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What is your number? John Pickering May 22

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Last night I had the honour to speak following the AGM of the Canterbury Medical Research Foundation (CMRF).  The CMRF are a fantastic organisation I’ve talked about before.  They are also one of three sponsors of my current research fellowship.  What I talked about was volunteers and clinical trials.  Two days ago the world celebrated Clinical Trials Day in honour of James Lind who in 1747 took some men aboard a ship and started to feed them citrus fruit to see if the Spanish (who had less scurvy than the British) were on to something.  I don’t know if he used volunteers or not, but I do know that since then millions of people have volunteered to be part of clinical trials.  I salute those volunteers.  I work with people who present to the Emergency Department with chest pain or are seriously ill in the ICU.  These people are vulnerable, often scared, and are asking “Am I having a heart attack?”  Yet, despite this, when approached and asked to participate in a trial they very rarely say no.  This shows to me an incredible generosity of spirit & a heart-warming willingness to do something for someone else, even when that someone else is a mythical patient some time in the future.  I salute those volunteers.  They are my heroes.

I didn’t record the talk last night, but have tried to reproduce it this morning and present it to you now. Click HERE to access from Researchgate. It is not the same as with an audience as some of it was interactive.  However, I hope you enjoy it.  It is about 20 minutes long (100Mb) and deliberately targeted at a lay audience.

logos w uni

Tagged: Acute Myocardial Infarction, Clinical trials, Heart Attack, Volunteers

Hot oil baths and other things to do on World Kidney Day 2015 John Pickering Mar 11

“In ancient times the Persian philosopher Avicenna [Ibn Sina] noted that urine may be retained in crisis of fever (s393) and prescribed hot oil baths (s413)(1). Unfortunately, apart from the supportive therapy of dialysis, there has been little progress since in the treatment of acute kidney injury (AKI).”(2)

Given that getting AKI at least doubles your chance of dying in hospital “no progress” is a major health issue.

Today is World Kidney Day and I get to post quite possibly the first blog post in the world on this day. I believe Avicenna would be thrilled with the attention paid to the organ which delivers urine. He may not be so thrilled that hot oil baths have been abandoned. Of course there is the obvious safety issues of scalding and drowning. Also, as Herod the Great found out, syncope (sudden loss of consciousness) is also a possible side effect (probably just because the heat constricted his blood flow [vasoconstriction] causing too little oxygen to reach his brain [cerebral anoxaemia].(3) Nevertheless, I think Avicenna is the type of person who would have welcomed a randomised controlled trial of hot oil baths verse today’s standard treatment.

91467137

The statue of Avicenna (Ibd Sina) to be found in Hamaden, Iran. http://www.panoramio.com/photo/91467137

If you don’t fancy a hot oil bath this World Kidney Day, then there are other things to do to minimise the possibility of Acute Kidney Injury. Have you got high blood pressure, diabetes or Chronic Kidney Disease? Be warned, ~10% of the adult population have Chronic Kidney Disease, many of whom are not aware, and many more are at risk of developing it. All add to your risk of multiple illnesses any one of which can trigger acute kidney injury. If you happen to have a heart attack or sepsis (very serious infection) you are more likely to get AKI and more likely to die because of these underlying conditions.

So, on the assumption that readers of this blog are smarter than the average bear, I shall give you some sound advice – for the sake of yourselves and your family LOOK AFTER YOURSELF (yes, I’m shouting and therefore sinning against the internet protocol police – but this is important). Cut the sugar intake, quit smoking, take a walk around the block. It ain’t rocket science (one of the simpler sciences that involves cylinders with fins and lots of explosives) – it’s easier than that.

Former World Kidney Day posts

2014 A day to celebrate https://100dialysis.wordpress.com/2014/03/13/a-day-to-celebrate/

2013 Happy WKD https://100dialysis.wordpress.com/2013/03/14/happy-wkd/

2012 I am a pee scientist https://100dialysis.wordpress.com/2012/03/07/i-am-a-pee-scientist/

References

  1. Avicenna: The Canon of Medicine [Internet]. 2nd ed. New Yourk: AMS Press; 1973. Available from: http://archive.org/stream/AvicennasCanonOfMedicine/9670940-Canon-of-Medicine_djvu.txt
  2. Pickering JW, Endre ZH: The definition and detection of acute kidney injury. Journal of Renal Injury Prevention 2014; 3:19–23 http://www.journalrip.com/Archive/3/1
  3. Retief FP, Cilliers JFG: Illnesses of Herod the Great. S Afr Med J 2003; 93:300–303

Tagged: Acute Kidney Injury, Acute Renal Failure, AKI, Avicenna, Chronic Kidney Disease, CKD, death, Diabetes, Hot oil bath, Ibn Sina, World Kidney Day

Cantabrians, this is your life John Pickering Feb 27

There is little more precious than our health and that of those we love. “Research saves lives” is  Canterbury Medical Research Foundation’s (CMRF) proudly held motto. The CMRF has been supporting the people of Canterbury for 55 years thanks to the generosity of Cantabrians. In that time they have funded more than $22 million in grants.  Yesterday I attended the launch of their new logo and branding.  The logo depicts a medical cross and the four avenues of Christchurch.  This new logo is intended to signal CMRF’s intention to be fresh and more external facing with a broader appeal to the Canterbury donating community and a bigger emphasis on  partnerships with other funding organisations to leverage money to best effect.  My own fellowship, jointly funded by the CMRF, the Emergency Care Foundation, and the Canterbury District Health Board is an example of that.  CMRF are also expanding the breadth of research they will fund and are now working to expand their influence in the translational, population health and health education spaces. Their vision is to be giving $2 million in grants per annum within 5 years.  What a great boost that will be to Canterbury. A key partner largely funded through CMRF is the NZ Brain Research Institute – their logo has also changed to mirror that of CMRF.

CMRF_launch

Tagged: Canterbury, Canterbury District Health Board, Canterbury Medical Research Foundation, Emergency Care Foundation, health, Research

Acute Kidney Injury Following Cardiac Surgery: A Well-studied Cohort of AKI John Pickering Feb 03

Originally posted on AJKD Blog:

Dr. John Pickering Dr. John Pickering

Acute kidney injury (AKI) following cardiothoracic surgery has been well reported in the nephrology literature with numerous studies published in the last decade, although the definition of AKI was variable in many of these studies.  In a recent article published in AJKD, Pickering et al perform a systematic review and meta-analysis of the literature to assess the different definitions of AKI in these studies.  Dr. John Pickering (JP), the first and corresponding author of the study, discusses this topic with Dr. Kenar Jhaveri (eAJKD), eAJKD Editor.

eAJKD:Can you explain why your team felt this topic was important to study?

JP: There is a long history of studies evaluating AKI after cardiopulmonary bypass surgery, but the information is heterogeneous and cannot be easily used to understand the extent of the problem.  We thought it was important to quantify the association and its consistency across several global…

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beyond reasonable doubt: a significant improvement John Pickering Jan 15

For the second time in a week I have removed the word “significant” from a draft manuscript written by a colleague of mine in clinical medicine. In a significantly p’d I wrote about the myth of significance – that is about the ubiquitous use of the term “significant” in the medical literature to mean a specific probability  incorrectly rejecting the hypothesis that two things (eg two treatments) are the same (you may need to read that twice).  What I pointed out was the “significant” does not mean “meaningful.”   Here I want to propose an alternative.  But first, I need to discuss two major problems with the term.

Where common is not specific

In my experience the common usage of “significant” to mean important is the normal interpretation of the word in the science literature even by many medically trained people and sometimes the authors of articles themselves.

The tyranny of p<0.05

When the maths wiz Ronald Fisher talked about significance (in an agricultural journal not a medical one!) he used 0ne in 20 (p<0.05) as an acceptable error rate in agricultural field trials so that trials did not have to be repeated many times.  That p<0.05 has taken on almost magical proportions (‘scuse the pun) in the medical literature is scary and shameful.  I don’t want to delve into all that now.  If you want to, a starting point maybe the Nature article here.

My proposal

I propose that in all scientific literature that authors replace the term “significant” with the phrase “beyond reasonable doubt” and that they only be allowed to publish the article if in the methods section they define what p value they choose to represent “beyond reasonable doubt” and they defend why they have chosen this value and not another.  “Beyond reasonable doubt” is a term used in the New Zealand judicial system where those charged with a crime are presumed innocent (Null hypothesis) until proven otherwise.  Perhaps those of us in science could learn something from our lawyer friends.

Tagged: Beyond reasonable doubt, medical literature, medicine, p value, reasonable doubt, significance testing

Cheesecake files: Just how deadly is it? John Pickering Nov 27

Everyone said it did, but how did they know and by how much?  Statements like

“The development of AKI [Acute Kidney Injury] after CPB [Cardiopulmonary Bypass Surgery] is associated with a significant increase in infectious complications, an increase in length of hospital stay, and greater mortality.” (Kumar & Suneja, Anaesthesiology 2011 14(4):964)

are common place in the acute kidney injury literature.  When I started to look at the references for such statements I realised that they were all to individual, normally single centre, studies and that the estimates of the increased risk associated with AKI after CPB varied considerably.  Furthermore, the way AKI is defined in these studies is quite varied. This lead to two questions?

  1. Just how deadly is getting AKI after CPB?
  2. Does it matter how we define AKI in this case?

These questions are important as the answer to them helps a surgeon and patient to better assess the risk associated with choosing to have cardiopulmonary bypass surgery and what the importance is in monitoring kidney function after such a surgery.  To answer these questions required a meta-analysis the results of which I have just published (a.k.a earned a cheesecake).  A meta-analysis involves systematically searching through the literature, a sentence which takes seconds to write but months to serve, for all articles reporting an association between AKI and mortality after CPB.  Then there is learning how to put all the, sometimes disparate, data together (I had to learn a lot of R for this one) and to report on it.  As this was my first meta-analysis, I was fortunate to have the assistance of two highly competent scientists & nephrologists with meta-analysis experience, namely Dr’s Matt James of Calgary, and Suetonia Palmer of my own department in the University of Otago Christchurch.

So – what did we find?

  1. If you get AKI after CPB you about 4 time more likely to die compared to if you do not get AKI after CPB even after accounting for things like age, diabetes, and other risk factors.
  2. Somewhere between 37 and 118 lives per 10,000 CPB operations could be saved if we could find a way to eliminate AKI.
  3. How AKI was measured did not make any difference to the results.
  4. AKI after CPB was also associated with increased risk of stroke.
Figure 1 from Pickering et al, AJKD 2014

A teaser of a figure from Pickering et al, AJKD 2014

Pickering, J. W., James, M. T., & Palmer, S. C. (2014). Acute Kidney Injury and Prognosis after Cardiopulmonary Bypass: A Meta-analysis of Cohort Studies. American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation. doi:10.1053/j.ajkd.2014.09.008

ps. Sorry about the paywall folks, but as I’ve said before, if we want to put this data in front of the people it is most relevant to we haven’t the budget to always make them Open Access.

 

Tagged: Acute Kidney Injury, Acute Renal Failure, AJKD, AKI, Cardiac Surgery, Cardiopulmonary Bypass, CPB, death, Dialysis, Kidney, RRT

Can Doctors and Nurses help Dialysis patients recover? John Pickering Nov 07

In the case of dialysis dependent acute kidney injury patients this is a question which Dr Dinna Cruz  and colleagues (University of California San Diego) are asking and seeking opinions from both nephrologists and non-nephrologist doctors and nurses involved in care of dialysis patients.  It was a question which arose out of discussions at this year’s Continuous Renal Replacement Therapies conference (CRRT 2014). Personally, I think it is a brilliant starting point for research to go out and seek the opinion of those “at the coal face” actually treating patients. If that includes you, please take a moment to complete the survey. If it includes someone you know, please pass this request to participate on.  Here is Dr Cruz’s request:

Currently there is much interest regarding the recovery aspect of AKI. A specific area of interest is how to enhance recovery in patients who remain dialysis-dependent at the time of discharge. It is hypothesized that patients with potential for renal recovery may require a different care plan than the “usual” ESRD patient.

Therefore we are asking your opinion regarding the post-discharge care of such patients, using this short survey. It will take only a few minutes of your time, and represents a starting point for developing potential strategies for these patients. We think it is very important to have the input of specialists from different healthcare settings and countries to give a more balanced view.

Kindly complete the survey appropriate for your specialty, then please share both these links with other colleagues so we get more responses from around the world

For nephrologists:

https://www.surveymonkey.com/s/postdischAKIcare_neph

For non-nephrologists, including acute and chronic dialysis nurses:

https://www.surveymonkey.com/s/postdischAKIcare

Thank you very much for your help!

Source: Anna Frodesiak-Wikimedia Commons

Source: Anna Frodesiak-Wikimedia Commons

Tagged: Acute Kidney Injury, Acute Renal Failure, chronic kidney injury, Dialysis, nephrologists, Nephrology, nurses, Research, survey, UC San Diego

$20bn for Medical Research! John Pickering May 15

Alas, not in New Zealand, but close … our Australian counterparts in medical research appear on the face of it to have scored big in what appears otherwise to be a grim Australian budget.  An AUD$20bn medical research “future fund” is to be established. This effectively means that by 2022-3 there will be twice the current budget available for medical research per annum (i.e. about $1bn).  How this will be divided up remains to be seen, but I note that Prof Mike Daub of Curtin University is suspicious that it is “Medical Research” not “Health and Medical Research.”

If this truly is a massive boost to medical research in Australia, what could it mean to New Zealand?

A negative possibility is that because there are already issues with recruiting medical specialists who wish to undertake research in New Zealand and because the Australian NHMRC already has successful contestable grant funding rates about twice that of New Zealand’s HRC (~16% cf ~7%), I expect there would be more one-way traffic of scientists to Australia. It is imperative that this be avoided, for all our health’s sake.

If, though, the funding recognises the value of collaborative research then it may be possible for New Zealand scientists to work more closely with their Australian counterparts on projects of mutual interest.  To that end, the New Zealand Government has (now) a great opportunity under CER to facilitate collaboration.  Perhaps, a dedicated fund that would support New Zealand researchers financially to play a role in Australian led research.  Apart from the high quality of NZ researchers (!), New Zealand should appeal to Australia because of the better integration of our health systems, especially with respect to tracing patient hospital events nationally, and because of the lower costs of doing research here.  Furthermore, health consumers in New Zealand demand the best (I know I do!) and the best is only available through research – ultimately more research across the ditch will benefit us here.  Thanks Tony.

______

ps. Catching the early flight to Sydney tomorrow to share some Trans-Tasman love and collaborate with my medical research colleagues at the Prince of Wales Hospital and the Royal Brisbane & Women’s Hospital.

Tagged: Australia, budget, future fund, HRC, medical research, NHMRC, Tony Abbott

A day to celebrate John Pickering Mar 13

If it weren’t for your kidneys where would you be?

You’d be in the hospital or infirmary,

If you didn’t have two functioning kidneys.

(with apologies to John Clarke aka Fred Dagg)

Happy World Kidney Day everyone.

This blog started off life as $100 Dialysis because I believe that if we can make a computer for $100 then surely we can do the same for dialysis!  Dialysis is a life saver, yet its cost kills as so many can not afford the treatment.

There’s some good news in the dialysis world.

Schematics of the zeolite nanonfibres and how they may look in practice

Schematics of the zeolite nanonfibres and how they may look in practice

Just last week the MANA – International Centre for Materials NanoArchitectionics announced  they have developed a method to remove waste from the blood using an easy-to-produce nanofibre mesh.  Importantly, they claim it is cheap to produce.  Details were published in Biomaterials Science (free access).  Despite the photograph, there have been no human studies yet, but I expect that won’t be too long in the future.

Dr Victor Gura and the Wearable Artificial Kidney (WAK)

Dr Victor Gura and the Wearable Artificial Kidney (WAK)

In the meantime, the FDA gave approval last month for human trials of a wearable dialysis device produced by Blood Purification Technologies Inc (the WAK).

New Zealand, and Dunedin and Christchurch in particular, lead the way in Home Dialysis.  One Dunedin tradesman has even taken Home Dialysis a step further and turned it into portable dialysis by dialysing in his work van during his lunch hour. Of course, those needing a holiday may go on the road in specially equipped camper vans (http://www.kidneys.co.nz/Kidney-Disease/Holiday-Dialysis/).

Cause for celebration in the New Zealand kidney community was the gong (Office of the New Zealand Order of Merit) given to Adrian Buttimore who for 40 years managed Christchurch’s dialysis service.

These are just a few pieces of good news as doctors and scientists work around the world to improve the lives of dialysis patients.

_________________

Hot off the Press… I couldn’t resist adding this…. Pee, the answer to the world’s energy problems. http://www.bbc.com/future/story/20140312-is-pee-power-really-possible

 

Tagged: Dialysis, Home dialysis, Kidney, Nephrology, pee, Urine, Wearable Artificial Kidney, World Kidney Day

How Academia Resembles a Drug Gang John Pickering Dec 02

John Pickering:

Worth a read for those interested in how academia works.
In the NZ context, I wonder how people see this. Is there a small cartel controlling the lives of the rest who plug away looking for grants in the hope of making the breakthrough?
Note: The increase in percentage of PhDs between 2000 and 2011 in NZ in the graph in this article is distorted by the large influx of international students in the late 90s and early 00s. This was further exacerbated by the change in rules to allow international PhD students to pay domestic and not international fees.

Originally posted on Alexandre Afonso:

In 2000, economist Steven Levitt and sociologist Sudhir Venkatesh published an article in the Quarterly Journal of Economics about the internal wage structure of a Chicago drug gang. This piece would later serve as a basis for a chapter in Levitt’s (and Dubner’s) best seller Freakonomics. [1] The title of the chapter, “Why drug dealers still live with their moms”, was based on the finding that the income distribution within gangs was extremely skewed in favor  of those at the top, while the rank-and-file street sellers earned even less than employees in legitimate low-skilled activities, let’s say at McDonald’s. They calculated 3.30 dollars as the hourly rate, that is, well below a living wage (that’s why they still live with their moms). [2]

If you take into account the risk of being shot by rival gangs, ending up in jail or being beaten up by your own hierarchy, you…

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