preserve trial – The Early Career Voice

Social Media In Medical Education: #mindboggling IMHO

January 8, 2018 Wei Ling Lau, MD

I have always been late in the game in terms of catching up with social media. When I started college in Canada, it took some convincing before I joined Friendster as a way to keep in touch with friends and family in Southeast Asia. Friendster lost popularity soon after, thus I was not jumping on the boat when Facebook surfaced a few years later. When it became apparent that FB was here to stay, I created an account and have found it to be valuable for maintaining connections in various circles (family, friends from elementary / high school / college / medical training, and last but not least, parents of my kids’ friends because that’s how I meet people now). But until very recently I still viewed social media as “social” and kept it separate from “work” and professional development.

That all changed when I was accepted into the AHA Early Career Blogger team this recent November and was given an ultimatum to start a Twitter account. I wanted to throw a fit right there on that comfy sofa in the #AHA17 Early Career lounge. We already spend too much time with electronics – for research, scientific writing, patient care, charting, email, Facebook lurking. I had the impression that Twitter was an avenue for self-promotion, cutesy looping videos and sales ads. Why would I create a social media “work” account that wouldn’t get me grants or patient referrals?

This is what I have learned during my first 2 months on Twitter: a lot of great information. I was correct to have misgivings in the sense that I am spending a *little* more time with my laptop. (Had to get over the fear-of-missing-out mentality with an obsessive need to refresh that Home icon…) The access to medical knowledge and peer experts is really quite amazing. For a succinct discussion on the benefits – and limitations – of social media for medical professionals, check out the recent article by #AHAEarlyCareerBlogger @chadialraies. From a nephrologist’s standpoint, below are some of the highlights of my Twitter experience to date:

Doctors and scientists doing each other’s homework: Posting a query to @askrenal or @nephjc taps into the collective Twitter nephrology community. There are dedicated educators out there who regularly provide feedback and links to helpful publications. Personal anecdotes from fellow clinicians are also valuable. As an example, I was curious as to how other nephrologists were monitoring for severe hypocalcemia which can happen when denosumab (a relatively new osteoporosis drug) is given to patients with advanced chronic kidney disease; @hswapnil offered his approach and @edgarvlermamd forwarded a Japanese cohort study that had a lot of useful information (but may not have popped up on my radar as it was not PubMed indexed).

Gender and minority representation: It is encouraging to see the diversity and achievements showing up in the posts with #WomenInNephrology, #IlookLikeADoctor or similar hashtags. (But don’t buy into this #ILookLikeANephrologist post.)

Live discussion forums: @nephjc hosts journal clubs where take-home points are summarized in high-yield visual abstracts and participants can join chat forums at designated times to contribute comments and questions to a live feed. It was especially neat when both the lead author and senior author from the PRESERVE trial were online to answer questions – equivalent to a celebrity sighting in our world. (See my prior blog about the PRESERVE trial.)

Inter-disciplinary learning: Who knew there were so many smart people out there besides nephrologists? (just kidding!) I read about platypnea-orthodeoxia syndrome, DNA-sensor technology to diagnose rare diseases, updates to the Infectious Diseases Society of America treatment guidelines for infectious diarrhea, and fascinating @neiltyson musings such as “If you accumulate all the flora, fauna, and metal your true love gives you each day in the “Twelve Days of Christmas” song, you’ll own 12 Trees, 40 Gold Rings, 140 Humans, and 185 Birds of 6 different species.” I know some of this info will serve me well during Internal Medicine boards recertification.

Of course, careful judgment is warranted since no policies are in place to guarantee that social media reflects evidence-based medicine. This an honor system that assumes medical professionals are engaging with social media in a responsible and ethical manner. Medical education through social media has evolved as an area of research in itself; a search on PubMed using the keywords “social media AND medicine” yields >7000 reports. When approached correctly, there is no doubt that social media is a powerful tool that connects patients, clinicians, scientists and industry, and facilitates learning via a global collective of experiences and differences.

Wei Ling Lau, MD is Assistant Professor in Nephrology at University of California-Irvine, where she studies vascular calcification and brain microbleeds in chronic kidney disease. She is currently funded by an AHA Innovative Research Grant, and has been a speaker for CardioRenal University and the American Society of Nephrology.

A Personal Take On The Interventional Trials At AHA Scientific Sessions

December 15, 2017 M Chadi Alraies, MD

American Heart Association Scientific Sessions always been inclusive of all cardiology specialties. Despite this breadth of science, each subspecialty in cardiology get enough depth to improve patient’s outcome.

Trials of interventional nature had big presence at the Scientific Sessions 2017. The PRESERVE trial was one of the landmark studies presented at the sessions. The study was run by VA which show the Among patients undergoing coronary angiography with chronic kidney disease, a strategy of IV sodium bicarbonate or oral acetylcysteine yielded no additional benefit for the prevention of death, dialysis or persistent kidney impairment at 90 days. This study put to rest a long debate of IV sodium bicarbonate or oral acetylcysteine use for prevention of acute kidney injury showing no benefit in either strategy. Going forward, interventionalist should feel comfortable not to use either strategies which will decrease complexity of care and cost. This study prove that Veterans Affairs Health System is able to deliver an important study to answer critical and practice changing question.

COMPASS trial is another interventional-related study which has been published before and showed decreased cardiovascular events in patients randomized to ASA plus low dose atherosclerosis versus aspirin alone. in patients with stable atherosclerosis. At the Scientific Sessions, the cost analysis showed decreased cost with ASA plus low dose rivaroxaban compared with ASA alone driven by the lower ischemic events in both CAD and PAD patients, as well the decrease in number of procedures required (i.e. angiogram, intervention, amputations, etc.). However, since the actual cost of this dose of the drug is yet unknown, overall cost savings and cost-effectiveness analyses are unavailable at this time.

Moving along, another important study looking into the antithrombotic regimen for patients with indication for anticoagulation undergoing coronary intervention. The RE-DUAL PCI trial was already published, but what presented at the sessions is sub-group analysis that focused on patients with acute coronary syndrome (ACS) and non-ACS at index event. Majority of patients received clopidogrel, while 12% of the patients received ticagrelor either as part of dabigatran dual therapy or warfarin triple therapy. The dabigatran dual therapy regimen used dabigatran and a P2Y12 platelet antagonist, while warfarin triple therapy combined warfarin, aspirin and a P2Y12 platelet antagonist. In the study, 83% of cases, DES was used, and were similar in patients with ACS and non-ACS. The study showed, that dabigatran with P2Y12 inhibitor is superior to triple antithrombotic strategy. More bleeding, obviously in the triple therapy group with no efficacy in terms of lower ischemic complications.

Another study that provided evidence for what we do in practice was the POISE-2 trials. The goal of the trial was to evaluate perioperative aspirin compared with placebo and perioperative clonidine compared with placebo among patients undergoing non-cardiac surgery. The POISE-2 trial showed that among unselected patients undergoing non-cardiac surgical procedures, neither the perioperative use of aspirin, nor clonidine, was beneficial in reducing the incidence of death or myocardial infarction. However, benefit was observed with aspirin among patients with prior stenting. This is consistent with what most cardiologists are practicing, where they recommend ASA continuation throughout the non-cardiac surgery for patients with previous PCI.

Different studies with different aims related to interventional cardiology presented at the sessions. AHA Scientific Sessions continues to support all cardiovascular specialties bringing science to practicing cardiologist that answer practice-based clinical questions and, more importantly, saves lives.

M Chadi Alraies, MD is an interventional fellow and vice chair of Council on Clinical Cardiology Fellow-In-Training & Early Career Committee of American Heart Association.

Back To Square One: Normal Saline For Prevention Of Contrast-Associated Kidney Injury

November 14, 2017 Wei Ling Lau, MD

I was in medical school when the JAMA paper came out that reported superiority with sodium bicarbonate IV fluids over normal saline in preventing contrast-induced acute kidney injury. This was a Big Deal. Kidney injury is associated with prolonged hospital stays and increased risk of death. I recall carefully making a note of the exact sodium bicarb formulation and pre- and post-contrast infusion rates, carrying this index card around in my coat pocket. Later during residency, I would diligently order the sodium bicarb fluids for high-risk patients pending contrast procedures and spell out the protocol in my chart notes.

A barrage of studies followed the JAMA report but the robust benefit in preventing kidney injury was not replicated. While some investigators were able to detect a modest benefit with sodium bicarb fluids (for urine alkalinization) or oral N-acetylcysteine (NAC, for scavenging of reactive oxygen species) other groups reported no difference, and small cohort sizes with low outcome rates was a prevailing limiting factor.

The PRESERVE trial (Prevention of Serious Adverse Events Following Angiography) definitively lays to rest all the uncertainties surrounding sodium bicarb and NAC. In a very anti-climactic fashion. Sodium bicarb was no better than normal saline, and NAC was no better than placebo. The study was funded by the Veterans Affairs Cooperative Studies Program and included about 5,000 high-risk patients with stage 3-4 chronic kidney disease (80% were diabetic) from 53 medical centers in the US, Australia, New Zealand and Malaysia. (I was born and raised in Malaysia, and am simultaneously impressed and bemused that Malaysia was the only Asian country involved in PRESERVE.) Rates of acute kidney injury were ~9% and death by 90 days ~2.5% across all treatment groups. PRESERVE trial findings were published in NEJM to coincide with Dr. Weisbord’s presentation at the #AHA17 late-breaking clinical trials session.

I chatted with Dr. Pastor-Soler, a nephrologist from University of Southern California who was the discussant at the media briefing session, expressing my disappointment that we don’t have more effective prevention strategies for contrast-induced kidney injury. In pragmatic fashion, she pointed out that the PRESERVE trial is important since sodium bicarb fluids often have to be prepared to-order by hospital pharmacies, and there are intermittent shortages plus increased cost. Based on the PRESERVE trial findings, we can confidently proceed with normal saline which is readily available, with more efficient patient care. (I’ll make a plug here for Women In Nephrology (WIN) where Dr. Pastor-Soler is President-Elect… if you’re a female in the field of nephrology, consider joining!)

So how much normal saline should we give? The PRESERVE investigators allowed a great deal of flexibility to participating medical centers: “1 to 3 ml per kilogram of body weight per hour during a period of 1 to 12 hours for a total volume of 3 to 12 ml per kilogram before angiography, 1 to 1.5 ml per kilogram per hour during angiography, and 1 to 3 ml per kilogram per hour during a period of 2 to 12 hours for a total volume of 6 to 12 ml per kilogram after angiography… In patients with a BMI of more than 30, we capped fluid-administration rates on the basis of a weight of 125 kg.” It sounds like if you give some NS before, during and after, you’re a winner!

To end on a sobering note, the PRESERVE statistics indicate that in high-risk stage 3-4 chronic kidney disease patients who require IV contrast procedures, about 1 in 10 will develop acute kidney injury and 1 in 40 will not survive past 90 days. Medical necessity for IV contrast should always be carefully weighed. And normal saline hydration – yes, definitely! – while keeping in mind that 1 liter of NS contains 3.5 grams of sodium and it is prudent to avoid excessive salt/water loading (volume overload being another key predictor of poor hospital outcomes).

Wei Ling Lau MD is Assistant Professor in Nephrology at the University of California-Irvine, where she studies vascular calcification and brain microbleeds in chronic kidney disease. She is currently funded by an AHA Innovative Research Grant, and has been a speaker for CardioRenal University and the American Society of Nephrology.