Saturday, 17 February 2018

Predatory journals recruit fake editor

We live in an age of digital scams. Not a day goes past when we aren’t tempted by emails or other messages from nefarious individuals attempting to extract money. Why should academic journals be any different?

A couple of decades ago, it was challenging to manage an academic journal; snail mail, printing costs, office rental, advertisers etc. The digital age and the open-access movement have made it such that anyone with some decent IT skills can create an official looking scientific journal in their attic.

The opening of this study does a great job of summing up the current state of play.

Thousands of academic journals do not aspire to quality. They exist primarily to extract fees from authors. These 'predatory' journals exhibit questionable marketing schemes, follow lax or non-existent peer-review procedures and fail to provide scientific rigour or transparency.

Crucial to the quality of an academic journal is its editors. They should have a strong research background, been involved with peer review and ultimately qualified for the job.

These researchers from Poland concocted a sting to see if a “dismally inadequate” scientist would be invited to be an editor. They created the profile of “Anna O. Szust.” (Oszust is the Polish word for “a fraud.”)

Her CV and application was sent to 360 journals. They were sent to one of three directories; the JCR (journals with an official impact factor), the DOAJ (Director of Open Access Journals), and finally to a group thought to be predatory journals (from Beall’s list).


None of the JCR journals accepted the application. By comparison, 40 predatory and 8 DOAJ journals appointed her as editor. There were some hilarious and sometimes disturbing responses from the journals. I strongly encourage people to read the original manuscript at this link

What should we take away from this?

  • There are over 10,000 predatory journals on the planet that do not exist for the advancement of scientific knowledge. They are fraudulent and have been created to make money.
  • Be VERY sceptical of papers published in predatory journals. They were likely accepted not on their merit & methodologic rigor but rather their ability to pay a fee.
  • If you are a researcher looking to publish a study, do your homework. Ensure that the journals you engage are known to be reputable.



Friday, 16 February 2018

Severe Hyperkalemia: The ECG can risk stratify for short term adverse events?

This may seem rather obvious, but these researchers found little formal evidence to support this notion. As such, they performed this decent but small study.

From their laboratory database, they were able to pull the records of all adult patients over a few years that had a potassium of >6.5 mEq/L. They included patients that had ECG’s done within one hour of the blood test and had no treatment for hyperkalemia.

Two blinded emergency specialists reviewed the ECG’s to record the rate, rhythm, peaked T’s, PR intervals and QRS duration.  

They defined short term adverse events as symptomatic bradycardia, VT, VF, CPR and/or death within 6 hours of the ECG. Relative risk was calculated to determine the association between the ECG changes and adverse events.


They found 28 short term adverse events in 188 patients with severe hyperkalemia. Most of these adverse events (22) were bradycardia. There were 4 deaths, and 2 episodes each of VT & CPR.

An increased likelihood for adverse events were found for:
  • Bradycardia RR 12.29 
  • QRS prolongation RR 4.47 
  • Junctional rhythm RR 7.46

There was no statistically significant correlation between isolated peaked T’s and short term adverse events. But all adverse events were preceded by ECG abnormalities.

So, it looks like bradycardia is the most powerful predictor?

Not so fast. (Get it… not so fast…)

In this study, bradycardia was both a predictor and outcome variable. Therefore, it comes as no surprise that bradycardia is associated with bradycardia. I’m not sure what to do with this…

The biggest limitation of this study was the small numbers of meaningful adverse events. As such there are wide confidence intervals. No study is really “definitive” and this research would officially be far from this standard.

Nevertheless, what are we to conclude?

An ugly ECG in the setting of severe hyperkalemia is a bad thing. But don't go bananas about isolated peaked T’s (in the short term.)

Ok… this is not earth shattering, but does help fill in the research gap.
Image result for potassium

Wednesday, 14 February 2018

Noninvasive Cardiac Testing vs. Clinical Evaluation Alone in Acute Chest Pain: Less is more

These researchers from St. Louis wanted to see if “nothing” was a good diagnostic strategy for the evaluation of low risk acute chest pain.

Ok… not really nothing. But they hypothesised that non-invasive testing (i.e. CTCA, treadmill, stress echo, SPECT) would provide no benefit beyond the typical evaluation using history, physical examination, ECG and troponins.

To try to answer this research question, they got their hands on de-identified data from the Boston led ROMICAT II study. This was a 1000 patient RCT looking at CTCA vs. standard practice in the evaluation of chest pain performed in 9 ED’s in the USA. This robust prospectively collected data was subsequently analysed by these new researchers using a different angle.

They found that 118 (12%) of the 1000 patients did not undergo non-invasive stress testing and they had better outcomes than those who got testing. Specifically, they had shorter lengths of stay, less downstream testing, less radiation exposure and less cost with no change in clinical outcomes.

Apparently there no advantage to performing these non-invasive tests. Less is more.

I love this message.

We never get congratulated for the tests we do not order. Perhaps now is the time for a cultural shift that emphasises the potential harms of these non-specific tests; radiation, cost, time, and most of all overdiagnosis. Let’s clap our hands together for doing nothing!

But unfortunately, my evidence-based bones just can’t completely embrace the conclusions of this study.

This subanalysis was not an RCT. It was up to the physician judgement as to who got non-invasive testing in the usual care arm. It is very likely that the cohort of patients that got nothing were at less risk for bad outcomes. (To be fair, they did try an adjusted analysis, but these are always fraught with problems.)

What are we to think?

It is likely true that over zealous non-invasive testing in low risk patients with chest pain is potentially harmful. A targeted approach for higher risk patients is probably better.

In the end, this study has raised a decent hypothesis for prospectively testing in a proper RCT. If you are a patient with chest pain, perhaps nothing can be a real cool hand.

Image result for cool hand luke


Friday, 1 December 2017

Incorporating point-of-care ultrasound into ACLS: Does cardiac activity predict survival?

From the Journal of No Shit comes this study looking at whether cardiac activity on ultrasound during ACLS is associated with improved survival.

This observational study was conducted in 20 ED’s in North America in patients presenting to the ED in PEA or asystole. Ultrasound was performed at the beginning at the end of ACLS and they looked at several outcomes.

793 patients were enrolled. 13 (1.6%) patients survived to hospital discharge (no mention if they were neurologically intact.)

For what it is worth, cardiac activity on initial ultrasound was the variable with the strongest association with survival at every endpoint investigated. In addition, they found 34 pericardial effusions and some patients with suspected pulmonary embolism.

Caution is in order as 3 patients with no initial cardiac activity on ultrasound survived to hospital discharge.

Of course, there could have been some bias as the decision to terminate resuscitative efforts was probably influenced by the ultrasound. In today’s environment, I don’t think blinding the ultrasound would have been ethical.

I think the most valid conclusion is PEA and asystole are extremely terrible prognostic signs regardless. Ultrasound without cardiac activity is also dismal (but not 100% perfect).

I have wondered why so much time & effort was put into answering a research question that seemed so obvious. It’s kind of up there with the parachute study… But I guess point-of-care ultrasound is still in the stage of trying to prove itself worthy.


Intra-Articular Hematoma Block for Ankle Fracture Dislocation: an RCT

I recently listed to an episode of the Ultrasound Podcast featuring the guru of nerve blocks Dr Mike Stone. This guy sleeps with his ultrasound machine…

With this background, I was shocked to hear that he does not bother with using ultrasound or procedural sedation for reduction of ankle fracture dislocations. He just does a quick ankle hematoma block, “it’s what the orthopaedists would do…”

I’ve done hundreds of hematoma blocks of the distal radius but never considered the ankle. This prompted me to review the medical literature and find the best quality published evidence to support this practice.

Here we go…

This 2008 prospective RCT from New York City randomised patients with ankle fracture dislocations to either intra-articular block or procedural sedation.

What happened?

The authors concluded, “…an intra-articular lidocaine block provides a similar degree of analgesia and sufficient analgesia to achieve closed reduction of ankle fracture-dislocations.” In addition, the average time for reduction and stabilization was faster with the hematoma block.

So, ankle hematoma blocks are great!

Before we get too enthusiastic, consider the following limitations:
  • They only enrolled 42 patients. Yes, 42… Therefore, high risk for type II error and it cannot make adequate claims about safety.
  • It was sloppy; no specified primary outcome, no power calculation, CONSORT guidelines not followed, no mention of ethical approval, junior orthopaedic residents were “indirectly supervised,” some silly comments about “conscious sedation” etc.

So, this is really the best quality evidence we have?


However, there is a wealth of published literature on hematoma & intra-articular blocks elsewhere and I think it is reasonable to conclude they are generally safe.

Subsequently, I have tried this technique a couple of times and had great outcomes; complete and long-lasting analgesia with wide awake happy patients. All the while not requiring a resuscitation room and all the resources of a procedural sedation.  I have an “n” of two. More poor-quality evidence?

I would encourage researchers to publish more on ankle hematoma blocks. To be honest, an RCT is probably not necessary to answer this research question. A large prospective case series should be adequate.

So, get injecting and pulling! (Please don’t quote me out of context)

To read more about ankle hematoma blocks, see paper referenced below. To hear Mike Stone talk about this on the Ultrasound podcast, check the link below and go to about the 11 minute mark.


ECMO for refractory cardiac arrest: the Sydney experience

“Our study is the first multicentre study of ECPR outcomes in Australia. Thirty-seven patients between 2009 and 2016 underwent ECPR across two ECMO referral centres, with an overall survival rate of 35%, and excellent neurologic outcomes in survivors.”

Sounds great. Sign me up for ECMO!!!

But is there a downside?

This audit and medical record review took place over 7 years at two busy Sydney ED’s with a catchment area of 7 million. Both hospitals had developed ECMO response teams consisting of cardiothoracic surgery, anaesthetics, perfusionist and ICU personnel.

In the end, they had 13 good outcomes.

So, about 1 patient per year in each hospital…

In a system with limited healthcare resources, could these efforts been put to better use?

(Of course, ECMO can be used in other circumstances; support of cardiogenic shock post ROSC, overdose, hypothermia, etc.)

It is reasonable to conclude that ECMO currently is not ready for prime time in most centres. But perhaps we are in the ECMO infancy and it will become more feasible and important as the technology improves.

What do we conclude?

The current state of ECMO requires a lot of buck for little bang. It requires many resources and may have a role in the rare highly selected patient. But watch this space…



Shared decision making in patients with low risk chest pain: empowering patients to go home

In patients presenting to the ED with very low risk chest pain, can a structured approach to shared decision making provide some benefit? Specifically, does it improve general comprehension and decrease resource utilization all in a safe manner?

In this study, 898 patients in the USA were randomised to a shared decision making facilitated by a decision aid or to usual care.

Inclusion criteria were:
  • Adults presenting to the ED with chest pain
  • Non-ischemic ECG
  • Negative initial troponin
  • No known prior coronary artery disease
  • Treating doctor wanted to admit to an observation unit to get a stress test or CTCA

(Yes… in many countries most of these patients would never have been admitted in the first instance. There are clearly some issues of external validity.)


With the decision aid, 15% more patients decided not to be admitted compared to usual care (52% vs. 37%).

Oh… and out of 898 patients, how many cardiac events were there?


This obviously begs the question as to why the vast majority of these patients could be sent home regardless of the decision aid.

Nevertheless, I think it does send the message that a structured approach to shared decision making may provide a better framework to educate our patients.