Cheesecake files: Just how deadly is it?

Everyone said it did, but how did they know and by how much?  Statements like

“The development of AKI [Acute Kidney Injury] after CPB [Cardiopulmonary Bypass Surgery] is associated with a significant increase in infectious complications, an increase in length of hospital stay, and greater mortality.” (Kumar & Suneja, Anaesthesiology 2011 14(4):964)

are common place in the acute kidney injury literature.  When I started to look at the references for such statements I realised that they were all to individual, normally single centre, studies and that the estimates of the increased risk associated with AKI after CPB varied considerably.  Furthermore, the way AKI is defined in these studies is quite varied. This lead to two questions?

  1. Just how deadly is getting AKI after CPB?
  2. Does it matter how we define AKI in this case?

These questions are important as the answer to them helps a surgeon and patient to better assess the risk associated with choosing to have cardiopulmonary bypass surgery and what the importance is in monitoring kidney function after such a surgery.  To answer these questions required a meta-analysis the results of which I have just published (a.k.a earned a cheesecake).  A meta-analysis involves systematically searching through the literature, a sentence which takes seconds to write but months to serve, for all articles reporting an association between AKI and mortality after CPB.  Then there is learning how to put all the, sometimes disparate, data together (I had to learn a lot of R for this one) and to report on it.  As this was my first meta-analysis, I was fortunate to have the assistance of two highly competent scientists & nephrologists with meta-analysis experience, namely Dr’s Matt James of Calgary, and Suetonia Palmer of my own department in the University of Otago Christchurch.

So – what did we find?

  1. If you get AKI after CPB you about 4 time more likely to die compared to if you do not get AKI after CPB even after accounting for things like age, diabetes, and other risk factors.
  2. Somewhere between 37 and 118 lives per 10,000 CPB operations could be saved if we could find a way to eliminate AKI.
  3. How AKI was measured did not make any difference to the results.
  4. AKI after CPB was also associated with increased risk of stroke.
Figure 1 from Pickering et al, AJKD 2014

A teaser of a figure from Pickering et al, AJKD 2014

Pickering, J. W., James, M. T., & Palmer, S. C. (2014). Acute Kidney Injury and Prognosis after Cardiopulmonary Bypass: A Meta-analysis of Cohort Studies. American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation. doi:10.1053/j.ajkd.2014.09.008

ps. Sorry about the paywall folks, but as I’ve said before, if we want to put this data in front of the people it is most relevant to we haven’t the budget to always make them Open Access.

 

Can Doctors and Nurses help Dialysis patients recover?

In the case of dialysis dependent acute kidney injury patients this is a question which Dr Dinna Cruz  and colleagues (University of California San Diego) are asking and seeking opinions from both nephrologists and non-nephrologist doctors and nurses involved in care of dialysis patients.  It was a question which arose out of discussions at this year’s Continuous Renal Replacement Therapies conference (CRRT 2014). Personally, I think it is a brilliant starting point for research to go out and seek the opinion of those “at the coal face” actually treating patients. If that includes you, please take a moment to complete the survey. If it includes someone you know, please pass this request to participate on.  Here is Dr Cruz’s request:

Currently there is much interest regarding the recovery aspect of AKI. A specific area of interest is how to enhance recovery in patients who remain dialysis-dependent at the time of discharge. It is hypothesized that patients with potential for renal recovery may require a different care plan than the “usual” ESRD patient.

Therefore we are asking your opinion regarding the post-discharge care of such patients, using this short survey. It will take only a few minutes of your time, and represents a starting point for developing potential strategies for these patients. We think it is very important to have the input of specialists from different healthcare settings and countries to give a more balanced view.

Kindly complete the survey appropriate for your specialty, then please share both these links with other colleagues so we get more responses from around the world

For nephrologists:

https://www.surveymonkey.com/s/postdischAKIcare_neph

For non-nephrologists, including acute and chronic dialysis nurses:

https://www.surveymonkey.com/s/postdischAKIcare

Thank you very much for your help!

Source: Anna Frodesiak-Wikimedia Commons

Source: Anna Frodesiak-Wikimedia Commons

Publication police and how to choose where to publish

“I confess, I published behind a paywall.  I’m sorry, sir, I didn’t want to, but but but I’m almost out of funds and and …..<suspect’s voice fades>”             Publication Police files, Nov.3 2024

Will peer pressure eventually lead to discrimination against those who publish behind a paywall?  Is it now a moral imperative that we publish everything open access?  If so, is that not simply morality by majority (a dangerous proposition at the best of times), or worse, morality by the most vocal?

I’m often asked “Where should I publish this?” and I must admit that “In an open access journal” is not my first response.  This is simply because there is a higher standard than mere open access (as great as that is).  Where to publish is first and foremost the answer to the question “Where will it get the attention it deserves?”  Of course, this is where ego can raise its ugly head and, worse, I have colleagues who think this means the journal with the highest impact factor, but those distractions aside, it is still the most important question.

Most of our science is simply an incremental step building on what is going before.  Most of the time it is of interest to a relatively small group of fellow researchers or those whose profession is impacted on by the research.  Furthermore, it will probably be of interest only for a short period of time before someone else builds upon it. The “attention a paper deserves” is the attention that these people for whom it has most meaning give it.  For this reason, it should be published in a manner which makes it easy for these people to read about it and access it. This will probably mean one of the professional society journals and/or one of the most read journals in the field.  In the fields of Critical Care and Nephrology where I’ve published most recently this will probably mean a European or American journal which has high readership in those jurisdictions because this is where most of the research is being done.    Of course, this does not mean my manuscript will necessarily be accepted by those journals, but if I deem it has something important to say, then that is where I should send it first.

Comparatively few of those journals are open access only, but all offer an open access option.  This tends to come with a publishing fee in the range of US$1500 to US$3000.  My budget does not stretch to paying such a fee for every publication. I am forced to be pragmatic. If my manuscript is accepted into one of those more high profile journals I have to pick and choose.  The more important I think the findings the more likely I will take the open access option.  Also, if I think the message has immediate application for clinicians (i.e. not just the narrow group of researchers in my field) I am more likely to choose open access.

There is, of course, the option to publish in more general online journals (PlosOne, PeerJ, F1000 etc) and I have done so.  However, my impression at this stage it that these do not rapidly reach the inbox of most of the very very busy researchers and clinicians in the fields I publish in.  A few (like myself), may have set up automatic search strategies or use social media to follow journals in their field, and, of course, if people are conducting PubMed or the like searches they may come across those articles.  However, their lack of specialisation and reliance on someone making more effort over and above reading the specialised professional journals they have always read, mitigates somewhat their usefulness to me to “getting the message out.”  Of course, I could choose to be a “early adopter” or “pioneer” and publish in a low cost open access journal (if my fellow authors would let me) with the hope that this will change the publishing culture of paywalls and high publishing fees elsewhere.  However, it would be at the cost of less exposure of my research to those who are most interested and active in the field.  For some of what I publish I must balance my obligation to advance the field the most by maximising the chances of exposure amongst those for whom it is likely to be of immediate interest with the more philosophical desire for open access to all and sundry from now to eternity.

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A funding model that works (for me)

I’ve been a strong critic of the bias towards project rather than people based funding in public grants for science research.  Now, I celebrate being the recipient of people based funding thanks to a combined initiative of the Emergency Care Foundation, the Canterbury Medical Research Foundation, and the Canterbury District Health Board. What has transpired is exactly what I believe the country needs much much more of, namely initiatives that get behind people and teams with broad goals and long term vision rather than narrow projects and annual funding angst.

Below is a press release.  Over the next 5 years I’ll share the ups and downs of the research we undertake.  I’ve already posted about a study I’m currently analysing the results of, which was designed to rapidly assess patients presenting to the ED with chest pain and to safely reduce unnecessary admissions to hospital.

On a more personal note I am grateful to Dr Martin Than (ED) who has championed this intiative and employed me to date this year, to Kate Russell and the CMRF board who have shown great support and helped to put this together, and to Carolyn Gullery and several others of CDHB Planning and Funding who have made possible those very important linkages and collaborations within the DHB. For the record, this is an 80%, 5 year, fellowship; I retain a 20% position with the University of Otago Christchurch, and will continue to undertake collaborative work with many research teams based there.

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MEDIA RELEASE

Health Board and Private Health and Research Foundations join forces to improve outcomes in Acute Care Delivery

The Canterbury Medical Research Foundation, The Emergency Care Foundation and the Canterbury District Health Board have put their collective might behind a new Senior Research Fellowship in Acute Care based at Christchurch Hospital.

The five-year fellowship will improve the quality of Acute and Emergency Care delivery at the hospital through targeted research and close collaboration with clinicians eager to see positive research outcomes translated into real-world clinical practice and, importantly, into improved patient outcomes.

The demand on acute services is large, around 140,000 patient visits a year across the health system. The challenge is to quickly, accurately and safely assess a patient’s condition and to ensure they access the services they need and don’t unnecessarily access the services they don’t need. The first projects this Fellowship supports will better identify which patients presenting to the emergency department with chest pain need admission and intensive monitoring, and who can be safely discharged home.

The Fellowship will be undertaken by Associate Professor John Pickering. Dr Pickering’s research has been cross-disciplinary. This began with the application of physics in dermatology and plastic surgery through the use of lasers in medicine, in particular he helped develop the use of lasers to remove birthmarks. Over the past seven years through he has advanced the diagnostic methods to detect acute kidney injury and most recently, has become involved in research to discover and translate into clinical practice, diagnostic protocols in the emergency department, particularly for patients presenting with chest pain and the possibility of a heart attack.

Dr Pickering sees medical science as a team effort involving, not only doctors, nurses, and scientists, but also the patients themselves, and funders. He is a keen advocate that publically funded research be made known and understandable to a lay audience through blogs and social media. He writes a blog on the Sciblogs.co.nz web site as “Kidney-punch.”

The Canterbury Medical Research Foundation and Emergency Care Foundation are delighted to be partnering with the DHB on a project that is likely to have long term effects on the delivery of acute care in the Canterbury Health system and further afield.

“This type of directly translational research that will give us definite and measureable improvements in patient care is something we are particularly interested in. Committing to five years will allow enough time for research findings to be properly utilized in improvement in practice patterns in real life clinical situations and that is very exciting.” Says Kate Russell, Chief Executive of the Foundation

“I believe that this is an excellent collaborative project to better integrate medical research with clinical care delivery. This initiative will actively facilitate the alignment of some excellent medical research that is taking place in Christchurch with the Canterbury District Health Board’s priorities and plans for improving care for patients with suspected acute, and particularly cardiovascular, illness” said Dr Martin Than, Emergency Care Foundation

For Canterbury DHB it represents an exciting era of partnering with private trusts and foundations to make inroads into issues of quality improvement and better outcomes for Canterbury people.

“We have already made significant progress in reducing acute demand on our hospitals, with more than 28,911 people receiving treatment and care in the community in the past year. This research will provide important evidence to support future decision-making about how, where and which services are funded and provided to ensure Canterbury people receive the right care, at the right time, in the right place, by the right person.” Said Carolyn Gullery, General Manager of Planning and Funding at the DHB.

ENDS
For further information please contact Dr Martin Than on Martin.Than@cdhb.health.nz

It’s all about the math, dummy!

No one understands the electoral maths of the NZ electoral system including the electoral commission apparently. Last night I put the latest figures from the “Poll of Polls” into the electoral commission calculator and I discovered the calculator was broken! I put the figures in with United Future winning one electorate seat, but when it crunched the numbers it gave me a parliament without United Future in it. Hmmm… have I uncovered a conspiracy to keep Peter Dunne out of parliament, or is it just evidence that someone got their math wrong. Let’s hope it’s the latter and that they’ll get it right on the night.

Electoral Commission calculator results captured 17 September 2014

Electoral Commission calculator results captured 17 September 2014

In the meantime, let’s consider two concepts this election hangs on – the so called “Wasted vote” and the “Overhang.” The Wasted Vote is the proportion of votes that go to parties that do not make it into parliament by either crossing the 5% Party vote threshold OR by winning at least one electoral seat. The overhang is when a party or parties win more electoral seats than the proportion of their Party vote entitles them too. This means that the size of parliament would increase. Normally 120 and 1/120th of the party vote (0.83%) is equivalent to one member of a party. However, for example, if a party receives just 1% of the vote, but wins 2 electorate seats then this will increase the size of parliament to 121. The various permutations of polls have the current election resulting in a parliament ranging from 120 to 124 seats.

The number of seats in parliament is crucial because it means the effective number of seats a party of block of parties must win in order to form the majority to govern increases. 61 seats are needed for a 120 or 121 member parliament, 62 for a 122 or 123, and 63 for a 124 member parliament.

About the Wasted vote two ideas are important:

The Wasted vote supports the party already with the most votes the most

The Wasted vote could determine who governs!

Let’s assume that 61 seats are necessary in a 120 seat parliament. Ie a block needs 61/120th of the party vote (50.83%) to govern. Crucially this percentage, though, is NOT the percentage of the vote that block gain on the night (which is what the polls try and predict). What it is, is the “effective percentage” after the Wasted votes are taken into account. A scenario could help. Consider an election with two parties crossing the 5% threshold to get into parliament and all the rest being wasted votes. Let’s call the two parties the Big, Rich and Totally Selfish (BRATS*) party and the Really After Total State (RATS**) party. Consider this, there are 1 million voters. BRATS gets 450,000 votes on the night (45%). But, 10% (100,000) of the vote is Wasted. That means the proportion of votes the BRATS get out of the non-wasted votes is 450,000/900,000 giving an “effective percentage” of 50% which would give them 60 seats in parliament.  The RATS would have the same in this scenario. We can turn this question around the other way and ask how high a proportion of the total vote does the Wasted vote have to be for the BRATS “effective percentage” to cross the 50.83% threshold needed to govern? This will depend on the total proportion of votes the BRATS receive  (in our example 45%). The graph below illustrates this.

The percentage of wasted votes the BRATS need in order to govern based on the actual percentage of votes they receive

The percentage of wasted votes the BRATS need in order to govern based on the actual percentage of votes they receive

So, folks, if on the night your vote is in the waste basket, rest assured it will have an effect on the outcome of this election.  The only truly wasted vote is the one that is not cast!

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*Led by Mr I.M. Wright

** Led by Mr M.Y. Tern

World Science Week: Where are we in the world?

It’s World Science Week.  So, where are we in the science world?  One measure showing our commitment to science is our expenditure on R&D.  If we compare ourselves to the other OECD countries, we see that we are right at the bottom of the pile at 1.27% of GDP and have recently been overtaken by Hungary.

OECD countries Research and Development expenditure as a function of Gross Domestic Product

OECD countries Research and Development expenditure as a function of Gross Domestic Product

You can explore this graph for yourself by clicking the link here.

In four weeks we will vote for a new government.  I blogged a link to party policies about health research last week. Labour have just released their policy and National are yet to. In the meantime, the Green party says we need another $1bn invested in R& D, which would add about 0.5% (based on a ~$200bn GDP) and United Future and Labour wish us to have at least the OECD average which means another $2bn or so investment.  In the meantime, UF, Greens, and Labour all want to re-establish tax credits for R&D which is intended to stimulate private investment in R&D.  If anyone knows the answer, I’d be interested to hear how many of the other OECD countries have R&D tax credits and what difference that has made to investment in R&D.

 

 

Policy our lives depend on: Health research in election 2014

We all care about health – ours, our family’s, and even that of one or two politicians (perhaps). We also care that the 15 billion dollar annual health budget is spent on health care that works.  I contend that both these cares are only as good as the health research that underpins the treatments we receive.  Therefore, I have compiled what I could discover about health research policy from the policy documents available online of the political parties contending the current NZ general election. I have tried to focus on where health research in a particular area is promised or on health research infrastructure. In some places I’ve extracted from a more general science and/or innovation policy those policies I think likely to impact health research.  Obviously some parties are still releasing policy.  I invite them to send me any policies that they think relevant and I will update.  I think you will be surprised at what is missing in the list below.

The parties are in reverse alphabetical order.

United Future*

Health Policy: http://www.unitedfuture.org.nz/policy/health

  • Increase funding for health research to bring New Zealand’s funding up to at least the OECD average as a proportion of GDP;
  • Establish a national register for Type 1 Diabetes, a diabetes research fund, and increase funding for Type 2 Diabetes testing;
  • Make no change to the legal status of cannabis for medicinal use until a robust regulatory testing regime is developed that proves cannabis use causes minimal harm to an individual’s health
  • Introduce a sabbatical scheme that would allow health professionals to take a year out of work every five years to update their skills and knowledge;
  • Promote more research to address youth related health problems such as suicide, alcoholism, and bulimia.

Science Policy: http://www.unitedfuture.org.nz/policy/research-science-and-technology

Too long to put in detail, but policies such as “simplifying different funding mechanisms” and specifying biotech as one of half a dozen key research areas requiring focus are likely to impact on health research.

Health spokesperson (Associate Minister of Health): Peter Dunne MP peter.dunne@parliament.govt.nz

 

New Zealand First

Health Policy: http://nzfirst.org.nz/policy/health

  • Ensure an on-going commitment to the funding of health research, research institutes, and for training.

Science Policy: None

RS&T Portfolio holder: Tracey Martin MP tracey.martin@parliament.govt.nz

Health Portfolio holder: Barbara Steward MP   barbara.stewart@parliament.govt.nz

 

National

Health Policy: https://www.national.org.nz/news/features/health

No specific policy on any health research

Science Policy: None

Health spokesperson (Minister of Health): Tony Ryall tony.ryall@national.org.nz

Science spokesperson (Minister of Science and Innovation): Steven Joyce steven.joyce@national.org.nz

 

Maori Party

Policy: http://maoriparty.org/our-policies-kawanatanga/

  • We will support: … Roadshows to promote educational pathways in areas where Māori are under-represented – ie health science academies (Te Kura Pūtaiao Hauora) or science camps.

Science Policy: No specific policy but some comments in the policy above about research and development include establishing an investment fund for Māori Research and Development which may impact on health research.

Health or Science spokespeople: Unknown

Contact: Teururoa Flavell MP teururoa.flavell@parliament.govt.nz

 

Mana

Health Policy: http://mana.net.nz/policy/policy-health/

No policy specifically dealing with health research

Science Policy: None

Contact: Hone Harawira MP hone.harawira@parliament.govt.nz

 

Labour

Health Policy: http://campaign.labour.org.nz/full_health_policy

  • We need a health system that is based on evidence about what works – not fixated on manufactured targets or political slogans

Health spokesperson: Annette King annette.king@parliament.govt.nz

Science Policyhttps://www.labour.org.nz/sites/default/files/issues/science_and_innovation_policy.pdf (UPDATE – released 25 August)

  • Reinstate post-doctoral fellowships for recent PhD graduates (scaling up to %6m per year)
  • Prioritise an increase in our public science spend to link New Zealand to the OECD average over time
  • review and reform the National Science Challenges, on the basis of advice from the science community and building on the success of respected funding bodies such as the Marsden Fund

    provide integrated support for innovation across the Crown Research Institutes and tertiary institutions, and through private-sector research activities, and sectoral and regional initiatives

    review the criteria of the Performance Based Research Fund to ensure that a broad range of research success is recognised

    support research in universities, including through a continued commitment to Centres of Research Excellence

    encourage closer association between business and university commercialisation centres to ensure ‘discoveries’ within the universities are most effectively brought to market and have the best chance for success

    support and foster a collaborative university system, where each of our universities is enabled to focus on its areas of research and teaching strength.

  • support research in universities, including through:
    • a continued commitment to Centres of Research Excellence,
    • ensuring the sustainability of the Marsden Fund and other research funds
    • supporting the career pathways of graduates, to encourage our researchers to develop their careers and contribute to New Zealand.

Science Spokesperson: Moana Mackey MP moana.mackey@parliament.govt.nz

 

Internet

Health Policy: https://docs.google.com/document/d/1g4RY7Sh-vYZN1WAIx_A-AEZlYzNjMhzY81KnfKLMGp0/edit

Copyright and Open Research Policy: https://docs.google.com/document/d/1Le3rY0wlh9tJaBzpxK5xrpeWID-j5FmeE4dqONdQATE/edit

  • Mandate that all taxpayer-funded research be open access with the public able to freely access and re-use it.

Health or Science spokespeople: Unknown

Contact: hello@internet.org.nz

 

Green

Health Policy: No general health policy, but some on particular issues.

Update 25 Aug:  I have been informed that the Greens have a health policy on a different web site https://home.greens.org.nz/policy/health-policy.  Their election site http://www.greens.org has no health policy.

No policy specifically dealing with health research.

Green innovation Policy: https://www.greens.org.nz/policy/smarter-economy/smart-green-innovation

Some aspects of this policy may impact health research, in particular:

  • $1 billion of new government funding over three years for research and development to kick-start a transformational shift in how our economy creates wealth;
  • The Green Party will fund an additional 1,000 places at tertiary institutions for students of engineering, mathematics, computer science, and the physical sciences.

Health or Science spokespeople: Unknown

Contact greenparty@greens.org.nz

 

Conservatives

Health Policy: None

Science Policy: None

Health or Science spokespeople: Unknown

Contact: Office@conservativeparty.org.nz

 

ACT

Health Policy: http://www.act.org.nz/policies/health-0

No policy specifically dealing with health research

Science Policy: No science policy

Health or Science spokespeople: Unknown

Contact: info@act.org.nz

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*Disclaimer: I used to be a member of United Future and made submissions on the health and science policies in 2008. A few echoes of those submissions remain in the policies.