the metablog

Posts written by Daniel Jolley.
Daniel Jolley

About the author

Daniel Jolley is an anesthesiologist, founder and CEO of metajournal, providing personalized medical research recommendations to fellow doctors.

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The Cardiology Referral: Avoid hypoxia, avoid hypotension?

Recently I needed to refer a patient preoperatively to a cardiologist for review. This is not an uncommon situation – one which happens thousands of times every week throughout the world. And yet it is a referral that anesthesiologists and anesthetists often do very poorly.

Avoid hypoxia, avoid hypotension?

We sometimes roll our eyes at recommendations made by physician colleagues: either providing unhelpful physiological parameters that we normally aim to maintain anyway (“avoid hypoxia?”), or stepping outside their expertise and boxing the anesthetist in by suggesting specific anesthetic techniques (“okay for a spinal”).

It is easy to be annoyed at both the lack of value this adds to our perioperative planning, as well as to the nonchalant ignorance of intraoperative medicine that it betrays. At the end of the day though, it’s our fault.

As Dr Andrew Silvers, a Melbourne cardiac and neuro-anesthetist recently opined, if your cardiologist replies with “avoid hypoxia and avoid hypotension” then YOU the anesthetist or anesthesiologist are at fault for not asking your cardiology colleague specific questions that will materially effect your perioperative planning.

Read more...

Now with full-text access for South African medical schools

Over the past week metajournal has added institutional access to full-text articles for six of South Africa's eight medical schools!

metajournal full-text access for South African medical schools

Metajournal now has the ability to link to more than 120 institutional full-text databases, and we're constantly adding more. To see if one of your institutions is listed simply click on 'add institutional full text' under any article, or visit your settings page.

metajournal Add institutional full text articles

If your institution is not listed, drop me a note and I'll do my best to add it!

Daniel

Full text article access through your institution!

One of metajournal's very special features is providing direct links to full text articles via your institutional subscriptions.

Many metajournal people already have full text access to their specialty journals provided by their hospital, university, college or professional organization.

Metajournal can provide direct links to your institution's library servers to, in most cases, take you straight to the full text article if your organization has a subscription to the journal.

After you have told metajournal your affiliated institutions, you will notice new links beneath each article taking you straight to a search for the full text at your institution.

metajournal Links to institutional full text articles

If you access these links while on your hospital or university network, then you will likely be taken straight to the full text. If you access from outside you will be taken first to a login screen for your institutional library system before being directed to the article (this should only need to be done infrequently).

Telling metajournal which institutions you are a member of is easy – simply click on the 'Add institutional full text...' link when you see it below an article, or visit your metajournal settings page.

metajournal Add institutional full text articles

You can add or remove any number of affiliations at any time through the settings page.

So far metajournal can add access to more than 250 institutions across more than a dozen countries. Unfortunately some institutions use better, more reliable full text systems than others so the experience can vary.

Please contact me if you run in to any problems, and especially if your institution is not listed – and I will work very hard to get it added to metajournal.

I hope you enjoy easier access to all the relevant evidence that metajournal finds for you!

Metajournal has CPD reporting

One of metajournal's lesser known features is:

Okay, I admit it doesn't sound very exciting – but I think this small feature will both save you time and make achieving your Continuing Professional Development requirements a little bit easier.

Many colleges and medical boards now require evidence of CPD activities, including medical journal reading and reviewing. Some require simply an estimate of the time spent, while others like ANZCA require submission of a bibliography of every article you have read!

Because metajournal keeps track of the abstracts you read, the articles you favourite and the full-text papers you retrieve, we can also provide you with a report for submitting to your CPD/CME organization.

metajournal PDF CPD report

Simply click on 'My CPD Reports' in the dropdown menu, choose which type of article-activities you want included, a date range and then whether you wish to view the report as a web page or as a PDF. Voilà!

metajournal CPD report choose PDF or HTML

Metajournal will even estimate how long you have spent reading papers!

metajournal CPD time estimate

And if that's still too much work, metajournal automatically emails out a quarterly PDF CPD report to all our subscribers.

Happy staying up to date!

Metoclopramide: it actually works!?

Metoclopramide had long been written off by many anesthetists and anesthesiologists, aware of trials and meta-analyses that show no or limited effect in treating or preventing nausea and vomiting – in particular limited ability to prevent post-operative nausea and vomiting (PONV). Most recently Henzi, Walder and Tramèr (1999) were able to show only very limited benefit for metoclopramide 10 mg in preventing vomiting and no significant effect in preventing nausea in adults.1,2,3

What is metoclopramide?

Metoclopromaide is a benzamide, predominately used for antiemesis and its gastric prokinetic effect. It is marketed under the names Maxalon®, Pramin® and Reglan® in various countries. Although considered an old drug its antiemetic action was first identified in 1964 by French doctors Justin-Besançon and Laville.3 (In contrast the analgesic tramadol is often considered a "modern" drug outside of Europe, but was launched by Grünenthal GmbH in 1977.)

Metoclopramide readily crosses the blood-brain barrier where it mediates anti-emetic effects primarily as a dopamine D2 antagonist in the chemoreceptor trigger zone (CTZ – located in the area postrema of the 4th ventricle). Metoclopramide also has mixed 5-HT3 receptor antagonist and 5-HT4 receptor agonist actions. The former may contribute to anti-emesis at higher doses and the later to its pro-kinetic effects. Muscarinic cholinergic actions have also been identified, both through increasing acetylcholine release and by increasing receptor sensitivity to acetylcholine in the upper GI tract – further contributing to the pro-kinetic effect.

Read more...


  1. Henzi I, Walder B, Tramèr MR. Metoclopramide in the prevention of postoperative nausea and vomiting: a quantitative systematic review of randomized, placebo-controlled studies. Br J Anaesth. 1999 Nov;83(5):761-71. 

  2. It's also interesting to note that there was no dose responsive effect regardless of route. NNT to prevent early (<6h) and late (<48h) vomiting were 9.1 (95% CI 5.5-27) and 10 (6-41) respectively. In children the best documented regimen was 0.25 mg/kg. NNT to prevent early vomiting was 5.8 (3.9-11); there was no effect on late vomiting. There was only a single documented case of extrapyramidal side effects out of 3260 patients, giving an incidence of 0.03%. 

  3. Justin-Besançon L, Laville C.C R Seances Soc Biol Fil. 1964;158:723-7. 

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