Jeremy S. Faust

Future evolution of traditional journals and social media medical education

Over the past two decades, the Internet has emerged as a powerful tool for the dissemination of medical knowledge. The routine online publication of peer-reviewed journals and the standardisation of the portable document format (.pdf) marked a coming of age for Internet technology allowing readers, authors and editors to quickly access articles old and new and share them efficiently. Although the most prestigious medical journals still view the paper versions of their journals to be the pinnacle product, it is now standard for articles to be e-published online ‘ahead of print’, weeks to months before the paper passes through the press, and arrives on the doorstep. Thus, for most web-savvy and voracious readers, by the time physical journals appear in mailboxes, important or controversial new research has often already been read, discussed and debated at length in online and ‘real life’ forums. Emails have been written and responses have been sent to the editors. Opinions have been formed. However, because of print delays, some of the most thought-out and qualified opinions (i.e. experts’ Letters to the Editor) have been embargoed from general consumption, waiting instead until future issues can be published. Meanwhile, print errors remain uncorrected. As the goals of peer-reviewed medical journals are to foster medical progress and improve research as a whole, this obsolete model must be phased out. The window between the acquisition of research knowledge and clinical translation can often gape longer than a decade. This was perhaps an acceptable although suboptimal reality before the advent of Internet-based technologies, but the recent social media revolution has made this untenable. If peer-reviewed journals adapt to a new reality, not only will such delays be shortened, but also the journals will find themselves to be more relevant than ever. On the other hand, those publications that fail to adapt will cease to be potent in the most meaningful ways. In this editorial, we suggest three key ways that peer-reviewed journals can maintain and increase their relevance in today’s milieu: first, by embracing real-time interactivity; second, by embracing new tools to measure clinical impact; and third, by finally eliminating print publication. Social media medical education might be the inspiration for many of these changes. However, medical social media is still in its nascent stages; it must evolve as well. It requires adoption and adaptation of systems for peer review and information verification to allow trust by clinicians. Furthermore, the time demands of product creation will not be sustainable unless there is a path for academic advancement to support these activities.

The Past, Present, and Future of the Centers for Medicare and Medicaid Services Quality Measure SEP-1: The Early Management Bundle for Severe Sepsis/Septic Shock

SEP-1, the new national quality measure on sepsis, resulted from an undertaking to standardize care for severe sepsis and septic shock regardless of the size of the emergency department where the patient is being treated. SEP-1 does not necessarily follow the best current evidence available. Nevertheless, a thorough understanding of SEP-1 is crucial because all hospitals and emergency providers will be accountable for meeting the requirements of this measure. SEP-1 is the first national quality measure on early management of sepsis care. This article provides a review of SEP-1 and all its potential implications on sepsis care in the United States.

Determination of a Testing Threshold for Lumbar Puncture in the Diagnosis of Subarachnoid Hemorrhage after a Negative Head Computed Tomography: A Decision Analysis.

OBJECTIVEnThe objective was to determine the testing threshold for lumbar puncture (LP) in the evaluation of aneurysmal subarachnoid hemorrhage (SAH) after a negative head computed tomography (CT). As a secondary aim we sought to identify clinical variables that have the greatest impact on this threshold.nnnMETHODSnA decision analytic model was developed to estimate the testing threshold for patients with normal neurologic findings, being evaluated for SAH, after a negative CT of the head. The testing threshold was calculated as the pretest probability of disease where the two strategies (LP or no LP) are balanced in terms of quality-adjusted life-years. Two-way and probabilistic sensitivity analyses (PSAs) were performed.nnnRESULTSnFor the base-case scenario the testing threshold for performing an LP after negative head CT was 4.3%. Results for the two-way sensitivity analyses demonstrated that the test threshold ranged from 1.9% to 15.6%, dominated by the uncertainty in the probability of death from initial missed SAH. In the PSA the mean testing threshold was 4.3% (95% confidence interval = 1.4% to 9.3%). Other significant variables in the model included probability of aneurysmal versus nonaneurysmal SAH after negative head CT, probability of long-term morbidity from initial missed SAH, and probability of renal failure from contrast-induced nephropathy.nnnCONCLUSIONSnOur decision analysis results suggest a testing threshold for LP after negative CT to be approximately 4.3%, with a range of 1.4% to 9.3% on robust PSA. In light of these data, and considering the low probability of aneurysmal SAH after a negative CT, classical teaching and current guidelines addressing testing for SAH should be revisited.

Eliciting renal tenderness by sonopalpation in diagnosing acute pyelonephritis

Diagnosing acute pyelonephritis relies on the combination of historical, physical, and laboratory findings. Costovertebral angle tenderness is important, although its accuracy is unknown. Point-of-care ultrasound-guided palpation (sonopalpation) may aid clinicians in localizing pain to discrete anatomic structures in cases of suspected acute pyelonephritis lacking classic features. We describe three low-to-moderate pre-test probability cases wherein maximal tenderness was elicited by renal sonopalpation, aiding in the diagnosis of acute pyelonephritis. In a fourth case, absence of renal tenderness to sonopalpation in a patient exhibiting typical acute pyelonephritis features led to an alternate diagnosis. Therefore, renal sonopalpation may be useful in confirming or refuting suspected cases.

The integration of social media into residency curriculum has obstacles.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Dr. Isbister is supported by an NHMRC Senior Research Fellowship ID1061041. Dr. Brown is supported by NHMRC Career Development Fellowship ID1023265.