NephMadness Choose Wisely Campaign (#NCWC)

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What to do?  So many good choices, so many ways this can go.  Will your bracket survive past your colleagues and friends or will you have to hear them go on and on how they  pity you or just tell you that you suck.  When the conversation at the next conference turns to NephMadness you don’t want to be the person saying, “Hey I have an early day got to go back to my room”.  Heck this madness is so crazy popular people have literally been kidnapped to prevent entry into the tournament!  

You think to yourself how do I get an edge on the competition.  You google best bets NCAA tournament, there are over 2 million hits.  Oh you meant google best bets NephMadness, first think that shows up is NephMadness for Dummies.  You almost throw your phone/tablet/computer against the wall to show it whose the boss, but wait you remember you will have to buy a new device and who knows if that device will be any smarter.

Then you head to twitter and you see salvation!  You come upon the NephMadness Choose Wisely Campaign #NCWC?  How did this happen? What is this?  Well you see Nephrology Social Media Collaborative (NSMC) Intern Mohamed Elrggal was in a deep sleep when the Knight of NephMadness Past came to him.  He immediately awoke and googled the below image as he needed to know who this Salt Whisperer was.

Image result for gandalf choose wisely

Mohamed thought to himself what does this mean? Suddenly an idea came upon him, what if he led a team to retrospectively analyze the history of the Blue Ribbon Panel, from publications to tweets to choice of coffee and input this data into a simulation model.  He could run the simulation a few thousand times and then be able to accurately predict the winning Teams in NephMadness.  He immediately communicated this idea to his Nephrology Social Media Collaborative (NSMC) co-interns and the team was assembled.  Mohamed’s brainchild became knowns as the Nephrology Choose Wisely Campaign#NCWC.

The first entry was done by the man Mohamed himself.  This was followed in rapid succession by more entries and to totally annihilate the competition check out the wonderful Visual Abstracts!

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Below are a list of hyperlinks, first link is to that region’s NCWC entry and then below is the hyperlink to that #specific region (click #NCWC for the whole collection in one spot):

Strong work by @ssfarouk on putting together the infographic summarizing the twitter polls below:

So now you start to feel like you might just win and start to plan a Championship Parade but WAIT WAIT WAIT!  Simply winning is not enough, you feel the need to embarrass your colleagues and walk around like a Boss at the office, to show those other fellowships “Yea we’re bad, What! What!”. Well to honor the idea of FOAMed (Free Open Access Medical education) and to keep your head spinning with content we rolled out the good stuff:

Still don’t know whom to pick, well if all else fails here are some free picks for you. Want free picks in Spanish, no te preocupes we got you covered.

Asking where can I look to find everything mentioned in this blogpost and more coverage of NephMadness click below:

#NephMadness

Shout out to all the contributors to this year’s NephMadness and all the wonderful posts and innovative educational tools used.  A special thanks to our NSMC faculty and the NSMC interns!

And let’s wrap this up with aShooting Starr Moment!

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Now let’s win this thing and go cut down some nets!

#nephmadness #nephforward #NSMC

See the source image

NephMadness Choosing Wisely Campaign (#NCWC): Pathogenic DSAs vs The Untransplantables (#TransplantRegion)

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The fight to come out of the Transplant Region is like a sibling rivalry.  Truly all four competitors relate to each other under the umbrella (aka family) of access to transplantfor various patient populations.  Get ready because you know in sibling battles there is no “illegal” weapon.  It is time to get down and dirty.  We are going to discuss Pathogenic Donor Specific Antibodies (DSA’s) versus The Untransplantables.  Please check out my NSMC co-intern Dr. Samira Farouk’s amazing game preview of Kidney Donor Risk versus VirallyInfected Kidneys.

Let us first take a look at Team Pathogenic DSA’s.  They have been scouted before with excellent reviews and concerns.  If one word describes this team as Dr. Dorry Segev mentioned in his overview of the Transplant Region it is “Enigma”. The detection of Pathogenic DSA’s allows for more appropriate matching between donors and recipients and avoiding acute antibody mediated rejection (ABMR). However, how do you know how significant the DSA is?   This brings us to the team leader Antibody Strength or his streetball name “Da MFI” (Mean Fluorescence Intensity).  A team’s leader can reflect both a team’s strength and weaknesses all at once.  “Da MFI” shows good game with great defensive MONITORING on the court, but has limitations such as getting caught out of position or not finishing at the basket.

Ideally the HLA antibodies bind proportionately to a standard amount of target antigen and high antibody levels will develop.  But what if using single antigen bead assays that give us the “Da MFI” the following happens?

1. There is a lower antigen density and despite high levels of antibodies produced there is a falsely low MFI

2.There are high antibody levels and complement activation leading to soluble C1q that blocks HLA antibody binding to the selected antigen, resulting in a falsely low MFI

3. Two different antigen beads have different HLA antigens but the same epitopes diluting the serum antibody resulting in a lower MFI

4. The patient had a sensitizing event leading to production of DSA after antibody testing

5. If you take the same samples with the same beads and do the same test over a course of a week you could end up with varying MFI’s

So Yes we can detect Pathogenic DSA’s but we definitively do not always know what it clinically means.

In 1968 the World Health Organization established criteria for screening practices and it was said that yes in theory was a good practice but there will be “snags”.

So yes there is a lot of science and fascination with Team Pathogenic DSA’s but I have to agree with Dr. Segev, the Team are a group of freshman with their “snags” that will grow together and change with new teammates over time, this is likely not the year but a title run might not be that far in the future

Also Pubmed articles by the Blue Ribbon Panel mentioning “Antibody”: 0

Our opposing team are the Untransplantables One easy rule in picking the winner in NephMadness is where is the most ready prime time player aka look for a relevant intervention with a significant transparent effect on diagnosis, treatment, or patient outcomes.  Well the Untransplantables were once a ragtag group that heard the words, “too sensitized”, “can’t go against nature”, “no student would ever EXCHANGE over to this team”, and “can’t land a hot shot recruit”, maybe not anymore.  They have a superstar in my opinion that would make the all tournament team, overcoming HLA incompatibility in transplantation.  The superstar has two primary offensive weapons, the paired kidney donor exchange (PKDE) and desensitization.  Let us focus on PKDE.  The National Kidney Registry (NKR) is a national registry in the USA of listing living kidney donors and recipients in need of a kidney transplant.  The NKR was founded in 2007 and as of early 2018 has resulted in 2598 transplants(https://www.kidneyregistry.org/index.php).  This goes beyond a patient being untransplantable with a potential donor, it also allows for a better match in terms of other factors such as age.  PKDE can be used in concert with desensitization via an  algorithmic approach.

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But do not forget there are a few other players that have given new hope to patients.  One of them is ABO incompatibility transplantation which is becoming more mainstream in particular with specific type B blood recipients receiving organs from donors with A2/A2B blood type.

Simply put, the Team Pathogenic DSA’s has plenty of team Defense and Monitoring.  However it is questionable how much this will lead them to a win.  On the other hand we have The Untransplantables whom have a great defense (since technically DSA monitoring is used in these patients) but can score in both natural and unnatural ways.

Plus if you ask who is the most prime time ready player that has made an impact measured by number of transplants, then it becomes an even easier decision.

Yep HLA typing and checking for DSA is a pillar of transplantation, but think about it if I find an issue using my DEFENSIVE MONITORING but then how do I SCORE off it?  Use one of the methods mentioned with the Untransplantables like desensitization or PKDE.

Plus if you think health care providers and patients aka our Blue Ribbon Panel want to overcome barriers not just hear they exist which way do you think they will sway?

Pick: The Untransplantables    

Close Encounters of the Virtual Kind

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The cartoon that graced the cover of the April 1924 edition of Radio News depicted a physician linked to a patient only by sight and sound i.e. the Radio Doctor. The term Telemedicine first appeared in the medical literature in 1950 after radiologic images were transmitted by telephone; a distance of 24 miles from West Chester to Philadelphia, PA. Fast forward to the 1990’s, with the rise of the internet, came the birth of the necessary framework for telemedicine to grow. This framework allowed for innovations including the development of electronic medical records (EMR) that could be effortlessly shared.

Jeff Bezos, the founder of Amazon, is one of the fathers of e-commerce. He envisioned something beyond the brick and mortar bookstores and the traditional method of book sales. He left his job as an investment banker and drove to Seattle to start Amazon. As health care providers, we should ask ourselves in today’s world of medical practice is there a similar opportunity with telemedicine.

The growth of telemedicine has been spectacular. Kaiser Permanente, the largest care organization in the US, has about 52% of their more than 100 million patient encounters as virtual visits. A retrospective analysis involving 19,246 consultations showed not only savings in cost and travel but also that telemedicine is “green” for the environment with a measured 1969 metric tons of carbon dioxide saved. Of course, an additional advantage is that the patient is able to avoid long wait times. There is even a telemedicine advocacy group called the American Telemedicine Association founded in 1993 with over 10,000 members. Multiple “techy” health conferences are available to attend.

Telemedicine typically is used via three modalities including 1. real-time (or live video), 2. asynchronous (store and forward), and 3. remote patient monitoring. Real-time telemedicine is an online-based audio-video consult. However, technology has developed to move this modality forward. Need to remotely auscultate the heart? A patient can hold a device like the Alivecor KardiaMobile EKG monitor or the iPhone-sized Eko Duo over their chest and it will record heart sounds and an EKG tracing. The sounds and tracing are uploaded to the EMR and transmitted to the remote physician for review. What if medical care is needed in an area difficult to travel to? Unmanned drones have been used to deliver medical supplies and interface equipment for a physician to treat these distant patients. This is already being done in the rural USA.

A provider using asynchronous telemedicine receives information for analysis first prior to responding to the sender. The hope is for better evidence-based medical recommendations. The patient or the primary care provider also have the option to discuss the case with the specialist at a convenient time. This removes the difficulty of multiple appointments and schedule conflicts.

A hybrid of both real-time and asynchronous telemedicine is Project ECHO (Extension for Community Healthcare Outcomes). New Mexicans with hepatitis C were going untreated because there were no nearby specialists. Dr. Sanjeev Arora, a hepatologist in Albuquerque, saw an opportunity and created Project ECHO. Local clinicians would meet with specialist teams via virtual clinics and present patients and receive medical advice (real-time). This medical advice was then used to treat the local population (asynchronous). Project ECHO-trained clinicians had similar outcomes to that of university-based specialists. Project ECHO today has expanded over multiple specialties all over the world.

Remote monitoring has made expertise care more available. One example is the telemedicine ICU where an intensivist oversees the care of a critical patient remotely. The boom of wearable devices introduced interesting opportunities. Need an example? A vest using radar technology gathers data detecting changes in lung fluid content that is sent wirelessly back to the medical provider. This device was show to help reduce readmissions rates in heart failure patients.

What about Telenephrology? It has been looked at from the management of Chronic Kidney Disease (CKD) to kidney transplantation. The Zuni Telenephrology Clinic experience in management of CKD described bringing specialized nephrology care to a rural area. In transplant it has been shown that remote living donation and recipient screening increases access to care. This could even be used to battle disparities in kidney transplant as transplant education can be provided in another avenue i.e. a home visit for the patient with the provider at their office.

What barriers exist? The health industry is in general slower to digitalize than other industries. Where else do you see a fax machine? Financially, Medicare, Medicaid and private payers do reimburse for telemedicine but it can vary dramatically. In the US to help overcome this, the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017 was passed. This bill directly affects the Nephrology community. Medicare’s requirement for monthly visits for home hemodialysis patients would be met if there is a face-to-face meeting every 3 months and monthly telemedicine visits in between. Another glitch in the US is using far away providers not licensed or credentialed in the patient’s state, one solution is the interstate Medical License Compact (IMLC) which is an agreement between 22 states and 29 medical and Osteophatic Boards in those states allowing physicians to practice across state lines.

Though these issues exist, Telemedicine and health technology is a locomotive train with plenty of steam going forward. In 1995, Newsweek published an article written by Clifford Stoll on why the internet would fail. He said that the internet would not replace the daily newspaper, a competent teacher, or the way government works. Though we might smile at such a thought today it was 1995 and Google was not even born yet. Guess it is a good thing Jeff Bezos did not listen to Newsweek. There is and always will be a role for the traditional delivery of health care but telemedicine is advancing and evolving quickly. It is here to stay, almost a 100 years later I think we can say “the Radio Doctor is in”.

Beje Thomas, MD

NSMC Intern 2018

Transplant Nephrologist. MedStar Georgetown Transplant Institute.