Robert Goulden @emrobg.bsky.social · 22/05/2026www.nejm.org/doi/full/10....nejm.orgPrehospital Resuscitation with Type O Whole Blood for Trauma and Hemorrhage | NEJMBlood transfusion before arrival at a hospital reduces mortality from traumatic hemorrhage and shock. Whether transfusion with whole blood is more beneficial than transfusion with blood components ... 000
Robert Goulden @emrobg.bsky.social · 22/05/2026TOWAR RCT replicates SWIFT finding no benefit of whole blood vs components for trauma shock. Quick meta-analysis of 30d mortality gives RR 1.17 (0.98-1.40), close to showing *harm* by whole blood. Huge credit to those who ran these RCTs; another physiology-based hype cycle falls 100
Robert Goulden @emrobg.bsky.social · 08/12/2025Great commentary on the paper and RDD in general jamanetwork.com/journals/jam..., and podcast discussion edhub.ama-assn.org/jn-learning/...jamanetwork.comEvidence for Clinical Treatment Decisions Without Randomized DataAmong critically ill patients, serum magnesium levels are commonly checked and repleted. Like many clinical decisions, the rationale for this practice is based on a combination of physiological conjec... 000
Robert Goulden @emrobg.bsky.social · 08/12/2025All this suggests that routine Mg supplementation of everyone falling below the reference range may be another example of low value care. Very low levels and high-arrythmia risk patients likely still need treatment, but not everyone who's number is red on the EMR. RCTs needed. 100
Robert Goulden @emrobg.bsky.social · 08/12/20251) Some CIs wide, and 2) Results only apply to subjects near the cutoff. However, vast majority of Mg supplementation is given to people who are only slightly below the cutoff, and result was consistent across the range of cutoffs we studied. 100
Robert Goulden @emrobg.bsky.social · 08/12/2025We did not find evidence that it did. There was no difference in the risk of tachyarrhythmias, shock, or death in the following 24 hours, comparing those just above and below the treatment cutoff. However, there's a few important limitations... 100
Robert Goulden @emrobg.bsky.social · 08/12/2025Patients either side of the cutoff differed significantly in their probability of Mg supplementation, but were otherwise well matched. How did this affect clinical outcomes? 100
Robert Goulden @emrobg.bsky.social · 08/12/2025We used multi-cutoff fuzzy regression discontinuity in a cohort of 171k ICU admissions to compare those just above and below the lower end of the reference range (depending on the hospital, anywhere from 1.6 to 2.0 mg/d, or 0.66-0.82 mmol/L) 100
Robert Goulden @emrobg.bsky.social · 08/12/2025We have a new study in JAMA IM asking: do all 'hypomagnesemic' patients need supplementation? Many reflexively prescribe Mg when the number is below the reference range, but is this indicated? We used a quasi-experimental design to find out. jamanetwork.com/journals/jam...jamanetwork.comMagnesium Supplementation and TachyarrhythmiasThis nonrandomized clinical trial evaluates whether giving magnesium supplementation to patients with hypomagnesemia reduces adverse clinical outcomes. 100
Robert Goulden @emrobg.bsky.social · 13/05/2025Epidemiologic methods are increasingly difficult for clinicians and policy makers (and epidemiologists?) to understand. Are they at least getting us closer to uncovering causal relationships? My argument in this new piece: we don't know, because we haven't checked: academic.oup.com/ije/article-...academic.oup.comTime for evidence-based methodology in epidemiologyA formalized counterfactual approach to causal inference has come to dominate epidemiology in recent decades. This was, in part, a response to widely recog 000
Robert Goulden @emrobg.bsky.social · 13/05/2025Less is more wins again. RCT of high MAP target in older adults with sepsis (50% w/underlying HTN), stopped early for harm, 39% mortality MAP 80-85 vs. 29% mortality MAP 65-70 link.springer.com/article/10.1.... Recall also that the 65 Trial hinted that MAP60 may be better than 65. How low can we go?link.springer.comEfficacy of targeting high mean arterial pressure for older patients with septic shock (OPTPRESS): a multicentre, pragmatic, open-label, randomised controlled trial - Intensive Care MedicinePurpose We examined the effect of a high-target mean arterial pressure (MAP) on septic shock in a previously underrepresented region. Methods A multicentre, pragmatic, open-label, randomised controlle... 000
Robert Goulden @emrobg.bsky.social · 20/11/2024journals.lww.com/jtrauma/full...journals.lww.comAdult emergency resuscitative thoracotomy: A Western Trauma ... : Journal of Trauma and Acute Care SurgeryAn abstract is unavailable. 010
Robert Goulden @emrobg.bsky.social · 20/11/2024New WTA resus thoracotomy (RT) algorithm. 2 new/key points: -Now incorporates POCUS: if no organised cardiac rhythm and no tamponade on POCUS, no RT (regardless of time since arrest / mechanism). -RT if pulse but refractory SBP <60 plus {blunt/penetrating thoracic injury OR tamponade on POCUS} 121
Robert Goulden @emrobg.bsky.social · 18/11/2024Diuretics may well ⬇️mortality in HF, we just don't know. But not for the first time, 'meta-analysis of RCTs' has laundered ambiguity and weak methods into apparently solid conclusions from the top of the evidence pyramid (4/4). 000
Robert Goulden @emrobg.bsky.social · 18/11/2024Now for the implausible mechanism. Of 12 deaths in the placebo arm, the commonest cause was cancer (4 deaths), vs. 1 cancer death in the diuretic arm. Anti-neoplastic effect of diuresis or random chance? You decide. (3/4) 100
Robert Goulden @emrobg.bsky.social · 18/11/2024First, the error. Cochrane mortality OR is based on 3/111 deaths w/diuretics vs. 12/110 w/placebo. But looking at the 3 source RCTs, there are in fact *4* deaths in the diuretic arm. Adding this, the OR remains just about 'significant', 0.30 (0.10-0.98), but very fragile (2/4) 100
Robert Goulden @emrobg.bsky.social · 18/11/2024Do diuretics ⬇️mortality in heart failure? UpToDate, quoting Cochrane, says yes OR 0.24 (0.07-0.83). Looking at the 3 small RCTs this is based on suggests an important error in the meta-analysis, and an implausible mechanism of the diuretic benefit (1/4) 100
Robert Goulden @emrobg.bsky.social · 14/11/2024Dr Adnan al-Bursh was an orthopedic surgeon who heroically served his patients in the most impossible circumstances; this new report suggests he was beaten to death by Israeli prison guards. He is 1 of around 1000 healthcare workers killed in Israel's war on Gaza www.youtube.com/shorts/iM6pa...youtube.comDoctor’s final moments revealedYouTube video by Sky News 000
Robert Goulden @emrobg.bsky.social · 12/11/2024It was all totally wasted. The findings were wrong and the net contribution to scientific understanding was negative. Publish or perish, ultimately pushed by funders and institutions, is driving a toxic culture of scientific waste. We have to stop. 5/5 000
Robert Goulden @emrobg.bsky.social · 12/11/2024Collectively the individual observational studies (plus the SRs, and the SR of the SRs) represents at least 10s of thousands of labour hours from researchers, ethics panels, funding reviews, journal reviewers etc., and a large amount of $$$. 4/ 100
Robert Goulden @emrobg.bsky.social · 12/11/2024Once again we have to ask: what was the point of this observational research? There was an obvious risk of unmeasured confounding, and none of the studies had a way to address this. But they published anyway! 3/ 100
Robert Goulden @emrobg.bsky.social · 12/11/2024Since 2020, at least 3(!) systematic reviews on this question (plus an SR of the SRs!). Pooled results were 0.65 (0.51-0.8), 0.71 (0.59–0.85), and 0.71 (0.63-0.79). There was an obvious risk of confounding by indiction: sicker patients -> more difficult IV -> IO . 2/ 100
Robert Goulden @emrobg.bsky.social · 12/11/20242 big new RCTs on IO vs IV access in cardiac arrest -> another chance to check on the utility of conventional observational studies. Relative risk/odds of IO vs IV for survival in the RCTs: 1.16 (0.87-1.56), 0.93 (0.72-1.21). What about the most recent observational studies? 1/ 120
