ACEi talk.

A pharmacist from Blue Cross, Kim Moon, sent me an e-mail and told me she was a fan of the PBFluids and my and twitter. That, of course, instantly made her my newest bestie. She then asked me to do a webinar addressing common issues that prevent primary care doctors from prescribing ACEi/ARB to patients with diabetes. I agreed, anything for a fan of the blog.

A couple of months ago and long before the lecture was written she needed a title, so I threw out, “ACE inhibitors, the good, the bad, and the ugly”

Then I saw this tweet:

‘The good, the bad and the ugly’ appears in the title of over 450 scientific papers. Just sayin’
— Dr John Weiner (@AllergyNet) June 9, 2014

How embarrassing. Well, here’s the show:

Link to video (740MB)
PDF (52.4MB) 
Keynote (132MB)

Streaming the video from google drive seems to be broken. Here is a forum describing the problem, and Google’s lack of response to the issue. My work around has been to pony up the $60 and join Vimeo plus.

Lecture on modern strategies to keep up to date in the medical literature. #FOAMed at Work.

I love it when fellows turn the tables on their attendings and school them on how the kids do it today.

Kamran Boka is currently a critical care fellow at Henry Ford Hospital but when he was a wee resident he worked with me at St John Hospital. This is an excellent lecture, make sure you check it out. Boka is fully engaged in the 21st century medical infosphere:

Check it out. He has important lessons for everyone.

World’s Best Potassium Lecture part 1 of 3

Once agin I have the honor of teaching the second year medical students at Oakland University William Beaumont School of Medicine. I have 4 points of contact with the students:

  1. I get to run the first TBL of the renal section. It is on sodium and water
  2. I get to run an Acid-Base workshop
  3. I get to deliver a traditional Acid-Base lecture
  4. I get one hour to do potassium. Last year I tried to squeeze potassium, metabolic alkalosis and secondary/monogenic hypertension into that one hour. What a disaster. So this year I am going to flip the class took so that the students can learn the basics of potassium on their own and then do an interactive case based approach to the more advanced concepts. We’ll see if I get better ratings this year.
The lecture is mostly done, but not quite ready to be posted for download. However I did record the first segment. You can see that here.
I should have the other two segments online soon and when I do the lecture will be available as a PDF and a Keynote 2014 file.

Lecture on Herbal Medicine and Kidney Disease

In August of 2013, I went to Chicago for the ASN Board Review Class. The week long class was filled with great lectures and compelling teachers, but it was a review and I had solid knowledge of most sessions, but one session was different. Warren Kupin (Hey, Warren, we are still waiting for your first tweet!) of the University of Miami gave an inspired lecture on interstitial nephritis and the dangers of herbal medications. It was one of the most interesting lectures I have ever seen and I decided that I would remix his lecture for my February grand rounds.

I gave this grand rounds at St Johns and Providence Hospital last week (two grand rounds, same subject, same week, that’s lecturing like a boss).

Here is a link to see the presentation with me narrating.
Same presentation but higher quality.

The original Keynote file is available here for remixing and editing.

A PDF of the presentation is available here.

Notes on the presentation

Much of the information on sulfanilamide comes from this article by the FDA.

The picture comes from an ad on Etsy. I didn’t get permission to use the photo, but I did buy the bottle, so that should be cool.

Harold Watkins committed suicide after the sulfonilamide disaster, though the owner of the Messengill Company never showed any regrets: Dr. Samual Evans Massengill, the firm’s owner, said: “My chemists and I deeply regret the fatal results, but there was no error in the manufacture of the product. We have been supplying a legitimate professional demand and not once could have foreseen the unlooked-for results. I do not feel that there was any responsibility on our part.”

Diethylene glycol, though it contains two molecules of ethylene glycol there is no evidence that it behaves like ethylene glycol in a poisonong and no evidence that fomepizole would be protective. Contemporary experience with diethylene glycol comes from the Haiti Contamination disaster and a PDF from JAMA.

There are various reports for how much was shipped and how much was confiscated, I took one set of data and ran with it. If I’m wrong, shoot me.

The Kelsey information is almost entirely from Wikipedia.

@kidney_boy One (minor) thing – McGill University is in Montreal, not Toronto. Can get folks upset here in Canada. 🙂 (McGill grad here)
— Michelle Gibson (@MCG_MedEd) March 4, 2014

Getting reliable data on the size of the herbal supplement business was nearly impossible, I found sources that used anywhere from 5 billion to 100 billion. Most sources were around 26 billion so that is what I used. I imagine it depends a lot on what you includein dietary supplements and herbal medication. Of note, GNC alone does 2.6 billion dollars in revenue.

I like this slide, but it doesn’t really fit into the lecture. I bet it gets cut in a future presentation.

The tag line that people take the drugs for years, what they may take changes but they will take something for years, comes almost verbatem from Kupin’s lecture.

I really like the chart styles I used in this lecture. One of the problems with pie graphs is trying to associate a color to a trend. what part of the pie is attached to what is happening. By making one color with maximum contrast and the other with no contrast (transparent), it becomes much clearer. If I were to change anything I would get rid of the title of the slide and increase the typeface over the pies. Kupin’s slide with the same data for comparison.

The silicate stone story is a little weak and could be cut.

Love this slide. Kupin’s idea to leverage physician familiarity with Grapefruit interactions with how St. John Wort interacts. He is really clever.

The Metabolife story is so good it should be made into a movie. And the only reason there is an anvil animation is so you can drop the bars over some guy. Love this slide.

The Seville Orange and synephrine works great. The Blue Cohosh data is a little light and the fact that there aren’t a million weight loss agents using it makes me suspect that it is not a very powerful alpha agonist. May need to research this herb more thoroughly.

I need to include the incredible aspect that Patrick Arnold was the guy who brought DMAA back from the dead. Patrick Arnold was the chemist behind BALCO and inventor of The Clear.

Wife helped me with this slide, the first version had patient temperatures and ambient temperatures on a single thermometer.

The Cheerios story is cute, and illustrative but it could be sacrificed.

One of the funniest parts of Kupin’s talk is when he goes off on the crazy ridiculous packaging of herbal medications (American products waving the Dutch flag, etc.). I couldn’t pull it off and added this single slide. I may talk a bit more about the packaging requirements of DSHEA.

This slide worked as well as I hoped it would. Big risk talking about erections for a slide with 43 builds. It worked.

Weight loss supplements, go home, you’re drunk.
Phenolphthalein. Really?

The Glycyrrhiza glabra joke? It’s Kupin’s. The guy is really funny.

The 11beta-hydroxysteroid dehydrogenase story comes from my metabolic alkalosis, potassium and monogenic hypertension lecture.

It’s principal cell not principle cell. Thanks Matt.

Love this twist to the Aruvedic medicine study. I find it so funny, it is the kind of thing that usually doesn’t make it into the methods. #OverlyHonestMethods

Kupin spent a lot of time in his lecture talking about this. I blew through it pretty quickly. I may make time for this in a future version.

Love the way I told the Aristolochic Acid story. And this story board where I select the different countries turned out just like I hoped it would.

The most important slides in the deck?

This slide didn’t work as well as I would like.

The next version should add some of the data I started to put together on vitamins, especially the SELECT trial and the USPTF statement saying that vitamins have no role in the prevention of cancer of cardiac disease.

hypokalemia and metabolic alkalosis

A few years ago I was talking one of my mentors at Kidney Week, John Asplin. He mentioned

that he taught an integrated lecture on metabolic alkalosis and hypokalemia. I thought this was an inspired idea.

Teaching separate classes on both subjects results in a lot of overlap because the renal mechanisms for both disease are the same, this means that many of the diseases that cause one, also cause the other.

Additionally hypokalemia can cause metabolic alkalosis and metabolic alkalosis can cause hypokalemia, so it makes sense to teach both of these conditions in an integrated lecture.

Lastly, teaching each electrolyte individually in isolation from each other is a missed opportunity. One can only appreciate the beauty of electrolyte physiology when one understands how each electrolyte fits together and how abnormalities in one is associated and affects all of the other electrolytes.

Unfortunately, I botched the lecture. I gave this lecture for the first time for the Oakland University Beaumont Medical School this past August. I knew it didn’t go too well, but this week I received the class feedback. Overall my statistical evaluations were excellent but when I read the comments the students were jackals. They savaged this lecture.

Timing was on my side, I was scheduled to give this lecture the day after I received feedback. I’m not done tweaking it but what I did for my Tuesday lecture was add more connective tissue between the concepts, and fill in with some additional summary slides.

Right now, I’m using it as a lecture to follow-up my potassium lecture, but at OU the students didn’t have any baseline potassium knowledge. In order for this lecture to work the students must already understand the basics of potassium, especially the central role that renal potassium handling has in potassium homeostasis. Hopefully I will be able to negotiate another hour into the GU schedule for this lecture.

My next plans for this lecture is to cut out a lot of the opening slides. The purpose of those slides is to quickly move from introducing potassium and hypokalemia to getting to the truth that hypokalemia is almost solely a disease of increased renal losses.

I want to add a slide about disease opposites:

  • Pseodohypoaldosteronism type 1 and Liddle syndrome
  • Godon’s syndrome and gittleman’s syndrome
  • Adrenal insufficiency and AME

I want to add some slides on how hypokalemia causes (specifically, maintanes) metabolic alkalosis and then how metabolic alkalosis causes hypokalemia.

Here is the lecture (Keynote version | PDF)