Hello world!

Welcome to PBFluids on WordPress. This is the first post created on WordPress. The import seemed to work pretty well.

 

There are a lot of pages and resources that have not been prted over to the new site. You can still visit the old site here.

Winning the Robert Narins Award

The Award

Saturday November 4, 2017 I accepted the Robert Narins Award from the ASN. This is the highest honor I could ever receive for the work that I have done in medical education.

Here is how ASN describes the award:

The Robert G. Narins Award honors individuals who have made substantial and meritorious contributions in education and teaching. This award is named for Robert G. Narins, who is also the first recipient of the award. 

Dr. Narins’ contributions to education and teaching started in 1967 when he was appointed to the faculty of the University of Pennsylvania. At Penn, and on the faculties of UCLA, Harvard, Temple and Henry Ford Hospital, he taught and mentored many residents and fellows. For eight years he chaired the ABIM’s Nephrology Board and also worked on the ACP’s Annual Program Committee. His contributions to education in the fields of fluid-electrolyte and acid-base physiology are prodigious and well-recognized. 

Dr. Narins was also involved in the creation and planning of many ASN educational programs during Renal Week and throughout the year, including: Board Review Course and Update, one and two day programs at Renal Week, Renal WeekEnds, and NephSAP. He also was instrumental in the decision to develop the Clinical Journal of the American Society of Nephrology (CJASN), the establishment of the Fellow of the American Society of Nephrology (FASN) program, and negotiated the successful partnership agreements with HDCN and UpToDate. Dr. Narins has been at the forefront of collaborative efforts with the American College of Physicians to increase the exposure of nephrologists to relevant updates in Internal Medicine and internists to chronic kidney disease. Collaborative educational programs with societies in Europe and Asia have helped to spread education and teaching in nephrology on a global scale.

To be recognized for this is amazing. I feel that social media and internet-based, distributed learning that leverages the skills and perspective of a large group of self-appointed experts is, and will, continue to swamp the old model of a few, highly selected, experts.

The future of medical education will not be televised. It will be streamed

In many ways, the reality of internet distributed medical education is the opposite of what people believed it would represent. I remember hearing people speak about the best lecturers being able to distribute their wisdom to the world through IP switching. The conventional wisdom was that the internet would allow all medical students to learn from the best teachers. The internet would eliminate location and size limits of the lecture hall so we would all get the Harvard education.

Social media altered that future. 

Instead of one vision being distributed to a million impressionable minds we got a million visions being distributed so that each mind could find the one that worked for them.
We are in the midst of a massive democratization of medical media.
Social media in medical education is moving us from broadcast video to YouTube, from radio and audio books to podcasts, from books and journals to blogs and tweets, from a few highly selected authority figures to a large number of educator hobbyists. 
And I am just a participant in this. I am an early adopter. I am at the front of the wave. However, I didn’t create the wave, and I can’t control it; I’m merely surfing the leading edge. And I believe ASN recognizes that. I believe that the ASN awarded me the Narins award as a symbol that distributed, social media-powered-learning, is now a valid and growing part of primary and continuing medical education. ASN is among the first of the medical societies to recognize this. I salute ASN for resisting the urge to circle the wagons and fight the inevitable. ASN should be commended for recognizing and embracing this new epoch in medical education.
That said, as much as I believe I was a just a symbol of the revolution that I am part of, they did pick me to be that symbol and for that I am grateful. And I would like to thank the people that have brought me on this journey. 
True story. I didn’t know there was a thank-you speech for the Narins award until 10 minutes before the morning session started #KidneyWk pic.twitter.com/AacOLqCPwv

— Joel Topf, MD FACP (@kidney_boy) November 5, 2017

That tweet is totally true. And in the rush to compose a coherent thank-you speech in my adrenalin addled brain I glossed over and missed some essential people.

The Patron Saint

Burton D. Rose. My favorite part of the Narins Award Legacy Video is when Rose says that Robert Narins brought fluid and electrolyte and acid-base teaching into the mainstream (1:35) and set the path for him.
I love this because Rose set the path for me, in two ways. 
One: Rose’s Clinical Physiology of Acid-Base and Electrolyte Disorders was the bible that taught me renal physiology and inspired me to pursue a career in nephrology. I bought it during my third year of medical school when I told the intern that I was working with that I was confused by eletrolytes. He suggested this book. Talk about a bad answer to a small question. I wanted a 5-minute lecture on what fluid to order and my senior suggested a 916 page, $70 tome.

But I was an idiot and I bought it.

And though it sat on my shelf for a year before I started it, when I began, I could barely put it down. I truly believe that one can draw a direct line from that terrible advice given to me at the Allen Park VA in 1993 to my position today. Sometimes bad advice can lead to the greatest of outcomes.

Rose’s book is a masterpiece because it strives to make the reader build a robust mental model of how the kidney works. Once that model is complete, it becomes easy to understand all of the electrolyte disorders.

Two: When I was an intern I was telling a doctor how much I loved Rose’s yellow electrolyte book and he told me to look him up in PubMed. I had previously looked up Berl and Schrier and I expected much of the same, but this is what I got:
Seven. Seven articles in pubmed by the great Bud Rose. The man that has done more for medical education and patient care than anybody since Osler (based on his work with UpToDate) had seven articles in PubMed in 1996. Go ahead, see for yourself. This convinced me that I could be a medical educator without being a medical researcher. I could pursue what I loved, without being distracted doing what I had little interest in doing.

The Inspiration

Joshua Schwimmer. Josh was the first nephrology blogger. I had been a long time reader for years before following his trail and starting Precious Bodily Fluids. And after a few months, Joshua gave me my first link and turned the microphone on. Thanks Josh.

The Collaborators

PBFluids and @Kidney_Boy stand apart as the only signifigant projects I have done alone. Everything else of significance has been done with a collaborator, co-author, or co-creator. This is an indisputable case of “I couldn’t have done it alone.”
Sarah Faubel as a co-author on the Microbiology Companion and The Fluid Electrolyte and Acid Base Companion
Joel Smith as co-creator of Alert and Oriented Publishing

Burke Mamlin for the work on Kidometer
Kenar Jhaveri for choosing me to be part of AJKDblog
Matt Sparks for NephMadness, DreamRCT, NSMC
Swapnil Hiremath for NephJC, NSMC
Edgar Lerma for Nephrology Secrets

Anna Burgner and Tim Yau for NephMadness

The Crew

#NephTwitter is a colorful and engaging place with an always on conversation anchored by people around the world. Here are a few of the people that populate that community.

Tom Oates, Roger Rodby, Paul Phelan, Michelle Rheault, Francesco Iannuzzella, Hector Madariaga, Graham Abra, Nikhil Shah, Matt Graham-Brown, Ian Logan, Scherly Leon, Dearbhla Kelly, Silvi Shah, David Goldfarb, Richard McCrory, F. Perry Wilson, Raymond Hsu, Benjamin Stewart, Brian Stotter.

The Enablers

My partners at St Clair Specialty have been involuntary partners on this journey and have been great. St Clair Specialty is a practice that values people that contribute to nephrology. This was clear from past CEO, Robert Provenzano, who was a major contributor to nephrology as a scientist and president of the RPA. And it is also clear with Keith Bellovich, RPA board member and chief of nephrology at St John Hospital and Medical Center. At a more single minded-practice, I could not have contributed to nephrology education as I have.

And lastly, and most importantly, I could never have contributed to medical education without my family. I need to thank the eternal patience and understanding of my wife, Cathy, and my kids, Laura and Simon Topf. Thank-you.

Site improvement

If you have been annoyed at all of the broken links at PBFluids. My apologies. Blogger doesn’t host any files so to use them you need to host elsewhere. For this reason alone I recommend WordPress or SquareSpace for people who want to start blogging.

Tonight I fixed the Handouts tab. A few weeks ago I fixed the Books tab. All of those links now work. Next up: the Lectures tab.

Question: Should old lectures that may contain out of date material be taken down, or remain up?

Fuck you Wikipedia

The Wikipedia entry for Journal Club used to have a comprehensive list of Twitter-based Journal Clubs. It looked like this

I went to add another journal club to the list yesterday (hello Journal of Hospital Medicine and #JHMChat) and it was gone. I went into the history and discovered that Twitter Journal Clubs are not notable so on September 28th that list was taken from the world. Sorry. 
I’m thinking of a new Wikipedia tag line, how does this sound: Wikipedia, where a comprehensive list of porographic actresses belongs in the encyclopedia, but Twitter Journal Clubs? Not notable.

Using visual abstracts in presentations

This past Saturday I gave a talk at the ACP of Michigan on SGLT2 inhibitors.

The talk went well, except my HDMI to thunderbolt converter failed in a big way and I had to export the presentation to Powerpoint and run it off a Windows Machine. Yuck.

I used visual abstracts from EMPA-REG and CANVAS as a significant part of the presentation. This segment demonstrates how I used them. What killed me was the cool animation, where the third panel flips to reveal the renal outcomes, was handled with complete incompetence by PowerPoint. Otherwise PowerPoint did a pretty good job displaying my slide, but botching my favorite animation in the entire presentation is bordering on unforgivable.


SGLT2i renal outcomes from joel topf on Vimeo.

Here are the two visual abstracts in question:

This slide isn’t in the above video. I will eventually get the whole presentation up, but I love this one so much I had to share.

Speaking of sharing. This Wednesday, Dr. Christos Argyropoulos will kick off the first Tubular Talk with a presentation on SGLT2 inhibitors. Should be great check out all of the details at GlomCon.

Things I want to write about eventually: Exercise induced rhabdomyolysis

Exertional Rhabdomyolysis during a 246-km Continuous Running Race

SKENDERI, K. P., S. A. KAVOURAS, C. A. ANASTASIOU, N. YIANNAKOURIS and A. MATALAS. Exertional Rhabdomyolysis during a 246-km Continuous Running Race. Med. Sci. Sports Exerc., Vol. 38, No. 6, pp. 1054 – 1057, 2006. Background: To evaluate the effect of continuous, moderate-intensity ultraendurance running exercise on skeletal muscle and hepatic damage, as indicated by serum enzyme activity measured immediately following the race. Methods: Thirty-nine runners of the Spartathlon race (a 246-km continuous race from Athens to Sparta, Greece) who managed to complete the race within the 36-h limit participated in this study. Mean finishing time of the study participants was 33.3 T 0.5 h and their average age, height, and body mass were 41 T 1 yr, 174 T 1 cm, and 67.5 T 1.1 kg, respectively. Blood samples, taken a day before and immediately after completion of the race, were assayed for the following variables: creatine kinase (CK), lactate dehydrogenase (LDH), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyltransferase (F-GT). Results: A dramatic increase in most of muscle and liver damage indicators was observed. The mean values for CK, LDH, AST, and ALT after the race were 43,763 T 6,764, 2,300 T 285, 1,182 T 165, and 264 T 37 IUILj1, respectively. These values were 29,384 T 4,327, 585 T 89, 5,615 T 902, and 1,606 T 331% higher than the corresponding values before the race (P G 0.001) for CK, LDH, AST, and ALT, respectively. However, there was not a significant increase in F-GT levels. Conclusion: Muscle and liver damage indicators were elevated at the highest level ever reported as a result of prolonged exercise, although no severe symptoms that required hospitalization were observed in any of the participants. The data suggest that even moderate-intensity exercise of prolonged duration can induce asymptomatic exertional rhabdomyolysis. Key Words: CREATINE KINASE, LACTATE DEHYDROGENASE, SPARTATHLON, ULTRAENDURANCE EXERCISE

So tasty.

Link

Get the NephRUN T-shirt While Fighting Multiple Myeloma

This tweet has taken off.

What do you call a nephrologists who likes to go jogging?

A Nephrun. pic.twitter.com/51pGZ0vQJh

— Joel Topf, MD FACP (@kidney_boy) October 3, 2017

A few people have expressed an interest in getting one for themselves. Okay, I’m a reasonable guy. How about this deal.

If you are going to Kidney Week and you donate $50 to the Multiple Myeloma Research Foundation for my trip to Everest I will get you a t-shirt. Your donation is even tax-deductible. This needs to happen in the next 10 days for me to get the shirts in time.

If you are not going to Kidney Week, donate $100 and I will send you a shirt.

Want a shirt and you already donated to the MMRF? Shoot me a tweet (DM or @) or e-mail and we’ll work this out.

After you have donated, fill out this form so I get you the right shirt and know how to get it delivered.

The shirt is really nice. The women’s version is a Hanes Ladies Cool Dri V-Neck Performance Shirt and the mens is the same shirt, but crew neck.

Have a nephrology question? #AskRenal to the rescue.

A couple of days ago, this came across my notifications

Prolonged OTC ingestion of sodium bicarbonate causing extremely low K+ (<1.5)
Any ideas as to the mechanism? @kidney_boy #askrenal

— Morgan (@Morgansb) September 27, 2017

The answer came quick.

How does bicarbonate cause hypokalemia

The video is here (complete with misspellings) and the Keynote file is here (with misspellings corrected)


How metabolic alkalosis causes hypokalemia from joel topf on Vimeo.

The beautiful #VisualAbstracts of the NEJM

This summer (I think) the NEJM began publishing visual abstracts on their twitter feed. Curiously, I was unable to find them on the page of the article that the visual abstracts references, or in the list of media types that you can search for.

The figure list on the right side does not include the striking visual abstract they created.

The “Browse Figures and Multimedia page has 19 different types of media, but visual abstract is not one of them.

The only way I could round up the visual abstracts was scrolling through the the NEJM Twitter feed. Here are the ones I found. Did I miss any?

Gorgeous work. Each one has a unique color palette and they have a pretty simple template, but three different ways of executing it. All of them look like they are from the same family except the tiotropium visual abstract. I really like that they give both the percentages and the raw numbers. No P-values or confidence intervals are found. These visual abstracts have as low an information density as I have seen. This is not a criticism, I think meh style has been increasing complexity to the detriment of my work. I need to turn up my inner NEJM.