine has tools to help you understand the maths and the jargon.

If you want to find systematic reviews the place to look is the Cochrane Library.

As to whether the lowered risk of ovarian cancer outweighs the increased risk of breast, cervical or thyroid cancer...in this post, at least, I'm not even going there.

(c) creative commons attributed

Bookmarks

Bookmarking is a way of making a quick link so you can find a website again without having to remember the URL or Google for it every time you want it.

When you are in Internet Explorer, for example, there is an option to bookmark a site or "add to favourites". If you bookmark lots of sites then you can subdivide your list of favourites into folders.

This is fine until you find yourself at another PC - because you are in the library, or at home, or in an Internet cafe. At that point your bookmark is stuck there on another PC and you have to Google for the website you want.

One solution is social bookmarks. This is a way of using (usually) free software to make bookmarks that are then stored on the Internet, rather than on a specific PC. That means you can access them wherever you happen to be. It also means you can share them with your friends or colleagues.

Online bookmarks can also be subdivided, although you use "tags" - descriptive labels - rather than folders. You can look at other websites that other users have tagged with tags you use to see if you can discover more sites of interest. You can also put a gadget on your toolbar that you can bookmark sites you visit in one click.

The library website uses one of these social bookmarking systems - del.icio.us - to make up a set of quick links. I just set up a link once to each page of tags and I can change the bookmarks on the pages as often as I like without having to update the library website each time. You'll find more social bookmarking facilities listed on Phil Bradley's very handy website.

Gadget users are a fickle lot, and I've got bored with del.icio.us. I forget to go and look for the things I've put on there, I forget to update. I'm now adding bookmarks to my iGoogle page. That means they are to hand whenever I'm on the Internet and I don't have to remember an extra password. I can organise them using labels and I can add a site fairly quickly to my bookmarks. As I'm starting from scratch again I don't have many bookmarks. I have yet to find a gadget that stops me bookmarking so many things that it starts being quicker to Google for a site than trawl through all my bookmarks....

(c) creative commons attributed

Brought to book

I realised recently that I've not really blogged about books. Good as web stuff is, the age of books is not yet over.

There are electronic and online books (your Athens password gives you access to a collection of mental health and WHO titles), but a lots of people still prefer to read the old fashioned sort. Over the last ten years this library has loaned out more and more books year on year. Perhaps that shows that more people are interested in keeping up to date or life long learning. Perhaps its because medical publishing has improved, producing attractive paperbacks with good illustrations, and responding to hot topics faster than before.

We used to have an online catalogue on the intranet, but it broke, and I couldn't fix it. We currently share an internet catalogue with our partner libraries across the region. It's not updated that often, and wont tell you if something is out on loan, but is gives you a taste of the kind of books you'll find in your local NHS library.

If you like books you'll love Amazon. If you sign in each time you use it then it will eventually start to form an opinion of what you like and recommend more of the same. Sometimes this works better than others, but it's a useful way of finding out about books new and old that you might not otherwise stumble upon. The reviews are useful as they are written by readers who have bought the books, rather than the publishers who are trying to sell them. One of my favourite aspects of the service is "search inside" which shows you the first and last few pages of some books. It can be useful way of deciding whether or not you want to buy.

Don't let Amazon make you feel obliged to spend all your pennies. Do what I do - get Amazon to recommend something and then borrow it from your library!

If you do succumb to temptation and buy books, how do you keep a track of them all? Some of us stick them on shelves, or in piles by the bed and the loo, and hope for the best. Does anyone keep a card catalogue system for their personal collection? The technically minded head for LibraryThing where you can list everything you own. Like Amazon it offers reviews, recommendations for further reading and chat about each book. I have to say this works better with books that lots of people have listed and that's more likely to be the latest Nigella Lawson than the latest anatomy book.

The other way to find useful books is to visit the websites of major publishers. Blackwell produces the ABC and Lecture Notes series, Radcliffe is very good on primary care and education, Oxford University Press does the Oxford Handbooks and Core Texts, Whurr is good for nursing, psychology and therapies, Pastest for Royal College Exam books, RCPsych (formerly Gaskell) for mental health, Jessica Kingsley for learning disabilities, and the giant Elsevier group for nursing.

Of course, there are those who feel they can get by in life without ever reading a book. Sir William Osler once remarked "It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it." Some doctors are prescribing books for their patients, perhaps thinking of Charles de Secondat who wrote that "I never knew any trouble that an hour's reading didn't not assuage." Or, in the less elevated words of Groucho Marx - "Outside of a dog, a book is a man's best friend. Inside of a dog it's too dark to read."

(c) creative commons attributed image 1 image 2 image 3 image 4

The wise child

News comes from the Times of a woman who is pregnant with her eighth surrogate child - a baby she is intending to carry to term and then give away to someone else. Depending on the arrangement it is possible that she will never see the child again.

The couple receiving the baby must be delighted - a real baby of their own. The genetic parents are likely to be themselves or one of them plus a donor, who might be the surrogate. They know who the surrogate mother is, and when their baby is coming. Perhaps they could have adopted, but babies aren't often adopted at birth, and then who knows who or what the parents are?

As for the surrogate mother - she is surely an angel, selflessly having babies for other people when she has none of her own. According to The Times she doesn't have a partner, and has never been in love, she is overweight and has had gastric banding, she suffers from depression. Is this a woman who needs care and help for her mental health issues? Is she a fit person to carry children for others? Is the organisation that arranged the surrogacy exploiting an unwell and unhappy person? She will gain £12,000 for carrying the child - what does she stand to lose?

Pregnancy is not without its risks. This woman has been through seven pregnancies already, which is bound to take a toll on her physical health. She is in her forties - an age at which some doctors feel it is unsafe for women to attempt pregnancy. How will the parents-to-be feel if this woman dies giving birth to their child? Or if the child itself dies? Or if the woman, falling into depression again, commits suicide - something she has already attempted. And what if this time the surrogate turns this into one of the 2% of surrogacy arrangements that end with the birth mother refusing to give up the child?

One person ( a man) commenting on this story condemns surrogacy as a "barbaric practice". He says mother and child will suffer trauma from being separated at birth and that this woman must be using "serial pregnancy" to fill the gap left by those seven missing children.

Others comments call surrogate mothers "selfless" women who give childless couples the child they long for. One suggests that as most MPs have children they can't know what it is to be childless and therefore are not fit to legislate on this matter. Does anyone have an absolute right to have a child, whatever the costs involved for others? Is it possible to live happily without children?

The BBC ran a story this month on twins who married each other, having been adopted as babies and never realising the true cause of their strong attraction. As family relationships - through multiple marriages and partnerships, surrogacy, IVF and so on - become more complex is it inevitable that individuals will suffer more problems? Or does infidelity and informal adoption mean that we're at no greater risk now than before of not knowing who our true parents are? They say it's wise child who knows his own father. Does it matter, except in terms of the new imperative to know our genetic history to predict our health?

One interesting take on surrogacy is the novel The Handmaid's Tale by Canadian author Margaret Atwood. It's set in a future where there are two classes of women - the rich, married and infertile and the fertile women whose job is to breed on their behalf.

What is the answer? Should we be more fluid and accepting of unusual family relationships, and perhaps relax the kinship laws that forbid some marriages, to allow people such as the twins to marry? Do we need artificial wombs or other scientific and technological advances to allow us to create as many children as we want? Do we need to change our attitudes to childlessness? Or to children?

Perhaps that's another definition of "ethics" - those questions for which there is no clear answer! And you know where to find more stories to spark ethical debate.

(c) creative commons attributed

A rose by any other name....

When you do the housework do you vacuum the floor or Hoover it? If you want to make a note do you reach for a ballpoint pen or a Biro? When you scribble a prescription are you prescribing ibuprofen or Nurofen?

Some brand names just stick, they become part of the language. Perhaps with drugs the reason that happens is that brand names are snappy names for marketing, while generics often fail to trip of the tongue. When sildenafil can be marketed generically I am sure we will all still be calling it Viagra. It's easier to say, easier to spell, and the word has passed into the collective consciousness through endless acres of newsprint and hours of TV coverage.

A commons public accounts committee thinks that GPs are too ready to write a brand name instead of a generic, bumping up the cost of pills and potions handed out each year to £8.2billion. As I drove to work this morning suggestion was made on the Today programme that the true cost of prescription drugs should be printed on packets for patients to see, to help them be aware how much the NHS is paying for them. On the one hand this might stop people collecting prescription drugs and then not bothering to use them. On the other, according to the programme, some people might press their GP for pricier brands believing they are better. We're used to thinking that generally speaking a £50 bottle of Bolly is nicer than a £3.99 supermarket own brand cava, that Harrod's cashmere is softer than Matalan's. Who is going to believe that they aren't just being fobbed off with five pounds worth of cheap pills when their friend has pills that cost £40 a packet?

The issue of generic versus branded is a problem elsewhere. Organisations like Oxfam campaign for developing world countries to be able to use cheaper generic drugs to treat their citizens. Drug companies feel that they should be able to use a patent to allow them to make money from their inventions, in which they have invested heavily. They say that if this didn't happen they wouldn't be able to afford to research and develop new drugs, and we'd all suffer. In the meantime, can it be right that they charge the NHS so much during the patented period when the market is, to all intents and purposes, a monopoly.

Oddly I've not been able to find anything from the pharmaceutical companies explaining why patents are important although I note that firms such as Novartis have information on ethical marketing practices and codes of conduct. These seem to focus on the way drugs are promoted to those who will prescribe them.

Eliminating the impossible

Counterknowledge. No - not a new word for arithmetic, or the things you need to know to be a successful shop assistant. Counterknowledge, according to Damian Thompson, is "misinformation packaged to look like fact." Apparently we are a gullible bunch and can be persuaded that all sorts of things are true, and it can be blamed on muddled gathering of evidence.

Thompson tells us that counterknowledge is behind conspiracy theories from Dan Brown to Diana, but also exists in health. Everything from belief in the usefulness of fad diets to a fear that MMR causes autism might be defined as counterknowledge.

Half truths work best when based partly on truth - there has to be a grain of credibility to start with. The best urban legends are always stories that happened to someone that you have some connection with. The story teller will also assure you it must be true because it happened to their next door neighbour's best friend's cousin. Even hoax emails tend to be prefaced with "my friend at BigCorporationBank sent this to me" or are apparently originated by a bigwig at Microsoft, Hotmail or elsewhere. We feel better disposed to trust something that comes from a source that is known to us.

Sometimes we believe because we want to hope, especially when we are sick. We want to believe that Aloe Vera, omega 3, coenzymes and carrot juice cure cancer if the alternative is to believe that we are going to die.

Health professionals are not immune to being hoaxed. We must all think as we read and question what we hear. I've mentioned CASP before, which helps you ask questions around evidence you find. The other important thing is to take care where you collect your evidence from. The National Library for Health, Intute, PatientUK, reputable charities are all a better start than the open web for good quality information - clean, clear knowledge. Oh - and did I mention that libraries can look for quality information for you and your patients?

(c) creative commons attributed

Stop thief!!

The Daily Telegraph has an interesting headline today - "Organs to be taken without consent." The article looks at the concept of "presumed consent" which means we assume that everyone wants to donate their organs at death unless they specifically say otherwise. After all, 90% of people, when asked, say they'd be happy to donate. At present we assume that no one wants to donate organs unless they specifically say so, and 40-75% of relatives refuse to allow organs to be taken when a family member dies.

The article moves on with some more emotive language. Patients' groups, it says, claim the plan will "take away patients' rights over their own bodies." The article plays on people's fears that sinister doctors will be whipping livers out of people before they are actually dead in order to pass them on to people awaiting organs.

There are two issues here. One is the way in which newspaper editors choose to present a story. The Telegraph wasn't alone in having a screaming headline on this. The Mail also chose to present it as a story of organs being taken without consent. The leading article in today's Independent claims that 1,000 people die each year waiting for a transplant, so the headlines could just as easily have read "Government to save 1000s from death."

The other strand here is around the ethics of consent. Consent has its difficulties, ethics are a complex. Neither is helped by knee jerk reactions and emotive language.

Yesterday's Independent on Sunday ran an article claiming that huge increases in the call for donations are due to binge drinkers destroying their livers and kidneys of the obese being damaged through the complications of diabetes. George Best received a liver to replace one damaged by drink. Should he have been given that liver? Are some people more deserving of new organs than others?

If we don't have enough organs to go around, how can we find more? One option being looked at is xenotransplantation - using organs from animals, including pigs. There are health risks involved - perhaps some that will only come to light too late. There are more ethical questions - is it right to breed pigs as if they were spare part factories for people, rather than animals in their own right?

Then there are artificial organs, including artificial hearts. Surely no ethical problems here? Perhaps the question edges into philosophy. If I have "bionic" limbs, and several artificial organs, to what extent am I still a human being, to what extent some sort of machine or robot? How much of the physical entity of "me" can be removed before I stop being "me"?

Part of the question around organ donation is to do with the ways in which we view death and what, if anything, happens to us after death. Will the dead be raised incorruptible? Is a dead body still the person we love? I can imagine that if I lost someone close to me I might want to sit with them for a while, growing accustomed to the fact of my loss. Those are precious minutes, hours, during which harvestable organs are deteriorating. If they were still on a life support machine could I really bear to have the organs removed when their heart was still beating, their lungs still breathing. What exactly is death?

UK Transplant has questions and answers on organ donation. Student BMJ, the World Health Organisation and the Nuffield Council on Bioethics all provide starting points for thought and discussion on this difficult topic.

(c) creative commons attributed

Blogroll

Suddenly there are a number of issues I'd like to post about. Rather than blather on at length about all three here's a quick posting on other places to visit in the blogosphere.

The Lancet has a blog looking at a range of health issues, from online early release of papers to press conferences. (Did you know - a listing on a blog of other recommended blogs is known as a blogroll.)

Blogs I've previously mentioned here are the Food Standards Agency blog and Ben Goldacre's entertaining and though provoking Bad Science blog. Intute has a health and life sciences blog and the BMJ has a rash of bloggers.

Blogs are online journals, diaries, ramblings, rantings and ravings. They might amuse, annoy, inform or mislead. One way to keep track of a number of different blogs is to subscribe to an RSS feed from the blog, where available. You can then set up a feed reader, such as Google Reader, subscribe through Internet Explorer if you have version 7.0, or use iGoogle and keep everything on your internet home page.

(c) creative commons attributed

C'mon, c'mon. I need an answer!

Towards the closing minutes of each episode of University Challenge Jeremy Paxman ups the ante by putting panels under pressure to answer as quickly as possible. Sometimes this pushes a team to greatness. Sometimes it results in spectacularly wrong answers, or a set of three straight "we don't know"s.

On the Today programme this morning the decision making of NICE was discussed. Apparently they make very good decisions but take forever over them - two years compared with four months for similar decisions to be made in Scotland. NICE, MPs say, should make decisions faster - we need an answer! (The Today programme website is not helpful. It gives no details of this discussion. Luckily the story is now on the BBC news website.)

When you look at how NICE make decisions it's no wonder it takes time - the process is lengthy and involves a wide range of organisations, as this example on how clinical guidelines are developed shows.

NICE does more than churn out guidelines. Each piece of guidance is accompanied by tables of evidence, search strategies, excluded studies, background information and patient leaflets. The patient leaflets carry Plain English Campaign crystal marks and are very good.

You can search for NICE guidance on their website or through the National Library for Health . The NLH search covers guidance from overseas, too.

NICE aren't the only ones issuing guidance. In Scotland there is the Scottish Intercollegiate Guidelines Network. Decisions about what drugs can be used are made by the Medicines and Healthcare Products Regulatory Agency. In the USA this job is done by the FDA - Food and Drug Administration.

MHRA focuses on benefits and risks, NICE tends more towards benefits and costs. Neither type of decision should be made in a hurry. When drugs are used or tested too early the results can be devastating - perhaps not immediately, but in the long term. Last summer there were concerns that diabetes drug rosiglitazone could cause heart problems. Other research considered a possible link between cancer and statins - the drugs that lower cholesterol.

Rush into a decision too soon and people could get hurt. Dither over a decision and people could die while you're at it. Either way Jeremy Paxman wont be there to say "too late! I'll tell you."

(c) creative commons attributed image 1, image 2, image 3

The book drop box is shut!

From time to time people stagger into the library, clutching books which they drop on the counter, saying "I tried to put these in the book drop box, but it's locked."

And they're right - it is locked. It gets unlocked just before we leave and we lock it again when we come in. Why do we do that?

Useful as the box is books tend to come out looking bashed and tattered. We like our books to look shiny and new. To limit the damage we'd rather they came upstairs to us.

We charge fines. Some of you hope that if you drop the books in the box we wont notice they are overdue. Librarians notice everything - and we keep notes. If you come on up and pay your debts immediately you get to leave with a clear conscience (and an empty wallet - but that's not our problem!)

From time to time you change your phone number or your email address and forget to tell us. Then you ask us for something and when we try to contact you we can't get hold of you. So if you come in we can hand over that paper you requested.

We like to see you! We're friendly folk in the library and we like to see people. Sometimes we might want to say something that didn't seem worth a phone call. We might want to point out a new book on the shelves or ask if you've seen a new website. We just like to say hello.

Apparently exercise is good for you. So go on - walk up the stairs! The book drop box is locked!

(c) creative commons attributed, image 1, image 2

Open the darned box!

I suppose some of you were too shy, or too busy, or wary of clicking strange links on the internet and so never found out what was in the box.

But the box is still there - so go on - take a look! See! It's full to the brim with online journals, brought to you by library elves. The BMJ is back, free, full text, online, for you. We're giving you the Lancet, Journal of Advanced Nursing, AMA Archives and the New England Journal of Medicine and much, much more.

All you need to do to gain access to this box of delights is sign up (if you haven't already done so) for an NHS Athens password.

Go on - treat yourself!

(c) creative commons

The library elves

Using a library is a bit like being a kid at home. There are always biscuits in the biscuit tin, clean clothes in your wardrobe and dinner on the table. It all happens as if by magic and you don't have to lift a finger or pay a penny for it. Marvellous!

It's not until you grow up that you realise that there isn't a dinner elf or a clean clothes fairy - it's all done by you poor hardworking mum. Later in life the same jobs are performed, perhaps, by your spouse, partner or flat mate, but the point remains the same. Dinner on the table doesn't just happen. Someone has to decide what to cook. trek down to the supermarket, prepare food, cook it, dish it up, wash up...

Having a library is somewhat similar. Admittedly we don't do your ironing for you or keep your larder stocked, but we do provide a lot of stuff that appears to you to miraculously materialise all on its own, for free, especially the bits you get online. However, most of that "free" stuff is bought and paid for either nationally, regionally or locally. There is a fair amount of admin work in the background to make sure you can access the bits you are entitled to, and not the rest. We check that Athens passwords are still valid, and issue new ones when you've lost yours. We compile and update spreadsheets of journals. We let you know what's new and what you can no longer access.

As with any domestic situation we can't please all the people all the time. In any family of four there will be at least four different favourite biscuits and the chances of finding them all in the biscuit tin at once are limited, because the biscuit budget doesn't stretch that far. The NHS family is HUGE and its tastes very varied, so we have to have metaphorical biscuits (journals) for doctors and nurses and physios and OTs and radiographers and managers and GPs and....

So next time you are looking in the biscuit tin please be aware that we couldn't afford all of your favourites because we had to think of the rest of the family. However, if you have a hankering for a particular journal article we will get it for you. Just fill in the form and ask. Easy peasy. It will materialise, apparently from nowhere, apparently for free. Marvellous! And while you're at it - spare a thought for the library elves.

(c) creative commons attributed image 1 image 2 image 3 image 4 image 5