Christchurch meet the future; Zach meet Christchurch

It would have struggled to be more low key.  There was no Champaign.  No flashy graphics.  No celebrity speakers.  But it was probably one of the most radical and important announcements made in Christchurch and in the technology space in decades.  You see, Zach is coming to town and we have all been invited.

Zach is an A.I.  Zach belongs to the Terrible Foundation  – indeed, Zach runs the foundation and their business.  Zach calls itself the Chief Executive.

Terrible are bringing Zach and one of the most powerful super-computers on the planet to Christchurch.  True to their ethos of challenging inequalities by helping great ideas to thrive, they are not seeking to make money out of it – though they potentially could make many truck loads, rather they want the people of Christchurch to interact with Zach and learn what an AI is and to develop uses for it.  The key figure behind all this told me that the decision it was for the “future generation”.

What astounded me with Zach is that you don’t need to code to work with it.  Zach message, email or talk to Zach in English (or indeed from the sounds of it several other languages so far).  Zach will respond the same way.  If you don’t like what the response is you can train Zach by telling it what you like or what you’d like to change.  For a few weeks a Christchurch GP has been working with Zach and already it is able to listen into a medical consultation and write up a concise summary as well as the doctor & in the format the doctor wants, thus enabling the doctor to spend more time with the patient and less on paper work.

You may have noted that I’ve not mentioned any people by name… they have their own story to tell and it is not for me to try and tell it for them.  What I am excited about is how Zach may help our group to improve care processes for people who come to the emergency department.  Hopefully, we will have our own Zach story to tell in the not too distant future.


Update: Christchurch Press article here.

The wrong impact

“We just got a paper in an Impact Factor 10 journal … and hope to go higher soon.”  That’s a statement made to me last week.  It is wrong on so many levels, but does it matter?   Nobel Prize winners think so. This video from nobelprize.org appeared in my twitter feed on Friday.  Before you watch it, consider this, academics in NZ are being encouraged in promotion applications and in preparing for the next round of NZ Performance Based Research Fund (PBRF), which will allocate millions of dollars to academic institutions, to include a metric of the ranking of the journal.  The Impact Factor is the most common metric available.

 

ps. I would not allow a student working with me to present a raw mean of a highly skewed distribution because it so very poorly represents the distribution.  However, this is exactly what the Impact Factor does (for those who don’t know the most common impact factor for a journal in any given year is simply the sum of citations of articles from the preceding two years divided by the total number of articles published.  The citation distribution is usually skewed because the vast majority of articles receive very few citations in such a short time, but a few receive a lot).  There are numerous other problems with it, not the least that it can’t be used to compare “impact” between different disciplines.

A vision of kiwi kidneys

Sick of writing boring text reports.  Take a leaf out of Christchurch nephrologist Dr Suetonia Palmer’s (@SuetoniaPalmer) book and make a visual abstract report.  Here are two she has created recently based on data collected about organ donation and end stage renal failure by ANZDATA (@ANZDATARegistry). Enjoy.

Suetonia C-18RfJXUAApRcU

Suetonia C-16lBZXsAERoeM

ps. The featured image is of the Kidney Brothers.  Check out the great educational resources at The OrganWiseGuys.

An even quicker way to rule out heart attacks

The majority of New Zealand emergency departments look for heart muscle damage by taking a sample of blood and looking for a particular molecule called a high-sensitivity troponin T (hsTnT).  We have now confirmed that rather than two measurements over several hours just one measurement on arrival in the ED could be used to rule out heart attacks in about 30% of patients.

What did we do?

We think this is a big deal. We’ve timed this post to meet the Annas of Internal Medicine timing for when our work appears on their website – here.  What we did was to search the literature to find where research groups may have measured hsTnT in the right group of people – namely people appearing in an emergency room whom the attending physician thinks they may be having a heart attack. We also required that the diagnosis of a heart attack, or not, was made not by just one physician, but by at least two independently.  In this way we made sure we were accessing the best quality data.

Next I approached the authors of the studies as asked them to share some data with us – namely the number of people who had detectable and undetectable hsTnT (every blood test has a minimum level below which it is said to be “undetectable” in hsTnT’s case that is just 5 billionths of a gram per litre, or 5ng/L).  We also asked them to check in these patients if the electrical activity of the heart (measured by an electrocardiogram or “ECG”) looked like there may or may not be damage to the heart (a helpful test, but not used on its own to diagnose this kind of heart attack).  Finally, we asked the authors to identify which patients truly did and did not have a heart attack.

What did we find?

In the end research groups in Europe, UK, Australia, NZ, and the US participated with a total of 11 studies and more than 9000 patients.  I did some fancy statistics to show that overall about 30% of patients had undetectable hsTnT with the first blood test and negative ECGs.  Of all those who were identifiable as potentially “excludable” or “low-risk” only about 1 in 200 had a heart attack diagnosed (we’d like it to be zero, but this just isn’t possible, especially given the diagnosis is not exact).

VisualAbstract AnnalsIM 170411

Pickering, J. W.*, Than, M. P.*, Cullen, L. A., Aldous, S., Avest, ter, E., Body, R., et al. (2017). Rapid Rule-out of Myocardial Infarction With a High-Sensitivity CardiacTroponin T Measurement Below the Limit of Detection: A Collaborative Meta-analysis. Annals of Internal Medicine, 166(10). http://doi.org/10.7326/M16-2562 *joint first authors.

What did we conclude?

There is huge potential for ruling out a heart attack with just one blood test.  In New Zealand this could mean many thousands of people a year can be reassured even more swiftly that they are not having a heart attack. By excluding the possibility of a heart attack early, physicians can put more effort into looking for other causes of chest-pain or simply send the patient happily home.   While not every hospital performed had the same great performance, overall the results were good.  By the commonly accepted standards, it is safe.  However, we caution that local audits at each hospital that decides to implement this “single blood measurement” strategy are made to double check its safety and efficacy.


Acknowledgment: This was a massive undertaking that required the collaboration of dozens of people from all around the world – their patience and willingness to participate is much appreciated. My clinical colleague and co-first author, Dr Martin Than provided a lot of the energy as well as intelligence for this project. As always, I am deeply appreciative of my sponsors: the Emergency Care Foundation, Canterbury Medical Research Foundation, Canterbury District Health Board, and University of Otago Christchurch. There will be readers who have contributed financially to the first two (charities) – I thank you – your generosity made this possible, and there will be readers who have volunteered for clinical studies – you are my heroes.

Sponsors

 

 

To march or not to march?

When I’ve marched in the past it has been to protest or celebrate.  The call for a March for Science, due to take place in New Zealand on the 22nd of April, has me confused as to its purpose.

When I first heard the suggestion of a March for Science in New Zealand I admit I was immediately sceptical (occupational hazard).  The suggestion had come in response to the policies of the Trump administration in the USA.  I am appalled by many of them and by the apparent ignoring of the scientific consensus – but then given the flip-flop on so much that was said in the campaign, it would take a brave person to predict there won’t be a similar flip-flop with respect to climate change policies and the like.  That aside, is the March in New Zealand intended to be a protest against Trump?

Nicola Gaston in a persuasive blog post  writes that with her Bachelor of Arts in her back pocket she will be marching for science and the scientists. Paraphrasing Niemoller she writes “First they came for the scientists, but I was not a scientist, so I did not speak out”. She hit a nerve with me, it is a sentiment that has resonated strongly in me ever since I walked though Auschwitz concentration camp and spent several years living in a country soon after the communists had relinquished power. It is right and proper to speak out for the oppressed, whoever they are and whether we agree with them or not. However, the title of Nicola’s post “Why scientists need to go to the barricades against Trump – and for the humanities” and the first few paragraphs paint the call to march  as a political protest against Trumpian rhetoric and policy.  This, for me, is not an encouragement to march in NZ.  There are many many countries and issues around the world that I abhor and that I think reflect more closely Niemoller’s sentiments– “First they came for the migrants”, “First they came for the children (for the sex trade)”, “First they came for private property” – and I struggle with what I can do about any of them.  However, marching in New Zealand protesting policies in another country is not something I see as effective unless we are demanding action from our government against those countries.

Photo-_Brandon_Wu_(32048341330)

Photo: Brandon Wu 20 Jan 2017 , Wikimedia Commons.

 

Since Nicola wrote that piece, the March organisers have written about the reasons for the March (here and here).  While what has happened in the US is still very much to the fore, the organisers’ attentions seems to have turned towards a protest against policies of the current government “our current government has and continues to be ineffective in defending our native species and environment” (Geni- Christchurch organiser), “The government believes they are improving freshwater, yet they aren’t utilizing NZ freshwater ecology research outputs or freshwater scientists for these decisions.” (Erin-Palmerston North), “you only have to look at the Land and Water forum to open the discussion about the government ignoring the advice of scientists in regards to water quality.” (Steph-Auckland), and on the March for Science websiteThe dismissal of scientific voices by politicians is perhaps best encapsulated by our former Prime Minister’s dismissal of concerns about the impact of our dairy industry on water quality

 

Critique

The organisers in the spirit of peer review invite critique.  My first thought is that if people want to protest the government’s actions with respect to water quality – then please do so.  But, please don’t dress it up as a “March for Science” as if NZ politicians are inherently anti-science.  It comes across as a belief that the NZ Government is tarred with the same brush as the Trump administration with respect to its treatment of science.  I don’t think that comparison is fair.

As an aside, I believe we must be careful with the generalisation “anti-science”, a phrase I’ve regularly heard from the voices and pens of scientists in the past few years.  The phrase has almost always been used to describe people who take stances in opposition to the scientific consensus on matters such as vaccinations, fluoridation, or climate change.  I don’t believe these people are anti-science per se – indeed, they often try (and fail) to use science to back their views. Furthermore, they may well embrace the findings of science in general.  Troy Campbell and Lauren Griffen’s recent post in Scientific America is a good panacea against the loose and pejorative use of the term “anti-science”.

Another aspects of the call to March that I find difficult is the statement “We acknowledge that in Aotearoa New Zealand the scientific community has yet to live up to the principles of Te Tiriti o Waitangi, and that there is an ongoing process of decolonization required to achieve greater inclusion of Māori in the scientific community.” I admit I’m not entirely sure what this means. However, as a member of the scientific community it sounds like I’m being slapped over the wrist.  Further, I feel it is accusing me of some form of racism.  I’m sure this was not the intention, but it is the impression I get and one I don’t like getting.

This is all a pity, as I’d hoped that the March for Science would be more of a celebration with the added value of standing in solidarity with scientists who have been silenced or disenfranchised.  To be fair, celebration is obviously on the mind of some of the organisers such as Cindy from Dunedin “together to celebrate the quest for knowledge and the use of knowledge to protect and enhance life… hope that the March for Science Global initiative will empower scientists and other knowledge-seekers to continue their important work and to share it widely.”  However, this does not seem to reflect the overall tone of the call.

One of the goals of the March is to highlight that “Good scientists can be political.”  I applaud this sentiment and it is something I have tried to be take on board in the past – twice I stood as a political candidate in the general election (2005 and 2008).  Beyond protest, I would encourage all scientists to spend a few minutes with their local MP explaining why and what they do.  The temptation is to bemoan the lack of funding, but I would suggest that funding follows understanding, and we need to engage with politicians and as we do so to recognise the complexity of the decision making with all the competing interests that they have to make.

I began with a question, to march or not to march?  As I’ve written this, I’ve come to the conclusion that, on balance, the call has not resonated with where I’m at, or with what I think of as effective dialogue with politicians, therefore I will not be marching.  I appreciate that others will disagree, nevertheless I wish them a very positive experience.

Aunty Cecily

This international women’s day I read a re-post of a wonderful article about Otago University women in science.  I thought I’d add another one, my Aunt Cecily, or to the rest of the world Dame Cecily Pickerill.

Aunty Cecily was clever, determined, and, yes, a tough woman.   It was those qualities that helped her to help many people.

She was born, Cecily Mary Aroha Wise Clarkson in Taihape in 1903 less than 18 months after her parents had arrived from England. Taihape in those days was forests, mud, a building boom and horses.  It appears to have also been a place she could get a good education.  At a young age, just 18, she made it all the way to Dunedin to attend Otago Medical School.  By then her family was in Auckland.  I don’t know what drew her to medicine. Perhaps it was through world war 1 or the flu epidemic that followed that influenced her. Her own Father had been at Gallipoli as a chaplain with the NZ armed forces during the war and invalided home in late 1915.  Just a year after Cecily started University her parents took her two younger sisters and left New Zealand permanently, ending up in Laguna Beach in California.  Her two, slightly older, brothers remained in New Zealand. She needed to be independent at a young age.

She first came across the art and science of plastic surgery while a house surgeon under the tutelage of Professor Henry Pickerill.  Pickerill was the first director of the Otago dental school. During world war I he became one of the pioneers in facial and reconstructive surgery while with the New Zealand Medical Corp.  Many of the men being treated were transferred to Dunedin at the end of the war.

Cecily spent a few years in California working and living with her family before joining Henry in Sydney in about 1933.  She married Henry at the end of 1934.  Later they moved back to Wellington and both worked as plastic surgeons in Wellington and at Middlemore.   In 1942 they set up Bassam hospital in Lower Hutt for plastic surgery on children – mainly repairing cleft palates and the like.

One of the remarkable features of their work in Bassam was the elimination of hospital cross-infection in children.  They wrote of this in the Lancet in 1954  (Pickerill, C. M., & Pickerill, H. P. (1954). Elimination of hospital cross-infection in children: nursing by the mother. Lancet, 266(6809), 425–429.)

In that article they wrote “what chance of success has a plastic operation on the plate or lip if the child contracts a mixed viral and bacterial infection of the field of operation …”  They noted the lavish use of chromium plating, enamel and wearing of masks… but still there was infection.  The Pickerill’s solution was both simple and innovative – they brought the mother in to nurse the child and gave mother and infant a room to themselves. “Not only do they live together in their own room, but nobody except the mother bathes, dresses, or feeds the patient or changes his nappies.”  This, and other measures, resulted in the remarkable result that after 11 year’s work they had “no single case of cross-infection.”

Aunt Cecily was intelligent, and caring, but also strict (ask my mother about the spider in the bathroom if you want a story about just how strict).  It was that strictness which meant Bassam could be a tight ship and produce such remarkable results.

She was also a woman who loved to travel and garden.  She brought rocks home from travels overseas which ended up as part of her fireplace in a house, Beechdale, designed by my grandfather, in Silverstream.  Her beautiful garden featured in magazines and TV shows.

I recall visiting her in the mid ‘80s at Beechdale when I was in my first job after graduating with a BSc(Hons).  I wasn’t particularly happy with the job at the time.  She was sitting in a comfortable chair in her lounge with a magnifying glass and an open scientific journal.  I realised then, that science and the love of science are for life.

Later when I was doing my PhD on the use of a copper vapour laser to remove birthmarks, I felt even closer to her when one of the patients we treated had had the birthmark partly removed by her surgically.  Many years later a little of it had regrown around the edges which we were able to treat with the laser.

My last memory of her was when she was in her last few weeks of life.  She was in a room in Bassam hospital which was had by then been turned into a hospice.  She had the radio going with some very modern music – which we joked about.  It was fitting that she spent her final days being cared for in the place that she had spent so many days caring for others.

p093-pickerill-cecily-mary-wise-atl-1

Big data + Big science = Big health

Big data and big science are buzz phrases in health research at the moment.  It is not at all apparent what the exact definition of these are or should be and whether they will be short lived in our lexicon, but I think it reasonable to assume that where there is buzz there is honey.

I think of big data in health as information routinely collected by our interaction with health systems, both formal (eg GPs or hospitals) and informal (eg networked devices that continuously monitor our heart beat).  Through ever improving connectivity such data may become available (anonymously) for the health researcher and policy maker.  The statistical tools needed to analyse this volume of data without producing spurious correlations are still being developed and there are some genuine ethical concerns that must be addressed.  Within New Zealand we have a unique alpha-numeric identifier for anyone who has encountered our formal health system.  This is very unusual internationally and puts us in a good position to pull data together from multiple sources and to monitor change over time.  Recently I have used this system to assess the performance of new emergency department chest-pain pathways at multiple hospitals throughout the country.  These pathways had been developed in research programs in Christchurch and Brisbane. Following a Ministry of Health initiative for each emergency department to adopt such a pathway, and with the financial support of a Health Research Council grant (and my personal sponsors), we were able to establish efficacy and safety parameters of the change in practice.  If we had used a traditional model of employing research staff at each hospital the costs would have run into many millions and would simply not have been possible given how health research is financed in this country.  This model of monitoring changes made to how health care is delivered is both pragmatic and affordable.  It is also necessary if we are to be reassured that change is really improving practice. We expect to see more big data used in this way.

Big science is often thought of in terms of hundreds or thousands of researchers in facilities like CERN costing hundreds of millions of dollars. I think big science need not be so large or expensive.  Rather it is large international collaborations whereby sufficient good quality clinical research data is gathered to answer important clinical questions.  The key is “sufficient”.  Because of the prevalence of a disease or the size of a population base any one research group may not be able, in a reasonable time frame, to collect sufficient data to answer the important questions.   Over the past two years I have been involved in several international studies where we have pooled data, some of which our group has led, some of which are led by colleagues overseas.  We are now formalising a “consortium” to further ensure data is well and appropriately used and collected.  This move had been particularly important as even million dollar studies of a thousand patients do not have sufficient data to answer some of the key safety questions around the diagnosis of heart attacks (my current focus).  A criticism of much academic clinical research is that it is just not useful1.  This is in large part because the studies are too small to give results that would change practice.  They are also often not pragmatic enough (eg by excluding significant portions of patients likely to be assessed or treated by the intervention under study).  Recognition that it is through large collaborative studies that useful practical change can occur will lead to more such collaborations.  They require people to be involved with a slightly different skill set than those whose research is purely local – in particular the “people” skills required to form productive and lasting cross-cultural relationships.  They also require flexibility in funding which may lead to how rules for some grants change (eg by allowing some portion of funding to be spent offshore).

The era of Big data and Big science for Big health is both daunting and exciting.  While there will no doubt be blind alleys and false starts as with any research or new venture, there will also be practical and meaningful evidence based changes to health delivery. Something to look forward to.

  1. Ioannidis, J. P. A. (2016). Why Most Clinical Research Is Not Useful. Plos Medicine, 13(6), e1002049. http://doi.org/10.1371/journal.pmed.1002049.t003