- Email: [email protected]
Social media guidance, conflicts of interest, and health inequalities
Correspondence
in patients in general intensive care (0·75, 0·59–0·96). Kong and Xia also suggest that the initiation of treatment by use of a large bolus injection was done only in sheep. This is not the case: according to Forceville,3 three studies in patients in intensive-care units (ICUs) have successfully used a bolus injection, the most notable of which is the SIC study.4 In that randomised, doubleblind, multicentre study, 1000 μg sodium selenite was given as a bolus, followed by 14 days of continuous intravenous infusion of 1000 μg in 238 ICU patients with severe systemic inflammatory response syndrome, sepsis, or septic shock. In the intentionto-treat analysis, 28-day mortality was non-significantly reduced from 50·0% in the placebo group to 39·7% in the selenium-treated group (odds ratio 0·66, 95% CI 0·39–1·1; p=0·109), although in the per-protocol analysis there was a significant reduction from 56·7% to 42·4% (0·56, 0·32–1·00; p=0·049). In predefined subgroup analyses, the mortality rate was significantly reduced in patients with septic shock with disseminated intravascular coagulation (p=0·018) as well as in the most critically ill patients with an APACHE III score of 102 or more (p=0·040) and in patients with failure of more than three organs (p=0·039). The transient pro-oxidant effect of an intravenous bolus (followed by the antioxidant effect of continuous infusion) might explain the apparent increase in efficacy of bolus treatment.5 Although I disagree with Kong and Xia on the points they have raised, I totally concur with their view that more studies of the use of selenium in the treatment of patients in ICUs are needed to elucidate the factors that affect the success or otherwise of such treatment. I declare that I have no conflicts of interest.
Margaret P Rayman [email protected] Department of Nutrition and Metabolism, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
472
1
2
3
4
5
Heyland DK, Dhaliwal R, Suchner U, Berger MM. Antioxidant nutrients: a systematic review of trace elements and vitamins in the critically ill patient. Intensive Care Med 2005; 31: 327–37. Avenell A, Noble DW, Barr J, Engelhardt T. Selenium supplementation for critically ill adults. Cochrane Database Syst Rev 2004; 4: CD003703. Forceville X. Effects of high doses of selenium, as sodium selenite, in septic shock patients: a placebo-controlled, randomized, double-blind, multi-center phase II study—selenium and sepsis. J Trace Elem Med Biol 2007; 21 (suppl 1): 62–65. Angstwurm MW, Engelmann L, Zimmermann T, et al. Selenium in Intensive Care (SIC): results of a prospective randomized, placebo-controlled, multiple-center study in patients with severe systemic inflammatory response syndrome, sepsis, and septic shock. Crit Care Med 2007; 35: 118–26. Manzanares W, Hardy G. Selenium supplementation in the critically ill: posology and pharmacokinetics. Curr Opin Clin Nutr Metab Care 2009; 12: 273–80.
The state of nursing and evidence-based practice Nursing has never been more pivotal to the health and prosperity of lowincome, middle-income, and highincome countries. Thus, it was only right that The Lancet recognised International Nurses Day in its May 12 Editorial.1 As editors (IN and RW) of the world’s highest impact and most cited nursing journals, and as active researchers, we agree: nursing must do better at reducing gaps between evidence and practice. However, the Editorial was wrong about the state of evidencebased practice in nursing, and damaging in its representation of nurses. Our profession’s challenges around care gaps are no different from those of medicine and exist despite 20 years of curricula to address evidence-based practice in both disciplines. Care gaps are actually reduced by influential leaders, systems that foster high-quality care and patients’ safety, and the hiring of well educated staff.2,3 Nursing’s greatest challenges in leadership around these solutions relate to identity and confidence. Too often in clinical settings a strong anti-intellectual streak prevails, which is hostile to research. Nurses themselves often perpetuate media discourse that newly educated nurses
are overeducated nurses. Regrettable but uncommon instances of poor care are mistakenly conflated with a nursing profession in crisis that must return to a supposed halcyon era opposed to the use of research in health care. The world faces a daunting future characterised by ageing and fiscal tightening.4 Infection control, treatment compliance, and health care provided by multidisciplinary teams, individuals, and families will be essential and primed to be addressed well by nurses. Medicine and nursing need research evidence and each other like never before. We declare that we have no conflicts of interest.
*Alexander M Clark, David R Thompson, Roger Watson, Ian Norman [email protected] University of Alberta, Edmonton, AB T63 2G3, Canada (AMC); Australian Catholic University, Melbourne, VIC, Australia (DRT); University of Hull, Hull, UK (RW); Journal of Advanced Nursing, Oxford, UK (RW); Kings College London, London, UK (IN); and International Journal of Nursing Studies, Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK (IN) 1 2
3
4
The Lancet. Science for action-based nursing. Lancet 2012; 379: 1763. Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care 2007; 45: 1195–204. Majumdar SR, McAlister FA, Furberg CD. From knowledge to practice in chronic cardiovascular disease: a long and winding road. J Am Coll Cardiol 2004; 43: 1738–10. World Economic Forum. Global risks 2012, 7th edn. Geneva: World Economic Forum, 2012.
Social media guidance, conflicts of interest, and health inequalities The Lancet’s April 28 Editorial1 calls attention to the UK General Medical Council’s (GMC’s) draft guidance, Doctors’ use of social media. Calling the guidelines “not dissimilar” to other available guidance potentially understates how the GMC’s guidance improves on its predecessors yet leaves crucial areas unaddressed. www.thelancet.com Vol 380 August 4, 2012
Correspondence
I declare that I have no conflicts of interest.
Matthew DeCamp [email protected] Johns Hopkins University and School of Medicine, Baltimore, MD 21287, USA 1
The Lancet. Social media: how doctors can contribute. Lancet 2012; 379: 1562.
www.thelancet.com Vol 380 August 4, 2012
2
3
4
5
Shore R, Halsey J, Shah K, Crigger BJ, Douglas SP, AMA Council on Ethical and Judicial Affairs (CEJA). Report of the AMA Council on Ethical and Judicial Affairs: professionalism in the use of social media. J Clin Ethics 2011; 22: 165–72. Snyder L; American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians ethics manual, 6th edn. Ann Intern Med 2012; 156: 73–104. Lesser CS, Lucey CR, Egener B, Braddock CH 3rd, Linas SL, Levinson W. A behavioral and systems view of professionalism. JAMA 2010; 304: 2732–37. Chretien KC, Azar J, Kind T. Physicians on Twitter. JAMA 2011; 305: 566–68.
Health authorities’ leadership reduces cholera deaths in Haiti 1·5 years after the first cases of cholera were reported in Haiti, 534 647 people have been infected and 7091 killed.1 We report on how the motivation and capacity of decentralised health authorities to lead the response and coordination of activities in one department were able to contain quickly a major cholera outbreak and reduce mortality. Cholera peaked in the northwest department in December, 2010. The capacity to respond to the epidemic was low and case fatality rates exceeded 20% in some areas. A major spike in cases occurred again in July, 2011; 1776 cases of cholera were identified and 1186 patients were admitted to hospital in Port-de-Paix, the major city of the department. The response to this second peak was swift. A joint effort led by the Ministry of Health and supported by the Inter-American Development Bank, UNICEF, WHO, and Médecins Sans Frontières France helped the two main hospitals of the city to scale up their bed capacity to 250 and 200 from 30 and 20, respectively. Additional health professionals and community health and sanitation agents (brigadiers) were hired and social mobilisation and home visits for early identification of cases were
stepped up. Daily coordination meetings chaired by the department’s director of health were held to identify needs and available resources for an adequate response, avoid duplication of efforts and activities among partners, and maximise the quality of services. As a result, the number of cases was reduced in 6 days and a low case-fatality rate of 0·8% was noted. Interviews with 11 key informants revealed several success factors including: strong coordination of partners by the department health authorities; a robust and functional community-based cholera surveillance system; clarification, adaptation, and widespread dissemination of treatment protocols including management of dehydration in severely malnourished children; increased awareness of prevention and early case detection of illness in urban and rural communities; installation of new oral rehydration points and cholera treatment units; availability of medicines (including antibiotics and zinc) and supplies; availability of sufficient funds to the department health authorities that could be disbursed immediately without any decision at the central level; a functioning patient transfer system; quick chlorination of water sources; community education campaigns for systematic handwashing with soap; and information on how to get quickly to treatment facilities. Tackling the cholera epidemic in Haiti effectively requires an accompaniment strategy and a commitment that strengthens local health authorities’ capacity and leadership. Until the Government of Haiti is able to ensure this throughout the country, the international community must not withdraw from providing the needed resources and technical support that would make it happen.
Niall Carson/PA Archive/Press Association Images
Compared with relevant others,2,3 the draft is more comprehensive and makes substantial progress in defining specific professional behaviours. Few as definitively prohibit discussion of individual patients, recommend against anonymity, or require disclosure of conflicts of interest. Because definition of specific behaviours is necessary for medical professionalism,4 the specificity of the guidance is a significant achievement that presents an opportunity for nascent research to assess accurately the type, frequency, and magnitude of (mis)behaviour online.5 The GMC guidance thus deserves praise, even if disagreement remains about—for example—whether discussion of patients’ information online is permissible or necessary to achieve social media’s benefits. Nonetheless, crucial issues remain unaddressed. For instance, “declaration” of conflicts (and not stringent management or elimination) fails to acknowledge how abridged, rapidly disseminated social media content makes disclosure uniquely challenging. Additionally, the GMC, like others, does not recognise or cross-reference health inequalities. Whether social media will exacerbate health inequities within the digital divide remains unknown. The comment period provided the opportunity to correct, if necessary, overly conservative definitions of specific behaviours (eg, discussing patients’ information online); to further specify unclear ones (eg, “you should usually identify yourself”); and to raise additional issues crucial to medical professionalism (eg, health inequalities). The global reach of social media made this opportunity all the more important to physicians worldwide.
We declare that we have no conflicts of interest.
473
in patients in general intensive care (0·75, 0·59–0·96). Kong and Xia also suggest that the initiation of treatment by use of a large bolus injection was done only in sheep. This is not the case: according to Forceville,3 three studies in patients in intensive-care units (ICUs) have successfully used a bolus injection, the most notable of which is the SIC study.4 In that randomised, doubleblind, multicentre study, 1000 μg sodium selenite was given as a bolus, followed by 14 days of continuous intravenous infusion of 1000 μg in 238 ICU patients with severe systemic inflammatory response syndrome, sepsis, or septic shock. In the intentionto-treat analysis, 28-day mortality was non-significantly reduced from 50·0% in the placebo group to 39·7% in the selenium-treated group (odds ratio 0·66, 95% CI 0·39–1·1; p=0·109), although in the per-protocol analysis there was a significant reduction from 56·7% to 42·4% (0·56, 0·32–1·00; p=0·049). In predefined subgroup analyses, the mortality rate was significantly reduced in patients with septic shock with disseminated intravascular coagulation (p=0·018) as well as in the most critically ill patients with an APACHE III score of 102 or more (p=0·040) and in patients with failure of more than three organs (p=0·039). The transient pro-oxidant effect of an intravenous bolus (followed by the antioxidant effect of continuous infusion) might explain the apparent increase in efficacy of bolus treatment.5 Although I disagree with Kong and Xia on the points they have raised, I totally concur with their view that more studies of the use of selenium in the treatment of patients in ICUs are needed to elucidate the factors that affect the success or otherwise of such treatment. I declare that I have no conflicts of interest.
Margaret P Rayman [email protected] Department of Nutrition and Metabolism, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
472
1
2
3
4
5
Heyland DK, Dhaliwal R, Suchner U, Berger MM. Antioxidant nutrients: a systematic review of trace elements and vitamins in the critically ill patient. Intensive Care Med 2005; 31: 327–37. Avenell A, Noble DW, Barr J, Engelhardt T. Selenium supplementation for critically ill adults. Cochrane Database Syst Rev 2004; 4: CD003703. Forceville X. Effects of high doses of selenium, as sodium selenite, in septic shock patients: a placebo-controlled, randomized, double-blind, multi-center phase II study—selenium and sepsis. J Trace Elem Med Biol 2007; 21 (suppl 1): 62–65. Angstwurm MW, Engelmann L, Zimmermann T, et al. Selenium in Intensive Care (SIC): results of a prospective randomized, placebo-controlled, multiple-center study in patients with severe systemic inflammatory response syndrome, sepsis, and septic shock. Crit Care Med 2007; 35: 118–26. Manzanares W, Hardy G. Selenium supplementation in the critically ill: posology and pharmacokinetics. Curr Opin Clin Nutr Metab Care 2009; 12: 273–80.
The state of nursing and evidence-based practice Nursing has never been more pivotal to the health and prosperity of lowincome, middle-income, and highincome countries. Thus, it was only right that The Lancet recognised International Nurses Day in its May 12 Editorial.1 As editors (IN and RW) of the world’s highest impact and most cited nursing journals, and as active researchers, we agree: nursing must do better at reducing gaps between evidence and practice. However, the Editorial was wrong about the state of evidencebased practice in nursing, and damaging in its representation of nurses. Our profession’s challenges around care gaps are no different from those of medicine and exist despite 20 years of curricula to address evidence-based practice in both disciplines. Care gaps are actually reduced by influential leaders, systems that foster high-quality care and patients’ safety, and the hiring of well educated staff.2,3 Nursing’s greatest challenges in leadership around these solutions relate to identity and confidence. Too often in clinical settings a strong anti-intellectual streak prevails, which is hostile to research. Nurses themselves often perpetuate media discourse that newly educated nurses
are overeducated nurses. Regrettable but uncommon instances of poor care are mistakenly conflated with a nursing profession in crisis that must return to a supposed halcyon era opposed to the use of research in health care. The world faces a daunting future characterised by ageing and fiscal tightening.4 Infection control, treatment compliance, and health care provided by multidisciplinary teams, individuals, and families will be essential and primed to be addressed well by nurses. Medicine and nursing need research evidence and each other like never before. We declare that we have no conflicts of interest.
*Alexander M Clark, David R Thompson, Roger Watson, Ian Norman [email protected] University of Alberta, Edmonton, AB T63 2G3, Canada (AMC); Australian Catholic University, Melbourne, VIC, Australia (DRT); University of Hull, Hull, UK (RW); Journal of Advanced Nursing, Oxford, UK (RW); Kings College London, London, UK (IN); and International Journal of Nursing Studies, Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK (IN) 1 2
3
4
The Lancet. Science for action-based nursing. Lancet 2012; 379: 1763. Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care 2007; 45: 1195–204. Majumdar SR, McAlister FA, Furberg CD. From knowledge to practice in chronic cardiovascular disease: a long and winding road. J Am Coll Cardiol 2004; 43: 1738–10. World Economic Forum. Global risks 2012, 7th edn. Geneva: World Economic Forum, 2012.
Social media guidance, conflicts of interest, and health inequalities The Lancet’s April 28 Editorial1 calls attention to the UK General Medical Council’s (GMC’s) draft guidance, Doctors’ use of social media. Calling the guidelines “not dissimilar” to other available guidance potentially understates how the GMC’s guidance improves on its predecessors yet leaves crucial areas unaddressed. www.thelancet.com Vol 380 August 4, 2012
Correspondence
I declare that I have no conflicts of interest.
Matthew DeCamp [email protected] Johns Hopkins University and School of Medicine, Baltimore, MD 21287, USA 1
The Lancet. Social media: how doctors can contribute. Lancet 2012; 379: 1562.
www.thelancet.com Vol 380 August 4, 2012
2
3
4
5
Shore R, Halsey J, Shah K, Crigger BJ, Douglas SP, AMA Council on Ethical and Judicial Affairs (CEJA). Report of the AMA Council on Ethical and Judicial Affairs: professionalism in the use of social media. J Clin Ethics 2011; 22: 165–72. Snyder L; American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians ethics manual, 6th edn. Ann Intern Med 2012; 156: 73–104. Lesser CS, Lucey CR, Egener B, Braddock CH 3rd, Linas SL, Levinson W. A behavioral and systems view of professionalism. JAMA 2010; 304: 2732–37. Chretien KC, Azar J, Kind T. Physicians on Twitter. JAMA 2011; 305: 566–68.
Health authorities’ leadership reduces cholera deaths in Haiti 1·5 years after the first cases of cholera were reported in Haiti, 534 647 people have been infected and 7091 killed.1 We report on how the motivation and capacity of decentralised health authorities to lead the response and coordination of activities in one department were able to contain quickly a major cholera outbreak and reduce mortality. Cholera peaked in the northwest department in December, 2010. The capacity to respond to the epidemic was low and case fatality rates exceeded 20% in some areas. A major spike in cases occurred again in July, 2011; 1776 cases of cholera were identified and 1186 patients were admitted to hospital in Port-de-Paix, the major city of the department. The response to this second peak was swift. A joint effort led by the Ministry of Health and supported by the Inter-American Development Bank, UNICEF, WHO, and Médecins Sans Frontières France helped the two main hospitals of the city to scale up their bed capacity to 250 and 200 from 30 and 20, respectively. Additional health professionals and community health and sanitation agents (brigadiers) were hired and social mobilisation and home visits for early identification of cases were
stepped up. Daily coordination meetings chaired by the department’s director of health were held to identify needs and available resources for an adequate response, avoid duplication of efforts and activities among partners, and maximise the quality of services. As a result, the number of cases was reduced in 6 days and a low case-fatality rate of 0·8% was noted. Interviews with 11 key informants revealed several success factors including: strong coordination of partners by the department health authorities; a robust and functional community-based cholera surveillance system; clarification, adaptation, and widespread dissemination of treatment protocols including management of dehydration in severely malnourished children; increased awareness of prevention and early case detection of illness in urban and rural communities; installation of new oral rehydration points and cholera treatment units; availability of medicines (including antibiotics and zinc) and supplies; availability of sufficient funds to the department health authorities that could be disbursed immediately without any decision at the central level; a functioning patient transfer system; quick chlorination of water sources; community education campaigns for systematic handwashing with soap; and information on how to get quickly to treatment facilities. Tackling the cholera epidemic in Haiti effectively requires an accompaniment strategy and a commitment that strengthens local health authorities’ capacity and leadership. Until the Government of Haiti is able to ensure this throughout the country, the international community must not withdraw from providing the needed resources and technical support that would make it happen.
Niall Carson/PA Archive/Press Association Images
Compared with relevant others,2,3 the draft is more comprehensive and makes substantial progress in defining specific professional behaviours. Few as definitively prohibit discussion of individual patients, recommend against anonymity, or require disclosure of conflicts of interest. Because definition of specific behaviours is necessary for medical professionalism,4 the specificity of the guidance is a significant achievement that presents an opportunity for nascent research to assess accurately the type, frequency, and magnitude of (mis)behaviour online.5 The GMC guidance thus deserves praise, even if disagreement remains about—for example—whether discussion of patients’ information online is permissible or necessary to achieve social media’s benefits. Nonetheless, crucial issues remain unaddressed. For instance, “declaration” of conflicts (and not stringent management or elimination) fails to acknowledge how abridged, rapidly disseminated social media content makes disclosure uniquely challenging. Additionally, the GMC, like others, does not recognise or cross-reference health inequalities. Whether social media will exacerbate health inequities within the digital divide remains unknown. The comment period provided the opportunity to correct, if necessary, overly conservative definitions of specific behaviours (eg, discussing patients’ information online); to further specify unclear ones (eg, “you should usually identify yourself”); and to raise additional issues crucial to medical professionalism (eg, health inequalities). The global reach of social media made this opportunity all the more important to physicians worldwide.
We declare that we have no conflicts of interest.
473