How to organize your scientific PDF library?

During my training I downloaded and collected tons of journal articles for future reference. Most of these articles were in a pdf form and I had assigned these to variously named folders for easy retrieval. Most of us probably have some version of such “digital library” on over laptops/desktops. And, I am confident in saying that when the time comes to find THAT specific paper – we struggle. Digital organization is not our forte!

I scoured the internet for ways to improve my digital library arrangement, watched videos read blogs and even made a new folder in my library about managing a digital collection of papers!! Eventually I started using Mendeley for reference management and file organization. While the reference management part was good, I was still not happy with the file library organization function.

Knowing that I was not the only one with this difficulty, I posed my question to ASN Communities, hoping to tap into the collective wisdom of the ASN. And sure enough, I received some excellent answers that I will summarize next.

Dr Edgar Lerma, a Chicago Nephrologist has an innovative and user-friendly way of organizing references. He created a twitter hashtag #Nephpearls to link tweets with reference articles/material. He organizes papers by firing off a tweet with the hashtag #Nephpearls AND the subject of the paper, with an online link to the pdf (if free) or PubMed (if gated). To make it even more enticing he usually has a figure or a table from the paper attached to the tweet. In this way, papers are archived online for everyone who wants to retrieve it. As an example say - you are looking for Cardiorenal syndrome, all you have to do is to type in the hashtag AND topic (#Nephpearls Cardiorenal), in the search bar in twitter and this will result in several relevant tweets with figures, tables, clinical trials, excellent reviews, textbooks and even comics, all related to cardiorenal syndrome. Everyone can share in this library using the same method as Edgar. He adds these nephrology pearls (Nephpearls) regularly. Brilliant!

Biomarkers in #Cardiorenal syndrome #Nephpearls #AskASN
👉🏼 https://t.co/C6iIEOLwx3 pic.twitter.com/OStmfGmwUp

— Edgar V. Lerma 🇵🇭 (@edgarvlermamd) February 14, 2018

Another very well-organized way also was the method described by Dr. Roger Rodby from Rush University. Dr. Rodby uses a Google drive to organize and share (with his Fellows) his greater than 6000 articles. He keeps the Master PDF “Literature” Folder on his personal computer which syncs only one way to the Google drive (his computer’s Literature folder to the Google Drive’s Literature folder). By doing that he prevents anyone other than him from adding or deleting any articles to the PDF database. And also in doing so he can assure that the filing system and naming system stays intact. Dr. Rodby classifies subject headings into 39 somewhat arbitrary Nephrology topic folders:

Then he uses a unique way for article nomenclature within each topic subfolder (which is something I found very unique and clever), thus keeping an organized list of entire disease condition topics. There is a fine line between “lumping and splitting” how an article gets titled in this organizational scheme. The key to it is a short name followed by an abbreviation of the Journal Source and the year it was published. Below is a but a small snapshot of his >1400 articles in the “GN” folder”:

Rarely a day goes by that he doesn't add an article or two.

In the same vein, Dr. Nikhil Shah a nephrologist at the University of Alberta, began using Google Drive for creating and sharing a literature library with his co-fellows and staff during his fellowship years. In addition to the Dr Rodby’s list of folders (see above), he incorporated presentations from staff and other fellows to this library. These presentations are Core Nephrology teaching presentations and Nephrology Grand Rounds presentations at the University of Alberta. This Google Drive is shared within the Nephrology group locally and provides an enduring collection of teaching material to all fellows and faculty.

Another important well-organized source of high-yield landmark trials in nephrology is the online site (ukidney.com) created by Dr. Jordan Weinstein. It is organized in nine major categories (see picture below). It also includes a separate section for #VisualAbstract.

I used Rodby's way to organize my digital library, and screen #Nephpearls and ukidney for topics I am looking for.

So, what is your method to this madness?? Share with us your organization methods and I will include them here as well.

Mohamed Elrggal 
Nephrologist
Alexandria, Egypt
NSMC Intern, Class of 2018

Dialysis vascular access in the elderly – The jury is still out

What is the Fistula First Initiative? 

The Fistula First Initiative (FFI) is a national quality improvement project that was established in 2003 to increase the use of arteriovenous fistula (AVF) for hemodialysis (HD) access in incident and prevalent patients. The aim of FFI was to have a functioning AVF in 66% of the prevalent dialysis population. The use of central venous catheters (CVC) before FFI was quite high and was significantly associated with increased morbidity and mortality mainly due to catheter related blood stream infections as well as increased costs due to hospitalizations and other complications. A recent DOPPS report shows an improvement in AVF use among prevalent patients in the US, however 70% of incident HD patients still started with a CVC (See #VisualAbstract below).

What are the advantages and disadvantages of AVF? 

AVF was promoted as the best hemodialysis VA due to its superior patency, low complication rate (especially infection and thrombosis) and low overall cost. However, creating a functional AVF is sometimes not that simple and straightforward. It turns out that creating an AVF is not the only challenge, rather, the major hurdle limiting it is maintaining its patency. As the rate of AVF creations increased, the rate of primary failure increased as well, along with an increase in the use of central venous catheters (CVC) as a bridge for a maturing AV access. Factors contributing to fistula failure of maturation include; advanced age, female gender, diabetes, coronary artery disease (CAD) and peripheral vascular disease (PVD). Furthermore, the hemodynamic changes after AVF creation (see figure) can be of serious concern, particularly in patients with pre-existing cardiovascular diseases for e.g. in patients with heart failure, where a successful AVF may actually worsen the underlying heart failure.

Vascular access in elderly: 

Vascular access placement in the elderly is a prime example of why the FFI may not always be ideal. There are several reasons for this conundrum:

1. Timing of access placement. In a study published in JASN, 4283 elderly patients (out of 7701) initiated dialysis before AVF/AVG placement or at the day of surgery and were excluded from the study.

Also, 15% of included patients died before dialysis, and 17.5% did not need dialysis until the end of the study (denoting early VA placement). This makes predicting the optimal time for AVF creation more challenging.

2. Shorter survival of elderly patients with multiple comorbidities makes it more likely that these patients may die without ever requiring dialysis (as shown in the table above).

3. High rate of maturation failure
This remains one of the biggest challenges to increase the use of AVF, more so in the elderly. In the same study, 50% of elderly patients with an AVF, actually initiated dialysis via a CVC due to failure of maturation of the AVF. In contrast, only 28% of those with a predialysis AVG needed a CVC at start. Thus, Lee and his group suggested more liberal use of AVG for elderly CKD patients approaching dialysis. They concluded that an AVG creation, closer to dialysis initiation, may serve as a “catheter-sparing” approach.

The Unclear case for AVG 

An AVG has 2 main advantages: shorter time to cannulation and the less frequent need for interventions. This is supported by earlier findings that creation of AVF in elderly patients with CKD (6–9months) was not associated with better AVF success at dialysis initiation, but resulted in more predialysis interventional access procedures. Another important finding was that in patients with CKD aged greater than 80 years, predialysis AVF creation demonstrated no clear survival benefit compared with AVG creation.

However, the hypothesis that, AVG placement after dialysis initiation with a CVC will result in shorter CVC dependence and lower infections and mortality, was not supported by retrospective observational data. Instead, they observed that elderly patients initiating hemodialysis with a CVC undergoing an AVF placement within 6 months had fewer hospitalizations due to infections and a lower likelihood of death than those receiving an AVG, despite extended CVC dependence in the AVF group. (See #VisualAbstract below).

In conclusion, in the era of precision medicine and individualized care, one size doesn't fit all and fistula may not always be First! Elderly patients have high rate of primary access failure, which increase CVC use as a bridge for another access or AVG. Studies are needed to figure out how to predict which patient will have primary failure of maturation, so as we can plan for better management of his vascular access.

Mohamed Elrggal
Nephrologist
Alexandria, Egypt
NSMC Intern, Class of 2018