Category Archives: $100Dialysis

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

Cheesecake files: A little something for World Kidney Day

Today is World Kidney Day, so I shall let you in on a little secret. There is a new tool for predicting if a transplant is going to be problematic to get working properly.

Nephrologist call a transplant a “graft” and when the new kidney is not really filtering as well as hoped after a week they call it “Delayed Graft Function.”  Rather than waiting a week, the nephrologist would like to know in the first few hours after the transplant if the new kidney is going to be one of these “problematic” transplants or not.  A lot of money has been spent on developing some fancy new biomarkers (urinary) and they may well have their place.  At this stage none are terribly good at predicting delayed graft function.

A while ago I helped develop a new tool – simply the ratio of  a measurement of the rate at which a particular substance is being peed out of the body  to an estimate how much the body is is producing in the first place.  If the ratio is 1 then the kidney is in a steady state. If not, then either the kidneys are not performing well (ie not keeping up with the production), or they have improved enough after a problem and are getting rid of the “excess” of the substance from the body.  This ratio is simple and easy to calculate and doesn’t require extra expense or specialist equipment.

A few months ago, I persuaded a colleague in Australia to check if this ratio could be used soon after transplant to predict delayed graft function. As it turns out in the small study we ran that it can, and that it adds value to a risk prediction model based on the normal stuff nephrologists measure! I’m quite chuffed about this.  Sometimes, the simple works.  Maybe something will become of it and ultimately some transplants will work better and others will not fail.  Anyway, it’s nice to bring a measure of hope on World Kidney Day.

This was published a couple of weeks ago in the journal Nephron.

 

Self plagiarism – a misnomer

The story so far…

Dr Jaimi Whyte publishes in the NZ Herald an article that portions of which are substantially similar to an article he published in Britain in 2005.  This was picked up somehow by @LI_politico who posted:

Twitter on Jaimi Whyte

 

The NZ Herald subsequently asked Dr Whyte for his reaction to the accusation of self-plagiarism & reported that he did not see anything wrong with submitting an article which was a variant of one he had already published and [besides] Dr Whyte added “There’s clearly no such thing as self-plagiarism.”

I tweeted the article in reaction to the statement about self-plagiarism saying that I agree with Dr Whyte.  This resulted in some very interesting twitter discussion with a number of academics including   .  There were a number of good points made about whether this was more a case which should concern a possible breach of copyright (Dr Whyte had originally published his views in a book; I am not sure who owns the copyright) or whether it was a case of plagiarism; and also about why Dr Whyte’s action may be wrong.

My initial point was that Dr Whyte’s action was not plagiarism. I made this because when I was asked to write an encyclopaedia article on plagiarism a few years back I found that the generally excepted definition was “To represent oneself as the author of some work that is in fact the work of someone else.”[1]  Critically, it is only plagiarism if it is someone else’s work that is being “passed off” as one’s own.  This, though, is not necessarily a universal definition.  pointed to a University of Calgary definition of self-plagiarism:

“Self-plagiarism, however, must be carefully distinguished from the recycling of one’s work that to a greater or lesser extent everyone legitimately does. … Among established academics self-plagiarism is a problem when essentially the same article or book is submitted on more than one occasion to gain additional salary increments or for purpose of promotion.

Like all plagiarism the essence of self-plagiarism is the author attempts to deceive the reader…”[2]

I don’t think Dr Whyte’s article in the NZ Herald would meet the the University of Calgary’s strict definition of self-plagiarism as there is no hint of publication to enhance promotion aspects.  Dr Whyte, is a former politician.   “Repeating oneself” as a politician has become an art form – infuriating in the extreme during election season when we only hear the same thing over and over again.  The angst within academia appears to be that if one repeats oneself in order to gain advantage (eg prestige, promotion etc), then that is deception and not to be done.  On the other hand, as academics we are required to promote what we discover and think (in NZ law to be the “critic and conscience of society”).  Where that comment is confined to the academic journals where we could self-cite (sometimes frowned upon) an issue of deception by replication may be easy to spot.  However, as academics increasingly make use of new media, much of which is not limited to academics, as a means to engage, discuss, debate, and pontificate the line between deception and merely conforming to the norms of the media – ie where citation is not the norm & self-citation may be seen as arrogance and loose one’s audience  – becomes blurry.

The cop-out on many a publication where the results of the experiment are somewhat equivocal is to write “Further study is needed.” [guilty as charged… but only when referees push for this kind of comment].  Certainly here, further discussion is needed.  If you do engage in such discussion, perhaps consider also that the context of plagiarism is culturally bound:

“Plagiarism in the West rests on the assumptions that individuals can and do own their own words and content. …In many non-Western cultures, people find value in their relationships and position in society rather than in their expression of self. In such collectivist cultures, plagiarism is not recognized as a social wrong.”[1]

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[1] Pickering, J. W. (2008). Plagiarism. In V. N. Parillo (Ed.), Encyclopedia of Social Problems (pp. 664–667). SAGE Publications: Thousand Oaks, USA.

[2] http://people.ucalgary.ca/~hexham/content/articles/plague-of-plagiarism.html#types

 

 

The transplant smile

Source Deviant Art

Source Deviant Art

“His mega-watt smile could power the Auckland grid” was how Herald columnist Wynne Gray so eloquently described this morning Joeli Vidiri after his kidney transplant.  In the meantime across the Tasman my long term colleague and head of Nephrology at Prince of Wales Hospital in Sydney, Prof Zoltan Endre, is celebrating 50 years of the transplant unit. There is a lovely story of a smiling Carolyn Hochkins who has survived 42 years with a kidney transplant.  Invaluable!

Transplants have become “normal” and rarely make the news unless it is of a famous face or a celebration such as in Australia this week.  They are far from “normal” for the recipients.  They are life changing – not simply a change from being tied to a dialysis machine for many hours a week, but better all round health.  The machine is merely supportive and it doesn’t manage to do everything a kidney can do.

Congratulations Joeli, Congratulations Carolyn, Congratulations all you donors and donor families, Congratulations all you dedicated nephrologists and surgeons that have made the kidney transplant a routine life changer.

A wound in the scientific body: a hypothesis

The social and professional media have had a field day with Sir Tim Hunt’s comments concerning women in the lab. Juxtaposed with that in New Zealand has been a very earnest discussion about the gagging of scientists. The purpose of this post is simply to highlight that the two are not unrelated and how we handle one affects the other.

The reaction to Sir Tim Hunt’s comments has been swift and brutal. It amazes me how 140 characters or a couple of columns in a newspaper cannot only hang, but draw and quarter. It also amazes me how swift such judgment can be without recourse to gathering all the evidence first. The issue of bigotry and bias against women in science are very real and very felt. I do not intend to re-litigate any of those issues. It is the brutal nature of the response that concerns me. Not only has one man been thoroughly lambasted in every corner of the world – something of an overkill – but with him so have vast numbers of others been lambasted as the epithets have spilt over to include whole generations of male scientists. I have also noted a bigoted reaction to those condemning Sir Tim Hunt, equally replete with pithy epithets that do nothing but to wound, raise hackles and expose one’s own prejudices.

What has this to do with gagging of scientists? Simply, that it raises the fear index for anyone thinking of making public comments. I was speaking with a very well accomplished scientist the other day who will not speak to the media about their own work because of the very negative reaction of colleagues when they once did so. I hypothesise that following the response to Sir Tim Hunt’s comments, and the response to that response, that there are scientists who are thinking twice about publically speaking out on their science let alone on a controversial issue – a.k.a. self-gagging. The wound is deep. It must heal, because without those voices then the public debates about such issues as sea level rise, euthanasia, medicinal cannabis, science education etc will be all the poorer for the absence of those voices. The missing ingredient, the only known treatment for the wounds that have appeared, is compassion and forgiveness. Not terms that normally appear in the scientific literature, but universals that can alone heal the wounds and lift people up to where they can empathise with others irrespective of race, sex or creed.