What’s your target BP for ruptured abdominal aortic aneurysm?

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A couple of years ago I was very (very, very) peripherally involved in an RCT investigating the management of ruptured abdominal aortic aneurysm. The IMPROVE trial was well designed and reported it’s results in 2014. The abstract is shown below, and I must admit that to my surprise there did not appear to be a definable advantage to endovascular repair.

Anyway, this post is not about the trials results per se, rather we received a comment from Prof. Janet Powell on behalf of the trial investigators that may have relevance for those of us in emergency and critical care medicine. One of the great advantages of large trials is the ability to look through data to see whether other themes and associations become apparent and this is what the trial team have done. Such data analysis has risks, but it can be an excellent way of generating hypotheses for future research, and observational data can also help us stop and think about current practice.

I digress. Read the letter from Janet below and then share your thoughts. As an emergency physician this observation raises a myriad of questions about data, analysis, resuscitation targets, association vs causality etc. and whenever I start thinking I know I’m getting better. So please, read, think, learn and please debate. Janet asks how we can work together to resolve and explore these results and surely that’s an offer that the EM and surgical communities should grasp.

vb

S

 

Blood pressure targets for the elderly with bleeding and vascular emergencies

The IMPROVE trial is the largest randomised trial of a strategy of endovascular repair versus open repair for ruptured abdominal aortic aneurysm, with over 600 patients [1]. Nearly all these patients started their care pathway in the emergency department and detailed evaluation of this large cohort of patients has raised some discussion points relevant for those in emergency care.

When we started this trial, we recommended that patients were managed with fluid restriction and hypotensive haemostasis, with systolic blood pressure targets of 70-80 mm Hg, to prevent further bleeding and optimise outcomes. These recommendations were based on emergency care guidelines for patients with abdominal trauma and the opinions of some leading vascular surgeons [2,3]. Hindsight is a wonderful thing. The patients we enrolled had an average age of 76.7 years: were these blood pressure targets far too low for this age group who were likely to have other cardiovascular disease and high cardiovascular resistance?

Cohort analysis has shown that there was a linear relationship between lowest systolic blood pressure and mortality (Table 1) and suggests that in these patients a blood pressure target of 100 mm Hg might save more lives. Lowest systolic blood pressure was directly related to outcome in a linear fashion, with each 10 mm Hg increase translating into a 13% relative improvement in the odds of survival to 30-days [4]. 30-day mortality rates of <30% were only achieved in those in whom the lowest blood pressure was 100 mm Hg or more.

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Management of other aortic conditions, particularly aortic dissection, may similarly be disadvantaged by unrealistic blood pressure targets. For aortic dissection the rapid blood pressure lowering to <100mm Hg, which is recommended [5], comes mainly from evidence in turkeys.

How can we work together to get the evidence for appropriate blood pressure targets for the elderly population with bleeding and other vascular emergencies? The current observational evidence is not sufficient and the question needs to be addressed in one or more randomised trials.

Janet Powell for the IMPROVE trial investigators

 

References
1 Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial IMPROVE trial investigators BMJ 2014;348:f6771
2 Joint Royal colleges Ambulance Liaison Committee. Ambulance Service Clinical Practice Guidelines; 2006. www.jrcalc.org.uk/guidelines.html‎ [accessed 1 September 2013].
3 Mayer D, Pfammatter T, Rancic Z, Hechelhammer L, Wilhelm M, Veith FJ et al. 10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms: lessons learned. Ann Surg 2009; 249: 510–515
4 Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm. IMPROVE trial investigators Br J Surg 2014
5 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Accessed March, 2014 at www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf

 

So you have your invitation. Get in touch with the IMPROVE team to discuss, share and explore this observation.

 

vb

 

S

Predatory Journals – Enemies or Inspiration?

Science – unlike deranged, furious cursing – is not best cloistered behind closed doors, in the dark, with no audience. Dissemination of medical evidence is critical to refinement of practice and the generation of future research hypotheses. Yet, most evidence resides behind electronic publisher paywalls, accessible only for a fee, or to those with specific institutional access.

Those of us in academics take such access for granted – yet, the other 7 billion on Earth, many of whom toil in conditions with a lower standard of living, have a much higher barrier to entry. Many journals offer free access to visitors from certain countries, a generous, but incomplete, solution to the free flow of information. A growing alternative, however, to traditional publishing are “Open Access” journals. Such electronically published journals are free to access for all, and in lieu of the typical advertising + reprint business model used to support editorial and typesetting functions, the authors pay fees to support the costs of publication.

Some of these, such as PLOS ONE, have grown to become the largest journals in the world – publishing 31,000 articles in 2013 alone. At USD$1,350 per publication, the revenue associated with such a model is substantial. And therein lay the critical issue – the promise of such riches has attracted the usual unsavory crowd.

Now, we have the phenomenon of the “Predatory Publisher”, a faux journal whose primary function is profit. These publications, masquerading as legitimate science, have grown from 18 in 2011 to at least 477 in 2014. Most academics are likely familiar with the near-daily spam e-mails soliciting article submission, editorial positions, or conference speaking roles. In many cases, the journals are indistinguishable from reliable publishers, and well-meaning authors, hoping simply to increase the audience for an article, are sucked in.

Despite the shoddy or non-existent peer-review – in which nonsense articles by such renowned authors as Ocorrafoo Cobange pass through with nary a critical eye – these articles are entering the scientific ecosystem in ever-increasing numbers. One of the largest for-profit open-access publishers, MedKnow, from Mumbai, India, claimed over 2 million article downloads each month. In an academic professional reality where publication means promotion, and open-access publishing means unfettered distribution – it is no wonder such journals are thriving.

This phenomenon, of course, massively dilutes the scientific literature with a locust swarm of substandard evidence. Traditional journals, with strong reputations and robust Impact Factors, are holding strong for now. But, at the fringes – if funds are available, why would one risk rejection in a more rigorous, but low-impact journal, where the study would lay hidden behind a paywall?

While these journals are certainly the enemy of reliable evidence, and transitively, the public good, they represent an interesting lesson – and possible inspiration – for how traditional academic publishing might evolve.

What are we doing in EM?

Screenshot 2014-06-12 08.46.02It’s been a tough few months in UK Emergency Departments and has caused me recently to do a bit of thinking, as I knew I was losing a bit of my zeal and enthusiasm for our specialty. Yes, there’s the constant unrelenting pressure over targets and working under very trying circumstances with overcrowding and understaffing on an almost daily basis. It remains an enigma to me that for a lot of aspects of our work aviation is taken to be a shining example of how CRM should be done, yet a pilot would not take to the sky with 170% capacity and half the crew missing but we do, carrying on with a”Dunkirk spirit” to the best of our abilities.

So much appears to be put in our way, when trying to care for our patients.  We are drowning under the mass of bureaucracy and paperwork, it reduces time available for patient care. Common sense and practicality have gone out of the window, you can’t admit a patient to the short stay ward for a few hours without completing a host of paperwork required by outside agencies. Cannulation forms, an assessment of VTE risk, estimation of alcohol intake and smoking habit, consideration of hidden harm, a falls assessment, etc etc. A folder bulges with Standard Operating Procedures (SOPs), some about important clinical topics, but others seem appear to be bureaucratic ticks in boxes.  We even had to write an SOP  and subsequently approved in numerous places to allow a patient to sit on a chair in a clinical area rather than a trolley, but only after consulting the SOP on how to write SOPs!

Unlike colleagues in other specialties, where patients appear more grateful for their care, those attending the ED seem rather less so and referrals for inpatient admission are rarely greeted with thanks.  As much as we all try to persuade ourselves we don’t need external validation to feel valued I for one will openly admit I feel a whole lot better about myself and the job I do if just occasionally someone says thank you, well done or good job.

The final straw came when I did a brief online questionnaire which revealed I’m at very high risk of burnout. Whoa! I’ve only been an EM consultant for 6 years, part time at that. So the rethink began and I’ve come to the conclusion that what I personally, and I believe we as a speciality, need, as corny as it sounds, is  to get back to basics. To do the fundamentals really well as part of team working.

burnout

I’ve distilled this down to three areas: self; patients and environment. For myself I will try to always be a role model to others: to smile, think positively and value myself and others. My patients I will keep informed, take away their pain and encourage regular observations. The environment we work in should be professional, clean, tidy and quiet. Most importantly of all I will never forget that at the heart of all of this is care and compassion for our patients.

None of these are revolutionary requiring a policy or SOP, they are common sense, low cost, communication based basics that everyone, medical, nursing and support staff can fully participate in. So no-one can change my enthusiasm and zeal for the job except me, I’m trying to get the fundamentals spot on and encouraging others to do likewise, will you?

Dr Sarah Robinson

Consultant in Emergency Medicine

ROBINSONSarah

Patients, are they the silent contributor to case reports?

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Patient participation (wikipedia CC)

We are in currently in the process of putting together a case report following a toxicological emergency in the ED. It’s an interesting case, deals with new street drugs and has some great lessons for emergency management…., well we would say that wouldn’t we, every case report author from the dawn of time has said the same…., but that’s not the point today.

Rather, as part of the writing process it is important to gain consent for publication. This is a routine requirement for any case report in the literature and here within the BMJ group you can visit the BMJ case reports website where the absolute and explicit requirement for patient consent is stated. The consent form is available in an impressive 13 languages so we obviously take this very seriously. Similarly there are explicit and clear(ish) instructions for authorship and contribution within the group as we clearly want those with their names at the top of the paper to have made a substantial and important contribution to the work. Authorship is defined differently to contributorship and it would be rare for patients to meet the following 4 criteria as lead out by ICMJE.

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Requirements for authorship.

I don’t think you need to be too clever to see where this is going. In a case report it is surely the patient who makes the most substantial contribution to the paper as without their involvement there is no case. Should we therefore offer patients the opportunity for acknowledgement on case reports?

Now you may argue that we need to protect patient confidentiality and that’s true so this could only ever function as an opt in rather than as an opt out, but should we at least offer the possibility of opting in? Those with paternalistic tendancies may argue that there are risks in patient identification. Coercion, willingness to please and the possibility that initial enthusiasm may subsequently turn in to a regret from sharing are clearly possible although the current trends in social media suggest that many patients share their injuries and illnesses in public forums already. My experience is that many patients are delighted to share their cases and some have expressed a wish to be acknowledged in publication, but as things currently stand it is unclear how to deliver this.

Patient involvement in publication is increasing. Examples exist such as the Patient Perspective series in journals such as the BMJ, but these are written contriubtions from patients with the time, talent and inclination to write. That is not typical of patients in case reports and in some cases it may not be possible for them to do so.

The ICMJE defines contributorship as non-authorship listing a number characteristics and ways of defining what constitutes authorship. Interestingly and perhaps disappointingly the contribution of the patient (the case of the case report) is missing. Examples include ‘caring for the patient’ but not ‘being the patient’ which I find a little strange and again somewhat paternalistic.

So, I ask the question of the readers, the editors and any patients who might be out there. If a patient wishes to be acknowledged as a contributor to the education of clinicians, should we make it happen, and if so how?

vb

S

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Gallows humour at the hanging committee

Have you ever submitted to the EMJ or to any other journal for that matter? If so then you will know the fear and trepidation that results as you wait for the answer from the editor. Will your paper be accepted (hurrah) or rejected (boo). I’ve experienced much pain at the hands of editors and reviewers over the years and I’m doing my best not to give any pain back, but to be honest being part of an editorial team is not a popularity contest. A key part of our role is to decide what’s in and what’s out, and it will ever be thus.

The editorial decision process will vary from journal to journal but here at the EMJ all papers initially go to the editor in chief, and then are disseminated to handling editors who recruit and then manage the peer review process. Once complete the handling editors advise the editor in chief on their decisions and opinions. Ultimately the buck stops with the boss, but the handling editors clearly play a key role. That’s my position in this organisation and in the most part the acceptance/rejection decision is fairly straightforward after careful reading of the manuscript in conjunction with the reviewer comments.

However, it’s not always straightforward. There are many circumstances where it’s just really difficult to make a decision on whether to recommend publication. Here are some examples.

  • A survey paper tackles a highly controversial and politically charged subject but has a less than perfect response rate. The information will be popular, interesting and controversial. This paper will be widely read by your subscribers, may attract media interest and (hopefully) some social media activity, but it’s not great science. Would you publish it?
  • A randomised controlled trial of a new drug fabulon is submitted. It is highly effective in treating madeupitis disease in South East Somewhere. It’s a great trial, but as far as you are aware this disease would rarely be encountered by your readership. Great science, but poor applicability. Would you publish?
  • An observational study of sedation in the ED is submitted and 4 reviews are returned. 2 reviewers recommend acceptance without correction, the other 2 recommend instant rejection. Both recognise flaws but the reviewer judgements are so distant that you wonder if they read the same paper. Would you publish?

So what next? As an author you may experience a pause in proceedings. It’s quite likely that the editorial team have referred you to a special place. It’s not somewhere where we flip coins to decide who gets in, nor do we throw darts at manuscripts on the wall, nor throw papers down the stairs and publish the ones on the top steps (honestly all of these accusations have been made by the disgruntled). No. Flipping coins or other arbitary methods of choice are considered very bad practice in the editorial world. It would be highly unfair to the authors so there must be another way and it’s entirely possible that you may have experienced a referral to THE HANGING COMMITTEE!!!

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When I was first referred to a hanging committee I was rather shocked as I imagined my work and toil being led to the gallows. Should it pass the committee it might receive a pardon and be passed on to production for publication. Should it be found wanting then it would be hanged there and then, despatched, killed and never seen again.

In truth my perception of the hanging committee was quite wrong, the origin of the term not being the gallows, but the rather more enticing, pleasant and appreciative world of art. I was surprised to learn that the hanging committee term originates from the art world where decisions are made on which paintings will be shown to the public. A judgement is made in committee on what to hang for public consumption and of course at this point it all makes sense. In publishing as in art there are judgements to be made on what to present and how it should be presented. The analogy fits and so the EMJ team meets to hang papers on a regular basis. The hanging committee sits not to sentence and murder, but to view, read, appreciate and try to select the best for the hard pressed pages of the journal.

So, if you get a referral to the hanging committee it’s not a death sentence and there may well be a reprieve. Hold tight and wait to see what the decision is, you might just catch the eye of the committee and find yourself hung rather than hanged.

Hanging Committee, Royal Academy, 1892 by Reginald Cleaver Wikimedia

Hanging Committee, Royal Academy, 1892 by Reginald Cleaver
Wikimedia

vb

 

S

@EMManchester

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An Unexpected Discussion; How to Close the Loop?

Screenshot 2014-05-21 17.44.47A few weeks ago, on one of my other digital knowledge translation projects, I wrote about an article published in the Emergency Medicine Journal: “Prehospital use of furosemide for the treatment of heart failure”. The content of the article – making an accurate diagnosis of dyspnea is difficult in the prehospital setting, and that many patients given furosemide prehospital failed to be ultimately diagnosed with heart failure – surprisingly resonated with an unexpected cohort of readers.

In fact, with over 4,000 views in just a few weeks, this post and subsequent discussion ranks among the most popular ever hosted on the site.

Yet, as hosted on the EMJ site, there are three “likes”, an Altmetric score of 30 based on mention in 37 tweets, and zero posted responses.

This article will certainly have some reach in print. But, as far as its digital life – the entire post-publication peer review and discussion is taking place entirely disjoint from the article. Visitors to the EMJ site have no indication of the critical appraisal, nor the discussion among physicians and paramedics, nor does it appear there is any mechanism through which the authors might alerted to these comments unless made happenstance aware.

This is a serious challenge and opportunity for those engaged in knowledge translation – how to transform scholarly publiciation from a static end-product, to truly just the beginning of discussion and discourse as part of a living body of evidence. How should traditional journals embrace and incorporate post-publication peer review and critical appraisal? What sort of editorial process ought be in place to moderate ongoing discussion?  How much difference does Open Access make?

The knowledge engines of medicine are changing. The newly minted digitally facile learner is consuming and connecting with experts and authors through online tools – Twitter, blogs, social media sites – in a way past generations were unable. As I’ve noted before, you can read at least 18 experts’ comments on Targeted Temperature Management – yet all these ideas live in their separate bubbles, with disconnected discussion, and disjoint from the digital home of the original publication.

What ideas do you have for tying all this knowledge together? How would you go about effecting change?  Should the independent bloggers band together to centralize their resources, or ought the journals take the lead on seeking out and collating the unsolicited post-publication peer review?

 

Ryan

Ryan Radecki