Muir Gray in the BMJ has recently described the development of the National Library for Health.

Modern healthcare professionals have to resolve the information paradox; they are overwhelmed with information but cannot find particular information when and where they need it. The internet and its associated technologies, especially the world wide web, have the potential to both exacerbate and reduce these problems. Simply providing access to the world wide web per se may exacerbate the problems of information overload, since every web browser has access to hundreds of millions of pages of information. However, the cost effective provision of access to timely, current, and high quality information is what internet technology potentially offers. Creation of the (NeLH) is an attempt to harness internet technologies to solve this information paradox.

Internet technologies potentially provide the tools to solve the knowledge paradox. At the most basic level, the web browser and hypertext link provide easy to use tools to view documents and to move between them. Hypertext links allow rapid movement from document to document in a way that is not possible with printed material.

Key internet tools which will be available in the National Electronic Library for Health will be a web browser to view the internet, hypertext links between documents, search engines to find information, alerts to warn users automatically about new information, and personalisation to allow users to customise the website to suit their needs

The metaphorical architecture of the NeLH will comprise an atrium with help desks and virtual branch libraries, know how (guidelines and audit), knowledge (best current evidence), NHS Direct Online (information for patients), and knowledge management (training in better presentation and use of knowledge)

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Bandolier 62 examined a systematic review¹ of how exercise affects bone mass in postmenopausal women. It was disappointing, with only six studies and only two of those randomised. Another, better review has now been published, with many more studies, much more data, and with comprehensible and useful results.

The review had a comprehensive strategy to identify randomised and non-randomised controlled trials looking at the effects of training programmes on bone mass. Journals were also hand searched.

The length of the training programme had to be at least 16 weeks

Outcomes looked for were bone mineral density measured by established techniques, lumbar spine or femoral neck measurements because these are at risk of osteoporotic fracture and separate analyses for pre and post menopausal women

There were 34 randomised comparisons and 19 non-randomised in training programmes ranging from six to 24 months. The effects of training on bone mass at the lumber spine in 552 postmenopausal women was a one-year percentage difference due to training of 0.79% for endurance and strength training programmes. For 204 pre-menopausal women there was a 0.91% benefit.

The effects of training on bone mass at the femoral neck in 409 postmenopausal women was a one-year percentage difference due to training of 0.89% for endurance and strength training programmes. For 174 pre-menopausal women there was a 0.90% benefit.

In both cases, non-randomised studies produced an estimate that was roughly twice as large as for randomised studies. Data from non-random studies are not included here.

The bottom line is that exercise-training programmes prevented or reversed bone loss of almost 1% per year compared with the controls. The effects were consistent for the lumbar spine and the femoral neck. The variability in the results was seen mostly in the smaller trials, and the larger trials showed results consistent with the overall effect.

Another notable feature is that two systematic reviews published within about a year of each other looked at different groups of randomised trials. In part this reflected the later cut-off point for searching, with several studies published in the mid 1990s that were likely to have been missed by the earlier review. In part it reflects a much more comprehensive search strategy.

The result is important – yet another benefit of exercise for women’s health. Most of the exercises were somewhat more vigorous than a brisk walk and included treadmill walking and running, and some resistance and back strengthening exercise or aerobics, for instance. Taken together, these are also a useful teaching aid for critical appraisal.

There is also a cautionary tale here for reading systematic reviews. If the amount of information found is small, perhaps with a few trials and tiny numbers, then the chances of the review being correct is greatly diminished.

Another general truth emerging from this and many other reviews is that poor studies are more likely to be reported if they have a positive result.

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1597 adults over the age of 50 were surveyed by Age Concern England to find out if they felt they had been subject to age discrimination in health services.

When asked "Do you feel the NHS has ever dealt with you differently since you have been 50 or older?" 10% of all participants said yes. When asked "Have you ever been refused treatment on the NHS since you have been 50 years of age or older?" 3 % of all those surveyed said yes; 3 % of people between 50 and 64 said yes and 5% of people over 65 said yes.

These people were asked which NHS professionals had dealt with them differently or refused them treatment. GPs and family doctors were cited more frequently than any other group of professionals. Others mentioned included: hospital consultants, hospital doctors, other members of staff at GP surgeries, hospital nursing staff and other health professionals.

Issues raised were: refusal of treatment, waiting and delays, problems with specific conditions, indifference, refusal of an examination and lack of respect.

The General Medical Council's Code of Good Medical Practice states that: 'you must not allow your views about a patient's lifestyle, culture, belief, race, colour, gender, sexuality, age, social status, or perceived economic worth to prejudice the treatment you provide or arrange.

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Ref to King's Fund paper