#TwitJC Transcript 5-6-2011

8/6/2019 #TwitJC Transcript 5-6-2011

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Transcript: Twitter Journal Club First Meeting

8pm, Sunday 5th June 2011

Rivers et al. (2001) Early goal-directed therapy in the treatment of severe sepsisand septic shock, NEJM - Available at http://bit.ly/jsxap2

Hosted by Fi Douglas and Natalie Silvey

twitjournalclubFi (@fidouglas) will be chairing & dealing with any technical issues, and Natalie(@silv24) will be presenting the paper. ^fd #twitjc -7:53 PM

twitjournalclubKey points - is this paper valid, what are the results and are the results validoutside of the context of the paper #twitjc -7:54 PM

welsh_gas_doc@Phillippajones Follow the hashtag #TwitJC. -7:54 PM

peds_id_doc @twitjournalclub Hmmm...the CASP toolkit is a start, but I have extra thoughts forthe budding researchers among ppl here... #Twitjc -7:54 PM

fidouglas@peds_id_doc Hold that thought - sounds interesting, but not sure there's the time/spacehere at the mo...! #twitjc -7:55 PM

twitjournalclubBoth @fidouglas & @silv24 are new to this so please bear with us ^ns #twitjc -7:55PM

peds_id_doc @fidouglas there'll be time I'm sure...If a suitable place pops up I'll slip something in.#ooermissus #Twitjc -7:56 PM

rodedun good luck to @twitjournalclub @fidouglas @silv24 for an excellent idea you guys are

amazing #twitjc -7:56 PM

parkerflashRT @rodedun: good luck to @twitjournalclub @fidouglas @silv24 for an excellent ideayou guys are amazing #twitjc -7:56 PM

silv24 RT @rodedun: good luck to @twitjournalclub @fidouglas @silv24 for an excellent idea youguys are amazing #twitjc -7:56 PM

behrouzn RT @rodedun: good luck to @twitjournalclub @fidouglas @silv24 for an excellent ideayou guys are amazing #twitJC -7:57 PM

tobyhillman Toby checking in for #twitjc Resp SpR. Eating, and trying to converse with wife, but

will follow attentively... -7:57 PM

fidouglasRT @rodedun: good luck to @twitjournalclub @fidouglas @silv24 for an excellent ideayou guys are amazing #twitjc -7:57 PM

fidouglas@peds_id_doc Jolly good! I'm just looking to keep things reasonable on topic this evening- gonna be easy to get sidetracked! #twitjc -7:58 PM

peds_id_doc @fidouglas if I need to I'll throw my thoughts out separately at the end ;-) #Twitjc -7:58 PM

anaestheticdoc ooooo ooooo is the tweetchat working.evening all! very impressed #twitjc -7:58 PM

Shazmo TweetChat is pretty cool..... #twitjc -7:58 PM

simonpeteryoung#TwitJC good luck, fab idea -7:58 PM


2/31

amcunningham #TwitJC hi Anne Marie, gp and lecturer with special interest in #meded sayinghello -7:59 PM

twitjournalclubFirst of all introductions....#twitjc -7:59 PM

aj0610 Hello to #twitjc; AJ, Pharmacology grad, 4th yr medic at Aberdeen -7:59 PM

TWSY Tom Young, emergency physician #twitjc -7:59 PM

peds_id_doc Peds ID fellow from Cambridge UK, currently in Upstate NY doing, err, the fellowship#Twitjc -8:00 PM

DrDLittle Tweetchat working well. I'm David, currently a teaching fellow, soon to be Radiologytrainee #Twitjc -8:00 PM

anaestheticdoc anaesthetic consultant, DGH in wales. #twitjc -8:00 PM

iamdoctord Richard CT2 Medicine in Northern Ireland saying hi too #twitjc -8:00 PM

drbrown1970 Russell Brown, GP in Sussex (will be mostly lurking tonight) #twitjc -8:00 PM

limn Hi #twitjc Neal, Y5 undergrad in Glasgow #twitjc -8:00 PM

Shazmo Charlotte, 1st yr med student. May have to dash soon but will catch up later (: #twitjc -8:00PM

JoBrodie #twitjc Jo, science info officer for @DiabetesUK keen on improving critical appraisal skillsfor medical papers -8:00 PM

kevfrost Kevin Frost, Antibiotic Pharmacist #twitjc -8:00 PM

welsh_gas_docDJ, Anaesthetics Reg, DGH in Wales. #TwitJC -8:00 PM

silv24 Hello all - Natalie Silvey, first year doctor currently working in gastroenterology #twitjc -8:00PM

parkerflashNice one! I'm back. Final year med student, soon to be academic foundation trainee.Love a bit of SIRS. #twitjc -8:01 PM

medicscott Scott Berwick, 1st Year Grad-entry Medical Student. Degree in Biomedical Science.#twitjc -8:01 PM

MargoJMilneHi I'm a non-medic with a degree in Health Studies / Human Biology #twitjc -8:01PM

EasternDocHello all, I'm Simon, FY1 working in East Anglia #twitjc -8:01 PM

dtwatkin Evening all. David Watkin, paediatrics trainee in the West Midlands #twitjc -8:02 PM

alexwintermute Hi, Alex here, grad entry medicine pre-fresher and HCA #Twitjc -8:02 PM

ryanmadanickmd #twitjc Just lurking... Ryan Madanick, Gastroenterologist, fellowship director inthe US (North Carolina) -8:02 PM

MedEdHelenHelen Morant, ex anaesthetist, now working at BMJ in online learning. (I once knewthis paper well - its been about 5 years...) #TwitJC -8:02 PM

ABLocalBargains#aberdeen RT @aj0610 -Hello to #twitjc; AJ, Pharmacology grad, 4th yr medic

at Aberdeen -8:02 PM

benazevedo 3rd year med student, Tulane University in New Orleans #twitJC -8:02 PM

chrisking01Hey I'm Chris, hospital pharmacist and soon to be medical student #twitjc -8:02 PM


3/31

behrouznHi everyone!! Behrouz, hoping to start medicine next year. Just reading tonight. #twitJC -8:02 PM

IwanttobeamedicNon medic Undergrad - shall be mostly lurking this evening #twitjc #twitjc -8:02 PM

rodedunHello all Rebecca, final year med student at UCL, listening from the bath. Lol. #twitjc -8:03PM

ChestcrackerHello everyone. I'm Norman, a cardiac surgeon in Sheffield. This is really exciting tobe on a world first #twitjc -8:03 PM

northern_doctor I'm Mark - ST3 in Geris & stroke; working as a TRF in North East #twitjc -8:03PM

Bambamaki Hello! just graduated starting in August as an FY1. #twitjc -8:03 PM

themattmak #twitjc Hi all, I'm Matt, F2, ACCS trainee to be -8:03 PM

fidouglasHello! I'm Fi - Med student at Cambridge, going into 3rd year this autumn - I'll be posting

under @twitjournalclub too this evening. #twitjc -8:04 PM

amreeevesHello! Andy Reeves, 3rd year student at Leicester, just observing tonight :) #twitJC -8:04 PM

FayetheGEP Evening, I'm Faye, biomedical sciences grad now 1st year medical student at Barts. Willjust be taking a back seat and watching! #twitjc -8:05 PM

simonpeteryoung SPY consultant anaesthetics & ICM, Glasgow #TwitJC -8:05 PM

AandE_SHOWhat it says on the tin #twitjc -8:05 PM

JimHigginson #twitjc Hi, I'm Jim, Surgical trainee, about to jack it all in for dentistry as a stepping

stone to maxfax. -8:05 PM

twitjournalclubThank you all for the introductions - great to have so many people joining in ^ns#twitjc -8:05 PM

DrElfy I have no interest in joining in (pub quiz beckons////) - just wanted to see if this would work ;-) #twitjc -8:05 PM

drgrumbleNHS Consultant somewhere in England #TwitJC -8:06 PM

twitjournalclubRight, people can introduce themselves as they arrive. For anyone unclear aboutthe paper, brief intro here: http://wp.me/p1BLwH-u #twitjc -8:07 PM

alexwintermute @JimHigginson Maxfax? You masochist! :p #Twitjc -8:07 PM

doseofnuxvomica hi, sarah, london, fy2 and soon-to-be psych trainee, currently eportfolio-ing likecrazy for sign-off. but will be watching #twitjc :) -8:08 PM

themattmak #twitjc So, how does one start discussing? I'm limited by being on iPhone in a car(passenger!) and dot have tweet chat! -8:08 PM

twitjournalclubThe framework we're using for discussion can be found here:http://bit.ly/kBwEPV fd #twitjc -8:08 PM

doctorblogsHi to #twitjc From annabel, london, interests: evidence-based commissioning @silv24

@fidouglas -8:08 PM

TWSY NNT to save one life? #twitjc -8:08 PM


4/31

twitjournalclub@themattmak Just set up a search on your iPhone's twitter client, & remember toput a #twitJC hashtag on each tweet so we can see it #twitjc -8:09 PM

siobhanfarmerHi. Siobhan, Public Health StR in the NW. May be only half watching #twitjctonight but will try to keep up :-) -8:09 PM

JimHigginson@alexwintermute: Pure Hardcore. Except that I'm scared of it all tonight and cryingfor my mum. #twitjc -8:09 PM

twitjournalclubThe first topic to be discussed this evening: Did the study ask a clearly-focusedquestion? #twitjc -8:09 PM

amcunninghamRT @Chestcracker: Hello everyone. I'm Norman, a cardiac surgeon in Sheffield.This is really exciting to be on a world first #twitjc -8:09 PM

johnoliverdunnEvening all-John-Oliver, Anaesthetics SpR, Wessex, UK. I'm on labour ward somay be distracted... #twitJC -8:10 PM

peds_id_doc I think we can safely say the question was good - also limited to a pt population thatseemed to make sense #Twitjc -8:11 PM

dralindsay #Twitjc Alistair Lindsay - JournalScan editor for @Heart_BMJ and Cardiologist -8:11PM

northern_doctorClearly focused question: Yes, I think so. Complex variables & outcomes, but welldefined and explained. #twitjc -8:12 PM

peds_id_doc One of the problems with any study is enrolling pts who might screw up the results byhaving conditions that confuse things #Twitjc -8:12 PM

JoBrodie Curious why it's named "Goal directed therapy" w'out specif naming what the goal ortherapy is ;) Could be for any old thing hehe #twitjc -8:12 PM

DrDLittle@twitjournalclub I guess it did ask a focused Q, 'does goal directed therapy improveoutcome in terms of mortality?' #Twitjc -8:12 PM

peds_id_doc @JoBrodie That was one of my issues - had to delve into the paper to figure out whatthat meant! #Twitjc -8:13 PM

DrDLittle@JoBrodie agreed, seems to be slightly unrelated to the main theme! #Twitjc -8:13 PM

peds_id_doc @JoBrodie I guess it should be "goal directed versus uber-goal directed" #Twitjc -8:13PM

JoBrodie I agree w @DrDLittle - I think it was a focused question. Seemed to me (non-expert) that

population was defined too. #twitjc -8:13 PM

MedEdHelen very clearly focussed question - but how useful a question is it? #TwitJC -8:13 PM

northern_doctor@JoBrodie Trying to be succinct, I guess. They do define it in the text, but it's notstraightforward. #twitjc -8:13 PM

amcunningham@peds_id_doc @jobrodie #TwitJC yes- is it basically about having guidelines? -8:14 PM

dtwatkin I felt a little ignorant not knowing what goal-directed therapy was! Explains itself furtherin! #twitjc -8:14 PM

silv24 Well-defined population with clear exclusion criteria, clear description of the intervention andoutcomes measured #twitjc -8:14 PM

aj0610 @TWSY I get 6.25 for in-hospital mortality #twitjc -8:14 PM


5/31

JimHigginson The goal was to "reduce incidence of MOD, mortality and use of healthcare resourcesin [SIRS]" - wasn't it? #twitjc -8:14 PM

anaestheticdoc @peds_id_doc @JoBrodie think the goals do become obvious once you read thepaper. and on the flow chart. #twitjc -8:14 PM

drgrumbleAre there no goals with standard treatment? #TwitJC -8:14 PM

basmahassan #Twitjc oh hello.. Basma.. Ct1 in the mess of a london hospital. -8:14 PM

iamdoctord Fair question, 'early goal-directed therapy before admission to the intensive care unit',but is admission to ITU same as mortality? #twitjc -8:14 PM

northern_doctor@JoBrodie This also raises an issue about how easy it would be to transferprotocols to practice & educate staff about it! #twitjc -8:14 PM

Annemcx bravo to see this happening - social organisation #twitjchttp://twitjc.wordpress.com/about/ -8:14 PM

theMedicator#twitjc FY1, obs and gynae -8:15 PM

parkerflash@peds_id_doc the abstract does outline what they meant by "goal directed therapy".It's more or less the headline of the paper. #twitjc -8:15 PM

JoBrodie@peds_id_doc I like to think all therapies are directed towards some goal or other ;) justan odd phrase, by itelf. OK in context #twitjc -8:15 PM

peds_id_doc @amcunningham @peds_id_doc @jobrodie more than that - the existing standardused guidelines, they were looking at more specific ones #Twitjc -8:15 PM

amcunningham@drgrumble indeed... I think just about guidelines #TwitJC -8:15 PM

drgrumbleDoesn't this paper just show that you need to get on a treat and not leave things till later?

#TwitJC -8:15 PM

silv24 @iamdoctord all were admitted to ICU - the mortality was looked at in-hospital not just in theICU #twitjc -8:15 PM

DrDLittle@anaestheticdoc @peds_id_doc @JoBrodie perhaps, but it is by no means clear what goaldirected therapy is for a non-expert #Twitjc -8:15 PM

MedEdHelen "goal directed" is a method of care. in kind, it is like studying if "directly observedthearpy" works #TwitJC -8:15 PM

MargoJMilne@KimMKendall Hey, have a look at #twitjc hashtag..idea is to discuss a medical paper

every Sun evening -8:16 PM

twitjournalclub So we think it was focussed in terms of population studied. What about theinterventions given? Were they sufficiently clear? fd #twitjc -8:16 PM

iamdoctord The flow chart is useful guide for interventions #twitjc -8:16 PM

drgrumble Treating very sick people promptly is better than delaying. Surprise, surprise. #TwitJC -8:16 PM

JoBrodie@MedEdHelen Aha, does that account for extra ScvO2 monitoring bit then? I think thatwas the main diff, & haematocrit (...googling!) #twitjc -8:17 PM

MedEdHelen In some ways, I think this is a quality improvement paper. It's about how we do care.#TwitJC -8:17 PM

parkerflash yes - a picture speaks a thousand words here. RT @iamdoctord: The flow chart is usefulguide for interventions #twitjc -8:17 PM


6/31

peds_id_doc @twitjournalclub interventions were VERY well laid out. Even as a non-intensivist itmade sense and I could follow the plan #Twitjc -8:17 PM

DrDLittle@twitjournalclub yes, the flowcharts were very clear about interventions #Twitjc -8:17 PM

kevfrost@silv24 #twitjc so doesnt necessarily apply to patients not admitted to ICU? -8:17 PM

amcunninghamRT @drgrumble: Treating very sick people promptly is better than delaying.

Surprise, surprise. #TwitJC -8:17 PM

anaestheticdoc not all therapies have a goal. Can be much fairly arbitrary when to start andcommence some treatments. #twitjc -8:17 PM

dtwatkin Agreed @iamdoctord, flow chart very helpful. #twitjc -8:17 PM

TWSY What a about a plain English 3 part question? #twitjc -8:17 PM

peds_id_doc @drgrumble I agree - I have my own thoughts on this from the IRB perspective...#Twitjc -8:17 PM

fidouglas They seem to define set physiological parameters which determine what treatment isinitiated. Which seems fairly clear-cut to me. #twitjc -8:17 PM

northern_doctor Interventions were well defined, but with the caveat of being subject to variableclinical decisions (eg. prescribing abx) #twitjc -8:17 PM

themattmak #twitjc I think the word 'early' is important here, as it most certainly improvedoutcomes hence protocols now with door-to-needle times -8:17 PM

peds_id_doc @kevfrost @silv24 I doubt anyone with SIRS won't float through the ICU at least for aday... #Twitjc -8:18 PM

alexwintermute As a non-expert, it wasn't that defined for me. It gives no method of how it could

be implemented. (our ward does send to ITU) #Twitjc -8:18 PM

northern_doctorHowever, the documentation of which interventions were made in each groupwas good #twitjc -8:18 PM

drgrumble@themattmak Agree. The key is early. #TwitJC -8:18 PM

silv24 I think the interventions were very clear - the flowcharts in the paper made it easy to follow thetreatment of both groups #twitjc -8:18 PM

amcunningham@peds_id_doc @drgrumble why might goaldirected therapy not have worked?Was there equipoise here? #TwitJC -8:19 PM

northern_doctor "@fidouglas: They define set physiological parameters which determine whattreatment is initiated." - Agreed. Important point. #twitjc -8:19 PM

tobyhillman@MedEdHelen to a degree, I don't think there was anything too revolutionary in therx, more in the rigid mode of delivery #twitjc -8:19 PM

peds_id_doc @fidouglas also, transfusing blood to get a set hematocrit isn't always the norm,especially with a view to maximise O2 #Twitjc -8:19 PM

MedEdHelen remember this paper is nearly 10 years old - it defined a lot of the way we are expectedto "do care" today. #TwitJC -8:19 PM

silv24 Agree with @fidouglas - the physiological parameters are set out well in the paper - easy tofollow #twitjc -8:20 PM

AandE_SHO #twitjc early treatment should be paramount in treatment of sepsis, provided you havea focus and no compromising differential diagnosis -8:20 PM


7/31

anaestheticdoc @tobyhillman @MedEdHelen thats exactly the beauty of this paper, doing simplethings quickly early and well #twitjc -8:20 PM

chrisking01@twitjournalclub believe the paper does have a well focused q, with clear specificprotocols. Goal directed therapy; explained well #twitjc -8:20 PM

Onisillos #TwitJC manuscript editor for the lancet. Hope I can keep up -8:20 PM

rodedun l.o.v.e. the flowchart. but that might be because i'm a tad simple. #twitjc -8:20 PM

drgrumble@amcunningham @peds_id_do Could be the wrong goal. What about that recentresearch from Africa in children? Fluids worse. #TwitJC -8:20 PM

peds_id_doc @amcunningham @drgrumble it just struck me that the study was ideal versus lessthan ideal (standard) care. #Twitjc -8:21 PM

northern_doctor@peds_id_doc I've never seen this done, but then again I'm not an intensivist...#twitjc -8:21 PM

aj0610 As a student and thus non-expert I thought the flowchart made things really clear #twitjc -

8:21 PM

tobyhillman@AandE_SHO was that learned independently of this paper - it has had a massiveinfluence since publication #twitjc -8:21 PM

iamdoctord The protocol is defined quite specifically in the 'methods section', no illusion as to whatoutcomes were expected... #twitjc -8:21 PM

drgrumble@peds_id_doc @amcunningham @drgrumble Quite. #TwitJC -8:21 PM

JoBrodie I keep having to look up Wikipedia for the big words :) Heard of some, can't rememberwhat they are. Also the flowcharts were good. #twitjc -8:21 PM

northern_doctor@anaestheticdoc As an anaesthetist, do you consider the interventions simple?Difficult to know from a medics PoV! #twitjc -8:21 PM

twitjournalclubFinal point in this section - would we agree that the outcomes were clearlydefined? ^fd #twitjc -8:22 PM

themattmak @MedEdHelen totally agree, we take a lot of the stuff they do in the paper for granted,but this was surprising news for many #twitjc -8:22 PM

peds_id_doc @northern_doctor we would transfuse to maximise crit...but only with a view to thecrit, not a central O2 measurement. #Twitjc -8:22 PM

fidouglas@aj0610 Agree with you there - made things quite clear for me, and I've got very limitedclinical experience. #twitjc -8:22 PM

peds_id_doc @northern_doctor obviously that's part of the rationale...but not specificallymeasured. Very cool approach. #Twitjc -8:22 PM

kevfrost@MedEdHelen #twitjc absolutely, this has heavilly influenced our sepsis protocol -8:22 PM

DrDLittle@AandE_SHO agreed! There is good evidence for that, mortality increasing with eachhour without abx etc etc #Twitjc -8:22 PM

MedEdHelen@amcunningham I think the point was to prove that non goal directed therapy wasdefinitely bad. #TwitJC -8:23 PM

JimHigginson@twitjournalclub APACHE II scores is clear enough for me. I don't like usingphysiological parameters though, too indirect. #twitjc -8:23 PM


8/31

drgrumbleDidn't both groups end up with essentially the same treatment. Just one was speedierthan the other. #TwitJC -8:23 PM

anaestheticdoc @northern_doctor @anaestheticdoc yes i would consider the interventions simple.#twitjc -8:23 PM

doctorblogsRT @MedEdHelen: remember this paper is nearly 10years old- it defined a lot of theway we are expected to "do care" today #TwitJC -8:24 PM

simonpeteryoung#TwitJC a lot of physiological targets in ICM based on close ties with cardiacanaesthesia, and the pulmonary artery catheter -8:24 PM

peds_id_doc @drgrumble @amcunningham depends how much fluid :-P #Twitjc -8:24 PM

theMedicator#twitjc interventions were clear and concise, I think that was one of the factors.. -8:24 PM

drbrown1970 @drgrumble that was my reading too #twitjc -8:24 PM

anaestheticdoc @drgrumble not really as a Vo2 was never managed in the non intervention group.

#twitjc -8:24 PM

themattmak @twitjournalclub definitely. Mortality at different set days is a good end point to study#twitjc -8:24 PM

drgrumble The interventions were simple but delivering them promptly is not always so easy inpractice. #TwitJC -8:24 PM

iamdoctord As a non-intensivist, APACHE scores can be confusing, but I understand what they tryto identify... #twitjc -8:25 PM

peds_id_doc @drgrumble No, the goal-directed group were given blood, more narrow BP range,dobutamine and ventilated per protocol... #Twitjc -8:25 PM

JoBrodie By outcome measures does everyone mean the mmHg / %O2 etc measurements., or death?Obviously I feel silly for asking :) #twitjc -8:25 PM

simonpeteryoung#TwitJC first RCT of physiological targets that I know of -8:25 PM

DrDLittleAgree RT @themattmak: @twitjournalclub definitely. Mortality at different set days is agood end point to study #Twitjc -8:25 PM

fidouglas@drgrumble One of the docs here would probably know more, but GDT group had scvO2,SaO2, Crit etc. monitored as well... #twitjc -8:26 PM

JimHigginson@JoBrodie both for the purposes of the research, but clearly the latter is moreimportant to patients! #twitjc -8:26 PM

peds_id_doc @JoBrodie all measurements! I guess the argument is by optimising the early goals,the end goal (mortality) is better #Twitjc -8:26 PM

drgrumble@peds_id_doc Was it the difference in treatment that mattered or the speed of delivery?#TwitJC -8:26 PM

northern_doctor@iamdoctord Same, but as long as we have early access to someone whounderstands them then the patient's heading in right direction #twitjc -8:26 PM

TWSY 3PQ then: In patients with sepsis, does early 'assertive' intervention aiming for physiologicaltargets improve survival #twitjc -8:26 PM

drbrown1970 @fidouglas @drgrumble Heh, that's what you get from GP's skimming papers...#twitjc -8:27 PM


9/31

JoBrodie@JimHigginson Haha, yes indeed :) #twitjc -8:27 PM

anaestheticdoc @TWSY yes #twitjc -8:27 PM

peds_id_doc @drgrumble maybe both - I'm sure some in the control group never gotblood/ventilated when they would have in the GDT group #Twitjc -8:27 PM

twitjournalclub Section Two: Was this an RCT? Why was this approach used? Is it suitable? ^fd

#twitjc -8:27 PM

MedEdHelen@JoBrodie they discuss a few outcome measures. more interesting to ask if it mattersif you have a great pO2 if you're dead. #TwitJC -8:27 PM

themattmak #twitjc although, it's interesting every pt had a CVP line before getting to ITU. Thatstill doesn't happen in today's world... -8:27 PM

AandE_SHO@DrDLittle #twitjc many variables tho, pt concerned, staff you have (competency) ...all been there, nothing is textbook unfortunately -8:28 PM

TWSY In terms of importance of the paper, are we agreed that it was an important question? #twitjc -

8:28 PM

simonpeteryoung#TwitJC remember CVP very dependent on many things (RV compliance, IPPV,etc) - many confounders -8:28 PM

Manjit49 RT @doctorblogs: RT @MedEdHelen: remember this paper is nearly 10years old- itdefined a lot of the way we are expected to "do care" today #TwitJC -8:28 PM

aj0610 Technically was an RCT but changed too many things so hard to interpret imho #twitjc -8:28PM

iamdoctord Certainly optimising numbers is one thing, whether they live or die seems anappropriate primary outcome measure... #twitjc -8:28 PM

peds_id_doc The RCT bit worries me...just how do you get "written informed consent" fromsomeone in SIRS...? Truly no influence..? #Twitjc -8:28 PM

simonpeteryoung#TwitJC lactate & SCVO2 prob make more sense as targets -8:28 PM

tobyhillman@themattmak context v v important, note art line and cvp in the Ed for each patient -am sure we will get to this... #twitjc -8:29 PM

AandE_SHO@tobyhillman #twitjc tbh u guys have more info than me, my adobe reader crashed.besides isnt this why we audit and have NICE -8:29 PM

JoBrodie Is it safe to assume that people in the state of sepsis / septic shock are REALLY ILL and...aha just seen @peds_id_doc's Q #twitjc -8:29 PM

kevfrost@twitjournalclub #twitjc were patient subgroups excluded because they couldnt consent? -8:29 PM

PhillippajonesEvening Phill Anaesthetic CT Wales #twitjc -8:29 PM

anaestheticdoc you can argue whether cvp is an acurate measure of rv filling, but it was one of thegoals which worked. #twitjc -8:29 PM

peds_id_doc As a study plan, the RCT approach is ideal to answer this question...but speaking as aclinical researcher...seems off key #Twitjc -8:29 PM

iamdoctord I concur RT @peds_id_doc: The RCT bit worries me...just how do you get "writteninformed consent" from someone in SIRS...? #twitjc -8:29 PM


10/31

alexscott292 @simonpeteryoung Is this Rivers or have you got a linky to this paper? #TwitJC -8:29PM

kevfrost@twitjournalclub #twitjc eg the unconscious? -8:29 PM

JoBrodie@peds_id_doc Yes I wondered, maybe they asked family members and I didn't spot it.#twitjc -8:30 PM

JimHigginson@themattmak should it happen? I thought CVP lines from A&E are more likely tointroduce infection than ICU ones? #twitjc -8:30 PM

northern_doctorRCT? Yes, although difficult to achieve full blinding. #twitjc -8:30 PM

anaestheticdoc @JimHigginson @themattmak not if they are insterted as part of the sepsis carebundle and done properly. #twitjc -8:31 PM

aj0610 @northern_doctor Does state ICU staff blind as to which treatment initially received but obvinitial tx not blind #twitjc -8:31 PM

peds_id_doc @JoBrodie they reference the Helsinki declaration. I think that even allows no

consent under emergency situations (must be approved) #Twitjc -8:31 PM

DrDLittle Blinding seemed to be a bit of a potential issue. #Twitjc -8:31 PM

amcunningham@aj0610 why only technically RCT? Good that happened in 1 centre sorandomization at level of individual- increased power #TwitJC -8:31 PM

MedEdHelen It took them 3 years to enrol 263 patients - I imagine they struggled with consent for alot of patients. #TwitJC -8:31 PM

silv24 Paper clearly describes an RCT (partially blinded) and think it was appropriate ...interestingissues with recruiting sick patients #twitjc -8:31 PM

northern_doctorThe study was designed to be clinically relevant, so they should be applauded forthat. #twitjc -8:31 PM

dtwatkin RT @peds_id_doc: The RCT bit worries me...just how do you get "written informedconsent" from someone in SIRS...? Truly no influence..? #Twitjc -8:31 PM

anaestheticdoc was it blinded, not so sure. #twitjc -8:31 PM

peds_id_doc @aj0610 @northern_doctor In our hospital we know every med/order done in ER.You NEED to know what meds they got there! #Twitjc -8:32 PM

fidouglas@kevfrost Exclusion criteria incl DNR/Advanced directives that restricted the protocol.

Asume not all patients conscious? #twitjc -8:32 PM

drbrown1970 @JoBrodie @peds_id_doc Where the rules any different re consent a decade ago? Idon't think so, but I could be wrong. #twitjc -8:32 PM

TWSY @twitjournalclub You are asking 'Was RCT the right design to answer this question?'. Yesbecause it is asking about an intervention #twitjc -8:32 PM

kevfrost@northern_doctor #twitjc you dont need blinding for it to be a rct, (unblind vs single blindvs double blind) -8:32 PM

fidouglas@anaestheticdoc Once they'd be transferred to a different team after 6 hours, it wasblinded. Before that, no. #twitjc -8:32 PM

tobyhillmanRT @anaestheticdoc: @JimHigginson @themattmak not if they are insterted as part ofthe sepsis care bundle and done properly. #twitjc -8:32 PM


11/31

northern_doctorHowever, I agree with @aj0610 that it's difficult to identify which (if any)variable made biggest difference... #twitjc -8:32 PM

iamdoctord Inclusion / exclusion criteria clear from paper... #twitjc -8:32 PM

JimHigginson@anaestheticdoc @themattmak fair enough - I've only worked in places with A&Estoo busy to do it properly. That obv. needs to change #twitjc -8:33 PM

northern_doctor ...but that wasn't the point of the study. It's about judging the efficacy of a bundleof care based on physiological principles #twitjc -8:33 PM

amcunningham@AandE_SHO @tobyhillman think we should all be able to critique NICE#TwitJC -8:33 PM

aj0610 @amcunningham Suppose I just thought too many variables to know which made thedifference #twitjc -8:33 PM

northern_doctor@kevfrost Agree, but not sure it could really have been as blind as they claim asall treating docs would have access to notes #twitjc -8:33 PM

anaestheticdoc @northern_doctor @aj0610 dont need to identify which one made a difference. itis a care bundle #twitjc -8:33 PM

JoBrodie@twitjournalclub Is this 'goal directed therapy' now normally done in all / most cases ofsepsis, where appropriate? Is it standard? #twitjc -8:33 PM

theMedicator#twitjc surely randomised controlled was the only option as questions regardinginterventions were being asked, non? -8:34 PM

silv24 Blinding: staff in the ITU who took over care didn't know which group the patient had been infor the first 6 hours of treatment #twitjc -8:34 PM

peds_id_doc @drbrown1970 @JoBrodie don't know if rules were diff...and any local IRB can be

more strict if they want. Many are. #Twitjc -8:34 PM

tobyhillman@northern_doctor is the conclusion not that the full bundle required to produce thedifference? #twitjc -8:34 PM

TWSY @anaestheticdoc @northern_doctor @aj0610 Care bundle, yes #twitjc -8:34 PM

MedEdHelen Full on double blinded RCT ? no. I can't think of how they could do better to answerthe question & care for patients ethically #TwitJC -8:34 PM

themattmak #twitjc not having this study as double-blinded doesn't reduce the quality of itsfindings -8:34 PM

northern_doctor@anaestheticdoc Agree - just made that point, but had to split into 2 tweets - obvwasn't fast enough in posting ;-) #twitjc -8:34 PM

twitjournalclub Section 3: Were participants appropriately allocated to intervention/controlgroups? Any confounding variables? Was it truly random? #twitjc -8:34 PM

amcunninghamRT @kevfrost: @northern_doctor #twitjc you dont need blinding for it to be a rct,(unblind vs single blind vs double blind) -8:35 PM

JimHigginson@MedEdHelen that's the paradox of clinical science though - same with surgery,can't double blind a surgeon! #twitjc -8:35 PM

DrDLittle@twitjournalclub Seemed to be appropriately random with an equal split between groups#Twitjc -8:35 PM

anaestheticdoc i know they say the itu were blinded, but the first thing you do on arrival to ITU isread patients notes #twitjc -8:35 PM


12/31

tobyhillmanRT @northern_doctor: @anaestheticdoc Agree - just made that point, but had to splitinto 2 tweets - obv wasn't fast enough in posting ;-) #twitjc -8:35 PM

northern_doctorTo clarify: Agree 100% blinding not necessary, just saying it prob wasn't as clearas claimed in paper! #twitjc -8:35 PM

twitjournalclub Sorry to hurry things along - we've got ten questions to get through, and thequestions get more interesting later on! ^fd #twitjc -8:35 PM

parkerflashRT @anaestheticdoc: i know they say the itu were blinded, but the first thing you do onarrival to ITU is read patients notes #twitjc -8:35 PM

MedEdHelen ah look, 3 tweets saying the same thing #we're all right. #TwitJC -8:36 PM

silv24 RT @MedEdHelen: Full on double blinded RCT ? no. I cant think of how they could do betterto answer the question & care for patients #twitjc -8:36 PM

amcunningham@aj0610 #TwitJC this is definitely a complex intervention... -8:36 PM

peds_id_doc MT @northern_doctor:...but that wasnt the point of the study. Its about judging the

efficacy of a bundle of care based on physiology #Twitjc -8:36 PM

EasternDoc@silv24 but were they truly blinded? Surely they could have easily found out from thepatient's notes prior to ITU admission? #twitJC -8:36 PM

northern_doctor "@anaestheticdoc: they say the itu were blinded, but the first thing you do onarrival to ITU is read patients notes"


13/31

amcunningham@EasternDoc @silv24 guess question is how might nonblinding have impactedoutcome? Receive different care in ICU? #TwitJC -8:39 PM

twitjournalclubContinuing the issue of blinding, Section 4: Were participants, staff & studypersonnel "blind" to participants' study group? ^fd #twitjc -8:39 PM

drgrumble@medicscott There have been examples of the 'right' envelope being chosen. #TwitJC -8:39 PM

iamdoctord Interestingly similar prop. of patients not making it to the 6 hour window, were thesepatients so sick that intervention futile? #twitjc -8:39 PM

peds_id_doc Question re: blinding tho. If you knew your pt was control, wouldn't you workHARDER on them in the ICU... (reverse bias) #Twitjc -8:39 PM

JoBrodie I'm collecting the hashtagged tweets here for reviewing later, this is moving quickly andI've lots to learn! http://is.gd/HAYA0V #twitjc -8:39 PM

aj0610 @TWSY Guess that is difficult when it's such a time-crucial study #twitjc -8:39 PM

silv24 Allocation and randomisation good - especially for a single centre study #twitjc -8:39 PM

JoBrodie@drgrumble @medicscott envelopes differently coloured? ;-) #twitjc -8:40 PM

fidouglas@peds_id_doc Surely you want to get a positive result so you'll work harder on the'intervention' group? #twitJC -8:40 PM

drgrumble@DrDLittle Somebody thought they might have struggled to get consent but thatsuggests not. Many studies are much worse. #TwitJC -8:40 PM

TWSY @aj0610 Is done in EDs, e.g. CRASH II, 3CPO and 3Mg #twitjc -8:40 PM

simonpeteryoung#TwitJC could quibble over sepsis vs SIRS but in the real world difficult to tease

out in early stages -8:40 PM

amcunningham@peds_id_doc ha! True. Hard to say impact of blinding #TwitJC -8:40 PM

chrisking01@twitjournalclub Think the paper requires more clarification as to the extent ofblinding and how this was achieved... #twitjc -8:40 PM

anaestheticdoc Secton 4 not convinced staff were blinded #twitjc -8:40 PM

DrDLittleDoes it say if patients were blinded? May have missed that. (although most probably toosick to know ;) ) #Twitjc -8:41 PM

drgrumble@JoBrodie There have been tales of envelopes held up to the light or one being thickerthan the other. #TwitJC -8:41 PM

TWSY @twitjournalclub Blinding inadequate, but ok to be pragmatic when you have to be #twitjc -8:41 PM

peds_id_doc @fidouglas depends...ICU versus ER rivalry. Not to be ignored ;-) #Twitjc -8:41 PM

CdrHBiscuitIII @peds_id_doc Knowing they're a control would make you feel they were morelikely to develop complications, it would bias research. #Twitjc -8:41 PM

silv24 RT @TWSY: @twitjournalclub Blinding inadequate, but ok to be pragmatic when you have tobe #twitjc -8:41 PM

iamdoctord RT @anaestheticdoc: Secton 4 not convinced staff were blinded #twitjc -8:42 PM

fidouglas@TWSY How would you go about improving the blinding? How can docs not know whatthey're doing to their patients?! #twitjc -8:42 PM


14/31

peds_id_doc @drgrumble @DrDLittle I routinely average 50% refusal for safe, alreadyapproved/tested vaccine studies. *rolls eyes* #Twitjc -8:42 PM

northern_doctor@DrDLittle Imagine it would be difficult to blind the patients if they're gettingcentral venous catheters inserted! ;-) #twitjc -8:42 PM

peds_id_doc @northern_doctor @DrDLittle I think everyone got a CVC - difference was what u didwith it. #Twitjc -8:42 PM

doctorpreneur Sorry to miss #twitjc today -> will try to join next time! @twitjournalclub -8:43 PM

TWSY @fidouglas Not sure you can improve the blinding, hence need to be pragmatic #twitjc -8:43PM

DrDLittle@peds_id_doc @drgrumble @DrDLittle wow! That's interesting! They did pretty wellthen #Twitjc -8:43 PM

fidouglas@doctorpreneur Stick around - we've got a while to go! #twitjc -8:43 PM

northern_doctor@fidouglas @TWSY Difficult to improve blinding under the circumstances.

#twitjc -8:43 PM

peds_id_doc @TWSY @twitjournalclub I agree - all things considered, I think they did the bestthey could with blinding #Twitjc -8:43 PM

drgrumble I doubt the blinding was a big issue. And the end point was hard. #TwitJC -8:43 PM

DrDLittle@peds_id_doc @northern_doctor @DrDLittle thats what I thought? #Twitjc -8:44 PM

MedEdHelen@doctorpreneur @twitjournalclub join in! we're still on blinding. Not yet got to themeaty bits... #TwitJC -8:44 PM

Charlotte_C89 On the train home, reading posts from #twitjc Really interesting. -8:44 PM

northern_doctor@DrDLittle @peds_id_doc @northern_doctor Fair point! I retract my sarcasm!!#twitjc -8:44 PM

twitjournalclub Section 5: Were all participants who began the trial accounted for at itsconclusion? #twitjc -8:44 PM

AandE_SHO agree with blinding unless done in separate departments/locations. ?no #twitjc -8:45PM

benazevedo Agreed. RT @chrisking01:Think the paper requires more clarification as to the extentof blinding and how this was achieved... #twitJC -8:45 PM

kevfrost@DrDLittle #twitjc how would a patient know, unless it was explicitly stated or they werean ICU doc, which they were receiving? -8:45 PM

drgrumbleWhat are the meaty bits. Is it that oxygen delivery is key or that early intervention is whatmatters? #TwitJC -8:45 PM

adriamarilla #twitjc perhaps the paper needs to clarify more in order to say if it was blind or not.. -8:45 PM

JoBrodie@twitjournalclub I thought they were pretty clear about what happened to each patient -seemed OK to my untutored eyes. #twitjc -8:45 PM

tobyhillman@DrDLittle @peds_id_doc @drgrumble appreciating context massively important,need to understand this when looking at own work #twitjc -8:45 PM

TWSY @twitjournalclub Accounted for yes, and included in intention to treat analysis too...veryimportant... #twitjc -8:46 PM


15/31

northern_doctor "@tobyhillman: @northern_doctor is the conclusion not that the full bundlerequired to produce the difference?" Absolutely! #twitjc -8:46 PM

medicscott I liked the round up of 'drop-outs'. Seemed to be fairly equal between groups, suggestingit was randomised well. #twitjc -8:46 PM

simonpeteryoung#TwitJC were the non-culture + ones accounted for? -8:46 PM

DrDLittleRT @medicscott: I liked the round up of drop-outs. Seemed to be fairly equal betweengroups, suggesting it was randomised well. #Twitjc -8:47 PM

northern_doctor I think we're all agree that elements of the design are not academically perfect,but well-balanced against clinical pragmatism! #twitjc -8:47 PM

MedEdHelen Section 5: Yes. We know what happened to all the patients who entered the study.#TwitJC -8:47 PM

DrDLittleRT @northern_doctor: I think were all agree that elements of the design are notacademically perfect, but well-balanced #Twitjc -8:48 PM

twitjournalclubHang on. I've dropped a Tweet somewhere. ^fd #twitjc -8:48 PM

amcunningham #twitjc its kind of disappointing that a lot more written about results than natureof intervention and control. -8:48 PM

silv24 Intention-to-treat in their analysis - seems to have been done well #twitjc -8:48 PM

iamdoctord All participants accounted for... #twitjc -8:48 PM

peds_id_doc @TWSY @twitjournalclub yes, ITT analysis is the closest to real world you'll get...#Twitjc -8:48 PM

northern_doctorWere all patients accounted for? Yes, no arguments from me there. #twitjc -8:48

PM

anaestheticdoc @Charlotte_C89 always welcome #twitjc -8:48 PM

iamdoctord RT @silv24: Intention-to-treat in their analysis - seems to have been done well #twitjc -8:49 PM

northern_doctor "@silv24: Intention-to-treat in their analysis - seems to have been done well"


16/31

peds_id_doc @anaestheticdoc ITT is important because in real world you may decide to treat a ptwith X but the actual treatment may change... #Twitjc -8:51 PM

adriamarillaNo doubt seems that all the patients accounted for.. #twitjc -8:51 PM

Assidens RT @rodedun: good luck to @twitjournalclub @fidouglas @silv24 for an excellent idea youguys are amazing #twitjc -8:52 PM

amcunningham@MedEdHelen yes but we don't have much idea what was process of care instandard group #TwitJC -8:52 PM

peds_id_doc @anaestheticdoc no use if a med is 100% effective if only 50% of pts take it. End resultis only 50% improvement. #Twitjc -8:52 PM

benazevedo @peds_id_doc @TWSY @twitjournalclub Why? (still learning about ITT) #twitJC -8:52 PM

anaestheticdoc @peds_id_doc thanks #twitjc -8:52 PM

twitjournalclubLittle bit of stats now. Section 7: Did the study have enough participants to

minimise the play of chance? #twitjc -8:53 PM

northern_doctor ITT analysis more representative of real clinical practice rather than an "ideal"research world #twitjc -8:53 PM

themattmak @amcunningham I think there's the possibility that even the non-intervention onesreceived better than 'standard' therapy #Twitjc -8:53 PM

peds_id_doc @anaestheticdoc No problem ;-) #Twitjc -8:53 PM

drgrumble@peds_id_doc The figures for ventilation and inotropes in the two groups were similar.#TwitJC -8:53 PM

peds_id_doc @twitjournalclub Holy crap - section 7. Anyone do a power calculation...? #Twitjc -8:54 PM

MedEdHelenWhat he said RT @northern_doctor ITT analysis more representative of real clinicalpractice rather than an "ideal" research world #TwitJC -8:54 PM

DrDLittle@themattmak @amcunningham How could you have prevented that? #Twitjc -8:54 PM

iamdoctord For those still bemused by ITT,http://en.wikipedia.org/wiki/Intention_to_treat_analysis #twitjc -8:54 PM

northern_doctorAdequately powered, if initial calculations were accurate. Fully disclosed, so no

reason to doubt. #twitjc -8:54 PM

peds_id_doc @drgrumble which would imply timing important... #Twitjc -8:54 PM

amcunningham@twitjournalclub p values seem ok #TwitJC -8:54 PM

fidouglasRe: Q7 - they did a provisional test of power of analysis beforehand. See pp1370. #twitjc -8:54 PM

AandE_SHO #twitjc what reference point is more relevant, ED or ICU? early treatment willgenerally start in ED.. -8:55 PM

MedEdHelen@peds_id_doc they've done it for you in "statistical analysis" section #TwitJC -8:55

PM

northern_doctorRT @iamdoctord: For those still bemused by ITT,http://en.wikipedia.org/wiki/Intention_to_treat_analysis #twitjc -8:55 PM


17/31

JoBrodie@twitjournalclub Well they said it did ;) But I don't really feel as confident in that aspect ofstatistics so... #twitjc -8:55 PM

drgrumble@peds_id_doc I think timing might just be the thing that really mattered - as we know itdoes for antibiotics. #TwitJC -8:55 PM

aj0610 If under-powered study, sure error bars would overlap and p value insignificant - not so inthis case #twitjc -8:55 PM

benazevedo @anaestheticdoc @peds_id_doc thanks #twitJC -8:55 PM

anaestheticdoc yes just calculated it and the trial was adequately powered......... honest. #twitjc -8:55 PM

fidouglas@amcunningham More important than P values are power. No statistician myself, butthey've talked about power values = good I guess?? #twitjc -8:56 PM

amcunningham@peds_id_doc @twitjournalclub yes they did a power calculation #TwitJC -8:56PM

aj0610 @drgrumble @peds_id_doc That's what I meant about too many changes - is it all necessaryor did just one bit make the difference? #twitjc -8:56 PM

peds_id_doc @MedEdHelen *re-reads methods section* why, so they did. And it looks awesome.Carry on, carry on. #Twitjc -8:56 PM

chrisking01@twitjournalclub can anyone break down the stats analysis for a stats novice? #twitjc -8:56 PM

fidouglas@aj0610 It's way more complex than that. Depends on type of error bar. SD? SE? 95% CI?#twitjc -8:56 PM

MedEdHelen@anaestheticdoc please show your workings in 140 characters or less. #TwitJC -8:56

PM

JoBrodie RT @chrisking01: @twitjournalclub can anyone break down the stats analysis for a statsnovice? #twitjc -8:57 PM

peds_id_doc @fidouglas @amcunningham Power needed to ensure enough chance to detect asmall change with sufficient confidence #Twitjc -8:57 PM

silv24 I will say that my knowledge on stats is poor at best but looks ok!! #twitjc -8:57 PM

peds_id_doc RT @MedEdHelen: @anaestheticdoc please show your workings in 140 characters orless.| LOL! #Twitjc -8:57 PM

anaestheticdoc @JoBrodie @chrisking01 @twitjournalclub no #twitjc -8:57 PM

amcunningham@fidouglas well if the study was underpowered we'd have to winder about nonsigresults #TwitJC -8:57 PM

Assidens @twitjournalclub @fidouglas @silv24 #twitjc" sorry not able to participate, howeverreading along with interest, well done to all involved. -8:57 PM

drgrumble@peds_id_doc But they did detect a difference so it really is irrelevant now. #TwitJC -8:58 PM

anaestheticdoc @peds_id_doc @MedEdHelen @anaestheticdoc lol #twitjc -8:58 PM

amcunningham@fidouglas but since calculation done, and differences seem unlikely to be due tochance - happy #TwitJC -8:58 PM

benazevedo @anaestheticdoc haha, nice #twitJC -8:58 PM


18/31

aj0610 @fidouglas I thought SD error bars were the norm but maybe just in my undergrad! #twitjc -8:59 PM

TWSY @AandE_SHO I think it about goal direction vs clinican's discretion, presumably not goaldirected not though that isn't made clear #twitjc -8:59 PM

twitjournalclub So we've established there's (probably) adequate power & there is definitelysignificance. Or something like that. *headspins* ^fd #TwitJC -8:59 PM

peds_id_doc @drgrumble hopefully, but suggests they didn't miss anything. Also explains theirtotal numbers of enrolled pts. #Twitjc -8:59 PM

twitjournalclubMuch more descriptive Section 8 which we've partly answered already: How arethe results presented and what is the main result? #twitjc -9:00 PM

MedEdHelen the "statistical analysis" section in methods is quite good at saying how and why theydid the stats they did. #TwitJC -9:00 PM

amcunningham@fidouglas was the study overpowered? Why 15% reduction in mortality? Mighthave been ok with less in trial? #TwitJC -9:00 PM

drgrumble@twitjournalclub This power thing is irrelevant because P=0.009 #TwitJC -9:00 PM

northern_doctor "@twitjournalclub: theres adequate power & there is definitely significance."


19/31

tobyhillmanRT @TWSY: NNT to save one life? #twitjc -9:04 PM

drgrumble@amcunningham Not if we are still arguing about whether or not the result ismeaningful. #TwitJC -9:04 PM

simonpeteryoung@drgrumble @twitjournalclub ah but then the non-sig results are leftvulnerable #TwitJC -9:04 PM

aj0610 @anaestheticdoc @TWSY About 6 #twitjc -9:04 PM

silv24 The headline figure as I said in the blog - is the reduction in in mortality - the primary outcomeof the study #twitjc -9:04 PM

drgrumble@northern_doctor True but it is not a question to ask at the end unless they had foundno difference. #TwitJC -9:04 PM

fidouglas If 16% ARR in in-hospital mortality, that's a NNT of almost exactly 6. (No calculator tohand) #twitjc -9:05 PM

DrDLittleRT @silv24: The headline figure as I said in the blog - is the reduction in in mortality - the

primary outcome of the study #Twitjc -9:05 PM

anaestheticdoc that low, blood hell. effective then. NNT of 6 #twitjc -9:05 PM

benazevedo @amcunningham I was wondering the same... #twitJC -9:05 PM

amcunningham@drgrumble we're not still arguing about whether result meaningful #TwitJC -9:05 PM

aj0610 @fidouglas I got 6.25 for in hosp mortality #twitjc -9:06 PM

twitjournalclub So aside from reduced mortality, which other results are particularly important?^fd #twitjc -9:06 PM

peds_id_doc Total mortality is NNT of 8 I think... #Twitjc -9:06 PM

northern_doctor@drgrumble Yes, I agree. Was referring to adequate power in study design.#twitjc -9:07 PM

silv24 RT @anaestheticdoc: that low, blood hell. effective then. NNT of 6 #twitjc -9:07 PM

aj0610 Length of hosp stay obv an issue re: cost etc #twitjc -9:07 PM

drgrumble@amcunningham Well I'm not either but if the trial had stopped earlier the P valuewould not have been so low #TwitJC -9:07 PM

benazevedo There was room to spared... RT @drgrumble: @amcunningham if the trial had stoppedearlier the P value would not have been so low #twitJC -9:09 PM

chrisking01 everyone's on about costs these days. Patients with early goal directed therapy spentless time in hospital #twitjc -9:09 PM

fidouglas@aj0610 Yup, agree with that, especially when money is such a consideration inhealthcare. Keepin' politicians happy 'n that! #twitjc -9:09 PM

northern_doctorNNT of 6 is very low! #twitjc -9:09 PM

simonpeteryoung#TwitJC alive or dead at a specific time period - quality measures, longevity, etc

but ridiculously hard to measure -9:10 PM

JoBrodie ~31% patients had diabetes - would that info be from their general medical records ortested from contemporaneous BG tests? #twitjc -9:10 PM


20/31

tobyhillman@chrisking01 they also used a whole load more blood #twitjc -9:10 PM

TWSY @twitjournalclub other important results would normally include bad outcomes fromintervention as a balance to the benefit #twitjc -9:10 PM

DrDLittle Shorter hospital stay = cheaper #Twitjc -9:10 PM

aj0610 @JoBrodie Well DM increases sepsis risk so high number of diabetics expected #twitjc -9:10

PM

medicscott Standard therapy stayed 'significantly longer' in hospital. Important for cost & risk ofnosicomial infections. #twitjc -9:11 PM

TWSY So, important question and answer (NNT = 6), valid up to a point......applicable though?#twitjc -9:11 PM

kevfrostNNT 6.25 if you use their percentages (derived from Kapler-Meier), lower from raw data RT@aj0610 I got 6.25 for in hosp mortality #twitjc -9:11 PM

peds_id_doc I would have liked to see days in ICU as an outcome...did I miss that? Didn't see it.

#Twitjc -9:11 PM

northern_doctor@fidouglas @aj0610 Cost less important for me. More about increased patientrisk with unnecessary bed days (HAIs etc) #twitjc -9:11 PM

drgrumble@northern_doctor A lot of people die so there are a lot who can be saved. Not likeaspirin given to fit people. #TwitJC -9:11 PM

MedEdHelen length of stay isn't just about cost. few patients prefer a longer length of stay. #TwitJC-9:11 PM

GabrielScally@twitjournalclub Length of stay. #twitjc -9:11 PM

twitjournalclub So section 9 is: How precise are these results? Again, we've discussed a bit aboutthis already, but what are your thoughts? ^fd #twitjc -9:11 PM

iamdoctord RT @medicscott: Standard therapy stayed significantly longer in hospital. Importantfor cost & risk of nosicomial infections. #twitjc -9:12 PM

fidouglas@northern_doctor @aj0610 Yup. spending time in hospital is just generally bad... #twitjc-9:12 PM

TWSY Sorry, jumping ahead #twitjc -9:12 PM

JoBrodie@aj0610 I wonder if the percentage of pwd even higher, with undiagnosed people, but I

expect they'd do glucose testing anyway. #twitjc -9:12 PM

aj0610 @northern_doctor @fidouglas definitely agree, better all round to get out of hosp asap!#twitjc -9:12 PM

chrisking01@tobyhillman reduced mechanical ventilation in early goal directed therapy. ? reducedrisk of vent assoc pneumonia? #twitjc -9:13 PM

JoBrodie@twitjournalclub Looking up to see exactly what 'precise' means in this context :) #twitjc -9:13 PM

amcunningham #TwitJC have we resolved question of whether there should have been interimanalysis? -9:13 PM

anaestheticdoc length of stay can again be a bit of a soft outcome. may just have kicked them outquicker. #twitjc -9:13 PM


21/31

silv24 Does the paper mention is there were any adverse events due to the early-goal directedtherapy? #twitjc -9:13 PM

TWSY @twitjournalclub Precision: no NNT in paper so no confidence interval for the NNT either. Itcould be worked out though #twitjc -9:14 PM

JoBrodie@amcunningham There were two of them weren't there? I'm not sufficiently able tocomment much tbh. #twitjc -9:14 PM

northern_doctor "@drgrumble: Lots of people die so a lot can be saved."


22/31

TWSY RT @MedEdHelen: re adverse events - surely the parameters measured would pick up adverseevents - or do you mean proper errors? #twitjc -9:18 PM

silv24 @fidouglas more aggressive fluid resucitation, blood transfuions earlier, use of vasopressorsearlier....all could impact #twitjc -9:19 PM

peds_id_doc Dammit, my youngest just woke up....may have to cut and run... #Twitjc -9:19 PM

JoBrodie@twitjournalclub Did results have to be repeated or was this paper meant to be definitiveon the topic? Was guidance tweaked? #twitjc -9:19 PM

fidouglas@peds_id_doc Awww. Get them to join in! Never too young to start developing a socialmedia addiction. #twitjc -9:19 PM

MedEdHelen@tobyhillman @chrisking01 yes, I thought that the most interesting. Does that meanwe're bad at predicting regardless of treatment? #TwitJC -9:19 PM

northern_doctorApplication of paper to other centres is most crucial point - main limitation ofstudy was that it was single centre only #twitjc -9:20 PM

simonpeteryoung#TwitJC there's a recent editorial with very good discussion points on thispaper - can anyone remember where it was? -9:20 PM

northern_doctorNot saying results/protocols aren't transferable, but that's not what study is setup to show #twitjc -9:20 PM

amcunningham@silv24 @fidouglas but agree that adverse outcomes would be covered withinthose assessed #TwitJC -9:20 PM

fidouglas@silv24 Ah OK, makes sense I guess. #twitjc -9:20 PM

anaestheticdoc i think the outcomes can be easily implemented, Just a case of doing what we do,but better and quicker, focusing on the goals. #twitjc -9:20 PM

themattmak #Twitjc @twitjournalclub easy! We're all using sepsis bundles and this led to theSurviving Sepsis Campaign... -9:20 PM

silv24 @ffolliet link to the Rivers et al paper at http://bit.ly/jsxap2 #twitjc -9:20 PM

tobyhillman@MedEdHelen or good at delaying the inevitable in some cases. Not possible to predictbeneficiaries prospectively though I guess. #twitjc -9:21 PM

amcunningham@northern_doctor why might results not be transferable? #TwitJC -9:21 PM

chrisking01@tobyhillman just read that now.. at the risk of sounding naive what does this mean in

clinical context though? #twitjc -9:21 PM

northern_doctor "Standard treatment" can vary between hospitals, but the fact we're all usingsepsis bundles speaks very clearly! #twitjc -9:21 PM

simonpeteryoung#TwitJC maybe PACMAN study would have been better targeting first fewhours -9:22 PM

TWSY @twitjournalclub Applicability issue 1 Rivers' patients sicker than the ones we would get in theUK fitting this criteria, I'm told #twitjc -9:22 PM

themattmak #Twitjc my hospital is one of the participants of a new multi centre trial looking atProtocolised Management in Sepsis -9:22 PM

TWSY @twitjournalclub Applicability issue 2 Our EDs not resourced to be able to do this... #twitjc -9:23 PM


23/31

northern_doctor@amcunningham They may well be (and probably are) - just saying that onlystudying single centre limits default wider application #twitjc -9:23 PM

MedEdHelen yes, massively influential in the literature "Cited by over 100 PubMed Central articles"http://t.co/ndt1sFp #TwitJC -9:23 PM

JoBrodie@themattmak That's a good name, at least it includes the word 'sepsis' :) #twitjc -9:23 PM

tobyhillman@amcunningham logistics / skills to 'do' egdt in local DGH ? Prepared to be told I'mwrong. #twitjc @northern_doctor -9:23 PM

AandE_SHO #twitjc sepsis bundle pathways are not correctly implemented in my experience andusually referenced inappropriately -9:24 PM

silv24 The Surviving Sepsis Campaign - the impact of care bundles is clearly seen in everyday practice#twitjc -9:24 PM

amcunningham@DoconaLimb there was 15% absolute reduction so ok:) #TwitJC -9:24 PM

JoBrodie Good point MT @northern_doctor: @amcunningham ...Just saying that only studying

single centre limits default wider application #twitjc -9:24 PM

anaestheticdoc @TWSY @twitjournalclub ED dont have to be implementing it, just need to getpatient to ITU quicker and start it there. #twitjc -9:24 PM

northern_doctor In real life we're all (or should be) identifying & treating septic patients earlierthan used to, and getting them to HDU #twitjc -9:24 PM

DrDLittle It is common sense that early, directed interventions will improve outcome. ?Same theoryapplicable elsewhere #Twitjc -9:24 PM

peds_id_doc @TWSY @twitjournalclub I think resources are a key point - research is useless ifcan't be applied. #Twitjc -9:24 PM

fidouglas Is this the first study of its kind? If so, isn't it logical that you would start small, then if itworks, try on a bigger scale? #twitjc -9:24 PM

TWSY @twitjournalclub Applicability issue 3 There was some talk about conflicts of interest andRivers... I don't know detail #twitjc -9:25 PM

tobyhillman@chrisking01 people take a long time to die in hospital but get out quickly if they getbetter? #twitjc -9:25 PM

drgrumble@northern_doctor Getting them to HDU? That's a delay. It's treating them ASAP.#TwitJC -9:25 PM

DerminatrixRT @northern_doctor: In real life we're all (or should be) identifying & treating septicpatients earlier than used to, and getting them to HDU #twitjc -9:25 PM

TWSY @twitjournalclub Applicability issue 3 actually a validity issue #twitjc -9:26 PM

madlawstudent loving the #twitjc just about following you all! -9:26 PM

tobyhillman@northern_doctor if you have an hdu for 'medical' patients #twitjc -9:26 PM

amcunningham@tobyhillman @northern_doctor I presume that study should be applicable whereany of these patients admitted? Anywhere with ICU? #TwitJC -9:26 PM

northern_doctor@drgrumble Only after initial treatment started, obviously. I rarely see CVP linesput in whilst in A&E. Fluids & abx, yes. #twitjc -9:26 PM

TWSY @anaestheticdoc @TWSY @twitjournalclub Get to ICU quicker if there is a bed on ICU #twitjc-9:26 PM


24/31

simonpeteryoung#TwitJC applicability less clear with de novo cases of sepsis in-hospital;presentation >24h to ICU; healthcare-acquired infections -9:27 PM

kevfrost@drgrumble Sepsis bundles initiated in A&E, with transfer to HDU if meets certain criteria#twitjc -9:27 PM

JoBrodieWas the mortality rate for standard sepsis therapy at that study centre, and at that time,much different from rate elsewhere? #twitjc -9:27 PM

silv24 Sadly sepsis is still not managed as well as it should be in - even with clinical guidelines #twitjc-9:27 PM

simonpeteryoung@TWSY @anaestheticdoc @twitjournalclub ICU without walls - don't need aphysical bed to manage these patients early #twitjc -9:28 PM

tobyhillman@anaestheticdoc @TWSY @twitjournalclub really, a quick transfer to Itu from thefront door? Occupancy often 2 high 2 make practical #twitjc -9:28 PM

northern_doctor Interestingly, they don't mention training of A&E staff. IMHO that's as importantas the protocols themselves. #twitjc -9:28 PM

fidouglas@TWSY Unsourced(?!) on wiki: Rivers has not gained from any propriety research in thisarea and has no conflict of interest. #twitjc -9:28 PM

anaestheticdoc @TWSY @anaestheticdoc @twitjournalclub or get ITU to ED, commencetreatment there. only needs CVP line, #twitjc -9:28 PM

GabrielScally#Twitjc It is an odd title, 'goal-directed therapy'. Who can argue in favor of therapywithout goals? But the effect looks very impressive. -9:28 PM

TWSY @simonpeteryoung @TWSY @anaestheticdoc @twitjournalclub 'Without walls' nice concept#twitjc -9:28 PM

northern_doctor "@silv24: Sepsis is still not managed as well as it should be in - even with clinicalguidelines"


25/31

anaestheticdoc hate to say this but one individual can implement this treatment. Its that simple.CVP and blood gases. Call the anaesthetist!! #twitjc -9:30 PM

JoBrodie RT @silv24 RT @northern_doctor: Intrstngly they dont mention training of A&E staff.IMHO thats as important as protocols themselves. #twitjc -9:30 PM

welsh_gas_docRT @anaestheticdoc: hate to say this but one individual can implement thistreatment. Its that simple. CVP and blood gases. Call the anaesthetist!! #twitjc -9:31 PM

tobyhillman@amcunningham early goal directed therapy = egdt #twitjc -9:31 PM

drgrumble@DrDLittle @northern_doctor This may be why it was a single centre trial. This level ofintervention in the ED could be challenging. #TwitJC -9:31 PM

benazevedo @amcunningham Early Goal Directed Therapy = EGDT #twitJC -9:31 PM

northern_doctor@drgrumble Realities of variation in practice. In my hospital, resus has 3 beds -need to shift patients after initial rx. #twitjc -9:31 PM

DrDLittle@aj0610 @silv24 yes, but also initiation of treatment #Twitjc -9:31 PM

amcunningham@drgrumble they were transferred to icu after 6hrs #TwitJC -9:31 PM

silv24 Yes - many still don't "speak sepsis" RT @aj0610: @silv24 Is that bcoz of delay indiagnosis/recognition? #twitjc -9:31 PM

simonpeteryoung#TwitJC sepsis VERY complicated. see PIRO for the bits we can influence, andbits we can't -9:32 PM

tobyhillman@welsh_gas_doc @anaestheticdoc if needs the anaesthetist, whole system of care hasfailed. Need multiple skilled peeps, not just one.#twitjc -9:32 PM

MedEdHelen They do mention the set up and the staff (treatment section of methods), and

reference a study from the same dept (3) #TwitJC -9:32 PM

northern_doctorYes, an anaesthetist is the person you want with you on shop floor, but staff needto know how to recognise those patients #twitjc -9:32 PM

kashfarooq@silv24 Love the #twitjc idea. May steal it for, say, #astrojc or #physicsjc Would wehave to pay royalties? ;-) -9:33 PM

silv24 @amcunningham not recognised early enough, not treated early enough...one of my majorbugbears #twitjc -9:33 PM

TWSY @fidouglas @TWSY Spoke from memory and can't source it. It may be untrue #twitjc -9:33

PM

welsh_gas_docEven after this paper and the following Sepsis Bundles, some hospital labs stillwon't even give you a lactate!! #TwitJC -9:33 PM

DerminatrixRT @drgrumble: This may be why it was a single centre trial. This level of interventionin the ED could be challenging. #TwitJC -9:33 PM

silv24 Indeed - especially delay in giving antibiotics!! RT @DrDLittle: @aj0610 @silv24 yes, but alsoinitiation of treatment #Twitjc -9:33 PM

MedEdHelen I think that this is more about early goal directed therapy than it is about sepsis.*discuss* #TwitJC -9:33 PM

iamdoctord Calling an anaesthetist isn't the only answer, we need all members of the team torecognise the problem and initiate early therapy! #twitjc -9:33 PM


26/31

simonpeteryoung@anaestheticdoc it's an interesting argument. Try and train all to manage(badly?), or a have a 'sepsis team' like the trauma team #twitjc -9:33 PM

chimenet @DrDLittle: Shorter hospital stay = cheaper #Twitjc< but under PbR means incomereduction for Trust? -9:33 PM

tobyhillman@northern_doctor or anyone who can put in a cvc and treat with fluids. #twitjcmedics/ surgeons should all be able to do similar -9:34 PM

anaestheticdoc Thats because anaesthetist is only ones who seem able to put CVP lines in thesedays #twitjc -9:34 PM

drgrumble@amcunningham Wasn't the intervention over by then? #TwitJC -9:34 PM

AandE_SHO #twitjc we start abx as soon as a focus is ascertained, and if not, rule out any otherdifferentials and consider co-morbidities, sod medreg -9:34 PM

fidouglas@TWSY Like many things, it's highly unlikely that the info is available on the net. Nomassive COI disclosed in the paper tho... #twitjc -9:34 PM

anaestheticdoc RT @simonpeteryoung: its an interesting argument. Try and train all to manage(badly?), or a have a sepsis team like the trauma team #twitjc -9:34 PM

adriamarillaRT @silv24: Yes - many still don't "speak sepsis" RT @aj0610: @silv24 Is that bcoz ofdelay in diagnosis/recognition? #twitjc -9:34 PM

rodedunMaybe we should incorporate #teddybearclub #geekdayout with and to celebrate success of#twitjc tonight thoughts! -9:35 PM

iaintrk @silv24 apologies for missing journal club - will be there next week promise! #twitjc -9:35PM

amcunningham@drgrumble but surely there is only point in intervention if ICU transfer possible?

#TwitJC -9:35 PM

DrDLittle@AandE_SHO what if focus not easy to find? #Twitjc -9:35 PM

TWSY Summary: important, valid up to a point and ... may be applicable depending? #twitjc -9:35PM

DerminatrixVia @northern_doctor: Staff need to know how to recognise those patients #twitjc -9:35 PM

northern_doctor@tobyhillman In theory. I've never done a CVC though, so wouldn't be happy togo it alone. Support always available (so far!) #twitjc -9:35 PM

silv24 @welsh_gas_doc and so many forget to do a lactate check - drives me mad. I teach medstudents about sepsis alot! #twitjc -9:35 PM

welsh_gas_doc@anaestheticdoc @simonpeteryoung Isn't a Sepsis Team, alerted by physiologicalparameters, what an ITU outreach team is for? #TwitJC -9:35 PM

iamdoctord@anaestheticdoc we're expected to learn CVP line insertion for core medical training,doing renal med was a bonus! #twitjc -9:36 PM

aj0610 @DrDLittle @AandE_SHO Surely take bloods etc for culture then start empirical abx?#twitjc -9:36 PM

chimenet @DrDLittle: I could do with learning some stats! #Twitjc< Normal, Poisson, Standarddistributions. Bit of Chi squared & voila, expert.. -9:36 PM

welsh_gas_doc .@silv24 Good. Someone has too. Because recognition and management of sepsissure as hell isn't taught properly by UG Curriculum! #TwitJC -9:36 PM


27/31

Assidens RT @silv24: @amcunningham not recognised early enough, not treated early enough...oneof my major bugbears #twitjc -9:37 PM

Assidens RT @welsh_gas_doc: .@silv24 Good. Someone has too. Because recognition andmanagement of sepsis sure as hell isn't taught properly by UG Curriculum! #TwitJC -9:37 PM

DrGDH Just discovered #twitjc , bit late to the party, and a shame cause who doesn't love a bit ofEGDT? Twitter JC... Fantastic idea! -9:37 PM

simonpeteryoung#TwitJC I do think putting a CVC in is NOT the key. Piss poor interpretation ofclinical signs and measurements is what'll kill patients -9:37 PM

northern_doctor Summary: Well-executed study; significant results; supports early monitoring &rx; good basis for current guidelines #twitjc -9:37 PM

tobyhillman@northern_doctor I hope support includes supervising your practical experience atcentral catheter insertion? If not, poss should. #twitjc -9:37 PM

TWSY @silv24 @fidouglas Well done. Great idea well executed. #twitjc -9:38 PM

JoBrodieWhat are the current guidelines for sepsis management, and do they reference this paper?#twitjc -9:38 PM

silv24 RT @northern_doctor: Well-executed study; significant results; supports early monitoring &rx; good basis for current guidelines #twitjc -9:38 PM

MedEdHelen@simonpeteryoung agreed..... and a bad system for getting care to patients when theyneed it. #TwitJC -9:38 PM

northern_doctor@tobyhillman It's on my to-do list! #twitjc -9:38 PM

iamdoctord Central line placement is a great skill, but needs the resources 'on-site' to be usedeffectively, even in MAU/HDU setting... #twitjc -9:38 PM

JoBrodie This x100 :) RT @TWSY: @silv24 @fidouglas Well done. Great idea well executed. #twitjc -9:38 PM

tobyhillmanRT @simonpeteryoung: #TwitJC I do think putting a CVC in is NOT the key. Piss poorinterpretation of clinical signs and measurements is what'll kill patients -9:39 PM

fidouglas@DrGDH We'll put an abridged transcript up online, as well as a post summarising thediscussion. Follow @TwitJournalClub for updates #twitjc -9:39 PM

northern_doctor I'm signing off - thanks folks, it's been fun! #twitjc -9:39 PM

tobyhillmanRT @TWSY: @silv24 @fidouglas Well done. Great idea well executed. #twitjc -9:39PM

rodedun From the little that I know, I don't think that the importance of sepsis get's the recognitionit deserves in our teaching #twitjc -9:39 PM

welsh_gas_doc@silv24 and @fidouglas should be VERY proud with how well this has gonetonight. Looking forward to more next week!! #TwitJC -9:39 PM

silv24 Thank you all so much for your contributions - I am over the moon #twitjc -9:39 PM

northern_doctorVote of thanks to @fidouglas and @silv24 - massive success; you guys deserve alot of credit! #twitjc -9:40 PM

DrDLittleRT @welsh_gas_doc: @silv24 and @fidouglas should be VERY proud with how well thishas gone tonight. Looking forward to more #Twitjc -9:40 PM


28/31

twitjournalclubThank you all very much for participating this evening. I've certainly had great fun!^fd #twitjc -9:40 PM

MedEdHelen@JoBrodie Surviving Sepsis Campaign http://t.co/hzewWXE #TwitJC -9:40 PM

kevfrostDitto from me :) RT @northern_doctor: I'm signing off - thanks folks, it's been fun! #twitjc-9:40 PM

DerminatrixAgreed! RT @TWSY: @silv24 @fidouglas Well done. Great idea well executed. #twitjc-9:40 PM

twitjournalclubWe'll put an abridged transcript and a summary blog post online in the next day orso. ^fd #twitjc -9:40 PM

JoBrodie@silv24 @fidouglas Thank you for coming up with the idea and implementing it :) Reallyenjoyed it. #twitjc -9:40 PM

aj0610 What a fab first chat tonight was - will be back next week! #twitjc -9:40 PM

DrDLittleRight, @frolickingfood is calling for attention, time to go. Well done all involved. #Twitjc -

9:40 PM

MedEdHelenQuite, Props to you both. RT @Derminatrix: Agreed! RT @TWSY: @silv24 @fidouglasWell done. Great idea well executed. #TwitJC -9:40 PM

AandE_SHO@aj0610 @DrDLittle exactly, large bore/central access if need, gas, cultures! treatempirically.. conservatively if needed #twitjc -9:41 PM

iamdoctord This has been great thank you! RT @twitjournalclub: Thank you all very much forparticipating this evening. #twitjc -9:41 PM

twitjournalclubAnd of course, feel free to use the #TwitJC hashtag to continue discussing thepaper. #twitjc -9:41 PM

medicscottWell done all, especially @silv24 and @fidouglas. Great experience, I eagerly await nextJournal Club discussion #twitjc -9:41 PM

benazevedo @JoBrodie: Found this. RT: What are the current guidelines for sepsis management?http://bit.ly/jbACzU #twitJC -9:41 PM

silv24 RT @DrDLittle: RT @welsh_gas_doc: @silv24 and @fidouglas should be VERY proud withhow well this has gone tonight. Looking forward to more #Twitjc -9:41 PM

AandE_SHO@aj0610 @DrDLittle cultures are rearely done appropriately by any walk of life #twitjc-9:41 PM

amcunningham@silv24 @fidouglas well done, excellent! #TwitJC -9:42 PM

peds_id_doc Current international guidelineshttp://www.survivingsepsis.com/system/files/images/SCC_reprint.pdf Rivers et al is ref 16 #Twitjc -9:42 PM

silv24 Thank you all and thank you to my partner in crime @fidouglas - really enjoyed it and lookforward to next week #twitjc -9:42 PM

DrDLittleReally enjoyed the first #twitjc even if it was a topic I knew little about! A great success,well done @fidouglas and @silv24 #Twitjc -9:42 PM

KP_LD @silv24 #twitjc looks very interesting! Let me know if you ever have a psychology relatedpaper :) -9:42 PM

chrisking01RT @aj0610: @northern_doctor V true, all well and good having protocols but if staffaren't trained in appropriate implementation then useless #twitjc -9:43 PM


29/31

simonpeteryoung#TwitJC this was AMAZING! well done all. I will be highlighting this to ourcabinet secretary for health (she's on twitter) -9:43 PM

twitjournalclubNext week, we'll be looking at Geoffrey Rose's 'Prevention Paradox' (BMJ, 1981).#twitjc -9:43 PM

peds_id_doc HUGE CONGRATS to @fidouglas and @silv24 on the inaugural twitter journal club.Amazing international achievement. #Twitjc -9:43 PM

welsh_gas_doc Should communication skills and sociology; or basic management of a commonkiller like sepsis emphasised in the UG Curriculum? #TwitJC -9:43 PM

doctorblogs .@silv24 @fidouglas another great EBM resource: critical appraisal tools etchttp://bit.ly/m56pcd from @cebmblog #twitjc -9:43 PM

parkerflashRT @welsh_gas_doc: @silv24 and @fidouglas should be VERY proud with how wellthis has gone tonight. Looking forward to more next week!! #TwitJC -9:43 PM

amcunningham@drgrumble but surely this wasn't a trial of whether rx could be carried out in EDalone? #TwitJC -9:43 PM

fidouglas@KP_LD I really like health psychology and psychiatry stuff. So I doubt it'll be too longyet...! #twitjc -9:44 PM

silv24 RT @twitjournalclub: Next week, we'll be looking at Geoffrey Rose's 'Prevention Paradox'(BMJ, 1981). #twitjc -9:44 PM

iamdoctord RT @twitjournalclub: Next week, we'll be looking at Geoffrey Rose's 'PreventionParadox' (BMJ, 1981). #twitjc -9:44 PM

silv24 RT @peds_id_doc: HUGE CONGRATS to @fidouglas and @silv24 on the inaugural twitterjournal club. Amazing international achievement. #Twitjc -9:44 PM

peds_id_doc @welsh_gas_doc both :-) #Twitjc -9:44 PM

chrisking01RT @welsh_gas_doc: @silv24 and @fidouglas should be VERY proud with how wellthis has gone tonight. Looking forward to more next week!! #TwitJC -9:44 PM

parkerflashRT @peds_id_doc: HUGE CONGRATS to @fidouglas and @silv24 on the inauguraltwitter journal club. Amazing international achievement. #Twitjc -9:45 PM

benazevedo RT @twitjournalclub: Next week, we'll be looking at Geoffrey Rose's 'PreventionParadox' (BMJ, 1981). #twitjc -9:45 PM

anaestheticdoc @silv24 @fidouglas well done ladies congrats #twitjc -9:45 PM

hullodave RT @welsh_gas_doc: Should communication skills and sociology; or basic managementof a common killer like sepsis emphasised in the UG Curriculum? #TwitJC -9:45 PM

hullodave RT @twitjournalclub: Next week, we'll be looking at Geoffrey Rose's 'Prevention Paradox'(BMJ, 1981). #twitjc -9:45 PM

fidouglas Thanks to everyone for saying 'well done', and to Natalie (@silv24) for helping pulleverything together! I *really* enjoyed that. #twitjc -9:45 PM

Rohit_SilhiRT @welsh_gas_doc: Should communication skills and sociology; or basic managementof a common killer like sepsis emphasised in the UG Curriculum? #TwitJC -9:46 PM

DrDLittleRT @twitjournalclub: Next week, well be looking at Geoffrey Roses Prevention Paradox(BMJ, 1981). #Twitjc -9:46 PM

parkerflashRT @anaestheticdoc: @silv24 @fidouglas well done ladies congrats #twitjc -9:47 PM


30/31

AandE_SHO does #twitjc count as revising? -9:47 PM

anaestheticdoc got to get 2hours of CPD for that.Anyone a fancy a 9pm start. Kids need puttingbed normally #twitjc -9:47 PM

amcunningham @twitjournalclub: Next week, we'll be looking at Geoffrey Rose's 'PreventionParadox' (BMJ, 1981). #twitjc wow! -9:47 PM

ashleighmartin1Really enjoyed reading all your tweets in #twitjc sadly I didn't read the paperthoroughly enough to contribute...maybe next week! -9:47 PM

amcunninghamRT @welsh_gas_doc: Should communication skills and sociology; or basicmanagement of a common killer like sepsis emphasised in the UG Curriculum? #TwitJC -9:48 PM

simonpeteryoung#TwitJC I shall also contact @RCoANews re: CPD value of this -9:48 PM

feralvarezlo RT @doctorblogs: .@silv24 @fidouglas another great EBM resource: critical appraisaltools etc http://bit.ly/m56pcd from @cebmblog #twitjc -9:48 PM

ross71521@welsh_gas_doc I've had more contact hours about Comm skills than sepsis, but surely

that's b/c sepsis is easier to teach? #TwitJC -9:49 PM

peds_id_doc Did you guys see #twitjc? @westr @astupple right up your alley. -9:49 PM

amcunninghamRT @simonpeteryoung: #TwitJC I shall also contact @RCoANews re: CPD valueof this -9:49 PM

EasternDoc@silv24 @fidouglas well done ladies, really good stuff. Sorry to lurk but I was doingeportfolio. Will be more involved next week #twitJC -9:50 PM

tobyhillmanRT @silv24: RT @twitjournalclub: Next week, we'll be looking at Geoffrey Rose's'Prevention Paradox' (BMJ, 1981). #twitjc -9:50 PM

tobyhillmanRT @anaestheticdoc: got to get 2hours of CPD for that.Anyone a fancy a 9pm start.Kids need putting bed normally #twitjc -9:50 PM

silv24 RT @simonpeteryoung: #TwitJC I shall also contact @RCoANews re: CPD value of this -9:51PM

amcunningham To move from a critical care paper to prevention paradox shows great breadth tobe covered in #TwitJC -9:51 PM

silv24 RT @simonpeteryoung: #TwitJC this was AMAZING! well done all. I will be highlighting thisto our cabinet secretary for health (she's on twitter) -9:51 PM

McConwaysHaven't a notion what they're talking about (smart medics) but #twitjc is brilliant. Anyother 'clubs' on twitter? I want to be in one. -9:51 PM

chrisking01RT @twitjournalclub: Next week, we'll be looking at Geoffrey Rose's 'PreventionParadox' (BMJ, 1981). #twitjc -9:51 PM

rodedun really enjoyed #twitjc. for those interested there will be a #teddybearclub #geekdayout inLondon 18th June Primrose Hill all invited :) -9:52 PM

anaestheticdoc @welsh_gas_doc will have to see my paper on why teaching communication skillsis a waste of time. #twitjc -9:52 PM

adriamarilla@silv24 and @fidouglas #twitjc great idea! can't wait for the next discussion! Welldone and thanks everyone for share your views :) -9:53 PM

dr_fiona RT @DrDLittle: RT @twitjournalclub: Next week, well be looking at Geoffrey RosesPrevention Paradox (BMJ, 1981). #Twitjc -9:53 PM


31/31

siobhanfarmerRT @twitjournalclub: Next week, we'll be looking at Geoffrey Rose's 'PreventionParadox' (BMJ, 1981). #twitjc -9:53 PM

whole_patients RT @amcunningham: @twitjournalclub: Next week, we'll be looking at GeoffreyRose's 'Prevention Paradox' (BMJ, 1981). #twitjc wow! -9:54 PM

MedEdHelen I can't wait till we integrate recording these into BMJ Portfolio, will be onto ourtechies about how tomorrow. @twitjournalclub #TwitJC -9:54 PM

silv24 RT @ffolliet: THIS is what twitter is all about @silv24 @fidouglas set up an online medicaljournal club. brilliant work, well done #twitjc -9:55 PM

twitjournalclubRT @rodedun: really enjoyed #twitjc. for those interested there will be a#teddybearclub #geekdayout in London 18th June Primrose Hill all invited :) -9:55 PM

simonpeteryoung@NicolaSturgeon twitter discussion re: infection management at #twitjc.continuing prof dev at it's finest AND on social media. model4future -9:55 PM

summerdaisy I will definitely be joining in #TwitJC once my exams are over in 3 weeks time! -9:55PM

anaestheticdoc @rodedun whats #teddybearclub, sounds like euphemism for something else tome. Primrose Hill or hampstead heath? #twitjc -9:56 PM

amcunningham@drgrumble sorry but this doesn't really tell us anything about transfer delay..Well I don't see how it does #TwitJC -9:56 PM

chrisking01 @ffolliet: THIS is what twitter is all about @silv24 @fidouglas set up an onlinemedical journal club. brilliant work, well done #twitjc -9:56 PM

doctorblogs PDF http://1.usa.gov/iM7Ybh RT @twitjournalclub: Next week, we'll be looking atGeoffrey Rose's 'Prevention Paradox' (BMJ, 1981). #twitjc -9:57 PM

amcunningham@drgrumble sorry I meant how transfer causes delay... #TwitJC -9:58 PM

dralindsay @silv24 @fidouglas Congratulations on #twitjc - a gear idea -9:59 PM

DrOliverWarrenRT @tobyhillman: RT @silv24: RT @twitjournalclub: Next week, we'll be lookingat Geoffrey Rose's 'Prevention Paradox' (BMJ, 1981). #twitjc -9:59 PM

#TwitJC Transcript 5-6-2011

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Transcript of #TwitJC Transcript 5-6-2011