What is your number?

Last night I had the honour to speak following the AGM of the Canterbury Medical Research Foundation (CMRF).  The CMRF are a fantastic organisation I’ve talked about before.  They are also one of three sponsors of my current research fellowship.  What I talked about was volunteers and clinical trials.  Two days ago the world celebrated Clinical Trials Day in honour of James Lind who in 1747 took some men aboard a ship and started to feed them citrus fruit to see if the Spanish (who had less scurvy than the British) were on to something.  I don’t know if he used volunteers or not, but I do know that since then millions of people have volunteered to be part of clinical trials.  I salute those volunteers.  I work with people who present to the Emergency Department with chest pain or are seriously ill in the ICU.  These people are vulnerable, often scared, and are asking “Am I having a heart attack?”  Yet, despite this, when approached and asked to participate in a trial they very rarely say no.  This shows to me an incredible generosity of spirit & a heart-warming willingness to do something for someone else, even when that someone else is a mythical patient some time in the future.  I salute those volunteers.  They are my heroes.

I didn’t record the talk last night, but have tried to reproduce it this morning and present it to you now. Click HERE to access from Researchgate. It is not the same as with an audience as some of it was interactive.  However, I hope you enjoy it.  It is about 20 minutes long (100Mb) and deliberately targeted at a lay audience.

logos w uni

Ten Commandments of PowerPoint™ presentations

In my “most cringing” file, ranking somewhere alongside brussel sprouts and Abba, are PowerPoint(TM) presentations that are unreadable and distracting. I have made it my mission to rid the world of annoying animation, fantastic fonts, garrulous graphs, and tortuous tables. The following are my commandments – ignore them and dreadful things will be visited on your presentations to the tenth generation, follow them and you will be showered with the blessing of satisfied audiences the world over.

  1. Thou shalt have no other PowerPoint but the compatible version

Make sure the version of PowerPoint you are producing your presentation on is compatible with that being used at the conference. Mysterious disappearing images and font changes can occur otherwise.

  1. Thou shalt not make thyself animated images

Little creatures running across the screen are no longer cute – just annoying. Everyone has seen them before. Furthermore, they have the disturbing habit of crashing programs. If you are new to PowerPoint they may excite you – do not fall into temptation.

  1. Thou shalt not sully a slide with masses of graven clipart

Any image displayed should be illustrative of a point being made. Rarely should one use more than one image per slide. Too many images are a distraction to the audience.

  1. Remember to contrast text and background and keep it sharp

Light coloured fonts must be on very dark backgrounds and vice-versa.   Yellows on pale blues, for example, are usually not visible when projected. Remember, the projector screen is going to have lights shining on it – so it will be much duller than your computer screen. A test is to try and read your computer screen from 5 or more meters away.

  1. Honour thy audience

This commandment requires you to consider your audience and their needs.   They can only take in “so much” information, so keep the number of PowerPoint slides to a minimum – no more than one per minute of presentation (preferably one per 3 minutes). Present your name and who you represent on the first slide (so they know they are in the correct room). Don’t display your full letterhead on every page. Be careful not to display images of half dressed women or cartoons that may offend someone in the audience.

  1. Thou shalt not write screeds of text

As a rule of thumb – No MORE than 6 or 7 lines of text per page. Unless there is a need to quote something AND for the audience to read that quote, then do not write paragraphs. Keep the text simple and short (bullet points). Remember – the text is to illustrate what you are saying and provide a skeleton to hang your points on. The text is NOT the presentation.

  1. Thou shalt not display small fonts

All fonts should be 24pt or above. It may look large on your computer screen, but to someone sitting 10 or 20 metres away from a projection screen it will be the equivalent of a 10 point font in a book.

  1. Thou shalt not display serif fonts

Serif fonts are those like Times New Roman or Garamond that tend to get thinner in the middle of the letter. These are good for reading on paper, but NOT for projecting as they are much more difficult than the non-serif fonts like Arial or Verdana to read. Also, only use the most common fonts that all computers are likely to have as you may find your favoured font is not displayed as you expect. Furthermore, avoid italics and any hand-writing fonts – they can’t be read.

  1. Thou shalt not use images as backgrounds

Images behind texts nearly always make the text difficult to read. Don’t do it.

  1. Thou shall at all times and everywhere minimise the use of graphs and tables and shall only display the necessary information

Alas, this commandment is one that is broken time and again. Any lines on graph must be AT LEAST 3 pt, preferably 5pt thickness. All axes must be labelled (preferably 24 pt). Put on the graph ONLY the data that you are going to speak about. If you are going to talk about a specific data point then put a large red circle around it. Similarly with tables – display ONLY the data you will talk about. You will find that you can’t fit more than about three columns and 4 rows of a table. If you have to, split the table up over a couple of slides. Alternatively, provide the full graphs and tables as handouts. Presenting graphs and tables that cannot be read easily by everyone in the room will irritate your audience and to fail to communicate.

In all that you do, remember that PowerPoint is but a tool to support your voice and your message. You should always be prepared to deliver your presentation if, for some reason, the PowerPoint projector fails.

Here endeth the lesson

John W. Pickering (C) 2005

Major government health directive monitored for efficacy and safety

Last year I was fortunate to become part of a team at Christchurch hospital led by emergency care physician, Dr Martin Than. About 7 years ago in response to some local issues with how patients presenting with chest pain were being evaluated for potential heart attacks, Dr Than began a research program that investigated what clinical, demographic, and biological (blood) factors could best be used to safely and efficiently rule-out a heart attack.

Someone turning up at the doors of the Emergency Department with chest pain desperately wants to hear those reassuring words “You are not having a heart attack.” Unfortunately, for the ED staff this a very difficult conclusion to come to rapidly. As a result, around the world, as many as 90% of patients being assessed for possible heart attack end up being admitted to hospital overnight or longer, although only 20% of them end up being diagnosed with a heart attack. Obviously this is not good for the patient or the hospital – especially given tight budgets and lack of bed space. Dr Than’s work addressed the problem with a large multi-national observational study which assessed if a decision making pathway (called an accelerated diagnostic pathway or ADP for short) could increase the proportion of patients who could potentially not be admitted to hospital instead referred for some outpatient testing(1). This was further refined in another observational study which reduced the number of blood biomarkers that needed testing(2). Finally, and uniquely a randomised controlled trial of the new ADP verse standard practice was run at Christchurch Hospital. This was very successful, nearly doubling the proportion of patients who could be discharged to outpatient care within 6 hours of arriving in the ED(3). More has been done since on refining the ADP … but that is for another post.

The Ministry of Health liked what they saw as did ED physicians and Cardiologists throughout the country. This has resulted in the MOH asking all EDs within New Zealand to implement an accelerated diagnostic protocol. In doing so they will join all of Queensland, and a sprinkling of hospitals throughout the world that have recently adopted an ADP. This kind of positive outcome to local research is what every scientist dreams of, and Dr Than and his team have a right to be proud. But wait, as they say, there is more. Thanks to a Health Innovation Partnership grant from the Health Research Committee we are able to put in place a mechanism to monitor the effect and safety of an ADP at eight hospitals around New Zealand. This is where I come in, as I am collecting, collating and analysing the data for this project.   It is very exciting to be involved not only in helping implement a change of practice, but to be able to assess if that change is effective across a range of New Zealand hospitals from major inner-city hospitals to small rural hospitals, each of which has to adapt an ADP to meet their own particular circumstances. As I write Middlemore, North Shore, Wellington, Hutt Valley, Nelson and Christchurch hospitals all have new ADPs in place. Most if not all EDs will have them by the end of the year.

Some of where accelerated diagnostic pathways have been implemented.

Some of where accelerated diagnostic pathways have been implemented.

The model of observational research -> randomised controlled trial -> local implementation with further research -> mandatory national implementation -> research the effect of that change on local and national levels -> refine processes etc, is I believe a very good one and one that should be standard practice for major health initiatives. The MOH, HRC, and various district health boards that have bought into this process should be commended. There are other similar initiatives happening around the country and a look forward to when as a health consumer I can have confidence in any procedure I may face as been similarly thoroughly assessed.


Thanks to my Acute Care Fellowship sponsors: Sponsors


and to the grant funding body:




  1. Than, M. P., Cullen, L., Reid, C. M., Lim, S. H., Aldous, S., Ardagh, M. W., et al. (2011). A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study. Lancet, 377(9771), 1077–1084. doi:10.1016/S0140-6736(11)60310-3
  2. Than, M. P., Cullen, L., Aldous, S., Parsonage, W. A., Reid, C. M., Greenslade, J., et al. (2012). 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. Journal of the American College of Cardiology, 59(23), 2091–2098. doi:10.1016/j.jacc.2012.02.035
  3. Than, M. P., Aldous, S., Lord, S. J., Goodacre, S., Frampton, C. M. A., Troughton, R., et al. (2014). A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Internal Medicine, 174(1), 51–58. doi:10.1001/jamainternmed.2013.11362

I’ve Got a Bad Feeling About This. . .

John Pickering:

My brother-in-law English lit professor shamelessly writing about a recent NZ sci fi book by his brother-in-law who’s not me…

Originally posted on Intelligently Artificial:

I’m not even going to pretend that there isn’t a conflict of interest here.  A better, more ethical person would take steps to maintain their objectivity and protect their sense of integrity.  But in a world where news anchor Brian Williams can singlehandedly drive the Taliban out of Afghanistan, and the US Supreme Court has declared that money is people, I will simply press on.  In the immortal words of Brian Williams, once more unto the breach!

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Hot oil baths and other things to do on World Kidney Day 2015

“In ancient times the Persian philosopher Avicenna [Ibn Sina] noted that urine may be retained in crisis of fever (s393) and prescribed hot oil baths (s413)(1). Unfortunately, apart from the supportive therapy of dialysis, there has been little progress since in the treatment of acute kidney injury (AKI).”(2)

Given that getting AKI at least doubles your chance of dying in hospital “no progress” is a major health issue.

Today is World Kidney Day and I get to post quite possibly the first blog post in the world on this day. I believe Avicenna would be thrilled with the attention paid to the organ which delivers urine. He may not be so thrilled that hot oil baths have been abandoned. Of course there is the obvious safety issues of scalding and drowning. Also, as Herod the Great found out, syncope (sudden loss of consciousness) is also a possible side effect (probably just because the heat constricted his blood flow [vasoconstriction] causing too little oxygen to reach his brain [cerebral anoxaemia].(3) Nevertheless, I think Avicenna is the type of person who would have welcomed a randomised controlled trial of hot oil baths verse today’s standard treatment.


The statue of Avicenna (Ibd Sina) to be found in Hamaden, Iran. http://www.panoramio.com/photo/91467137

If you don’t fancy a hot oil bath this World Kidney Day, then there are other things to do to minimise the possibility of Acute Kidney Injury. Have you got high blood pressure, diabetes or Chronic Kidney Disease? Be warned, ~10% of the adult population have Chronic Kidney Disease, many of whom are not aware, and many more are at risk of developing it. All add to your risk of multiple illnesses any one of which can trigger acute kidney injury. If you happen to have a heart attack or sepsis (very serious infection) you are more likely to get AKI and more likely to die because of these underlying conditions.

So, on the assumption that readers of this blog are smarter than the average bear, I shall give you some sound advice – for the sake of yourselves and your family LOOK AFTER YOURSELF (yes, I’m shouting and therefore sinning against the internet protocol police – but this is important). Cut the sugar intake, quit smoking, take a walk around the block. It ain’t rocket science (one of the simpler sciences that involves cylinders with fins and lots of explosives) – it’s easier than that.

Former World Kidney Day posts

2014 A day to celebrate https://100dialysis.wordpress.com/2014/03/13/a-day-to-celebrate/

2013 Happy WKD https://100dialysis.wordpress.com/2013/03/14/happy-wkd/

2012 I am a pee scientist https://100dialysis.wordpress.com/2012/03/07/i-am-a-pee-scientist/


  1. Avicenna: The Canon of Medicine [Internet]. 2nd ed. New Yourk: AMS Press; 1973. Available from: http://archive.org/stream/AvicennasCanonOfMedicine/9670940-Canon-of-Medicine_djvu.txt
  2. Pickering JW, Endre ZH: The definition and detection of acute kidney injury. Journal of Renal Injury Prevention 2014; 3:19–23 http://www.journalrip.com/Archive/3/1
  3. Retief FP, Cilliers JFG: Illnesses of Herod the Great. S Afr Med J 2003; 93:300–303

Cantabrians, this is your life

There is little more precious than our health and that of those we love. “Research saves lives” is  Canterbury Medical Research Foundation’s (CMRF) proudly held motto. The CMRF has been supporting the people of Canterbury for 55 years thanks to the generosity of Cantabrians. In that time they have funded more than $22 million in grants.  Yesterday I attended the launch of their new logo and branding.  The logo depicts a medical cross and the four avenues of Christchurch.  This new logo is intended to signal CMRF’s intention to be fresh and more external facing with a broader appeal to the Canterbury donating community and a bigger emphasis on  partnerships with other funding organisations to leverage money to best effect.  My own fellowship, jointly funded by the CMRF, the Emergency Care Foundation, and the Canterbury District Health Board is an example of that.  CMRF are also expanding the breadth of research they will fund and are now working to expand their influence in the translational, population health and health education spaces. Their vision is to be giving $2 million in grants per annum within 5 years.  What a great boost that will be to Canterbury. A key partner largely funded through CMRF is the NZ Brain Research Institute – their logo has also changed to mirror that of CMRF.


Acute Kidney Injury Following Cardiac Surgery: A Well-studied Cohort of AKI

Originally posted on AJKD Blog:

Dr. John Pickering Dr. John Pickering

Acute kidney injury (AKI) following cardiothoracic surgery has been well reported in the nephrology literature with numerous studies published in the last decade, although the definition of AKI was variable in many of these studies.  In a recent article published in AJKD, Pickering et al perform a systematic review and meta-analysis of the literature to assess the different definitions of AKI in these studies.  Dr. John Pickering (JP), the first and corresponding author of the study, discusses this topic with Dr. Kenar Jhaveri (eAJKD), eAJKD Editor.

eAJKD:Can you explain why your team felt this topic was important to study?

JP: There is a long history of studies evaluating AKI after cardiopulmonary bypass surgery, but the information is heterogeneous and cannot be easily used to understand the extent of the problem.  We thought it was important to quantify the association and its consistency across several global…

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