Wednesday, July 19, 2017

The Curbsiders: Hyponatremia

I was invited back to the Curbsiders for a second podcast.

We did an hour and a half on hyponatremia. Matthew Watto took what was a pretty rough interview and turned it into podcast gold. Take a listen:



The whole process was fun. Team Curbsider is a great gang and they are doing a bang up job bringing #FOAMed and Podcasts to internal medicine.

The Curbsiders have a really solid website with links to all of the references we talked about and a great index of the podcast. Take a look.

Tuesday, July 11, 2017

Acetazolamide versus Spironolactone for the Prevention of Altitude Sickness

I am going to Mount Everest Basecamp with the Multiple Myeloma Research Foundation (please donate). They have a program called Moving Mountains for Multiple Myeloma. These are even driven fund raisers. They put together a team of patients, doctors, patient caregivers, and people climbing in memorial for someone they lost to multiple myeloma.

The trek to Everest basecamp starts at 4,500 feet in Kathmandu and ends at 18,192 in Everest Basecamp. The trek isn't until next march but this past week-end the trekking team got together to meet and do some high altitude climbing around Colorado. We went to the top of Mt Democrat at 14,178 feet. This is the highest I have ever hiked.

One of the goals was to treat this Colorado trip as a shakedown trip. Try out all of the gear we will actually use on the trek to make sure it works. One of the pieces that needed to be tried out was acetazolamide, or Diamox, to prevent acute mountain sickness. The team has a few myeloma doctors and a plastic surgeon, but I am the only nephrologist. One of the participants singled me out and asked an interesting question. This trekker is on spironolactone for hypertension, and wanted to know if it was safe to combine spironolactone with acetazolamide. This made the hair on my neck stand up. Both drugs cause metabolic acidosis so that doesn't seem like a good thing. Both drugs have an opposite effect on renal potassium handling, acetazolamide causes potassium wasting, spironolactone causes potassium retention. And lastly, one of the down sides of a diuretic during mountain trekking is preventing hypovolemia, as both insensible and sensible water losses are increased with activity and getting, purifying, and carrying enough water is a constant concern on these trips. All of this made me feel that spironolactone and aldactone were a bad combination.



I asked Twitter for their thoughts and as usual they did not disappoint:




The article the Edgar found was particularly interesting.


The article is worth a read. I made a visual abstract. It seems that spironolactone does not provide protection and may make people more susceptible to mild, acute mountain sickness.


Monday, June 26, 2017

Schrödinger's Unchecked Lab

He is a 57 year old man. Husband. Father. A bit over weight, nothing too extreme. He likes to play basketball. He drinks bourbon, an occasional scotch; he rarely over indulges. The more I learn about him, the more familiar he is. He looks like any one of my friends. He only found his way to my office after his family practice doctor got frustrated trying to control his blood pressure. Maybe it's sleep apnea or too much salt in the diet. Sometimes I find a rare salt-retaining hormone abnormality.

On the first visit I did a routine urinalysis. It showed a hint of protein. When he came back, delighted with his improved blood pressures, I delved a little deeper and discovered the hint of protein was a lot more significant, with a strange ratio of albumin to protein. This is the pattern we see in myeloma. All of a sudden, the hemoglobin that looked like routine anemia yesterday is now the car crash I can't turn away from. The arthritis he mentioned transforms in my mind into myeloma bone pain. 
I tell him what I'm thinking and the casual, good natured clinical encounters become heavier. I order the myeloma tests I learned about in medical school, the PEP brothers, SPEP and UPEP. I add on the plasma free light chains that the myeloma specialists perseverate on. 
A few days later I see the electronics flag indicating unviewed lab results.
Like Schrödinger's cat in the box, at that moment he has myeloma and doesn't have myeloma. 
Time for the ambiguity to end. Time to open up the box and look inside...





This bit of medical fiction was me trying to express why I'm raising money for multiple myeloma.

I am raising money for the Multiple Myeloma Foundation as part of their Moving Mountains for Myeloma program. The peak of this endeavor will be a trip to Mount Everest Basecamp. My role is to bring awareness of myeloma, I hope this helps give an impression of one small aspect of this devastating but increasingly treatable disease. Help myeloma research.

Sunday, June 18, 2017

I got mentioned on Back to Work, kind of.

In between rounds of getting crushed by my son in Mario Cart 8, I came across this tweet...



Merlin Mann, if you are not aware, is a staple of podcasts and inventor of In Box Zero. In June sixth's Back to Work, Merlin recounts coming across my twitter bio and how it stuck with him as something interesting. I love how he can't come up with my Twitter handle or the exact quote, but he did get the word Nephrologist and totally understood the meaning of the bio, and he got why I think it is important.

My twitter bio:
Saying the product of the kidneys is urine is like saying the product of a factory is pollution. Urine is a by-product. The product is homeostasis.
This is not an original thought but me just reprocessing Homer Smith's masterpiece for Generation Twitter:
The lungs serve to maintain the composition of the extra-cellular fluid with respect to oxygen and carbon dioxide, and with this their duty ends. The responsibility for maintaining the composition of this fluid in respect to other constituents devolves on the kidneys. It is no exaggeration to say that the composition of the body fluids is determined not by what the mouth takes in but what the kidneys keep: they are the master chemists of our internal environment. Which, so to speak, they manufacture in reverse by working it over some fifteen times a day. When among other duties, they excrete the ashes of our body fires, or remove from the blood the infinite variety of foreign substances that are constantly being absorbed from our indiscriminate gastrointestinal tracts, these excretory operations are incidental to the major task of keeping our internal environments in the ideal, balanced state.  
Merlin is a skateboarder and the right age to have probably placed a few Andre the Giant has a Posse stickers. He may appreciate my homage:



Merlin's voice has been flowing into my ears since I used iTunes to download podcasts to hard drive  based iPods (2004?). He has given me hundreds of interesting ideas that have poked at my cerebral cortex for weeks. I am delighted that I have been able to do the same for him, even if it was just once.
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