Last fall I crossed the $10,000 finish line that was established for every participant on the MM4MM trip to Everest Basecamp. To everyone who donated thank you! 🙏🏽
Now I want to squeeze the last bit of generosity 💵 from everyone in my network.
I’m raising the roof. The new goal is $14,000.
So once again I come to you with hat in hand.
I’m asking you.
I’m begging you.
If you have ever:
downloaded a lecture or
laughed at a tweet or
Looked smart from a nephrology factoid you learned here or
Played NephMadness or
Learned about a new article at NephJC
Then consider throwing a few bucks toward multiple myeloma research. I’d love $100 donations. But what I’m really asking for is a mountain of small donations. Can you spare 25 tax-deductible dollars? What about 10?
Part of me feels that if I can’t engage my network to raise money for something as good as the MMRF then what good is this whole social media thing?
If you are the suspicious type, take a look at what I wrote about the MMRF here. This charity is doing medical research right. They take steps to keep doctors in the drivers seat of study design and that strategy is paying off with new drugs and breakthroughs.
Lets make a great fund push in the last week before I ship out to Nepal!
The trek to Everest base camp is a once in a lifetime experience. I should be bouncing with excitement but that is not what I feel. I feel unease. I feel unsettled. I read about the side effects of high altitude trekking: weakness, confusion, headaches, insomnia, nausea. This makes me nervous.
I look at the weather and see temperatures in the low teens. And that is at Lukla, elevation 9,300 feet, only half as high as Kalapatthar, our ultimate goal. I think of the previous times that I have been to high altitude. The top of Breckenridge at a hair under 13,000 feet, the top of Mount Democrat at 14,154. When you are on these peaks it is cold and windy and the plan is always to quick snap some pictures and get down. In a couple of weeks, we’ll be at those altitudes and the plan will be to go further up the mountain. We will go nearly a mile higher than anything in the continental United States. This is unsettling.
But this nervousness is in the name of something much greater. Something bigger than my personal discomfort. This trek is not an adrenaline fix. It is not about putting a dent in the bucket list. This is more important than my uneasiness and general anxiety. This trek is about rewriting the medical textbooks. It is about changing the narrative of a disease that just a few years ago had a dismal and short disease course. Multiple myeloma has a new narrative, one that is filled with words like remission, and hope, and dare we say…cure.
The Multiple Myeloma Research Foundation is a new type of disease charity. One that is focused on real advances. The MMRF is bringing treatments to patients and lighting lanterns of hope for patients everywhere, because if the story of multiple myeloma can be rewritten, so can any disease.
And so we climb. We trek. We hike to altitudes found few places in the world. We do it to call attention to this disease and the patients that are beating it. We are a symbol of a better future and for that I will suppress my anxiety and ignore some discomfort. This is big.
Help me get to the bottom of Everest. Please use this link to donate to the MMRF through Moving Mountains for Multiple Myeloma
Ten years after starting to use RunKeeper I just crossed 5,280 miles.
5,280 feet in a mile.
A mile squared.
My adult running career began with this post by Mac Developer and personal hero, Cabel Sasser.
I was inspired and the following year I bought a pair of Nikes and the Nike+ system and started slogging miles. I ultimately logged over 1,000 miles with the Nike+ system. I loved the Nike+ system. The Nike+ system was tied to the iPod and so it was a late innovation for a technology that was an evolutionary dead-end.
In 2008, I bought my first iPhone, an iPhone 3g, and downloaded one of the first running apps, RunKeeper. It used GPS to log your distance. The early iPhones had lots of holes. RunKeeper couldn’t play music, burned the battery, and crashed my phone. But the program kept getting better. Features came. Features left. The scrappy Boston start-up behind RunKeeper was bought by Big Shoe (Asics). But the program kept getting better.
Items at the bottom of the to-do-list never get done. And because you never get to the bottom, things that are important can’t be put there. If you only exercise when everything else is complete you will never exercise. You need to take care of yourself before everything else is done. Not before anything else is done, but before everything else is done.
I retweeted it, but sometimes a retweet is not enough.
Publishing is not evolving. Publishing is going away. Because the word “publishing” means a cadre of professionals who are taking on the incredible difficulty and complexity and expense of making something public. That’s not a job anymore. That’s a button. There’s a button that says “publish,” and when you press it, it’s done.
One of the things that is intoxicating about social media is watching how many people see, interact and respond to your content. This is at the heart of the difference between the little red circle on Twitter (dopamine!) versus the the little red circle on Mail (dread!).
Tracking likes and Retweets
The simplest analytics are shown below the tweet and anyone can see them.
Impressions and Engagements
The next level of analytics can only done one’s own tweets. Select one of your tweets, preferably one with a picture or a link, or both, and press “View Tweet activity”
This opens up a panel that reveals two new analytics: Impressions and Total engagements.
Impressions are a bit confusing. Here Impressions represent the number of people the Tweet was actually displayed to. So someone that was scrolling through twitter and this tweet passed her eyes would add one to the impression. This is very different than how that same term is used by Symplur (see below).
Engagements are the total number of people who have interacted with the tweet in some way. Click View all engagements to see what that means.
Twitter does a nice job of tracking and breaking down the elements that make up engagements.
Analyzing Your Twitter account
The next level in analytics is looking at your twitter account. Make sure you are logged into your twitter account on the web and then type in https://analytics.twitter.com
The analytics page has an explosion data. The top gives you your 28 day trend for Twitter.
There is a menu of additional pages of information. The only one that I find useful is Tweets. More on that later.
Scrolling down you see a summary of every month you have been on Twitter Actually I’m not sure how far it goes back, but pretty far. For each month it tells you:
Your Top Tweet. The tweet from that month with the most impressions
Your Top media Tweet. The tweet with an embedded picture, video, gif, or poll(?) with the most impressions (if your Top Tweet has attached media, the Top Media Tweet will be the tweet with the second most impressions)
Top Follower. The Twitter account that followed you that month with the most followers. Some of my months don’t list a top follower. I wonder if that is because that person no longer follows me? (And no I don’t know why Follower is capitalized)
Top mention. The Tweet that mentioned you that garnered the most impressions that month.
Next to these four pieces of information is a summary of your use of Twitter that month. I find it interesting to scroll through and see how your Twitter activity climbs and falls month to month.
Now click on Tweets at the top of the page (between Home and Audiences)
At the top Twitter shows you a histogram with the number of tweets (grey) and impressions (blue). On the right rail there are a series of histograms with the daily count of some of the components that make up engagements.
The bulk of the page is a collection, in reverse chronologic order, of all of your Tweets for the month. If you want to look at another time period you can do that with the date picker in the top right corner of the page. For each tweet you can see impressions and engagements and the rate (engagements/impressions). For each tweet you can click to reveal the full breakdown of engagements. You can sort and filter the list by pressing Top Tweets and get a short list of your top Tweets.
There are a few more tabs to explore in Analytics, but I have not found them useful.
At the end of every #NephJC and #AskASN, Matt and I race to see who can post the analytics for the chat first. To do this we are taking advantage of a service called Symplur. Symplur tracks all health hashtags. If you come up with a new health hashtag for a conference, you should go to Symplur and register that a hashtag. To use Symplur, go to their homepage and click on the magnifying glass and enter your medical hashtag.
Then click on #NephJC in the search result page. This take you to the #NephJC page in Symplur.
Ignore the schedule in Symplur, NephJC moves around inside the month enough that they never have it right. To get the Symplur analytics for an event you need to scroll to the bottom of that page, use the date picker to select the time you are interested in and press Get Analytics.
This will give you the analytics for that time period. Here is the analytics for the ACC/AHA Hypertension chat on January 16th.Mentions is the number of times a person on Twitter was mentioned along side the hashtag in question (#NephJC in this case). Tweets is the number of tweets composed by the individual which contains the hashtag. And then there is Impressions. These impressions are not the same as the impressions that Twitter tracks. Twitter impressions are real. Symplur impressions are a lie. Symplur impressions are the number of tweets multiplied by the number of followers the author has. Since I have 11k followers, each of my tweets increases my impression count by 11k. Impressions rack up gaudy numbers fast and often a larger conference will have impression counts in the 100s of millions. This is absurd. Do not believe impressions. Matt and I, when we tweet the analytics for the chat, edit out impressions. However in one of our publications we did publish impression counts for NephJC. Matt swears it wasn’t him and I swear it wasn’t me but it’s in there. Sorry.
Good 2 know. Impressions don't have a primary place in #SoMe Best Practices. Your recent 2/2017 paper gives a different portrayal pic.twitter.com/S1WhD5J2uM
That’s the basics on Twitter analytics. A number of people have developed more advanced analytics that you might want to explore but I have not found that they add much witter experience. This is enough for me. Your mileage may vary.
The St John Nephrology Fellowship is excellent. One of the reasons it is good is we continually use feedback to fix holes. In last year’s in-service exam we found some weakness in calcium so I was asked to buff the fellows calcium knowledge.
Today I started that with a lesson on CKD-MBD where we focused on the KDIGO 2017 update. I pulled what I feel are the the most important articles in this area published recently. Here is what I pulled:
What did articles did I miss? What are your favorite CKD-MBD articles
P.S. My favorite part of the guidelines, the part that tell you everything you need to know about KDIGO is 4.2.2:
Here it is in 2009:
And here it is in 2017
And the best part is how the level of evidence has not changed. 2C for both. It’s like they just woke one morning on a different side of the bed.
The University of Michigan invited me to speak on social media to the division of nephrology on January 31st. They asked me how I wanted to handle it and I told them that I would love to get an opportunity to show them rather than just tell them about social media and they responded “How about both?”
Show: At 3pm I will guide the fellows and anyone else who shows up through the European NephJC Twitter journal club chat. We will be talking about metformin in advanced CKD.
Tell: Then after NephJC, I will roll into a traditional lecture on The History and Future of Medical Education.
Please join me in University Hospital 2nd floor, room 2C-224 UH at 3pm (for NephJC)or 4pm (for a lecture). I have been told the room can hold up to 80 people. It would be fun if we could fill it.
Everyone knows the famous George Mallory answer to the question about why he was climbing Mount Everest , “because it’s there.” But I just learned that he continued after that mic drop and spoke about doing science on these mountain climbing missions:
Sometimes science is the excuse for exploration. I think it is rarely the reason.
The three primary causes of high altitude sickness:
Lake Louise Acute Mountain Sickness severity score for acute mountain score:
Preventing AMS is usually dependent on limiting altitude gain, avoiding alcohol and drinking a lot of water. Acetazolamide 125-250 bid is also effective.
The headache of acute mountain sickness can be decreased or avoided with medications:
Aspirin 320 mg po q4-hours x 3 doses, starting 1 to 2 hours prior to arrival
Ibuprofen 600 mg po q8-hours for at least 3 doses, starting 6 to 24 hours before ascent.
Ginko Biloba has been used with variable success as prophylaxis. 160-240 mg in divided doses
Dexamethasone 8 mg daily in divided doses can also be used for prophylaxis.
Nice review of AMS treatments and prophylaxis can be found here.
In studies looking at the etiology of AMS and HAPE, Vascular Endothelial Growth Factor and its soluble receptor sFlt-1 were thought to play a role. However in a study of 51 Denali mountaineers, blood levels were not associated with AMS.
The body has a number of strategies to adapt to high altitude trekking. Among the changes is the observation that the density of capillaries per unit of muscle rises. This sounds cool until you read that some scientists believe this is primarly due to a loss of muscle mass rather than growth in new capillaries.
Other strategies for adaptation include
Hyperpnea and tachypnea leading to hypocapnia
Hypoxia may trigger several receptors, including airway chemoreceptors
Tissue hypoxia also induces the production of hypoxia-inducible factor (HIF) transcription factors
Changes in metabolic pathways including oxidative metabolism, cell cycle and diminished myogenesis
Changes in hemoglobin oxygen affinity that alter arterial oxygen saturation and release to tissues
Increase in mitochondria and cytochrome oxidase occur but only after 7-9 days at altitude
High-altitude renal syndrome is an asymptomatic chronic condition of high-altitude dwellers defined as:
Relatively preserved glomerular filtration rate
High altitude renal syndrome is part of the complex adaptive response to altitude.
Creatinine based GFR is unaffected by increases in altitude, however a study that used cystatin c based GFR assessment found a 3ml/min drop in GFR for every 1,000 meters the mountaineers ascended.
Interestingly, AMS was associated with higher eGFR.
Most electrolytes fall:
The decrease in serum bicarbonate comes from hypoxia induced respiratory alkalosis. Arterial pH at the top of Everest is estimated to be 7.7 to 7.8. PaO2 was 35 mmHg!
Trekkers in the mountains have hypovolemia due to increased insensible losses, increased anorexia, and decreased thirst. Additionally there is altitude induced diuresis. This diuresis seems to be an obligatory early phase of adaptation to altitude. The diuresis can cause a 1-3 liter loss of body water resulting in a 38% increase in blood viscosity at 5,800 meters.
The diuresis has variably been explained by suppression of ADH, increases in ANP and increases in BNP. Increases in BNP are associated with increased risk of AMS.
This paragraph is very interesting:
It remains unknown whether the altitude-induced decrease in plasma volume is adaptive or potentially harmful. If adaptive, then less effort should be made to correct ‘dehydration’, and fluid intake should be limited to simply following the thirst mechanism and to offsetting insensible losses (admittedly difficult to estimate, much less measure, on the mountain). Indeed, as discussed above, fluid retention rather than dehydration is associated with AMS. Perhaps diminished plasma volume is part of the body’s effort to supply oxygen to the most vital organs, overriding the not insubstantial risks of hyperviscosity and thrombosis associated with hemoconcentration.
There could be two beneficial effects of high-altitude diuresis:
Early hemoconcentration elevates the blood concentration of hemoglobin prior to the slower onset of EPO-stimulated erythropoiesis
Volume depletion reduces intravascular pressure and volume load on the lungs and brain, and may decrease renal oxygen consumption (90% of which reflects renal sodium reabsorption) due to diminished filtration
I received an outpatient consult for acute kidney injury. One of the things that makes Saint Clair Nephrology a remarkable nephrology group is our ability to get patients in quickly. While competing practices in the area have a 3-month wait list to see new patients we get patients in within a week. This patient was seen two days after his doctor called.
The patient was frightened. He had previously been healthy and his doctor told him his kidneys were failing and that he needed to see a nephrologist. He arrived with a creatinine in the high 2s from a base line of 1.2 mg/dL. Along with the AKI his blood pressure was touching 180 systolic, out of character for him. Of note on the initial labs his calcium was 13.6 mg/dL.
The initial work-up showed suppressed PTH. SPEP and UPEP were normal.
On the next visit I checked the 1,25 vitamin D and it was 117 IU. I suspected lymphoma or sarcoidosis but the chest x-ray was unremarkable and the patient did not have any palpable lymph nodes or abnormalities on the CBC. No weight loss, night sweats, or fevers. ACE levels were unremarkable.
On further questioning on his third visit, the patient mentioned he was taking a generic knock off of Mega Red Fish Oil. Fish oils can have significant amounts of vitamin D and the supplement is famously lax with quality control. He stopped the fish oil, we started him on oral prednisone and the 1,25 vitamin D level quickly responded within a couple of weeks. The patient had a full recovery from the hypercalcemia, hypertension, and acute kidney injury.
Some great comments from Twitter
Why did you start steroids if sarcoidosis was low in your ddx?