Friday, February 16, 2018

It's not Lupus: It's Lupus in India

Time: 11:30 pm
Place: Emergency Department (ED) of a public hospital in Mumbai (average attendance ~ 550 patients per day).

A weary and teary mother wheels in her daughter ‘Asha’* who is in her early twenties. They have traversed 600 km from their remote district to Mumbai. Asha is pale, edematous, short of breath and her chest is full of crackles. She has not been able to lie flat since past 1 week secondary to difficulty breathing. She had been symptomatic for over a year with multiple complaints ranging from fatigue, fever, rashes to joint pains. The family initially consulted a local ‘tantrik’ (a faith healer who liberates possessed souls, see here for a notorious example). After that didn’t help much, she visited a local doctor who treated with her IV fluids for ‘the weakness’ and prescribed what she remembers as colorful tablets which were likely multivitamins. To note, ‘doctors’ in smaller villages and towns (and even cities) in India may or may not be qualified doctors, and even if qualified, may sometimes be homeopathic or ayurvedic doctors. It is difficult to comment as there is no formal record of any actual treatment administered. For her worsening joint pains, an orthopedic surgeon was consulted, who started her on steroids and NSAIDs. Asha had no recollection of any blood pressure measurement or urine examination being. At presentation in the ED, she is oliguric and is in pulmonary edema with a blood pressure of 180/90 mm Hg with a serum creatinine of 6.8 mg/dl. There are various striking features of ‘this’ presentation of lupus nephritis (LN) which is quite common in Indian population. It is well documented that there are substantial ethnic and socio-economic differences in presentation and outcome in Hispanics and African-American populations. Indian patients also have been reported to have lower eGFR and a higher chronicity index at presentation. Retrospective data from our institutional records (presented at ISNCON 2017) of 191 patients revealed a mean serum creatinine of 2.85 mg/d at presentation and 23% presented with rapidly progressive kidney failure requiring dialysis. However, apart from this inherently severe disease they suffer from, what is more disturbing is the fragmented care which they receive at various levels ranging from primary physicians to the specialists (rheumatologists, hematologists, dermatologists, orthopedics, gynecologists). Most of them don’t envision the disease in its entirety and even may be blissfully unaware of treatment prescribed by others (big thanks to poor documentation). This therapeutic muddle is amplified by the faith healers, whose treatment is mostly concealed by the patient.

Another aspect of this presentation is the delay in seeking medical care, which is massively influenced by the fact that lupus predominantly affects women. The gender bias in seeking medical care is multifaceted and is irrespective of economic constraints. It is deeply rooted in social prejudices such as a lower willingness of the family to spend their time and resources for the health of women, disadvantages in matrimonial prospects for a woman even after therapy, abandonment by ‘in laws’ after knowing about the chronic illness with difficulties in conception, etc. An interesting aside is that LN is not a favorable illness even for males, as it is often the last differential considered and hence often missed or diagnosed late.

Asha remained dialysis dependent for a week, received pulse steroids while her kidney biopsy confirmed class IV LN with crescents. Now, the biggest dilemma was that the available evidence for therapeutic options in such severe patients is scarce and most of the studies have excluded patients like Asha. Given that there is some evidence supporting ethnic differences in responses to induction immunosuppression, it is imperative that we opt our choices based on evidence from Indian patients. Also, not to forget that Asha’s body surface area (like most Indians) was 1.1m2 and the safer “low dose cyclophosphamide regimen” is equivalent to “high dose” (0.5- 1g/m2) for her.

Asha’s father couldn’t accompany her as he was himself afflicted with pulmonary tuberculosis. This alerted me to the rampant risk of infections which will be compounded by my immunosuppression. In my effort to salvage the kidney, I may end up losing the patient to infection. This is another reason why we need to have indigenous treatment guidelines which can prevent over-immunosuppression in this infection prone population.

After induction with pulse cyclophosphamide and steroids, Asha’s eGFR had stabilized and she was dialysis independent at discharge. However, managing her immunosuppression is very difficult as long-term therapy with MMF is (economically) out of her reach. Drug non-adherence was an independent predictor of progression to ESKD in our data. Monetary constraints topped the causes, others being- stopping drugs after feeling better, being fed up with long years of therapy, and social taboo. One young girl was so embarrassed to take medications in college that she regularly skipped afternoon doses. Some of them get confused with the complicated prescription and take vitamins but miss immunosuppressives. One important factor was the lack of universal availability of drugs and physicians. Asha’s district has no access to immunosuppressives and specialists within 500 km, hence the travel expenses for every visit are added to the cost of treatment.

Our experience of setting up a Lupus Nephritis Clinic 

Our nephrology unit caters to patients from all spheres of nephrology (general, pediatric, critical care, and transplantation). Initially, these patients were equally divided into five clinics over the week, each with an attendance of over 100 patients. With a vision to serve patients like Asha better, we started a dedicated lupus clinic every month with about 50-60 patients per clinic. This has improved patient satisfaction as their waiting time is reduced. Committed time for counseling on specific issues like the importance of long-term adherence, pregnancy, and contraception has helped us move from disease-centric to patient-valued goal directed care. In addition, group counseling sessions have proved quite effective and time efficient. Apart from enabling us to provide better care in the resource-limited setting, the specific lupus clinic model has also helped in streamlining and analyzing data to generate much needed information on indigenous populations of india to help fine-tune our practice patterns. 

Asha is now regularly following up in the lupus clinic and is in partial remission. Her initial desolation has decreased after meeting other lupus survivors in the clinic. She now also encourages other patients for seeking timely and regular care.

Divya Bajpai
KEM Hospital
Mumbai, India
NSMC Intern Class of 2018

*Note- This is a fictionalized story based upon a composite of many real patients; names and other information is altered. The name ‘Asha’ means ‘Hope’ in Hindi.

Wednesday, February 14, 2018

Close Encounters of the Virtual Kind

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.

Tuesday, February 13, 2018

Hunger in Patients with Kidney Disease – Why it matters and what to do about it?

As a new pediatric nephrology fellow, my first weeks taking care of patients on hemodialysis were overwhelming. Each of my patients had complex problems and intricate physiology, and I initially learned to focus on the numbers – clearance, blood pressures and weight – in order to optimize therapies for each patient’s clinical disease and status. About three months into fellowship, however, I was stumped by a young girl with ESRD whose numbers just didn’t make sense. She was losing weight, admitted repeatedly for infections, and had worsening clinical and laboratory parameters which wouldn’t improve with interventions. Despite nutritional supplements, additional dialysis sessions, and medication adjustments, nothing changed. Finally, the root cause became clear – she was hungry, and her family couldn’t afford to buy food. 

Unfortunately, this isn’t a rare experience in the United States. Food insecurity is common, affecting 16.6% of American households and 7.8% of American children – and appears to be more common in those with chronic illness, such as kidney disease. Food insecurity is defined as limited or uncertain availability of nutritionally adequate and safe foods, or limited or uncertain ability to acquire such foods in socially acceptable ways. I have seen families frequently make trade-offs between buying medication versus food, or choosing inappropriate food for their children’s medical problems due to cost. Parents have told me they often go hungry in order to feed their children – providing a human face to the statistics published by the U.S. Department of Agriculture (USDA) Economic Research Service showing that half of all parents or caregivers experiencing food insecurity shield their children from having to skip meals by skipping meals themselves. 

Why should food insecurity matter to nephrologists? Food insecurity is an essential social determinant of health with significant implications, including poorer overall levels of health, chronic medical conditions, and lower levels of psychosocial and physical functioning. A recent report showed that two-thirds of families with food insecurity have to choose between paying for medical care or food within the past year.These findings in children mirror studies in adult ESRD patients where food insecurity was associated with worse nutritional status and poorer quality of life. Among adults with chronic kidney disease, food insecurity accelerates disease progression, and may increase the risk of ESRD. Patients with food insecurity often use coping strategies which are deleterious for their health, including medication under-use or non-adherence, postponing or forgoing preventive care, or relying on a low-cost diet of energy rich but nutrient-poor foods. 

While awareness of food insecurity has increased in pediatrics and screening for food insecurity is frequently part of general pediatrics care, there no similar recommendations in either pediatric or adult subspecialties. Given the implications for our patients and their diseases, I would argue that all patients with kidney disease, especially those with ESRD, should be screened for food insecurity as part of their routine nephrology and dialysis care. Physicians, dietitians, and other health providers often counsel patients with kidney disease on dietary interventions, and awareness of food security status is paramount in providing optimal care. Many interventions and recommendations (such as a low-salt diet or phosphorus restriction) may be challenging or impossible to implement for patients who are food insecure. Screening should be performed with a standardized screening instrument, with several available and validated by the AAP, AAFP and USDA. Screening should be coupled with timely and appropriate referrals to food resources – an area of intervention that requires innovation, collaboration and community-based solutions. While eliminating food insecurity may be the eventual goal, the first step is to screen patients at risk; as only once we recognize, name, and quantify a problem can we start to identify solutions. 

 Post by Michelle Starr, NSMC Intern Class 2018

Monday, February 12, 2018

My First Experience in Interprofessional Education: A Missing Piece in Our Training?

Having completed four years of medical school, three years of residency, and now a few months away from my completing my training as a nephrology fellow, I experienced a new type of learning – interprofessional education (IPE). IPE is defined as an occasion when learners from two or more professions in health and social care learn together with the objective of cultivating collaborative practice to provide patient-centered care. As nephrology fellows, we have significant interactions with other health professions everyday: dialysis nurses, technicians, medical/surgical nurses, patient care assistants, nurse practitioners, and physician assistants.

IPE has been endorsed by the Institute of Medicine (IOM) and described as an important step in advancing health professional education for many years. Not surprisingly, the IOM states that patients receive safer, higher quality care when health care professionals work effectively as a team, communicate productively, and understand each other's roles.

The IPE workshop I participated in was set in an advanced medical simulation center and involved physicians and nurses. The simulation room was complete with a monitor for vital signs and telemetry, a wide variety of medications and medical equipment, and a jarringly realistic patient mannequin who not only blinked and talked, but also had palpable pulses, audible heart and lung sounds, and even ultrasoundable tissue.

The simulation began with the assignment of roles (i.e. physician, nurse, respiratory therapist) and the description of a clinical scenario. Our first scenario was a patient with altered mental status in the setting of profound hypoglycemia. After the simulation began, we were recorded on video and also observed by a “debriefer” with whom we would discuss the simulation afterwards. The vital signs, physical exam findings, and voice of the patient were controlled by other members of the simulation team (who were behind a one-way mirror) in response to our actions in the simulation. Subsequent simulations involved situations where the patient experienced anaphylactic shock after receiving an antibiotic, crushing chest pain concerning for myocardial infarction, and cardiac arrest.

The debriefing session with the debriefer and all simulation participants, perhaps the most enlightening portion of the activity, allowed the entire team to talk about what went well and what didn’t go so well. Most importantly, we discussed how our teamwork and communication skills could improve. Had tasks been delegated effectively? Did all members of the team know their role and feel part of the team? Was the ultimate goal clear? When and why did communication breakdown?

The discussions often led to thoughts on perceived perceptions of other professional roles and important clarifications of what each team member can contribute. In one simulation, our “actual” roles were reversed, which led to an even richer discussion during the debrief session. We briefly discussed and received feedback on clinical management, though clinical performance was not the main focus of the debrief session.

Though this type of activity requires the participants to buy in to the simulation experience to maximize its effectiveness, it provides a unique opportunity to practice and learn from an almost real-life setting. Before attempting venipuncture on a patient, trainees can practice on their colleagues. Before placing central venous catheters or performing cardiopulmonary resuscitation (CPR), trainees may practice on mannequins. Interprofessional communication is a core skill set that everyone needs to practice and hone. Mastery of this skill set will ensure the delivery of the highest quality of care. I believe that we, as a medical community, need to start including IPE into the curriculum at all levels of medical training. If practice makes perfect, shouldn’t we all start practicing how we interact with other professionals?

Samira Farouk, MD
NSMC Intern 2018
Chief Nephrology Fellow, Icahn School of Medicine at Mount Sinai

Sunday, February 11, 2018

Starvation Ketosis: A Rare Cause of Metabolic Acidosis

As a child growing up in India, I have seen several family members performing ritual fasting. Fasting is a ubiquitous religio-cultural practice that is found, in varying forms, across the world. The month-long Ramadan and Buddhist Lent fasts are examples of religious observances practiced by followers of Islam, and Buddhism, respectively. These fasts are characterized by a documented impact on metabolic health, which can be minimized by well-known management strategies.The practice of fasting is a major part of Hinduism and can range from light restriction to extreme abstention. Mahatma Gandhi was a fervent supporter of fasting by religious conviction and as a way of freeing oneself of the constraints of the body. He used fasting as a means of exerting political pressure and engaged in several hunger strikes to protest with non-violence.

In the western countries, starvation ketosis or ketoacidosis has been reported in individuals with strict dieting (e.g.carb-restricted, ketogenic diets or Atkins diet), extreme exercise, and rarely with malnutrition. Few cases of starvation-induced ketoacidosis during pregnancy and lactation, and during the perioperative period have also been reported in literature.

I saw a young non-verbal woman with quadriplegia who was admitted from a nursing home with a two-day history of worsening abdominal pain and leakage around her percutaneous endoscopic  gastrostomy (PEG) tube site. Her medical history was significant for severe developmental delay and chronic constipation. She was afebrile and the rest of the vitals were stable. Her PEG tube feeds had been stopped one day prior to the hospital admission due to abdominal pain. Additionally, she received small doses of iv morphine for pain control. Due to no oral intake, she was maintained on isotonic intravenous fluids.

Laboratory blood work revealed  high anion gap metabolic acidosis (HAGMA). I started going down the GOLDMARK mnemonic for differential diagnosis of HAGMA to ascertain the cause.
Serum blood glucose, lactate and salicylate levels were normal. Alcohol was not detectable in serum, and there was no known exposure to any toxins. Osmolal gap was not elevated. Urine pregnancy test was negative. Urine analysis showed significant ketonuria. Serum beta-hydroxybutyrate was negative.

After ruling out the common causes of acute metabolic acidosis (lactic acidosis, diabetic ketoacidosis, drug-induced ketoacidosis, ingestion of toxic alcohols, uremia, and acute kidney injury), we concluded starvation ketosis was the cause of HAGMA due to elevated urinary ketone levels.

In clinical practice, fasting or starvation is seldom suspected to be the cause of significant metabolic ketoacidosis. Ketone bodies, which are water-soluble, fat derived fuel  are produced by the liver during the time of glucose deficiency. These ketone bodies are used by body tissues for energy generation, when there is limited glucose availability. Additionally, starvation results in decreased insulin and increased lipolysis. The resulting increase in the delivery of free fatty acids to the liver exceeds the capacity of acetyl-CoA to enter the Krebs cycle,which is then diverted into ketogenesis. In otherwise healthy individuals, mild ketosis (ketoacid concentration of about 1 mmol/L) develops generally after 12-14 hours of fasting and arterial pH remains above 7.3.

Since the degree of ketoacidosis usually remains relatively mild, the term "ketosis" is typically used rather than "ketoacidosis." But starvation combined with physiological stress can lead to increased anion gap and ketoacidosis.This usually occurs when there is a relatively large glucose requirement, as occurs with fasting in the very young (eg, normal neonates generally have some degree of ketosis for several days), or in pregnant or lactating women.

Our patient was started on a D5-half NS drip. Following an exchange of her PEG tube, feeding was restarted. The metabolic acidosis resolved within two days and the patient was discharged back to the nursing home. This was a great learning case for me. It is consults like these that make nephrology so challenging and exciting!

Read this excellent review article on ketone bodies.

Post by Manasi Bapat, nephrology fellow at Icahn School of Medicine, Mount Sinai, NY and NSMC Intern 2018



Saturday, February 10, 2018

Quick Survey on Board Prep Resources in Nephrology from ASN

ASN wants to know how you study and prepare for the boards. This quick 8 question survey will help the course directors improve the ASN Board Review course. Take a few moments and fill out this quick survey.

here is the link 

Posted by Roger Rodby
TPD Rush Nephrology

Thursday, February 8, 2018

Of Mice and…Kidney Fibrosis: 6 Ways to Study Fibrosis in Mice

Kidney fibrosis is the common final pathway where all forms of kidney diseases converge– whether it is diabetic nephropathy, rapid progressive glomerulonephritis, or chronic allograft nephropathy in transplantation. Once significant irreversible fibrosis or scarring has developed, nephrologists are faced with the unfortunate position of realizing a point of no return. Though our understanding of kidney fibrosis has progressed significantly over the past few decades, the complex pathogenetic mechanisms underlying the initiation and progression of fibrosis remain somewhat elusive. Thus, our therapeutic options remain limited.

Mice have been increasingly used to study kidney disease, not only because of their small size and homology with humans, but also because of the ability to manipulate genes by knockdown, knockout, and over expression systems. Scientists have produced a variety of inbred strains with varying degrees of susceptibility to kidney injury. Over the last several decades, the development of multiple kidney fibrosis models has allowed for sophisticated study of fibrotic pathways that ultimately has led to not only a better understanding of fibrosis, but also a model in which potential therapeutic agents can be tested. For example, if we knockout gene X and then induce kidney fibrosis, the resulting kidney pathology may provide some insight into gene X’s role in kidney fibrosis. The most robust studies use a combination of the models below and it is important not to rely on only one model.

Let’s review some of the most popular models of fibrosis:

1. Unilateral ureteral obstruction (better known as “UUO”): As the name implies, the UUO model involves physically tying off one of the ureters with a suture which leads to interstitial fibrosis due to both hemodynamic and metabolic changes. This model has been used since the 1970s in a wide variety of animals: first in lambs, and later possums, rabbits, pigs, dogs, monkeys, rats, and mice. The obstruction leads to tubular injury and cell death by apoptosis and necrosis, glomerulopathy, infiltration of macrophages and cytokine release, proliferation of fibroblasts, and eventually severe fibrosis seven days after the obstruction in wild type mice. The surgery is relatively easy to perform and can be completed in 15 – 20 minutes. While the contralateral kidney can serve as the control kidney in UUO experiments, it also compensates for the injured kidney and thus markers of kidney function such as serum creatinine and urea provide limited information. While this is a convenient model to induce fibrosis, many have argued that the mechanism of fibrosis in UUO is rapid and extensive and thus might not be reflective of human CKD. However, UUO remains one of the most popular methods.

2. Sub-Total Nephrectomy: Like the name implies, this is surgical removal of just about all kidney parenchyma. To achieve this, unilateral nephrectomy is first performed followed by either ligation of the contralateral renal artery branches (which leads to infarction of both renal poles) or ablation and excision of 50% of the contralateral kidney. Though the ligation model cannot be performed as easily in mice due to limited renal artery branching branching, this model leads to more severe proteinuria. The remnant kidney develops both glomerulosclerosis and tubulointerstitial fibrosis. This model is most commonly performed in rats, as there can be some variability with mice depending on the strain and amount of tissue excised. Interestingly, one strain of mice carries only one copy of the renin gene and thus fibrosis phenotypes may be less severe given the pathogenic importance of the renin-angiotensin system.

3. Aristolochic-acid (AA) nephropathy: While AA-induced nephropathy commonly shows up on the nephrology board exam, intraperitoneal injection of AA into wild type mice leads to a phenotype similar to chronic tubulointerstitial fibrosis that is seen in humans. Unlike UUO, the development of fibrosis can take several weeks depending on the AA dosing and frequency of administration.

4. Adriamycin nephropathy: In 1977, a case of kidney injury due to the anthracycline Adriamycin (doxorubicin) was described. In rodents, doxorubicin also induces a phenotype similar to chronic proteinuric kidney disease with histological changes of focal segmental and global glomerulosclerosis, podocyte fusion, and tubulointerstitial inflammation and fibrosis. Changes can be seen as early as 1-2 weeks after intravenous administration and become more severe by week 4. Unlike the relative ease of UUO or intraperitoneal administration, intravenous injections in rodents can be challenging due to small vein sizes.

5. Folic acid nephropathy: The seemingly harmless water-soluble B vitamin can cause acute tubular necrosis and chronic interstitial fibrosis when administered in mice intraperitoneally at extremely high doses. Folic acid both obstructs the tubular lumen by forming crystals and is directly toxic to the tubular epithelial cells.

6. Ischemia-Reperfusion Injury (IRI): The IRI model is commonly used to study acute kidney injury (AKI), but long term outcomes include tubular atrophy, interstitial fibrosis, and inflammation. In a model of bilateral IRI, clamping of renal pedicles for 21 minutes led to significantly elevated levels of serum creatine and urea at 1 year. Histology at one year revealed significant scarring and immune infiltration. Though the development of fibrosis here requires a longer period of time, the IRI model closely mimics IRI experienced by deceased donor kidney transplants.

In addition to these 6 models, numerous other models have been utilized to induce fibrosis. Share your favorite models in the comments below.

Samira Farouk, MD
NSMC Intern 2018, Chief Nephrology Fellow
Icahn School of Medicine at Mount Sinai

Wednesday, February 7, 2018

How to Answer Board-Style Multiple-Choice Questions Like a Boss

From Gomerblog
The multiple-choice question (MCQ) is the workhorse of medical education. All of the major testing stakeholders (National Board of Medical Examiners, American Board of Medical Specialties, etc.) use MCQs to make major promotion and licensing decisions. So, it’s important to understand how to answer MCQs accurately and efficiently.

Let's review how to approach board-style MCQs. Because they’re so heavily scrutinized, these MCQs tend to be bulletproof against the hacks that unravel poorly written questions. However, a strategic approach to MCQs can help you apply your knowledge to achieve the score you deserve.

First, some definitions are imperative. MCQs consist of a stem and options. The options consist of several distractors and one correct answer (highlighted yellow in this blog).

In normal lung physiology, which of the following gases is exchanged across the alveolar membrane? [stem]  
A. Oxygen [answer]  
B. Helium 
C. Methane
D. Radon 
E. Chloroform

First, look at the stem, and ask yourself, “is the material in the stem needed to answer the question?” Board-style MCQs infamously include an exhaustive case presentation with extraneous history, exam, and lab data. With an average time allotment of only 2 minutes per question, it may be helpful to ignore anything you don’t need. In the following question, the options have no relationship with the stem, so looking at the options first can save a lot of time:

A 62-year-old man presents with acute, substernal chest pain. Physical exam reveals diaphoresis and bibasilar crackles. Serum troponin is 20 ng/ml and EKG reveals ST-segment elevation in leads V2–V6. Which of the following is a risk factor for coronary artery disease?  
A. Cigarette smoking 
B. “Type B” personality
C. Diet rich in fruits and vegetables
D. Excess water intake
E. Regular exercise 
Second, look at the options, and ask, “are the distractors plausible?” Board-style MCQs usually supply reasonable options, but the list is often easily reducible to 2-3 likely possibilities. In this question, only one of the options could reasonably be correct, at least by the standards of modern medicine:

Which of the following is the MOST EFFECTIVE treatment for an acute gout attack?

A. Purging
B. Bleeding
C. Moxibustion
D. Radioactive waters
E. Colchicine 

Third, ask “are the options homogeneous?” Asymmetric options are rare in board-style MCQs, but differences in option length, verb tense, and number agreement can alert you to distractors. In this question, the longest option, which includes a singular response to match the singular question (“next test”), is correct:

A 23-year-old woman with no significant medical history presents to the emergency department with sudden-onset, severe headache. Blood pressure is 186/102, heart rate is 56, and temperature is 38.6°C. Funduscopic exam reveals mild papilledema. The most appropriate NEXT TEST would be
A. WBC count
B. Head CT, followed by lumbar puncture if no mass lesion is found
C. Frequent neurologic exams
D. Cranial decompression
E. Antibiotics 

Finally, again considering the options, ask yourself, “did I avoid superlatives?” Options that contain “always,” “never,” “all,” or “none” are frequently distractors because the absolute nature of these terms doesn’t match the real-life uncertainty of clinical medicine. On the other hand, descriptors such as “usually normal” may be too vague to be listed in a correct answer:

A 19-year-old woman notes a malar, photosensitive rash and wrist arthralgias. Heart and lung exams are normal. White blood cell count is 2.6 K/mcl, hemoglobin is 9.2 g/dl, and platelets are 36 K/mcl.

A diagnosis of lupus is MOST LIKELY in this patient for which of the following reasons?

A. Malar rash is always diagnostic of lupus.
B. Pancytopenia may be associated with lupus.
C. Pulmonary exam findings are never normal in lupus.
D. Joint exam findings are usually normal in lupus.
E. All of the above.

While these strategies can’t substitute for true understanding, they may help you avoid some common pitfalls in answering MCQs. Good luck on the boards!

 “Superficially, it might be said that the function of the kidneys is to make urine; but in a more considered view one can say that the kidneys make the stuff of philosophy itself.” 
-- Homer Smith, Lectures on the Kidney, 1943
More Reading
How to Construct Multiple Choice Questions
NBME Constructing Board Questions
Effectively Writing Questions
Another good review on writing questions

James Novak
Nephrology Program Director
Henry Ford Hosptial

NSMC Intern Class of 2018