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