Andrew Lee @ AGT & BGT

I'm proud to share that our M'sian celebrity magician - Andrew Lee, has made it all the way to BGT! The knife throwing act was performed so well and it has captivated the whole audience.


Here's his act in the recent AGT at semi-final. It was done so charmingly, hilarious at the same time and with a perfect twist in the end.

Follow him for more impressive magic to come! A very well done to him, and all the best in his BGT!

Extracardiac Compression of Right Atrium by Hepatic Cysts in ADPKD

What is the impact of growing hepatic cysts in patient with polycystic kidney disease? We reported a rare complication - the cysts have caused extracardiac compression of right atrium resulting in impaired filling. Patient is at risk of refractory hypotension in the presence of significantly impaired right ventricular filling. Beside this, hepatic cysts burden has been reported to cause inferior vena cava compression, hepatic venous outflow obstruction and portal hypertension. Therapeutic options for symptomatic patients include cyst aspiration and sclerotherapy, cyst fenestration, transcatheter arterial embolization, or surgical intervention including cyst resection and liver transplantation.

Full Text:
KG Lee, SH Teo, H John, KWQ Guo, JL Kwek. Extracardiac compression of right atrium by hepatic cysts in a patient with polycystic kidney disease. Kidney International 2016; 90:230.

If you're interested in updates in ADPKD, a position statement by European ADPKD Forum can be read here.

Outcome of AVF Creation, Effects of Preop Vein Mapping and Predictors of Fistula Success in Incident Hemodialysis Patients

This single-centre study reported arteriovenous (AVF) outcomes of incident hemodialysis patients with 19,450 patient-month follow-up, successful AVF maturation was achieved in 78% with 1-year cumulative patency rate of 74%. Routine pre-operative vein mapping was not necessary if veins are suitable on physical examination for AVF creation.

Full text:

KG Lee, TT Chong, N Goh et al. Outcomes of arteriovenous fistula creation, effect of preoperative vein mapping and predictors of fistula success in incident hemodialysis patients: A single-centre experience. Nephrology (Carlton) 2017; 22:382-7.

 

SCE Nephrology Exam Questions Writing

I am glad to be invited for authoring questions for SCE Nephrology Prep Course and all the questions were accepted. The guidance provided in authoring MCQs and replies from Editors are enlightening. Overall a good learning process!

Read more about the SCE Nephrology exam:

http://darrenmagic.blogspot.my/2012/04/sce-in-nephrology.html

Hyperkalemia - Principles of Management

Nice animation of ECG changes during hyperkalemia - this shows clearly that time is life when dealing with severe hyperkalemia.

5 essential principles of management, in simple terms:

1. Protect the heart - IV Ca Gluconate/ Ca Chloride (note contains 3x more calcium) to antagonise the cardiac membrane excitability thereby protect the heart against arrhythmias;

2. Shift K into cells - Insulin/ glucose infusion, nebulised Salbutamol (unlikely to work for patients on non-selective beta-blockers), Sodium Bicarbonate (not for routine use, comes with risk of Na and fluid overload);

3. Remove K from the body - Cation exchange resins (Resonium/ Kalimate, new agents: Patiromer, Zirconium), hemodialysis;

4. Monitor K level - do monitor for rebound hyperkalemia which is common;

5. Prevent recurrence - Do not walk away without knowing the cause of hyperkalemia and to stop further K accumulation, stop ALL potential offending drugs immediately.

Read more at:

CPG of Treatment of Acute Hyperkalemia

Rivaroxaban and Topical Miconazole - Do Not Mix

1. Direct oral anticoagulants (DOAC) are being increasingly use. Rivaroxaban is metabolized via CYP3A4, with in vitro studies supporting the involvement of P-glycoprotein as the responsible active transporter in renal secretion of rivaroxaban.

2. Antifungal imidazole derivatives have been shown to demonstrate significant inhibition of CYP450. Miconazole, a combined p-glycoprotein and strong CYP3A4-inhibitor, can potentially cause significant drug interaction and increased rivaroxaban concentration.

3. Interference of topical miconazole with warfarin has been reported, but not with DOAC. Systemic absorption appears to be enhanced when miconazole is applied under occlusion on large surface, close to mucous membranes or in cases of intertrigo skin lesions.

4. In summary, the use of topical miconazole may have significant drug interaction with rivaroxaban resulting in adverse event from over-anticoagulation.

The prescribing clinician should be aware of this possible interaction and exercise close monitoring if simultaneous use is indicated.

The interaction has been highlighted previously as a short communication (http://journals.sagepub.com/doi/pdf/10.1177/201010581502400209), and it was cited in Reactions journal as the first report of such interaction (https://link.springer.com/article/10.1007/s40278-015-4084-y).

Full text:
KG Lee, DL Jennifer. Increased bleeding tendency from interaction between rivaroxaban and topical miconazole: Case report. Proceedings of Singapore Healthcare 2015; 24:121-2.

Star Fruit - No Good for Kidneys?

Star fruit is not safe for any patient with chronic kidney disease.

1. Star fruit is a popular fruit in tropical and subtropical countries and its consumption is high in Asia. Multiple case series have reported its nephro-and neurotoxicity in CKD patients as well as in people with normal renal function.

2. The amount of fruit ingested which causes toxicity is related poorly to severity of symptoms. In cases of moderate to severe intoxication, neuropsychiatric manifestations can occur and may progress rapidly to coma and refractory status epilepticus, resulting in death.

3. Star fruit nephrotoxicity is believed to be due to its high oxalate content which could cause acute obstructive tubular nephropathy. Prompt treatment with intensified hemodialysis and hemoperfusion, close monitoring and supportive care has been propsed as an effective therapeutic approach.

I have highlighted this previously in a letter to Clinical Medicine (RCP Journal), and it was cited in a review for kidney toxicity due to herbs and dietary supplements in Food and Chemical Toxicology journal.

Full text:
KG Lee. Star fruit intoxication with acute kidney injury. Clinical Medicine 2012; 12:494

Grit: In Medicine

I looked back and realized about my this article written in 2008 which was published in the UCSI School of Medicine newsletter. It is now 10 years after it and I feel that my view on housemanship has somewhat changed. It was partly written in another post on evaluation system on housemen.

Housemanship is undeniably a hardship period, but it is not really over after you completed it. You have a growing medicolegal responsibility when you advance further, along with many other sources of stress and requirements (e.g. finding time to prepare for exams during busy work, locuming for extra income to pay for exam fees, family commitment etc.), the hardship is in fact never-ending. You work extra-hard during HOship in order to be a competent MO, just as same when you work extra-hard during MOship to train to be a Specialist, and subsequently to a Subspecialist.

To be able to keep this journey going, I think the key element needed is grit. Modified from Angela Lee Duckworth's famous quote, I'd say that, "Grit is surviving journey of medicine like it's a marathon, not a sprint." It's true - you need the power of passion and perseverance at all levels, not just the HOship!

David Blaine is Back

This is David Blaine's performance which everyone has been talking about. I find it hard to describe what he did, the show is absolutely more than just "entertaining", but utterly shocking. I can't call this just "magical" because it is simply flawless and looks REAL. In The Tonight Show, he sewed his mouth shut (literally), and performed an impossible card transposition, and ended with a huge surprise (which you have to check it out).

From his first TV special Street Magic, to then many of the endurance stunts including Buried Alive, Frozen in Time, Vertigo, Above the Below, Drowned Alive etc, he has never failed to impress not only the audience but the magic society.

Duplicate SVC on Arteriovenous Fistulography

"Left SVC persistence, a rare but important congenital vascular anomaly with a reported incidence of 0.3% to 1.3% in the general population, results when a left superior cardinal vein fails to regress during gestation. Left SVC drains into the RA through the coronary sinus with no major hemodynamic effect and patient is usually asymptomatic...However, there are practical implications when the patient is subjected to endovascular interventions...in which the procedure may be made difficult by the anatomic variation and serious complications including arrhythmia and coronary sinus thrombosis have been reported."

Full text:
KG Lee, RY Tan, VA Chidambaram, SC Pang, CS Tan. Duplicate superior vena cava on arteriovenous fistulography. J Vasc Surg Venous Lymphat Disord 2017; 5:739.

Frank's Sign

 

"First described in 1973, Frank’s sign, also known as diagonal earlobe crease (DELC), was observed to be an aural sign of coronary artery disease (CAD). Since then, there has been much interest in examining this unique association. This may occur as a result of age- or disease-related weakening of dermal and elastic fibers in the ear lobes, making it a dermatological predictor of an underlying coronary vessel insufficiency. Over the years, more insights were gained from studies showing the association of DELC with significantly increased prevalence, extent and severity of CAD, independent of traditional CAD risk factors, with good sensitivity and positive predictive value. Recent studies have also demonstrated DELC’s independent association with increased carotid intima-media thickness as well as cardiovascular events (CVE) comprising not only coronary, but ischemic cerebrovascular and peripheral vascular diseases, suggesting that DELC may be a marker of generalized atherosclerotic disease. Wong et al. in a study of 558 consecutive patients (445 patients had CAD on coronary angiography), found that the presence of DELC is independently associated with 5-fold higher risk of CAD. Of note, there has been proposed classification of DELC based on the characteristics of length, depth, bilateralism and inclination of the crease. Although bilateralism has been shown to have good specificity for CVE association, the significance of the characteristics needs to be further studied."

Full text:
KG Lee. Frank's sign - A dermatological link to coronary artery disease? Med J Malaysia 2017; 72:195-6.

A Golden Buzzer Act that Will Make You Cry

Have you watched Marc Spelmann's brilliant act at Britain's Got Talent? A mentalism prediction of multiple outcomes performed in perfection, revealed with a deeply emotional story - it moved the whole audience and the Golden Buzzer was just well-deserved. "Utterly extraordinary (performance)", told by Amanda Holden, which I just couldn't agree more. Beautiful!

Nephrology Board Exam M'sia

I somehow feel that my Nephrology journey is filled with exams, one after another. After my MRCP and USMLE, I did my SCE Neph exam (UK) in 2012 in preparation to enter the Singapore Renal Fellowship (Senior Residency) program. During the 3-year training, there is annual US in-training exam (ABIM exam in Nephro), and additionally at second year an ACGME-I Graduation Exam, and finally at end of third year there was a Singapore JCST Board Exit Exam as completion of training and for Specialist Board Accreditation.

As now I have returned to home country for family, I was required to obtain the certificate of M'sian Nephro Board Exam, and I'm glad to share that I have successfully completed it.

Pursuing Nephrology has been my dream and passion. Having been exposed to different examination format (UK/ Singapore/ US/ M'sia), I would like to share on a series of Nephrology topics and hope these help if you're also preparing for any Nephro exams:

Nephrology Foundation

Nephrology Guidelines

Nephrology Updates 2017

Nephrology Resources

And many more to come!

A Dermatologist Magicienne

Angela Funovits - a highly impressive magicienne (female magician) that you'll ever see. I wrote about her many years ago that she was a Dean's list medical student and was professionally performing magic. She then completed her Dermatology Residency in Cleveland, Ohio where she served as a Chief Resident. This is her recent appearance on Penn & Teller Fool Us episode - a mentalism act elegantly performed. Looking at her extraordinary academic and magic portfolios, all I can say is she is truly inspiring and magical!

Takumi Takahashi - the "Green" Magic

Takumi Takahashi's magic on "The Amazing Magicians" has shocked thousands of audience with his impressive sleight of hands. He, however, has commented his performance as 'awful' and I believe that he did appear somewhat nervous on stage. You'll understand why if you watch the clip below, on his 'usual level' of performance, and his signature "laser deal":


This is card magic at its finest and perfection. As his teacher, the legendary Lennart Green has given him the highest compliment, "Takumi has surpassed me."

Will Tsai the Visualist

I think many of you would have watched Will Tsai's performance on AGT (America's Got Talent) last year. His sensational act has successfully attracted millions of views and also triggered off some heated discussion among magicians' societies, which has been quite controversial since then. Too unreal or unbelievable? I shall not reveal any of the secrets here, but the answer actually lie in his title - he calls himself a "Visualist" for a reason! Anyway, it is still fascinating to watch it as an entertainment ;)

Knowledge vs Experience

(Image from cartoonist Hugh Macleod)

This is a great image. What I see in it is - the 'dots' can be anything we learn from textbooks, but the skill of connecting all of them is best learned from Ward Rounds and apprenticeship under our mentors, which the experience and wisdom is irreplaceable.

Best of CNY 2018

What's the highlight of this CNY shows? Yes, when Jay Chou meets Will Tsai (a.k.a the Visualist), with an eye-catching performance combining magic and song - Well, enjoy the audio-visual feast!


This song is a blast! By our young and powerful local talents - 陈颖恩×谢少唐×古洁縈, the song is filled with positive energy, and definitely more than just a CNY song! Listen to it and, Dare to Dream!

A Fairer Evaluation System to HOs

Weeks before I left, I received this warm message from one of the house officers (HOs) from my ward. I am glad that he had a fruitful posting in Nephrology. No, this is not a "self-kembang" post, but more about "HO evaluation" - what is our role, as a senior, when a HO is posted under our supervision?

Just to elaborate more - I'm often asked why am I not "harsh enough" to HOs. In fact, I hardly even raise my voice to them. Am I not a strict senior? Certainly I am, I actually supervise them closely although it might be indirectly. I wrote my concern about them years ago. There shall absolutely be no compromise in the way we train them, but I am just saying, the feedback can be done in a fairer and more professional way.

I came from the time that HO could be shouted at with the voice as loud as across the entire ward. Morning ward rounds were stressful and could even be a "live show" to the patients and relatives. Remarks such as, "Are you sure you have graduated from med school?" "If you can't manage this, you're worse than a medical student!" are often heard. A HO could be chased out from the ward just because the specialist said, "I don't like to see your face." However, when these were mentioned to senior, the reply is commonly, "Well, (shrug shoulders) during our time, a casenote could be just thrown to your face. It is considered better now."

Surely, things have changed with time. There are less glaring scenes during ward rounds nowadays, partly also because of prevalance of social media. The complaints have shifted to facebook/ whatsapp etc., where a particular HO can be "openly" discussed in the group without him/ her knowing. Let's pause for a second and think, is this a fair evaluation to them?

During my fellowship training, I was exposed to a different evaluation system and just to share:

1. During each posting, a resident will be evaluated by 2 supervisors - one on the knowledge part (by conducting mini viva in between and the end-of-posting exam) and one on the working efficiency part (the ward consultant that he/she is under). In this way, the evaluation covers both academic and work output parts.

2. "360 evaluation" - every 6-monthly, evaluation forms will be sent to your seniors, peer colleagues, juniors and nurses on your professionalism, interpersonal & communication skills and patient care etc. This evaluation is to get a more all-rounded and objective feedback of the resident.

3. "Self-assessment" - a self-check on your competency level, strengths and weaknesses. To be discussed with supervisor on how to further improve.

4. Finally, the evaluation system is mutual and you do get a chance to evaluate your ward seniors. Are they approachable? Motivated to teach? Do you find their rounds useful? How is the leadership?

Yes the paperwork can seem overwhelming, but it is undeniably a fairer evaluation system with less potential biases as compared to evaluation done one-way.

IMHO, If you're an evaluator or becoming one in future, what we can try to do or think about:

1. Focus your assessment on the right attitude and how safe/ professional is the HO, rather than knowledge alone. The latter can be learned. The fact that seniors know more simply because of "lead-time bias" i.e. we have worked longer. It is therefore our reponsibility to teach and guide them, not demoralize them!

2. (Try to) Get rid of the thinking of "New generations of HO are getting hopeless". This contains sense of grandiosity to some extents, I often think that it is either you're underestimating them, or overestimating your performances "during your time". Given time and proper training, they will just shine as well or even outperform us.

3. Avoid too negative or personal remarks. This is neither professional nor helpful. E.g. When they are unsure of an answer, "Can you go back and read, and share with the team tomorrow?" is definitely a more positive approach.

4. When the performance is not progressing as expected, before labelling as "acopia - i.e. failure to cope" or "failure to thrive", it would be more reasonable to first find out what difficulties are they facing, or is there any family/ personal issue behind impairing the learning.

5. Deal with error professionally. No medical professionals will say that there is no single error in their entire career. When it occurs, the discussion can range from personal feedback to larger channels such as M&M meetings - the key is to learn from mistake and avoid the next occurrence.

Finally, one of my mentors used to say, "In work, practise intelligent and efficient medicine, the emotional shouting part is not going to help. Why kill someone's interest in their earliest phase of career? It is a vulnerable group, give them a good training environment so that they can grow and be better than us."

Don't you feel the same way? :)

Studying Nephrology - The Resources

Continuing from the previous post on "The guidelines", this post is about some essential and useful resources when you want to study about Nephrology.
 

 

ASN (American Society of Nephrology) tops the list. ASN is actively leading the fight against kidney diseases by educating, sharing new knowledge and advancing research. In the website, you can access the learning center and their excellent Nephrology self-assessment program (NephSAP), reading their official journals of JASN and cJASN, and subscribing to their Kidney News as well. Membership is free for any Nephro trainees.

 

 

 

ISN (International Society of Nephrology) Academy is an interactive e-learning platform and mobile app providing access to latest knowledge and updates in nephrology. By being a member, there is access to ISN's official journal - Kidney International which is one of the most premier Nephrology journals.  

ISPD (International Society for Peritoneal Dialysis) has been introduced in the previous post. Besides the guidelines, ISPD also provides free access to PD curriculum which cover important PD topics such as PD prescription, adequacy, techniques, ultrafiltration issues and PD complications etc.

Other resources are as follow:
1. HDCN (Hypertension, Dialysis & Clinical Nephrology)
2. SSN (Singapore Society of Nephrology)
3. MSN (M'sian Society of Nephrology)

Meet the Greatest Mentalist

Lior Suchard - an Israeli mentalist who is known to perform "supernatural entertainment". This is one of his signature shows which he did impromptu mind-reading effortlessly and successfully mass-influenced the audience to have the same thought - and he'd tell you how he did it in the end!

Yif Magic

Yif is not new - he became a YouTube sensation years ago. His magic is very controversial and gathered compliments as well as criticism, both to the quite extreme. But I must say that his magic is creative and artistic, and truly leaves you with a sense of wonder. This is my favourite of his effects so far - the coin transposition to cup (you can watch from 5:40). Some might say the audience was over-reacting? I would have reacted the same too, I would say. Watch to believe!

Nephrology Updates in 2017?

Yes this post title is obviously over-ambitious.
For a much more informative version and with Visual abstracts please visit Neph JC on their "Top Nephro Stories of 2017".

Just to share a few updates that are particularly insightful in our clinical practice:

1. Two trials of Levosimendan  - LEVO CTS and CHEETAH, (sadly) showed that its use in cardiac surgery did not reduce RRT requirement or mortaliy. We lost another hope to improve CSA-AKI (cardiac surgery-related AKI) outcome. On the other hand, while pharmacological intervention seems not favorable, the KDIGO care bundle was shown to reduce CSA-AKI in this RCT.

2. The two RCTs of using high cut-off dialysis in myeloma cast nephropathy - EuLITE (not published yet) and MYRE are both completed and showed no difference in renal recovery outcome, but with adverse effects due to electrolyte and albumin loss. The routine use cannot be recommended.

3. Updates from IgAN classification workgroup - beside the MEST, the crescents are also predictive of outcome. So it is now MEST-C score.

4. 2017 was thought to be an exciting year for IgAN - but it turned out to be quite negative. Earlier STOP-IgAN trial did not favour immunosuppression to supportive treatment, this is further supported by recent trial showing addition of MMF/ Aza add no benefit but just more side effects. The TESTING study was terminated early due to fatal infectious events. We are now awaiting phase III trial of targeted-release Budesonide and novel agent Avacopan.

5. As compared to the good result of EMPA-REG, the CANVAS study in T2DM showed lower risk of CV events, however renal benefits are not statistically significant, and has increased risk of amputation primarily at level of toe or metatarsal. The LEADER trial - adding Liraglutide in T2DM patients with high CV risk, resulted in less newly-diagnosed macroalbuminuria but no difference in AKI, CKD progression or RRT requirement.

6. KDIGO guideline on CKD-MBD 2017 has been released.

7. Expert opinion on AKI prevention and renoprotection in ICU by European Society of Intensive Care Med (ESICM) was published - a good summary of evidence from 1966-2017 on potential protective strategies in AKI.

8. Another study supporting the evidence that UF cut off rate of >13ml/kg/hr is associated with increased cardiovascular and all-cause mortality (previously known) and intra-dialytic hypotension (in this paper).

9. After the landmark TEMPO 3:4 , the 2-year extension study (known as TEMPO 4:4) showed the sustained disease-modifying effect of Tolvaptan in ADPKD. The REPRISE study subsequently showed that use of Tolvaptan in late-stage ADPKD still slows the eGFR decline. Note the high discontinuation rate due to SE (10%) and risk of elevated ALT >3x ULN (5.6%).

10. ISPD published guideline on Encapsulating Peritoneal Sclerosis. The discussion about EPS as a potential complication of PD should be undertaken - not necessarily at the start of PD but more reasonably at the 3-4 year point of therapy.

11. PRESERVE study - RCT on 5177 patients with eGFR stage 3b-4 or 3a with DM undergoing angiography, IV isotonic bicarbonate is not better than normal saline, and Acetylcysteine is no better than placebo in terms of outcome including death, need of RRT or contrast-induced AKI. This has led to a change in recommendation in UptoDate that oral NAC is no longer recommended for prevention of CI-AKI.

12. Hypertension in adults is redefined - the change is mainly from meta-analysis of observational studis that the pre-hypertension (in old guidelines) is not benign and is assoc with higher CV risk.

13. Early initiation of RRT (defined as within 8 hours of KDIGO stage 2 AKI) led to 15% less 90-day mortality and shorter lenght of stay. The long-term clinical outcome study subsequently showed the early initiation further led to 20% all-cause mortality at 1 year and 35% less risk of renal non-recovery at 1 year. Note this is in AKI with risk of progression only (risk stratified by using NGAL biomarker).

14. After the CARI guidelines on ADPKD in 2015, European ADPKD forum has published their position statements focusing on patient-centered approach and multi-disciplinary coordination in care of ADPKD patients.

Recommended great topic reviews on:
1. Infection in Organ Transplantation - the timeline chart is now with relative risk at different time point!

2. Nutritional Management in CKD

3. Chronic Kidney Disease - from global prevalance to practice recommendations and future potential therapies.

4. Intravenous fluids - physiology, concepts and evidence-based prescription.

Let's look forward to 2018 and we shall always be hopeful in breakthroughs in better care of our renal patients!