Wednesday, March 27, 2013

Duty hour limitations

Latest headline regarding duty hour limitations:
There was no improvement in residents' reported sleep and general well-being in 2011, however, and the proportion of medical trainees who said they'd made a serious error in the past few months rose from 20 to 23 percent.

Well I'm glad we trashed decades long tradition and culture of medicine for that. One of the most important lesson I learned in medical school was from Ron Trunsky, a psychiatrist and medical sage Medicine is not like selling shoes. He would say that when ever there was patient care to be done but someone wanted to go home. Medicine is important. Medicine is hard. Medicine requires a commitment not found in regular jobs. Patients' needs do not fall between the hours of 9 and 5 but around the clock. Part of residency is training you to accept that. Part of residency is turning normal people into physicians.

Working insane hours during residency was the forge that allowed me to be cast me into a physician. Like boot camp in the military, long residency hours broke you down and reformed you into a specific type, the physician.

There is a lot to criticize about this system, but it was an important part of the physician ecosystem and it irresponsible to trash one component of that system without doing prospective studies on what will happen. Now, 9 years later what are supposed to do with this data. Apparently working 30 hours in a row was a key part of reducing medical error and made no difference in the hours slept or resident depression.

This agrees with my experience. Reduced duty hour requirements is forcing residents to spend more and more of their time watching the clock, filling out attendance records, missing lectures and skipping rounds. Trading improved fatigue for less investment in patients was a terrible bargain.

Awesome kidney video



From the website Laboratory equipment.

Nils Lindstrom, from the Univ. of Edinburgh, earned third place honors at the Small World in Motion Photomicrography Competition with his video, “Growing complexity in the kidney.”  Lindstrom’s research is focused on understanding how the kidney and nephrons are patterned during embryonic development. His image, captured as part of his ongoing research on that topic, shows a metanephric kidney, cultured in vitro and imaged over four days.
Lindstrom submitted the time-lapse video because it’s such a striking example of how a kidney starts from a simple structure and gradually becomes a highly complex collecting duct system in a matter of days. He says that how tissues are structured and patterned is a fundamental aspect of kidney development.

Tat tip Joshua Schwimmer

Saturday, March 23, 2013

Bracketology: Vicki Ivancevic

I first Twitter met vicki a couple of months ago. The Armstrong thing was blowing up. I made a joke
The story of my frantic run with Lance.
I was a real admirer of Armstrong and I lost countless hours listening to Bob Roll and Phill Liggett as US Postal and then Radioshack preyed on the Peloton in the Alps and Pyrenees  When the myth of Armstrong finally collapsed it stung.

A month later I posted a picture of my dietician's phosphorous jail. Our unit was having trouble with phosphorous, so our new dietician was throwing some creativity around. If your phos was at goal you got out of Jail, otherwise, you were doing time. In real jail you bust rocks, in our jail your arteries turn to stone.


While not loved by all:


I thought it was valuable to get a patient perspective. It can be hard to motivate patients. Techniques that work for some are pejorative or childlike to others.

The technique seems to be working, our unit numbers are improving.




On a whim I sent Vicki a #NephMadness invitation. No one needed personal invitations to play, but I can see a patient being intimidated by a doctor gag like NephMadness. I was delighted to see her enthusiasm:




With no further ado:
Hello Dr. Topf!

Here are my NephMadness brackets. It was very interesting to read the descriptions of the "teams" on the blog and make the correlations to my experiences with dialysis and my nephrologist (Dr. Hsien-Ta Fang from Edward Medical Group in Naperville, IL). I am going to bring a copy of my bracket to him on my next appointment and see what he thinks :-)  
I filled out the bracket completely from my experience and what has helped me the most as I have navigated this disease and its treatment options. This is why, for example, I chose EPO as the winner of the Loop of Henle bracket as it is EPO that keeps my hemoglobin in some sort of decent range. And since I have already gotten two calls for a transplant plus had many living donors tests (and unfortunately fail), this is why I chose Transplant as my overall NephMadness champion.

Thank you again for suggesting that I fill this out!

Vicki Ivancevic


And one final bit of VikWhit




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).

Thanks,

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.

Tuesday, March 19, 2013

NephMadness

I spend some of my blogging time at AJKD's blog, eAJKD. We have just launched what I think is the most ambitious project the nephrology blogosphere has seen. It is an NCAA-style tournament of the biggest ideas in nephrology.

Get PDF and PPT versions of the brackets at eAJKD.com


On the surface, it is simply a set of brackets that pit 64 different ideas, projects, discoveries and drugs against each other. But what makes this important are the descriptions of all 64 entities. The National Cooperative Dialysis Study was published in 1981, the year my fellows were born. They have no knowledge of these landmark moments in dialysis. The 8 posts which describe all 64 concepts can be found here:

Some of the descriptions of the match-ups are awesome. Top notch blogging. Definitely worth perusing through.

I had my partners and fellows fill out brackets today. They all had a lot of fun doing it. There is something light and joyful pitting these heavy topics against each other in totally absurd ways. Take a crack at it, have fun. Post your brackets to twitter with the hashtag #NephMadness or email them to nephmadness@cluemail.com.

Here are some of the highlights from today. 

Dr. Steigerwalt

Dr. Steigerwalt is a hypertensive specialist and a big proponent of ACEi/CCB combination so I was sure she was going to select ACCOMPLISH over ALLHAT. Interesting that she went the other way and brought ALLHAT all the way to the Final Four. When she first glanced at the brackets she told me how couldn't ESRD Medicare Benefit win it all? Well, she answered her own question because in the face of the RCT, even the Medicare ESRD benefit falls. Rounding out her final four is kidney transplant and UpToDate.


Keith Bellovich, Fellowship Director


Dr. Bellovich and I are are on very similar wave lengths and I agree with finals matchup and a lot of his early round choices. His Final four are: ESRD Benefit, Transplant, FGF-23, and NephSAP. His Cinderella team, the NCDS, going all the way to the Elite 8! He also has the TTKG making an improbable run to the sweet 16.

Three fellows filled out brackets. I will protect the innocent and just summarize their choices:

Fellow 1
  • Final Four
    • Randomized Controlled Trial
    • FGF-23
    • UpToDate
    • Kidney Transplant
  • Cinderella: Burton Rose Clinical Physiology of Acid Base... going to the sweet 16 from a 13 seed
Fellow 2
  • Final Four
    • Randomized Controlled Trial
    • ACCOMPLISH
    • Transplant
    • UpToDate
  • Cinderella: ACCOMPLISH, a 12 seed advancing to the final 4. Honorable mention the U/A and Rose's book both to the Sweet 16.
Fellow 3
  • Final Four
    • Randomized Controlled Trial
    • FGF-23
    • UpToDate
    • Kidney Transplant
  • Cinderella: Burton Rose's Clinical Physiology of Acid Base, and Rituximab... going to the sweet 16. And the DOPPS study (which has not been getting any love in the brackets I have looked at) going to the Elite 8!
Since I have a role running the tournament I will keep my brackets secret until a winner is declared.

Update:

Graham Abra, of the Renal Fellow Network was doing what all bracketologists do, trash talking other people's brackets. This is what he had to say:
Here is my fellow's reply:
I liken FGF-23 to the Gonzaga of college basketball.  It shows up whenever you talk about MBD-CKD (as the bball team makes it to the bracket almost every year)  you know it has a huge impact but not sure how much to apply it to clinically taking care of patients, but you are just waiting for the time that it all fits (aka Gonzaga wins the championship)
My reply:

Thursday, March 14, 2013

World Kidney Day: Do the ASN's bidding

I want to write more about World Kidney Day, and maybe I'll get back to this later today but for now, everyone needs to go to the ASN and answer their survey. The ASN is trying to get a handle on AKI burden. Let's do our part, because after the sequester this maybe the closest thing we get to an NIH sponsored randomized controlled trial in nephrology.



If we are really successful maybe in the future when you misspell nephrology by one letter, Chrome won't suggest neurology.


Brilliant little videos



Tuesday, March 12, 2013

Comment Spam

If you google image search best comment ever.
This  is one of the top hits.
Over the 5 years that I have been blogging, the landscape has noticeably changed. Early on, I would receive rare comments but they were good ones. As I built an audience I received more comments but rarely would I see any significant discussions like the ones you see on KevinMD or other smart medical blogs. About two years ago this trend reversed. My audience continued to rise but comments really began to drop off and I started getting more and more comment spam. I believe this transition was a direct result of the rise of Twitter.

In the last year I have been having repeated high quality discussions about posts, research and projects on Twitter. Online discussion, except in rare exceptions, has moved to Twitter.

Comment spam is robot generated text that tries to get published in order to improve the google ranking of a target website. I never publish them, though a a few may have slipped through. Here are some examples:
Anonymous has left a new comment on your post "Coffee + MacBook Air = No posts for awhile":
Helpful information. Fortunate me I found your website by accident, and I'm stunned why this accident did not happened earlier! I bookmarked it.
Here is my web page; essay experts review 
Anonymous has left a new comment on your post "How do you go from an EGD to acute kidney injury?":
Apρreсiate this ρost. Will try it out.
Alѕo visit my sitе may tinh 
Anonymous has left a new comment on your post "cyberNephrology, what a piece of cyberCrap--update...":
It's enormous that you are getting ideas from this post as well as from our discussion made at this time.
My web site ... dial 's for men Grocery coupons 
Today I received the best comment spam ever:
Anonymous has left a new comment on your post "Coffee + MacBook Air = No posts for awhile":
Do you have a spam problem on this website; I also am a blogger, and I was
curious about your situation; many of us have created some nice practices and we are looking to trade strategies with other folks,
be sure to shoot me an e-mail if interested.
Have a look at my web-site ... computer 
Comment spam going meta. Love it.

Update: Evan Williams, one of the founders of Twitter, newest venture is Medium, a content network that may exploit the movement of the conversation from comments to Twitter. Here is what Dave Weiner had to say about this:

Medium's strength appears to be the elegance and HTML 5-ness of its editorial tools. It feels nice using their editor. Like the content networks, being able to create content there is invite-only. But I'm assuming at some point it will be open to everyone, the way Tumblr or WordPress are.
An advantage Medium is likely to have is a connection to Twitter, which doesn't have a blogging system, and has recently had success with Vine. Twitter giving Medium a boost is good business, for the owners of both companies. ;-)

Saturday, March 9, 2013

So what did the FDA do?

This is just a running series of potassium facts.

From Sterns' article on sodium polysterene sulfonate (Kayexalate) and its ineffectiveness for treating hyperkalemia:
Sodium polystyrene sulfonate (SPS), an ion-exchange resin designed to bind potassium in the colon, was approved in 1958 as a treatment for hyperkalemia by the US Food and Drug Administration, 4 years before drug manufacturers were required to prove the effectiveness and safety of their drugs.
From Watson's counter editorial on sodium polysterene sulfonate and that its reasonable safety and effectiveness:
When SPS resins were first introduced, dialysis was an in- frequent procedure, and loop diuretics were in development.
You mean loop diuretics had to be developed? There was a time before lasix? Mind blown.

More random potassium trivia. The risk of hyperkalemia in anuric dialysis patients rises twice as high if they are on ACEi or ARB. Colonic and skin potassium excretion?



This is the closest thing to proof I've seen for the old saw that hyperkalemia is better tolerated in dialysis patients.

From the same article, looking at recurrent episodes of hyperkalemia:
There were 70 individuals (0.21%) who had more than 20 events [in one year of reporting!, Only one episode per day allowed], and a greater proportion of these patients had CKD, ACE-I and/or ARB use, and diabetes than the general population with hyperkalemia.

Friday, March 8, 2013

Cool Wikipedia page of the day: Hickam's Dictum. Updated.

Imagine for a moment, a patient with hypertension and galactorrhea. The patient is on risperidone, a notorious cause of galactorrhea. So the patient has hypertension and drug induced galactorrhea. But Occam's Razor is irritating my brain. There must be a single diagnosis that ties these two symptoms together. Could she have a pituitary tumor causing Cushing's disease and a prolactinoma? So I turn to my global and highly educated consulting crew, Twitter:
I received a few great responses:
and
Hickam's Dictum. I'd never heard of it even though Hickam ultimately became Dean of Indiana University, where I did residency.
For a long time I've wanted a counter argument to Occam's Razor and now I have one. Thanks Jimmy Wales!

Tuesday, March 5, 2013

College, parties and dialysis


I am on the National Kidney Foundation of Michigan's Scientific Advisory Board. Today, at the board meeting, Celeste Castillo gave a presentation on patient and family centered care. She is a dialysis patient and told a personal story of patient centered communication. She developed end-stage renal failure when she was in college. Every week-end she wanted to do what other college students did and that was drink, so every Tuesday she would show up at dialysis with too much fluid.

Her nephrologist kept wagging his finger at her until one day he sat with her on a Tuesday and started working through the problem with her. The solution: skip the beer and learn to love...tequila. Twelve ounces of beer is roughly equivalent to 1 ounce of tequila, presto, 91% reduction in volume.

Tequila for the win.

The craziest nephrology fellow assignment

In 1971, Congress was debating adding a dialysis benefit to Medicare, and extending that benefit to all Americans. As part of his testimony to the House Ways and Means Committee, Shep Glazer was dialyzed in front of the committee. The process only lasted a few minutes but the event is considered to be the moment where Congress became committed to providing the benefit.

Glazer's testified the following:
I am 43 years old, married for 20 years, with two children ages 14 and 10. I was a salesman until a couple of months ago until it became necessary for me to supplement my income to pay for the dialysis supplies. I tried to sell a noncompetitive line, was found out, and was fired. Gentlemen, what should I do? End it all and die? Sell my house for which I worked so hard, and go on welfare? Should I go into the hospital under my hospitalization policy, then I cannot work? Please tell me. If your kidneys failed tomorrow, wouldn't you want the opportunity to live? Wouldn't you want to see your children grow up?
The part of the story I never knew was that George Schreiner, the Chief of Nephrology and head of the National Kidney Foundation was the primary architect involved in lobbying congress for the dialysis benefit. He provided the dialysis machine but the National Kidney Foundation did not want to lend dignity to what they considered a risky stunt and barred Schreiner from attending.

So Schreiner sent his fellow to attend the procedure.

Can you imagine getting that page from your attending. "Hey, listen Topf, I've been barred from the hearing, but here's what we're going to do: You are going to take that dialysis machine, in that truck, to Capital Hill and then set it up. Just like I taught you. Yeah, in the hearing room for the House Ways and Means Committee. Yeah, they'll all be there. Just ignore the national press. And the TV cameras. Then I need you to give dialysis to this guy who's flying in to testify. After that, come on back and we'll finish rounds. Okay?"

The fellow was James Carey who had this to say about the event:
Several years later, Carey disclosed to Schreiner that Glazer had gone into ventricular tachycardia during the dialysis session before the committee. Carey had immediately clamped the lines. The "treatment" was very short, perhaps five minutes in all, long enough to open the blood lines but hardly a dialysis session. Nevertheless, the few members of the committee who were present characterized the episode as "excellent testimony."
That was when being a nephrology fellow was really cool.

As recounted in Biomedical Politics and Christopher Blagg in AJKD.

Monday, March 4, 2013

Salting the baby or assaulting the baby (see what I did there)

One of the causes of hypernatremia is water loss from the skin. This is increased in hot weather or if the skin damaged due to a lesion, burn or other wound. But I did not know hypernatremia cold result from cutaneous salt absorption.

Cutaneous Salt Toxicity
Fatal hypernatremia Na = 196
So in parts of the Middle East, Turkey, India, and China it is traditional to salt a newborn. Salt is dissolved in water, and olive oil and rubbed on the skin. There have been multiple reports (PubMed search | case report PDF | Google Search) of systemic cutaneous absorption of salt that causes hypernatremia.

Report from Neonatal Intensive Care Unit in Amman Jordan
  1. Three days old boy admitted with severe hypernatremia, serum sodium 194 mmol/L and intracranial hemorrhage who died.
  2. Eight days old girl with hypernatremia, serum sodium 164 mmol/L, severe hyperbilirubinemia, serum bilirubin 30 mg/dl, and intracranial bleeding.
  3. Fourteen days old boy with generalized healing skin lesions, had normal head circumference at birth but developed severe microcephaly subsequently.
  4. Six days old girl admitted with fever, meningitis and UTI, serum sodium 142 mmol/L.
  5. Seven days old boy with hyperbilirubinemia, serum bilirubin 21.5 mg/dl, and serum sodium 155 mmol/L.
 A turkish report (unsourced from a website on Turkish Living):
...from a study conducted in Turkey in 2008 about practices in pregnancy and post partum... Eighty percent of the respondents were literate/primary school graduates, 45% had given birth at home. The most potentially harmful practices among women were swaddling (81%), dressing the baby with a sand-filled nappy ('holluk') (35%), and bathing the baby in salt water (40%). A relationship between traditional postpartum practices and demographic characteristics of women such as age, educational status, age at marriage and birth place was observed P<0 .05.="">
Sounds like this practice is still common in Turkey. A neonatal team from Jordan did a presentation on this practice at a conference and their slides are online. As part of the research they interviewed 112 women who gave birth at their hospital.


According to Wikipedia this is also a biblical practice. Ezekial 16:4
Newborn babies were rubbed with salt. A reference to this practice is in Ezekiel 16:4: "As for your nativity, on the day you were born your navel cord was not cut, nor were you washed in water to cleanse you; you were not rubbed with salt nor wrapped in swaddling cloths."The significance of rubbing a newborn with salt is to indicate that the child would be raised to have integrity, to always be truthful.
What do CAM advocates say about this natural and traditional folk practice?

Just bought this last night from Fotolia

Cool Wikipedia page of the day: Salt in the Bible

Came across this page while researching up the tradition of salting a newborn. We live in a golden era.



Sunday, March 3, 2013

Renal salt wasting as a cause of hyponatremia

Any one ever see this?
Full text available here.

I hope to get back to this at some time but for now here are some comments from twitter:
and

Saturday, March 2, 2013

The first nephrology blog


Precious Bodily Fluids is part of the old guard among nephrology blogs. My first post was May 30th, 2008. Nate Hellman, creator of the Renal Fellow Network was a month earlier on April 23rd, 2008. But we were by no means the first.

The first nephblogger was Joshua Schwimmer. March 7, 2005! I remember reading Josh intermittantly right from the beginning. I even met him for coffee during an ASH meeting in 2006 or so. He was a fan of the Fluids book and encouraged me to blog. When I finally got my ass in gear and started blogging it was his endorsement which turned the microphone on. When he announced PBFluids I had already been working on it for months and suddenly I went from no traffic to a little traffic.


But Joshua has moved on. His Kidney Notes Blog has been replaced by his Tumblr InfoSnacks. Infosnacks is less of a nephrology-themed blog and more of a Joshua-themed blog. He posts anything he is interested in, and some of it is nephrology. A favorite recent post was this picture:


With the caption, K=9. Josh has evloved into the professor emeritus who has establish his role in academics and is now free to investigate what ever touches his fancy.

The current cohort of talented neph bloggers all owe Joshua a debt of gratitude. Next time you see him, kiss the ring.

Rotisserie Medical Science

Spring training is in full swing and my invitation to rejoin my fantasy baseball league has arrived. I was excited to be invited back after my poor showing last year. Yes, I'm looking at you Cliff Lee.

It got me thinking that the game I would really like would be fantasy medical scientist. You would draft a cohort of medical researchers. You would need a complete roster with a cardiologist, oncologist, ID/microbiologist, surgeon (or surgical sub-specialist) a nephrologist, endocrinologist and two other medical scientists to play utility positions.

For the next year you would score points for every paper published by the scientist. The points awarded would be the impact factor of the journal. You would lose triple impact factor for retractions.

Who's in?

Updates from Twitter:




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