North American Chat
GMT chat
Quite close - and the stats from Symplur don't capture all the differences. Very different feel, and discussion. Storify to follow.
Swapnil Hiremath, MD
#NephJC has RSS subscribers?
A few months ago, we mentioned how to subscribe our feed with RSS.
At that time, we had one subscriber (Swapnil) - and to our great surprise, it seems to be that RSS is back. Just see below:
Unless there are spam RSS subscriptions somehow....
In some other news, we would like to thank Marjorie Lazoff for mentioning us in the LITFL blog - go check out their literature review here.
Swapnil Hiremath, M.D.
The AUA v ACP guidelines. Fight!
Tonight's and Wednesday's #NephJC is going to focus on the ACP guidelines. But it is important to recognize that a different group looked at the same data and came up with very different conclusions of what CPG should look like.
The systemic review that is the primary source...
...was the same in both clinical practice guidelines.
The American Urological Association Guideline (PDF) consists of 27 guidelines covering:
- Evaluation
- Diet therapy
- Pharmacologic therapy
- Follow-up
The AUA did consider 18 additional studies that were not part of the AHRQ analysis. The recommendations are graded and the authors interpreted the grades thusly:
- Clinical Principle. This is a statement about a component of care that is widely agreed upon by urologists or other clinicians for which there may or may not be evidence in the medical literature. My sense this is, that these recommendations are so woven into the fabric of stone care that people would not be able to get a study of these practices past an IRB.
- Expert Opinion. This is a statement, achieved by consensus of the Panel, based on clinical training, experience, knowledge and judgment for which there is no or insufficient evidence.
- A or B level evidence translated into Standards
- C level evidence becomes Recommendations
- Options are non-directive standards that may or may not be based on evidence. There is only one and it was evidence grade B
Background
- The prevalence of stones is increasing. It has gone from 5.2% in 1988-94 to 8.8% in 2007-2010.
- It is affecting more women so that it is much male dominated. The male:female ratio has slipped from 1.7:1 in 1997 to 1.3:1 in 2002.
- They looked at the diet studies that used stone formation as the outcome. Those studies found that increased water intake reduced stones. It found beneficial effect by avoiding cola.
- They looked at multicomponent diets and described the ability of a low sodium, normal calcium, low animal protein to reduce stones more than a low calcium diet.
- Two other studies restricted animal protein as part of a multicomponent diet and was unable to find any advantage.
- The authors point out that changes to urinary stone risk factors has not been validated as an intermediate endpoint.
The authors are transparent about one of the primary gaps in the use of diagnostic information about the nature of a stone in the therapy for that stone.
One caveat, all the RCTs diet studies were done in stone forming men.
The Guidelines
The 27 guidelines themselves are pretty straight forward and read like a description of what takes place in a well run stone clinic. The authors are again transparent, labeling many of the guidelines as Clinical Principle and Expert Opinion. In terms of the final score it looks like this:
Well over half the guidelines are opinion or clinical principle (which is just an opinion in a new hat).
Here is the breakdown by section:
Not surprisingly, only pharmacologic therapy has received significant RCT attention.
The AUA and ACP guidelines are based on the same evidence but ultimately look very different. The ACP guidelines look at this evidence desert and provide guidelines so sparse they end up functionally useless. The AUA, on the other hand, hitches the evidence to common sense, scientific innuendo, and long-held medical habit to provide fairly comprehensive guidelines that primary care doctors and part-time stone-physicians can use to actually take care of patients. The AUA guidelines paired with the AHRQ evidence analysis are documents I would have every fellow add to their iPad library. The ACP guidelines? Not so much.
In the end the ACP guidelines read like political statement protesting the sorry state of stone evidence, while the AUA guidelines provide a practical manual guiding stone care while still being transparent about the poor state of evidence.
Joel Topf, MD
What are the characteristics of a great journal club?
We are working on a survey of NephJC and I am trying to wrap my mind around what are the most important questions to ask. I really want to know how well NephJC compares as an educational experience to "In Real Life" journal clubs Thinking about that lead to this discussion on Twitter:
NephJC afterparty
Some of the best NephJC discussions come after the hour long chat and can be off topic.
A red letter day for the GMT chatters
With a healthy bump in participants post #ERAEDTA15, just compare the participants. 'Nuff said.
The American chat
The GMT chat
PD/CHF: GMT chat storify
As promised, the GMT chat storify is here, complete with the after party discussion on diuretics. Another superb curation by Hector!
Hector does the Storify for American PD/CHF chat
Hector Madariaga - Nephrology Fellow from Syracuse and #NSMC intern - has now joined the #NephJC team. And you can see that why with the excellent job he has done with the storify of last week's chat. Watch this space for more contributions.
NephJC: GMT chat slightly delayed this week
In case you were all wondering where the EU/African leg of the PD/CHF #NephJC chat disappeared, it will be held - albeit with a week's delay - on Wednesday June 3rd. It is all for a good reason. It has been quite busy for the Europeans this week - as you must have seen with all the furious tweeting from Charlie Tomson, Daniel McGuinness, David Arroyo, and many more including our very own Paul Phelan (who also wrote some excellent AJKD blog posts).
But, better late than never - and we hope many of you join us this week for the PD/CHF #nephjc chat.
Nice article on tweeting the meeting
Add this to the two articles by Alex Djuricich to flesh out your live-tweeting medical library.
Solid turnout and great chat for: AKI Alerts
The author and a number of AKI scientists joined NephJC Tuesday night to discuss F. Perry Wilson's study.
Need any more evidence that #NephJC rocks?
You may have seen the evidence pyramid before, with animal studies and case reports at the bottom, and systematic reviews on the top.
Well, an interesting paper was published a few days ago, in the Journal of Medical Internet Research. Go ahead, click on that link and check it out.
It is a systematic review of all twitter-based journal clubs (and they seem to have captured all that were existing at that time). They have then examined the impact of these journals clubs using many different metrics. Interestingly, the one that immediately stands out is in table 2:
Table 2 from Roberts et al, http://www.jmir.org/2015/4/e103/
There's only one journal club with over a million impressions. Take a bow, all of you who have ever participated in a #NephJC chat!
The paper does make for interesting reading, apart from what we mention above. Some of the analyses agrees with our thoughts after the first dozen #nephJC chats.
Tonight's #Act4Kidneys Chat. Join us at 9 PM EDT
The chat begins at 9PM EDT, in just an hour. The topics will be:
- Topic Zero: What is an advocacy day? What can law makers do to help kidney patients and the field of nephrology?
- Topic one: 20 million Americans have kidney disease. The NIH spends only $29/patient. This is low compared to heart disease and cancer. Why is that?
- Topic two: One of the primary asks of #Act4Kidneys is The 21st Century Cures. What is this? What will this do for patients? What will this do for investigators.
- Topic three: The other ask for the "CKD Improvement in Research and Innovation Act" what is this and what will it do for our patients.
- If we are not going to the hill this week, what can we do to support these initiatives. Should we throw money at anyone? Call people?
From the ASN Advocacy and Public Policy page:
On Thursday, April 23 in Washington, DC, dozens of ASN members are heading to Capitol Hill to talk with Congress about important policies related to kidney patient health and kidney research.
Join their ASN Kidney Health Advocacy Day efforts by asking your members of Congress to support newly introduced kidney legislation – the Chronic Kidney Disease Improvement in Research and Treatment Act of 2015 (H.R. 1130, S. 598).
This bill will address key needs for patients with kidney disease: eliminating barriers to transplantation, improving our understanding of kidney failure in minority populations, and investing in life-saving kidney research.
Join ASN in calling on Congress to support this important, bipartisan bill now. Click here to send a message to your members of Congress asking them to sign onto this vital legislation.
click the image to down load the 21 page house version of the bill.
Here is the House Committee on Energy and Commerce website about the 21st century cures.
What not to do when you are the medical director
If it wasn't from the pages of the New York Times I wouldn't believe it.
Please join us on #NephJC, Tuesday at 9PM EDT and Wednesday at 8PM GMT for a discussion of proper medical director behavior.
The NephJC 23 (warfarin) American chat Storify - and analytics
It was pretty well attended...
So was the GMT chat next day...
and the GMT chat storify of NephJC 22
Nikhil does the BK storify
So our NSMC intern, Nikhil Shah not only did a super job of writing the sumary up for the BK virus #NephJC 22, he also has done a great job of curating the first chat into a storify.
NephJC 22: GMT chat
The American chat (mostly by virtue of its longevity) still has more participants and tweets, but the GMT (EU/African) chat makes up by being fun and entertaining. Tom Oates, Paul Phelan, Francesco and their merry band of tweeters make for delightful reading. Jungle Juice, scud missiles and more. See some highlights below
#NephJC number 22 is in the can.
The BK nephropathy discussion was interesting. No one was interested in further exploring quinolone for BK, which I guess indicates that this was a compelling study.
All and all it was a very interesting discussion and I learned a lot.
Storify forthcoming.
Palliative care chat #HPM on Wednesday at 9EST
March is Kidney awareness month and in honor of that, Pallimed, the Hospice and Palliative Care Blog is talking about intersection of nephrology and palliative care. They asked NephJC co-creator, Joel Topf to host their chat. This happens on Wednesday. Topf wrote the introduction:
Have you ever read a journal article and as soon as you finished the abstract you had this forbidding feeling that if the authors actually proved what they claimed to have discovered your medical life will never be the same?
This happened when I read, Functional Status of Elderly Adults before and after Initiation of Dialysis by Tamura et al. in 2009.
The study simply looked at mortality and functional status of nursing home residents who initiated dialysis. The cohort consisted of 3,704 Americans. The average age of this predominantly white (64%) female (60%) cohort was 74 years. The outcomes were horrifying:
- Within three months of starting dialysis 61% had died or had a decrease in their functional status
- By one year that figure was 87%
- By one year only 1 in 8 patients had maintained their functional status from before dialysis
While this study did not track patients who deferred dialysis it is hard to imagine they could do much worse. The view of dialysis as a way to improve functional status by clearing uremia leading to improved nutrition and other downstream benefits was revealed to be a false hope. Instead we have a treatment that appears to be too rough for frail, at-risk patients and left them significantly worse than they were before dialysis.
The discussion section of the article had a sentence that should be embroidered to every nephrologists white coat:
“...kidney failure may be a reflection of terminal multiorgan dysfunction rather than a primary cause of functional decline, and thus the initiation of dialysis may not rescue patients from an inevitable decline.”
As nephrologists we need to elevate conservative, non-dialytic, therapy to be a clear option for patients, one that should be discussed along with peritoneal dialysis and transplant. Conservative care should not merely be a last resort when all other options have been exhausted.
I hope you will join us as we discuss the intersection of nephrology and palliative care this Wednesday at #hpm chat.