Transcript: Twitter Journal Club – Third Meeting 8pm, Sunday 19th June 2011

CRASH-2, The Lancet Website: http://bit.ly/iXd0CA - PDF of the paper: http://bit.ly/kyMkFM Hosted by Natalie Silvey

twitjournalclub Good evening and welcome to the third week of the journal club - this is @silv24 tweeting #twitjc -8:01 PM Shazmo Hellllo, Charlotte here, med student, probably mostly observing tonight :) #twitjc -8:02 PM twitjournalclub A summary of tonight's paper CRASH-2 & list of the discussion points have been posted on the blog http://twitjc.wordpress.com #twitjc -8:03 PM TaranehDean #twitjc have we started? -8:03 PM twitjournalclub First introductions... #twitjc -8:03 PM GabrielScally #twitjc hello. Just arriving back from Belfast. Check in later. Great choice of study. And a great study to have run! -8:03 PM welsh_gas_doc Goooood evening everyone, DJ, Anaesthetics Reg. #TwitJC -8:04 PM twitjournalclub Good evening - I am Natalie (tweet as @silv24) and I am an F1 in gastroenterology #twitjc -8:05 PM themattmak Hello #Twitjc Matt, currently medical SHO on call in a London Hospital and therefore likely to be catching up later. Great paper tonight -8:05 PM behrouzn Hi! Behrouz, pre-med just going to be observing :) #twitJC -8:05 PM catherineleng Hi, Catherine here, third year medic - just here to observe also. Keen to see how the pros analyse papers:) #twitjc -8:07 PM twitjournalclub CRASH-2 is a very interesting paper, it was awarded BMJ Research Paper of the Year at the recent BMJ awards #twitjc -8:07 PM MsPhelps Hello #twitjc! Dutch medical infomation specialist / clinical librarian. -8:07 PM DrDLittle Dave, clinical teaching fellow, soon to be radiology trainee. Mainly watching tonight #TwitJC -8:08 PM christianassad RT @TheLancet: A reminder that you can join tonight's twitter discussion on CRASH-2 at 7pm GMT using the hash tag #twitjc -8:08 PM TWSY Tom Young, emergency physician. Recruited for CRASH-2 and given TA since its publication. Putting my head up above the parapet #twitjc -8:09 PM twitjournalclub First discussion point: Was the study population relevant to the question being asked? #twitjc -8:10 PM twitjournalclub i.e. how they identified patient's with or at risk of significant haemorrhage? #twitjc -8:10 PM welsh_gas_doc The study group was appropriate, they defined "trauma" in the way the majority of people would, and excluded people appropriately #TwitJC -8:12 PM

silv24 They recruited any trauma patients with haemorrhage (defined as systolic <90 or HR >110 or both) or at risk haemorrhage #twitjc -8:12 PM TWSY 'trauma patients with or at risk of haemorrhage' #twitjc -8:13 PM GabrielScally #twitjc I think the clinical criteria were fine. There is an amazing range of settings involved - both developed and developing countries. -8:13 PM TaranehDean #twitjc Good evening.I am Tara and involved in CA skills since I had the pleasure of teaching it with David Sackett at Oxford few hrs ago. -8:13 PM PaedsSHO @GabrielScally Agree, the range of settings was really impressive. #twitjc -8:13 PM silv24 Are these criteria good enough? They are clinical which makes the study very relevant to real life practice #twitjc -8:14 PM welsh_gas_doc The words "at risk of..." are somewhat open to interpretation, but good inclusion criteria. #TwitJC -8:14 PM paramedicsa #TwitJC Matthew, Paramedic, Pre Hospital interest, observing -8:14 PM silv24 Think that is such a strength of this trial - a protocol that could be used in 40 countries with varying healthcare systems #twitjc -8:15 PM TWSY The openness of interpretation was deliberate I believe...pragmatism #twitjc -8:15 PM riazdharamshi Take a break from the #twitjc to read my latest blog - 'Is there anything you would like to ask me?' http://t.co/rK7ieSh -8:16 PM silv24 @TWSY I agree, the openness meant that it reflected real life practice more when we aren't always sure #twitjc -8:16 PM twitjournalclub Are there any criticisms about the protocol used or how patient's were recruited? The trial protocol had been peer reviewed #twitjc -8:17 PM TWSY Seeing as TA will rarely be clearly indicated or clearly not indictated, includes most trauma patients bleeding (or at risk of) #twitjc -8:18 PM silv24 I have read through the protocol several times and can't find anything obvious that would need improving #twitjc -8:18 PM AandE_SHO Apologies #twitjc, just finished.. Hopefully join in next time. -8:19 PM TWSY Protocol ok as far as I am aware. There may have been criticisms previously around the consent process #twitjc -8:19 PM ambulancemandan #twitjc Dan Paramedic, just catching up, so observing ATM. -8:19 PM TWSY Consent was by proxy or deferred, and I see in some cases, waived #twitjc -8:20 PM Assidens Good eve everyone, I'm a public health nurse with an interest in research, a little out of my depth, but learn so much from you all #twitjc -8:20 PM twitjournalclub Point two - did the paper ask the right question? (i.e. was the primary mortality by 28 days the right one to measure?) #twitjc -8:20 PM TaranehDean #twitjc good incl/ecl criteria. What is not clear is the prop. of target pop. who did not meet the criteria through the physician's decision -8:21 PM MsPhelps I do wonder a bit at the range in number of participants per country - could not find a clear explanation #twitjc -8:21 PM

twitjournalclub @TWSY @PaedsSHO the last discussion point will be an interesting one regarding consent and potential time delays #twitjc -8:21 PM bioethix Would love to join in on this one but currently on a train with intermittent net access. I'll just be watching tonight folks #TwitJC -8:22 PM silv24 @MsPhelps in a trial with this scope & varying levels of trauma between different centres & consent rates prob expected #twitjc -8:23 PM MsPhelps 6 countries of the 40 contributed > 75% of participants, see picture for breakdown #twitjc (still re: question 1) http://twitpic.com/5dynkp -8:23 PM TWSY I think all cause mortality is the right outcome to look at, with other outcomes. 28 days though? Arbitrary? Used for other studies? #twitjc -8:23 PM silv24 The primary mortality is an interesting one as showed an all cause decrease with TA, was this expected? #twitjc -8:24 PM TaranehDean @TaranehDean #twitjc -8:24 PM MsPhelps @TWSY Agree, looking at Fig 2 (of the paper) the results would prob. have been equal with 14 days follow-up. #twitjc -8:25 PM TWSY Expected in the sense of makes vbasic science sense and previously seen in the elective surgery systematic review, yes #twitjc -8:26 PM silv24 RT @MsPhelps: 6 countries of the 40 contributed > 75% of participants, see picture for breakdown #twitjc (still re: question 1) http://twitpic.com/5dynkp -8:26 PM iamdoctord I think 28d appropriately covers the early mortality from the primary insult and secondary complications which were to be evaluated. #twitjc -8:26 PM silv24 RT @iamdoctord: I think 28d appropriately covers the early mortality from the primary insult and secondary complications which were to be evaluated. #twitjc -8:26 PM silv24 @iamdoctord I agree, earlier cut off may possibly have missed complications #twitjc -8:28 PM TheNerdse Even though I can't contribute to #twitjc it's great to read & find interesting new people to follow! -8:29 PM twitjournalclub It is interesting that all cause mortality was reduced in these trauma patients, not just outcomes related to bleeding #twitjc -8:29 PM TaranehDean #twitjc When you do multiple-centre multiple-national trials you need to be sensitive to health systems and ease of long term data n -8:30 PM TWSY @twitjournalclub prolonged shock and need for massive transfusion affects all systems, hence impact on all cause mortality #twitjc -8:30 PM chrisnjones @welsh_gas_doc #twitjc Agreed mine too. Now use TA (first bolus) on HEMS in Sydney -8:31 PM MsPhelps @iamdoctord @silv24 Good point, definitely agree for secondary outcomes. #twitjc -8:31 PM TaranehDean #twitjc Yes it is interesting but this happens. A good example was the trial on Does Stroke Units save lives? Same thing. -8:32 PM twitjournalclub Adverse events - the paper reported no adverse events as serious, unexpected or suspected to be related to the study treatment #twitjc -8:32 PM ijwhitehead Hello - We use TA not just in trauma - You see the difference in cell salvaged blood too #twitjc -8:33 PM

twitjournalclub Was the study adequate to detect any adverse effects of the use of TA in these patients? #twitjc -8:33 PM chrisnjones @twitjournalclub #twitjc Apologies....anaesthetic reg -8:34 PM paramedicsa #TwitJC @TWSY, with normal Trauma mortality at 60% within first 24hrs, should period be reduced from 28days? -8:34 PM cringlem #twitjc looking in while doing my other research!! -8:35 PM iamdoctord By numbers recruited, I think serious adverse events would have been picked up... but what is defined by 'serious'? #twitjc -8:35 PM twitjournalclub Is there a risk that the study under-reported the frequency of adverse events? #twitjc -8:35 PM TaranehDean #twitjc the study was certainly not powered to detect any difference in adverse effects even if there was some -8:36 PM ambulancemandan #twitjc - quite out of my depth here, but did it not mention TA and Increase in seizures? -8:36 PM TWSY @twitjournalclub Studies are rarely large enough to detect rare events. Yes, a risk of underporting or not recognising rare events #twitjc -8:37 PM Assidens @twitjournalclub that's interesting, I wonder why that would be? I can't see that they acknowledge this (may have missed it though) #twitjc -8:37 PM silv24 @iamdoctord that's why I am not entirely clear about! The issue of adverse events isn't that clear in the paper in my opinion #twitjc -8:37 PM PaedsSHO RT @iamdoctord: By numbers recruited, I think serious adverse events would have been picked up... but what is defined by serious? #twitjc -8:38 PM MsPhelps Adverse effects (other than included outcomes) had to be suspected to be related to treatment - might be cause of underreporting? #twitjc -8:39 PM TWSY 'we cannot exclude the possibility of some increase in risk' (in the discussion) #twitjc -8:39 PM paramedicsa #TwitJC @ambulancemandan Seizures where noted in "postoperative cardiac surgery" pt's. -8:39 PM silv24 mention of non-fatal vascular occlusive events but they state the relative risk should be unbiased even if possibly under-reported #twitjc -8:39 PM iamdoctord Are 'predictable' complications of a pro-thrombotic agent, which are analysed later, not a type of 'adverse event'? #justthinking #twitjc -8:40 PM silv24 As the mortality data for the TA group was significantly improved do the queries over adverse events matter? #twitjc -8:42 PM iamdoctord The group's pre hoc methodology was sound, pre-specified subgroups according to prognostic features that may influence mortality. #twitjc -8:43 PM ambulancemandan @paramedicSA of course and the study was for Trauma.However surely for pts recieving CT surgery fm trauma the effects maybe similar? #twitjc -8:43 PM twitjournalclub Leads onto the next point - TA was shown to be effective but the mechanism of how exactly it works in trauma patients is unclear #twitjc -8:45 PM Assidens @silv24 really difficult to judge as all info seems to 'play down' possible side effects, would need more data on side effects #twitjc -8:45 PM

twitjournalclub Should research into how it does work be a priority or is it enough that it does & therefore should be used in trauma patients? #twitjc -8:45 PM silv24 TA was effective & reduced mortality - don't think the uncertainity over mechanism of action matters that much #twitjc -8:47 PM ambulancemandan @silv24 More research into how it works and side effects promote better safeguarding? #TwitJC -8:47 PM paramedicsa #TwitJC @ambulancemandan I read it as a caution, my understanding that this was in a dose of TA 2-10 higher than CRASH2 -8:47 PM iamdoctord Biologicals start from first principles,then trialled in clin. practice. If TA needs 'reverse' translational medicine, too costly? #twitjc -8:48 PM iamdoctord RT @silv24: TA was effective & reduced mortality - dont think the uncertainity over mechanism of action matters that much #twitjc -8:48 PM TWSY The mechanism of action is important but I'm not sure it effects the importance and applicability of the findings #twitjc -8:49 PM ambulancemandan @paramedicSA Fair point, and probably worth the risk for better general outcome from traumatic haemorrage...#twitjc -8:49 PM MsPhelps Given prior research (incl. SR on TA in elective surgery) I think doing such an effectiveness trial is totally justified. #twitjc -8:49 PM TWSY RT @TWSY: The mechanism of action is important but Im not sure it effects the importance and applicability of the findings (if true) #twitjc -8:49 PM welsh_gas_doc It would be an act of intellectual masturbation to spend money researching HOW Tranexamic Acid works. Fun, but ultimately pointless #TwitJC -8:49 PM silv24 Could you ever justify not giving a treatment that potentially reduces mortality just because the mechanism of action is unknown? #twitjc -8:50 PM MsPhelps Esp. since they were conservative in the dosage used. More research into mechanisms are also justified of course. #twitjc -8:50 PM engeltjeconnie And as a researcher, wouldn't you WANT to know? (I'm Connie, editor at the Dutch Journal of Medicine, mostly observing #twitjc) -8:50 PM silv24 @welsh_gas_doc I agree, it has been shown to be effective & therefore could save lives #twitjc -8:51 PM TWSY RT @welsh_gas_doc: It would be.... Fun, but ultimately pointless...(unless it throws up other potential clinical benefits) #twitjc -8:51 PM silv24 Apologies if my maths is wrong but the NNT was 67, that is impressive. But we don't really know why it works #twitjc -8:51 PM silv24 @engeltjeconnie indeed, but we don't really know how alot of drugs work - paracetamol as an example #twitjc -8:54 PM Assidens @welsh_gas_doc isn't that the same for paracetamol? #twitjc are we being too cautious? 8:55 PM collabovation @silv24 how many MOAs are completely understood anyway? #twitjc -8:55 PM Assidens @silv24 ha ha, great minds :-) #twitjc -8:56 PM silv24 @MsPhelps I agree more research but should doubts over mechanism stop it being widely used? In my humble opinion no #twitjc -8:56 PM

iamdoctord Is full comprehension a pre-requisite for application to clinical practice? #twitjc -8:56 PM DrPlumbster @silv24 yes......look what happened with novo 7 in trauma... admittedly we have never had evidence for this like we do from CRASH-2!#twitjc -8:56 PM welsh_gas_doc It isn't clear exactly how most anaesthetic drugs work; theories abound, but nobody is 100% sure . . .(I know, but it's a secret) #TwitJC -8:56 PM twitjournalclub Last discussion point & a very interesting one... #twitjc -8:57 PM DrPlumbster @welsh_gas_doc not necessarily as there are potentially somany complex pathways in the coagulation pathway that we don't understand..#twitjc -8:57 PM DrPlumbster @welsh_gas_doc do it might lead to new therapies #twitjc -8:58 PM twitjournalclub The subgroup analysis showed earlier treatment is better, after 3 hours the treatment actually increased risk of death from bleeding #twitjc -8:58 PM Assidens @silv24 good point, I really think we are programmed to be so cautious #twitjc -8:58 PM GabrielScally #twitjc If we knew how it worked it might be possible to improve its effectiveness further and reduce side effects. -8:58 PM MsPhelps Forgive the naive question (not a clinician) but: Is TA expensive? Could it become standard treatment in hemorr. trauma? Worldwide? #twitjc -8:59 PM twitjournalclub Consent for participation an area of delay - should consent be necessary in the emergency setting when there is clinical uncertainty #twitjc -8:59 PM DrPlumbster @MsPhelps cheap as chips!!#twitjc -8:59 PM DrPlumbster @MsPhelps its very cheap... so yes... #twitjc -9:00 PM silv24 @MsPhelps not sure of the exact cost but it isn't at all expensive & it could be used worldwide. That is the beauty of this trial #twitjc -9:00 PM silv24 In this study there was real clinical uncertainty over whether giving the drug or not was best, but still the need for valid consent #twitjc -9:01 PM DrPlumbster @twitjournalclub but.. were those who received it later sicker and therefore were likely to have a worse outcome anyway?#twitjc -9:02 PM MsPhelps @DrPlumbster @silv24 Great! #twitjc -9:02 PM TheNerdse #twitjc consent need not be sought in emergency where the treatment proposed is viable, needed fast, life saving & proven. In my opinion. -9:03 PM TWSY Emergency care research allows for retrospective consent in certain circumstances e.g. if preagreed before hand by ethics committee #twitjc -9:03 PM silv24 @DrPlumbster that is a definite possibility. But the question remains, can we bypass full and valid consent if time critical? #twitjc -9:03 PM MsPhelps Really difficult point - expected adverse effects come into play, but it's a very valid ethical point regardless... #twitjc -9:03 PM themattmak Oops, #Twitjc- the issue of consent here is the same that prevents/dissuades many EDs from doing good research - need to find a solution -9:03 PM GabrielScally @TWSY #twitjc See the very good letter from Roberts et al. about consent in respect of this study. The delay was about one hour. -9:04 PM

Assidens #twitjc this study is a cost effectiveness analysis, and uses data from CRASH-2 trial http://t.co/BEati7S -9:04 PM stevenjgibbons @GabrielScally Why and how has TA come to be used so extensively when the mechanism is understood so poorly? #twitjc (I am not a medic.) -9:05 PM silv24 @GabrielScally @TWSY and we know now that giving it early led to better outcomes, hindsight is a great thing #twitjc -9:06 PM DrPlumbster @GabrielScally @twsy could you post a link to the letter?#twitjc -9:06 PM GabrielScally @stevenjgibbons #twitjc Simply because it works! There are quite a few treatments where the precise mechanism is not known. -9:06 PM Assidens @stevenjgibbons we could ask the same of paracetamol though? #twitjc -9:06 PM TWSY @stevenjgibbons @GabrielScally Understanding mechanism of action not requirement as long as works and is safe #twitjc -9:07 PM Jun 19th, 201 paramedicsa #TwitJC @Silva24 'valid' cnsent is possble in Hosp enviroment. Pre-Hosp we rely on 'implied consent' Q: Consent at the roadside or bedside? -9:07 PM TWSY From BNF: Injection, tranexamic acid 100 mg/mL, net price 5-mL amp = £1.55 #twitjc -9:07 PM iamdoctord @MsPhelps TA - 100 mg/mL, net price 5-mL amp = £1.55 from bnf.org #twitjc -9:07 PM amcunningham RT @stevenjgibbons: @GabrielScally Why and how has TA come to be used so extensively when the mechanism is understood so poorly? #twitjc (I am not a medic.) -9:08 PM amcunningham RT @GabrielScally: @stevenjgibbons #twitjc Simply because it works! There are quite a few treatments where the precise mechanism is not known. -9:08 PM twitjournalclub @DrPlumbster the Roberts paper is http://download.thelancet.com/flatcontentassets/pdfs/S0140673611603176.pdf #twitjc -9:08 PM DrPlumbster @stevenjgibbons @gabrielscally ? because it is so cheap? readily available and was thought to cause relatively little harm? #twitjc -9:08 PM MsPhelps @DrPlumbster http://t.co/V9GUxMD #twitjc (quick and dirty link, sorry) -9:09 PM amcunningham @DrPlumbster also risks with tranexamic acid so would be good to investigate mechanism #twitjc http://www.ncbi.nlm.nih.gov/pubmed/20831841 -9:10 PM silv24 Roberts et al argue that the need for urgent trial treatment excludes possibility of fully informed consent #twitjc -9:10 PM silv24 And that if consent delays treatment that could be beneficial seeking consent is actually unethical #twitjc -9:11 PM silv24 RT @donotcallmemike: @silv24 there are loads of drugs we don't fully understand how they work, but they do and help many patients #twitjc -9:11 PM amcunningham @silv24 yes, but trial was conducted because benefits not known.. could have done harm... in that case consent needed #twitjc -9:12 PM silv24 When we have real clinical uncertainity for a trial treatment should we just treat without consent?! #twitjc -9:13 PM carlylou #TwitJC I think a higher level of consent is needed for trials though, patients need to know they are part of an experiment, not receiving> -9:13 PM

silv24 @amcunningham I agree, interesting they argue that there might be treatments missed or underestimated due to informed consent #twitjc -9:14 PM amcunningham @silv24 no. no. no! when uncertainty then consent definitely needed! #twitjc -9:14 PM carlylou > established treatment. Consent in emergency situations always problematic though imo #TwitJC -9:14 PM silv24 RT @donotcallmemike: @silv24 are two earlier ones about consent for trials in emergency settings as thats something I'm involved in #twitjc -9:14 PM iamdoctord Despite uncertainty, and if patients know such uncertainty exists, we cannot relinquish their right to choose their therapy. #twitjc -9:15 PM DrPlumbster @silv24 no... this is too simplistic an approach #twitjc -9:15 PM amcunningham @silv24 what would be worrying is if participation in the trial and waiting on consent delayed OTHER known beneficial aspects of rx #twitjc -9:16 PM engeltjeconnie @silv24 If I were the patient, or his relative, i would surely want to be fully informed. #twitjc -9:16 PM silv24 @amcunningham playing devil's advocate. Roberts et al argue that regulation by ethic committees can do more harm than good #twitjc -9:16 PM iamdoctord We quote figures regarding treatments to patients regularly when consenting, we (the clinicians) cannot predict individual outcomes #twitjc -9:17 PM silv24 RT @donotcallmemike: @silv24 I think patients need to be aware. One such current research trial is STEAM which is PPCI vs PHT #twitjc -9:17 PM MsPhelps Interesting re: adv. effects: Trial data point to possible > risk of death due to bleeding when TA started late... PMID 21439633 #twitjc -9:18 PM MsPhelps Full link: http://www.ncbi.nlm.nih.gov.proxy.library.uu.nl/pubmed/21439633 #twitjc 9:18 PM silv24 What about emergency treatment outside trial settings? Don't stop for informed consent even if not entirely sure what the effect is #twitjc -9:19 PM DrPlumbster @silv24 well, ethical barriers (I mean committees) can do more harm by delaying trials... but they are there for a reason #twitjc -9:19 PM silv24 Think Roberts et al raise some very interesting points in their article, this is an ethical minefield! #twitjc -9:19 PM paramedicsa #TwitJC No way some of my poly trauma pt can give informed consent at the roadside, do I wait? -9:20 PM DrPlumbster @silv24 wow...... now we are really talking maverick medicine! haha #twitjc -9:20 PM silv24 RT @donotcallmemike: @silv24 That's STREAM not STEAM #twitjc -9:20 PM DrPlumbster Being zealous for improving care is important but sometimes this can lead to harm... again novo 7 people!!#twitjc -9:21 PM iamdoctord @silv24 act in patient's best interests when capacity uncertain, with the assent (if possible) of next of kin, and Rx likely to help #twitjc -9:21 PM TWSY Do good, don't do harm, do best for patient, do best for population and .... team effort? #twitjc -9:21 PM

silv24 @DrPlumbster let's be honest we know not everyone is going to benefit from a treatment but we still give it based on uncertainty #twitjc -9:22 PM cringlem @ijwhitehead have a look at #twitjc tonight. You will be very interested as it's a trauma paper -9:22 PM DrPlumbster what is informed consent anyway? Do the ladies that I stick epidurals into in labour actually give me true informed consent?!!#twitjc -9:22 PM iamdoctord RT @TWSY: Do good, dont do harm, do best for patient, do best for population and .... team effort? #twitjc -9:23 PM silv24 @iamdoctord what about in trials? If there is an real uncertainity are we acting in patient's best interested to include them #twitjc -9:23 PM DrPlumbster @silv24 don't get me wrong (Massive fan of TA.. use it a lot!) #twitjc -9:23 PM amcunningham @silv24 #twitjc "Every doctor is faced with literally hundreds of instances in which he has no idea of the be… (cont) http://deck.ly/~NfoIy -9:23 PM NicolaBotting #twitjc haven't read paper and I am psych not dr but important diff hr betwn research consent and clinical consent -9:24 PM DrPlumbster @silv24 I am just highlighting the juxtaposition....#twitjc -9:24 PM carlylou @iamdoctord @silv24 but can a treatment on trial ever be defined as being in patients best interests? #TwitJC -9:25 PM crashmatt @carlylou Yes. Where there is no existing treatment is one example #TwitJC -9:26 PM twitjournalclub Thank you for participating tonight - yet again it has been fascinating & please use the hashtag to continue it or post on the blog #twitjc -9:26 PM twitjournalclub Will be posting a transcript and a summary ASAP and would love to hear further comments on this paper #twitjc -9:26 PM iamdoctord @carlylou I think this emphasises @NicolaBotting's point regarding the diff between clinical and research consent (I think!) #twitjc -9:27 PM twitjournalclub The paper for next week will be announced tomorrow, once again thank you! #twitjc -9:27 PM iamdoctord My earlier point referred to clinical consent, I lack sufficient knowledge regarding research consent #twitjc -9:28 PM carlylou “@NicolaBotting: #twitjc haven't read paper and I am psych not dr but important diff hr betwn research consent and clinical consent”<agreed -9:28 PM MsPhelps @twitjournalclub @silv24 Thanks for hosting! #twitjc -9:28 PM NicolaBotting #twitjc @carlylou often 'wider' benefit ie we lrn more for nxt client - but sometimes survival occurs whre wouldn't-this is a good benefit! -9:29 PM iamdoctord My earlier point referred to clinical consent, I lack sufficient knowledge regarding research consent #twitjc -9:28 PM carlylou “@NicolaBotting: #twitjc haven't read paper and I am psych not dr but important diff hr betwn research consent and clinical consent”<agreed -9:28 PM MsPhelps @twitjournalclub @silv24 Thanks for hosting! #twitjc -9:28 PM NicolaBotting #twitjc @carlylou often 'wider' benefit ie we lrn more for nxt client - but sometimes survival occurs whre wouldn't-this is a good benefit! -9:29 PM

TheNerdse @twitjournalclub thanks #twitjc -9:30 PM crashmatt @carlylou After risk/reward eval if outcome is likely to be better than standard, then in best interest. I take your point though. #twitjc -9:30 PM MsPhelps Correcting one of my earlier tweets http://twitpic.com/5dynkp: almost 75%, not more than 75% #twitjc -9:30 PM amcunningham @twitjournalclub also from Dr. Murley #twitjc " If any patient really is genuinely frightened about being … (cont) http://deck.ly/~eXwOx -9:31 PM

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