Wednesday, March 20, 2013

Updates and reader feedback

was updated with a letter from a reader describing how important Myron Miller was to their decision to be a nephrologist and some insight in to teaching Na and water.

Dialysis for cast nephropathy

In that post I mention my frustration with a Springer Paywall, in the days after I pushed that out, four different readers sent me the pdf. Awesome. There are advantages to living in the ivory tower.

Another letter, this one about the Fluids book

I've written in on your blog before thanking you for your book. It was the singular great read of my undergraduate medical education nearly 15 years ago. I recommend it to my trainees regularly, and like you, alternate between despair and hope that they'll "get it." I'm writing to encourage you to release an updated version soon. The motivation for me is that Clinical Physiology of Acid-Base and Electrolyte Disorders will be updated this spring after a 13 year hiatus. Your Companion is about as old as the 5th edition of Clinical Physiology and offers a more tractable entry point for medical students and resident physicians.

I am an endocrinologist with a basic science laboratory. I would be happy to provide some input (no desire for credit solicited by this offer) on topics to include. Off the top of my head, discussion of TTKG, expansion of adrenal steroids and evaluation of hypermineralocorticoid states ranging from congenital adrenal hyperplasia syndromes to adult exotica (e.g., deoxycorticosterone tumors, ectopic ACTH syndromes, and expansion of licorice poisoning and related molecular disorders).


Amnon Schlegel, MD, PhD
University of Utah
I told him that I am reworking the fluids book for a second edition and he had these insights on the state of medical education:
I claim no expertise in marketing; however, my interaction with our second year medical students (I give a 3 hour marathon on everything lipid, and one hour on mineralocorticoids) and residents (one hour of triglycerides alternating yearly with one hour on mineralocorticoids) suggests that they don’t read anything outside testable material. The motivated residents buy MKSAP early and wade through it. The students buy assorted review books, but read only if the lectures are presented poorly. I see Rose’s 5th edition languishing on our book store’s shelf (along with many others).

My lectures get very high reviews because I’ve given up: I stuff the .pptx files with long comments beneath each slide that restate what I lectured using stiffer sentence structure.

Our nursing and pharmacy students buy and read books. Your strategy might meet that need and have a spill-over to medical students.

I think your target to below 500 pages is feasible: the first 100 about water can be condensed, as I’m sure you’re thinking. Similarly, the Winter’s formulae can be presented more briefly. Consider how terse A.B. Anup’s Arterial Blood Gas Made Easy is in this regard: it’s under 100 (small 5¼” x 8½” ) pages and is mostly quiz ABGs to practice with.

What prompted my writing you is the obtuse manner in which our house staff evaluate electrolytes. I do 2 weeks of ward attending per year, and no one knows anything about sodium. Your book will not cover loop diuretic pharmacology, but in my fortnight of explaining seemingly trivial things about oral bioavailability of furosemide, torsemide, and bumetanide, I saved the government tens of thousands of dollars by discharging fluid over-loaded patients quickly by switching to torsemide and bumetanide whenever possible. Similarly, in my capacity as the endocrinology consultant (again, not full-time like you: merely 6 weeks per annum), I try to get the residents to realize that clear understanding of physiology will help in evaluation of electrolyte disorders: in the past I was asked to see a severely hypertensive and hypokalemic man 5 days after the renal service had. They’d ordered appropriate 24 hour urine collections for aldosterone and cortisol, but these are slow-turn around test. When I saw him, the terrible hyperglycemia, thin skin, and big bruises at phlebotomy sites had me steer them to ACTH-dependent Cushing syndrome as the unifying diagnosis with more rapid blood tests (the urine aldosterone was 0 mcg/24 hours, eventually).

Your book would certainly help them think more broadly and order tests more gracefully. Similarly, vaptans are here and your deep familiarity will strengthen the water metabolism aspects.

Wow, great thoughts.

In a final addendum he wrote:

That patient ended up having small cell lung cancer (the first “Liddle syndrome” since Grant Liddle described non-pitiutary ACTH syndrome in 1962 and coined the term “ectopic ACTH syndrome” in 1963, while  his eponymous syndrome was reported in1963).
  • Meador CK, Liddle GW, Island DP, Nicholson WE, Lucas CP, Nuckton, JG, Luetscher JA. Cause of Cushing's syndrome in patients with tumors arising from "nonendocrine" tissue. J Clin Endocrinol Metab. 1962 Jul;22:693-703.
  • Liddle GW, Island DP, Ney RL, Nicholson WE, Shimizu N. Nonpituitary neoplasms and Cushing's syndrome. Ectopic "adrenocorticotropin" produced by nonpituitary neoplasms as a cause of Cushing's syndrome. Arch Intern Med. 1963 Apr;111:471-5.
  • Liddle GW, Bledsoe T, Coppage W. A familial renal disorder simulating primary aldosteronism but with negligible aldosterone secretion. Trans Assoc Am Phys 1963; 76:199-213.

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