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.

How to subscribe to the CJASN Podcast

On the home page of the CJASN they advertise their excellent podcast

Don't miss this month's discussion of frailty by Dr. Johansen. 

It is actually less of a discussion and more of a essay read out loud. I don't think the format is great for a podcast, but it is really well executed with solid writing and great sound quality.

If you go to iTunes to subscribe to the CJASN podcast, you will be stymied:
You can find to ASN podcasts where they discuss the journal CJASN but not the CJASN podcast. Not sure why CJASN hasn't submitted the podcast to iTunes, but there is an XML feed for the podcast. Paste this into your favorite podcast app to subscribe to CJASN:


Saturday, June 17, 2017

No more dragons left to slay

For years one of the fronts that social media advocates battled was the freedom to tweet at meetings. A number of meetings (we are looking at you ATC) were less than welcoming. I suspect many conferences were used to selling access to the meeting to people who did not participate through video tape, audio recordings or other means and they saw the social media coverage as unnecessary competition.

Why let bloggers and social media gadfly provide for free what we can sell.

Conferences are also typically run by people not on social media and who are unfamiliar with the norms of those communities. Organizers paraded excuses of academic purity and protecting authors. The issues are well documented here.

This all bubbled over last week at the American Diabetes Association national meeting in San Diego (#2017ADA). The organizers tried to enforce a no pictures policy:

One take down notice, lead to another, lead to another and suddenly the @AmDiabetesAssn feed was nothing but take down notices:

I think Swapnil hit the crux of the issue with this Tweet:

If a conference is going to wade into the world of Twitter and encourage people to participate and spread the knowledge and experience of the conference they must play by the rules of the social media platform they are using. MedTwitter is firmly in the camp of information wants to be free. Encouraging people to tweet while at the same time abandoning one of their core tenets is going to fail every time. 

In the end the ADA was made to look like fools (for the second time in two years, check out this story from 2016, and note that the embargo was designed to keep the information secret for 30 minutes before the article was published). And towards the end of the week the ADA appeared to be backtracking:

One quote, one tweet:

Linda Cann, the association's senior vice president, was quoted by Liz Neporent, " The association will be reevaluating the policy after the meeting is over"

I think this marks the end of photo bans at conferences. The ADA tweet stream was such a mess and the photo ban distracted from any scientific messaging the conference wanted to convey that no conference will again try to enforce a similar ban. You may still see signs and slides urging people not to tweet but you can say good bye to aggressive take down notices and heavies hired to patrol the conference rooms.

Matt Sparks and I have been working on ASN for a couple of years and with a final push from the ASN Communication Committee, the ASN Council has reversed their (unenforced) photo ban. This will be the rule going forward. The good guys won this one.

Friday, June 2, 2017

Lecture on autosomal dominant polycystic kidney disease

My practice has a number of nurse practitioners and physician assistants. The partners do quarterly teaching sessions for them. It is some of my favorite teaching. They come to each session with a lot of experience and the sessions are more like guided conversations rather than traditional lectures. I usually try to frame the session with a clinical practice guideline and we just go through it step by step. This time I did autosomal dominant polycystic kidney disease. I couldn't find a clinical practice guideline, so I just went with the KDIGO Controversies paper and went from there.

Update from Twitter (where else?)

The slides:

We use these to make sure we cover all aspects of the disease during the session. They really don't stand alone. They serve primarily as an outline of the conversation.

9 mb Keynote | 4.7 mb PowerPoint | 5.4 mb PDF

The bibliography:

  1. Clinical practice. Autosomal dominant polycystic kidney disease (PubMed)
  2. Autosomal-dominant polycystic kidney disease (ADPKD): executive summary from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference (PDF)
  3. Blood Pressure in Early Autosomal Dominant Polycystic Kidney Disease HALT-PKD (PubMed)
  4. Extended Follow-Up of Unruptured Intracranial Aneurysms Detected by Presymptomatic Screening in Patients with Autosomal Dominant Polycystic Kidney Disease (PMC full text)
  5. KHA-CARI Autosomal Dominant Polycystic Kidney Disease Guideline: Management of Renal Stone Disease (PDF)
  6. The Natural Course of Unruptured Cerebral Aneurysms in a Japanese Cohort (NEJM)
  7. Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease TEMPO 3:4 (NEJM)

The Tweets:

The Cake:

The NPs andPAs bought me a cake for winning the Robert Narins Award. So nice.

Sunday, May 21, 2017

NephJC this week is on AKI from running a marathon

I went through the PBFluids back catalog to find three posts on the dangers of running marathons. Two on hyponatremia and one on coronary calcium. Enjoy. Hope to see you on the Twitter with hashtag #NephJC on May 23, at 9pm EST, and May 24, at 8pm GMT.

Saturday, May 20, 2017

Herbal Medication talk for Wayne State School of Medicine Alumni Day

I was invited to speak at the Wayne State Alumni Day. It felt pretty special to come back to my old medical school and speak. They put together a great morning of lectures for their CME session.

Here is a Twitter moment from the morning

I gave my herbal medicine lecture. Download the slide deck here.

176 mb
This is a shorter 30 minute version of the talk.

You can find the full length lecture and additional information at these links:

Link to the 1-hour presentation I gave at the ACP of Michigan.

450 mb

Nephrology Update 2017 for the Michigan State Medical Society

I had the honor of speaking at the Michigan State Medical Society last night. I gave an update on nephrology.

The talk covered 6 subjects:
  1. Contrast Nephropathy
  2. NSAIDs and CKD
  3. Timing of dialysis in AKI
  4. PPIs and CKD
  5. Empagliflozen
  6. Sodium intake and excretion
I am recording screen casts of each section and will post them here.

1. Contrast Nephropathy, Maybe not so Dangerous

2. NSAIDs, Maybe not so Dangerous

I got a lot of push-back from the audience on these first two sections. One participant was was very frustrated with the message and felt it was irresponsible to present the data showing the apparent lack of toxicity from contrast and NSAIDs.

I lived through the great anemia debacle and after that I swore that I would no longer trust the experts. I wouldn't swallow the guidelines whole. If the data didn't back it, neither would I.

3. Timing of Dialysis

This was probably too wonky for a general medicine audience. I would take this out if I was going to do the talk again.

4. PPIs and CKD

5. Epagliflozen

Update in Nephrology: Empagliflozen from joel topf on Vimeo.

6. I don't have a video for the sodium story. It's only a few slides, not worth recording a video.

The Keynote file is available here.
101 MB 

Saturday, May 6, 2017

NephSAP beef

I love NephSAP. It is the greatest life long education product that I use. In my mind, it is the crown jewel of an ASN membership.  Thank-you Bob Narins.

We have embedded it into our fellowship curriculum. When I do the questions I get blown away. They are really hard. I have to go searching hard to answer them. I figure I'd get aroound 50% without access to Dr. Google and the Preview Search box. The only exception is the fluid and electrolyte issues. I can handle those pretty well. This month's NephSAP I nailed with only two misses. One of those misses annoys me. Here is the question:

So the TL;DR summary is you have a transplant patient with some graft dysfunction likely due to the concurrent volume depletion. His potassium is elevated and he has some worrying ECG changes (peaked Ts and a prolonged PR interval). Of note, he is on two medications that can provoke hyperkalemia: tacrolimus and trim/sulfa. This month's NephSAP has a great section on why tacrolimus causes hyperkalemia. Tacro causes a drug induced Gordon's syndrome:

Gordon Syndrome (pseudohypoaldosteronism type 2) is a gain-in-function mutation of the thiazide sensitive NaCl co-transporter in the distal convoluted tubule. The increased sodium resorption means there is no/little sodium available for the eNaC in the cortical collecting duct. No sodium resorption means no negative charge in the tubule driving potassium and hydrogen excretion.

The clinically relevant pearl is that calcineurin inhibitor induced hyperkalemia is particularly sensitive to thiazide diuretics. So I was hunting for some HCTZ or indapamide among the foils. 


Then I went looking for some saline to correct this patient's hypovolemic acute kidney dysfunction and increase kaluresis. 


So I was left with the unenviable position of picking among choices that I would not actually do in this circumstance. 

Fludrocortisone. I am a big fan of fludro in the treatment of hyperkalemia. But in this situation where there is both eNac antagonism by the trim/sulfa and tacro blocking distal sodium delivery, this did not seem like an effective treatment.

Patiromer. No data on patiromir for acute management of hyperkalemia, but not a bad option and this NephSAP did show some data on speed of treatment so I went with this.

Hemodialysis. This seems a bit extreme for an increase in creatinine from 1.2 to 1.4. But if the patient had a functional hemodialysis access, this is something I could be convinced to do.

But the right answer was our old friend bicarbonate. I thought we killed this one in the 90's.

The answer key says:
A sodium bicarbonate infusion would not only correct the hypovolemia, but would enhance lumen electronegativity in the cortical collecting, thereby facilitating potassium secretion. 
The reference leads you to Sterns recent review in Kidney International. Here is the relevant paragraph in that reference:

Reference 76 sounds intriguing. It is a KI article from 1977. It was an uncontrolled, but still somewhat convincing study. See the full open access manuscript here.

My beef comes from the NephSAP authors taking their eye off the ball. We don't want to lower the potassium, we want to avoid arrhythmia. The consensus in nephrology is that IV calcium is the best way to avoid arrhythmia and the NephSAP authors specifically state that IV calcium is given. My concern is why should we then give a treatment that will counteract the antidote to hyperkalemic cardiotoxicity? Raising the pH decreasea the ionized calcium. Will that precipitate arrhythmia? I don't know. I'm not sure anyone does. Without convincing prospective data I'm sticking with saline.

Wednesday, April 26, 2017

My talk from MedX (Now updated with intact audio!)

Matt Sparks and I submitted an abstract for MedX and we were selected for an oral presentation.

Here is a video slide cast of the presentation:

Here is the presentation in Keynote.

Tuesday, March 21, 2017

The Curbsiders

I love podcasts. I listen to them on my commute and when I walk my dog twice a day.

Bo the Dog

In the last year I have become addicted to The Curbsiders, what I consider the best internal medicine podcast. These three guys get interesting experts and interview them on topics with a primary care angle. They do a good job of digging deep to get good engagement from them and though they are respectful they do ask challenging questions (though honestly, I thought I got all softballs, listen to the podcast on coronary calcium scores for some probing questions).

Most importantly they are entertaining. I don't need NephSAP audio digest. That stuff kills me. Never absorbed a sentence of it. The Curbsiders make listening to medical science fun.

Looks like they stopped doing these in 2013. Anyone miss them?

And this week they had me as a guest. I enjoyed the experience immensely, but in an hour of talking off the cuff I made some embarrassing mistakes:
  • In describing water reabsorption I said it occured in the cortical collecting duct rather than the medullary collecting duct.
  • In describing my cure for cramps I tell the story of Gitelman's and say it is like congenital loop diuretics rather than congenital thiazide diuretics
  • I mucked up the story about MRFIT and how it allowed a head to head comparison of HCTZ and chlorthalidone. I really oversold what happened.
          Here is how Carter et al described the MRFIT story:
it was observed that in the 9 clinics that predominately used HCTZ, mortality was 44% higher in the special intervention (SI) group compared with the usual care (UC) group.10 The opposite was true in the 6 clinics that predominately used chlorthalidone. The MRFIT Data Safety Monitoring Board changed the protocol near the end of the trial to exclusively use chlorthalidone. In the initial clinics that used HCTZ that had a 44% higher mortality in the SI group, the trend was reversed after the protocol was changed to chlorthalidone, and they then had a 28% lower risk (P=0.04 for comparison of coronary heart disease mortality at the 2 time periods).
Like sending out newsletters, in Podcasts (especially when you are the guest) once it is recorded, you own your words with no chance to edit them.

Give The Curbsiders a listen, I think you'll enjoy them.

Monday, March 13, 2017

NephMadness Twitter Participation

Here is a summary of the first four editions of #NephMadness

And here is where we stand today.

And on March 22: 600 participants is bonkers!

And on March 26: Closing in on 700 participants.

The release of the first round results caused another surge in Twitter use:
It has also driven AJKDblog traffic to highest level ever.

Medical Greek and Medical Latin

It all started with a simple tweet by @MDaware

Chris Carrol corrected him

And I piled on

As I was posting this I was thinking. Nephrology is Greek. What ever, no one will care. Yeah, right.

The reason I knew that nephrology is Greek goes back to the early days of the The Fluid and Electrolyte Companion. We were planning the book and Sarah Faubel and I wanted to have a lot of little icons for little interesting factoids for the book. Here is the key for what made the cut:

But in earlier versions we had a lot of other icons. And one of the ideas was to have an icon for medical Latin but quickly we found that most words we wanted to define were actually Greek. We created a Medical Greek Icon, but it didn't really work so we ended up using the light bulb. Here is an example of Medical Greek as found in the Book.

This is what the unused medical Latin icon looked like:

Tricks of the Trade: How to get rid of those red squiggly line

This came across my Tweet Stream:

We are honored to have the @ISNKidneyCare Social Media Task Force covering NephMadness. However the image needs some first-aid.

Up first is getting rid of those ugly black bars on the left and right.

Solution: Use ⌘⇧4 to get a selection cross hairs, drag across your target, release the mouse button, and presto.

Tricks of the Trade: screeen shots from joel topf on Vimeo.

Alternatively. Open the picture in Preview, select the target and press ⌘K to crop.

Tricks of the Trade: Cropping in Preview from joel topf on Vimeo.

The other problem are the names on this picture, everyone of them has the spelling squiglies under the names. Here the problem is that the screen shot was taken in editing mode The two solutions are to export the document to images or put the document in Show Mode and take the screen shot. Demo time:

Tricks of the trade getting red of squigglies from joel topf on Vimeo.

Tuesday, March 7, 2017

NephMadness 2017

NephMadness launched today for the fifth consecutive year. The fourth sequal to an original is a precarious place to be. Exhibit A: Fast and the Furious resorted to bringing in Dwayne Johnson. We looked into it and sadly, he was not available.

And do we even need to mention Rocky V?

So it was with this ominous precedent that we began the journey to NephMadness. In our fifth year we were able to get 31 completely fresh concepts, with the only repeat being antiPLA2r which showed up in the inaugural NephMadness in 2013.

The regions have a few more repeats as we revisited Dialysis, Nutrition, Genetics and Biomedical Research. The theme for the year is Old versus New. More on that in an upcoming editorial (just one of a number of posts that didn't quite get finished for the launch).

If you are not familiar with NephMadness, these two videos maybe helpful.

For the next month these are the essential tools:
Brackets (PDF)

AJKDblog website for all of the scouting reports so you can make the best pics possible. bracket entry site.

Now get to it!

Saturday, March 4, 2017

Talk to Medical Students about "Why Nephrology"

I was invited to talk to the Internal Medicine Interest Group at Wayne State Medical School. Here was the deck I used, but to be honest it was mostly a discussion. Much more two way communication and less top down.

What would you have added?

Friday, March 3, 2017

Social Media Manifesto

Sharing: The Currency Of Social Media

Many people say information is power. I don’t believe that. Information sharing is power. People are more than willing to share information not because they are being paid but because they get a feeling of satisfaction that somebody else found their information useful. — Vint Cerf, Chief Internet Evangelist, Google, Inventor of TCP/IP

In this quote, Cerf was describing the value of sharing in order to explain the phenomenal success of social media sites like Facebook and Twitter, but I found that it explained much of my own Internet behavior. I think the principle is so useful: People should optimize their online creative output in order to make the content more useful for others.
Facebook has a billion people on a single network. This is unprecedented in human history, and the incentive to be part of this network comes from friends, relatives, and acquaintances volunteering information to be shared. Everything people add is effectively controlled by a third, profit-motivated, party. One would think this would paralyze sharing, yet 293,000 statuses are updated and 136,000 photos are uploaded every minute. The biggest mystery surrounding Facebook is why so many donate their time, energy, and privacy to this endeavor. The reason is not magnanimous generosity, but rather that these hundreds of millions of people are getting satisfaction from sharing.
I am a teacher and blogger. I teach nephrology to medical students, residents, fellows, and an occasional attending physician. I share all of my teaching materials on my blog. When I share these materials, I share them in a way that makes them most useful for the reader. Handouts should not be limited to PDFs but should be available in their native, editable, word processing files. How is this more useful? If you are a student and want to get my lesson, grabbing the more versatile and lighter-weight PDF makes sense; however, if you are a teacher and want to adapt a figure, or a small segment of the handout, having access to the native files is critical. The greatest satisfaction I get as a networked teacher is when I get an e-mail or tweet from a colleague thanking me for making a handout or presentation.

What was so enlightening about the explanation from Cerf was seeing that sharing is not strictly generosity but is powered by self-interest: By increasing usefulness of the resource, I get more satisfaction.
PowerPoint presentations can be distributed multiple ways over the Internet: Presentations can be exported as PDFs, SlideShare presentations, PowerPoint shows, or as native .ppt or .pptx files. Some of those formats are Read Only: PDFs, SlideShare presentations, PowerPoint shows, in that they cannot be edited or remixed by the user. Native .ppt and .pptx files are Read/Write formats that allow the user to see the presentation and freely edit, copy, and reuse parts of it.
The NYU Division of Nephrology has weekly renal grand rounds done by the fellows. In the spirit of Internet sharing, they post every presentation on the division’s website. Every presentation is available only as a PDF. This form of sharing is strictly Read Only; providing the information solely as a PDF limits users from remixing your content. Posting a presentation as a PDF says to users:

“You can use my material, but only if you use all my information. The way I teach this subject is the only way to teach this subject and my information is eternal and infallible.”

However, the Internet is inherently a Read/Write culture. The optimal way to post those presentations is as native PowerPoint files (or Google Docs Presentations or Apple Keynote presentations) so future fellows can leverage previous work, adding new data, correcting mistakes, and reworking the old into the new. Make the materials you provide online flexible to make them more useful, because the source of your satisfaction is usefulness to others.
Medicine and medical education need to abandon the Read Only assumptions about teaching materials and embrace a Read/Write culture: Students can become participants in their own education, and authors of a personalized textbook. This is how I post presentations on my web site:
  • I first have a picture of one of the slides; this helps me fly through the growing list to find a specific presentation.
  • Then I have the title and links to the native format and the PDF. The PDF is useful for people who are looking for the Read Only experience and for people without the software needed to read the native file. It is important to provide both.
  • After that, I have a few bullet points about the scope of the presentation: when it was last updated, weaknesses that need to be fixed. In this case, it has links to a supplementary handout, again as both native file and PDF. Other useful metadata includes how long the presentation is, and the size of the files.
One of the foundations of academic tradition is the ethic to attribute everything. I have seen professors seethe in national meetings as their slides or figures are used without attribution. I want to stress that providing easy ways for people to adapt and remix material in no way relieves them of the ethical obligation of attribution. In fact, attribution is another way to increase the usefulness of the work. Credibility is a primary ingredient in the usefulness of medical material, so a thorough chain of references is seen in the best medical adaptations of source material.
Putting up electronic locks in hope of dissuading people from using material without attribution is a failed strategy. It punishes the lawful without stopping the ruthless. And — importantly — if your effort to lock down your materials means that it is less useful to your audience, you get less satisfaction from sharing.
The currency of social media is sharing. If you want to build an audience and add value to whichever social media realm you occupy, you need to provide content that others can share.
If you create content, you want that content to be in the form that is most shareable. We live in a remix culture. People see content and they want to take it, change it, make it their own, and reshare it. Operating in the social media realm of medical education requires doctors to adapt to the customs of the realm and that means disposing the handcuffs of academic ownership and embracing the reason we are all educators: the dissemination of knowledge.

This post was originally published at Wing of Zock
May 8, 2013

Wednesday, March 1, 2017

One of these days...

...I'm moving my blog from blogger to WordPress.


        •  5 Reasons to switch

        •  7 Reasons to switch

        •  How to switch from Blogger to WordPress

Wednesday, February 22, 2017

In Honor of Moving Mountains for Multiple Myeloma (MM4MM) a Review of Acetazolamide

I'm going to Mount Everest Basecamp next year to help raise money and awareness for multiple myeloma. Basecamp is at 18,500 feet. In honor of that altitude, here is a review of all the times I have blogged about acetazolamide.

Please take the hint and make a donation. 

It is for multiple myeloma. 

It is a 4 star charity.

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