Category Archives: General

Week 8 – Author’s Thoughts: FEAST

Firstly, I would again like to thank everyone who took part in the discussion of the FEAST study. I would like to especially thank Annabelle South for her invaluable contribution.

Before the discussion I emailed Professor Kathryn Maitland and was delighted to receive an email back with some thoughts ahead of the discussion (posted in the introduction to the paper). Following the discussion I received another email from Professor Maitland with her thoughts for each of the discussion points and with her permission I have posted these below. I would like to thank her for taking the time to do this and to engage with the journal club and to Annabelle for her help with sending me a version my old laptop could cope with:

 1. Was the inclusion group in this trial too wide, especially in regards to ages (from a 60 day old baby to a 12 year old child)?

 Rational: The trial was designed to be pragmatic: the WHO classify children into age group: young infant (0‐60 days) and children thereafter. Guideline for shock management for children do not treat children < 1 year differently that older age groups.

A: Overall, age did not affect response to bolus: we specifically examined the age group < 1 year – outcome was the same in this group.

 2. An editorial in the Archives of Disease of Childhood criticised the study and highlighted what they felt was the most harmful limitation, the reliance on one non-specific clinical feature for the diagnosis of hypovolaemic shock (see this BMJ rapid response for further details). Does this make the study invalid for evaluating fluid boluses in children with hypovolaemic shock?

 How is shock diagnosed in the UK? With the same signs as were used in the FEAST trial – (delayed capillary response; temperature gradient and a weak pulse). We acknowledge problems with inter-observer variation and specificity of the bedside determination of shock, however these are the standard criteria that populate all international shock definitions. Whether one or more of these features were present the results were the same – boluses were harmful. The World Health Organization shock criteria (requiring all four parameters including a capillary refilling time of 4 or more seconds) identified very few children 65 (2%). Even so outcome was substantially worse in the bolus groups (see Appendix): 48% in bolus versus 20% in no bolus. This equates to an absolute risk of death of 28 % (95% CI 3.4% – 52.5%). In other words for every 100 children receiving fluid boluses this would result an extra 28 deaths compared to children not receiving boluses. Moreover, outcome was worse with fluid boluses even in children with observer-independent measures of shock (moderate hypotension) or poor tissue oxygenation (severe lactic acidosis > 5mmol/l) (see tables in FEAST). The remarkable consistency of these findings all point to the same conclusion. There have been a number of editorials: it’s a shame that these two were highlighted1-3.

 3. How applicable are these results to the use of fluid boluses in the developed world?

The 2008 Surviving Sepsis Campaign Guidelines, informed by a modified Delphi process, graded the ACCM paediatric recommendation for fluid resuscitation as 2C, indicating weak recommendation based on low quality of evidence, largely from observational studies and expert opinion. There are no paediatric trials of fluid resuscitation outside of those conducted in malaria, dengue and a very small sepsis trial in India4. These recommendations together with the FEAST trial now raise questions about the commonly used treatment. Children in theUK have access to ICU – adverse consequences maybe masked by this.

 The first response should be an audit of practice: who receives fluids and outcomes (including admission to ICU). Mortality is very low compared to adult sepsis: so would need a huge trial for this endpoint

4. Does there need to be a similar study in developed countries? If so, would such a study ever get ethical approval?

 See above: Even if given ethical approval there may be insufficient uncertainty about risks of fluids. These data need to be generated (if they do exist) to create equipoise around current practice before clinicians would be happy to enrol a child into a controlled trial.

1. Duke T. What the African fluid-bolus trial means. Lancet 2011, Jun 15.

2. Myburgh JA. Fluid Resusciation in Acute Illness – Time to Reappraise the Basics. N Engl J Med. 2011, May 26

3. Hilton AK, Bellomo R. Totem and Taboo: Fluids in sepsis. Crit Care, 2011;15(3): 164

4. Akech S, Ledermann H, Maitland K. Choice of fluids for resuscitation in children with severe infection and shock: systematic review. BMJ. 2010;341:nc4 416.

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I have to apologise in the delay in posting the summary for the FEAST paper. It turns out that starting a new job, revising for the first part of MRCP and having a life outside of work with its own trials and tribulations means that I either have to become superwoman or realise I can’t do everything at once. The post is nearly finished and will be posted as soon as I get a spare minute.

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Welcome to #TwitJC’s new home!

Welcome to the new Twitter Journal Club website!

All of the pre-existing content has been kept (all the posts and comments have been transferred), and we’ve kept the structure of the site largely the same. The main differences are that we have our own URL and it looks a bit more shiny.

However, since we are now running on wordpress.org rather than wordpress.com, it gives us a fair bit more flexibility with what we can do with the site. As such, it would be great if people could suggest features that they would like to see for the site, and if possible, we will try and implement them where possible. (Feel free to add your suggestions as comments to this post).

Also, if you haven’t yet, please could you complete this survey so we have an idea of which areas of medicine people are most interested in.

Finally, a massive thanks to everyone who has supported #TwitJC over the last couple of months: proof-reading posts, suggesting papers, offering ideas for improvements, and taking part in discussions. We really do appreciate it.

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Reflections on last week

Twitter Journal Club is only in its infancy and it is something we see evolving over the weeks with input from everyone involved. Thank you to all those who have given feedback on our first week and for your helpful suggestions of how to improve. Also thank you to those who have suggested papers for us to discuss.

The first two papers chosen were simply because they are favourites of Fi and I. Some criticism has been given of the fact that we started with two “old” papers, Rivers et al was published in 2001 and Rose in 1981. However the significance of these papers to our medical practice today cannot be underestimated.

As discussed last week, Rivers et al has been one of the key papers in developing the Surviving Sepsis Campaign and the guidelines at the hospital I work at for the management of sepsis very closely resemble the interventions used in the early-goal directed therapy group.

This week’s paper is Geoffrey Rose and “Strategy of prevention: lessons from cardiovascular disease” – commonly referred to as the ‘Prevention Paradox’. The Prevention Paradox describes the situation in which the majority of cases of a disease come from parts of the population at low or moderate risk, not from the higher risk part of the population as may be expected. The burden of disease simply does not come from the part of the population most at risk of it.

The impact of this paper and of the Prevention Paradox is extremely relevant to clinical practice today: it has been cited over 600 times. Many interventions that aim to improve health actually only have small benefits on the health of most of the population.
Tonight in our discussion we aim to look at this paper and the impact that it has had on clinical practice and the way we think about how to prevent disease. A recent paper in the BMJ discussed this in relation to statins and I highly recommend reading it: Hingorani and Hemingway, How should we balance individual and population benefits of statins for preventing cardiovascular disease? BMJ 2011; 342:c6244

Also of interest in the run up to tonight’s discussion are:

1. Jackson et al. Preventing coronary heart disease. Does Rose’s population prevention axiom still apply in the 21st century? BMJ. 2006 March 18; 332(7542): 617–618.

2. Manuel et al. Revisiting Rose: strategies for reducing coronary heart disease BMJ. 2006 March 18; 332(7542): 659–662.

Fi will also shortly be posting an introduction to the paper, which you may wish to read before this evening.

Over the weeks I hope to develop a resource based on this blog of technical terms that are used when discussing papers, for example last week intention-to-treat analysis was discussed. This will take some time. At the moment Fi is writing up a research paper as well as conducting another lab-based project (as well as learning to row and a few other things – you can’t help but be impressed!). I am working as an F1 in gastroenterology, finishing a paper, have a set of A&E oncalls fast approaching, and working towards taking the first part of the MRCP in September. Both of us are working on this in our very fleeting spare time. We appreciate your time and patience as we develop this and thank you for all the feedback we have received.

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Some initial thoughts after the first #TwitJC

Thank you to everyone who participated in Twitter Journal Club this evening, and to my partner in crime, Natalie. All in all, I think it went very well, and I rather enjoyed myself – from the tweets I’ve been reading, the general consensus was that it was a success.

I am, overall, astonished at the power of Twitter. From one tweet a week ago, to an international online journal club with participants ranging from from pre-med students to consultants, is testimony to how social media can be put to good use. It was fantastic to have such a range of people discussing the management of sepsis.

For me, as a student, it was a fantastic opportunity to learn, and I very much hope everyone else felt they gained something from it.

A few people feel there are some points about this evening’s paper that still need discussion, for example differences between practice in the US and UK. Please do use the #TwitJC hashtag to continue the discussion and to chat about anything else you may think of that’s relevant to the paper.

Just a quick reminder, next week’s paper is Geoffrey Rose’s ‘Prevention Paradox’ officially titled ”Strategy of prevention: lessons from cardiovascular disease”, available here.

A transcript of this evening’s chat should be appearing on this blog in the next day or so, along with a summary of what was discussed.

Thanks again for making the first Twitter Journal Club such a success! :-)

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The plan for this evening

With the first Twitter Journal Club taking place this evening (8pm UK time / 7pm GMT), I thought I would outline some of the practical aspects of how we intend things to run. The intention is for the discussion to last somewhere between one and two hours, but do feel free to drop by and leave whenever.

This may all be a little obvious for those who participate in Twitter chats regularly, but please bear with me.

Every tweet you post in the discussion should be tagged with #TwitJC, otherwise it won’t get picked up by people following the hashtag. In my personal experience, this is easy to forget, so if you use a client that automatically adds the tag, then that’s great. I’ve used TweetChat in the past, though I’m sure other clients exist. If you log into TweetChat using your Twitter account, then type in the hashtag at the top, you can see every tweet from the discussion tagged with #TwitJC, and can respond via Twitter from within TweetChat.

Alternatively, if you just want to read the discussion, you can do so on TweetChat without needing to log in, or just by searching #TwitJC on Twitter.

So this evening, myself and Natalie (@silv24) will introduce the talk. It’s nice if everyone participating then writes a tweet saying a little bit about themselves (student/doctor/what grade?/interests/etc.) at the beginning, so we know who’s joining us.

We’ll then go through the paper using the NHS’s “Solutions for Public Health” Critical Appraisal Skills Programme Tool for Randomised Controlled Trials, details of which can be found here on their website. In essence, it’s a ten-step guide to evaluating an RCT, which we hope will help guide and structure the discussion. Many thanks to @lou_hurst for bringing this to our attention.

Natalie will publish a post a bit before we start outlining key points about the paper, although ideally it’s better if people try and read it themselves beforehand. The full PDF can be found here.

Any questions, please just comment or this post, or tweet at either myself (@fidouglas), Natalie (@silv24) or Twitter Journal Club (@TwitJournalClub).

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Welcome

Hello. Welcome to the Twitter Journal Club, which came about as a result of some Twitter conversations last Sunday.

First to explain what Twitter Journal Club is: Essentially, it will provide a forum for doctors, medical students, and anyone else interested, to discuss research and how it may affect clinical practice. We intend to stick to landmark studies which will be of interest to a number of people in a wide range of specialties.

Initially, we’re going to try 8pm UK time on Sunday evenings (so 7pm GMT). Hopefully this will mean the fewest people being at work. If it proves to be a disaster, we can move it to a more convenient time.

For those not used to Twitter chats, the chat will operate through Twitter using the #TwitJC hashtag. You can either view this within Twitter by searching the #TwitJC tag (sluggish, but usually works), or set up a column for the hashtag in e.g. TweetDeck.

Alternatively (and this is probably best for easiness/reliability), if you go to TweetChat, and type in #TwitJC at the top, all the relevant tweets will appear. If you use Twitter to log into TweetChat, you can post from within the site as well, and it automatically adds the hashtag to your posts.

As with all journal clubs, it’s probably best to read the paper beforehand. Then we’ll start off with brief introductions, followed by a discussion about the paper. Goodness knows where the conversation will go, but isn’t that part of the fun!? At the end, people can suggest other papers to discuss.

The first paper we’ve picked is Rivers’ Goal Directed Therapy in Early Sepsis (http://bit.ly/jsxap2) which should be of interest to those involved in managing critically ill patients.

We hope you’ll join us, and look forward to seeing you at 8pm tomorrow…!

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