I was given the opportunity to work with Satellite Healthcare on their NephTalk podcast and hosted three episodes. The first one, on infection in dialysis units, was posted via RSS and picked up by iTunes. But the next two episodes I hosted were not posted to the RSS feed and so won’t show up in your podcast player of choice (by which I mean Overcast).
So you you’ll have to listen to them like your grand father did, as he walked to school bare foot, through the snow, uphill, both ways, via a web player. Sorry.
Satellite Healthcare is a non-for-profit dialysis company. They partnered with NephJC to do Bloggger’s Night the last three years and sponsor the NephJC Kidneys. This year they launched a Podcast, NephTalk. I was lucky to get invited to help out. I have hosted one, an interview with Sumi Sun about preventing blood stream infections. Here is her abstract from Kidney Week:
Background: CVCs are associated with catheter-related bloodstream infection (BSI) resulting in increased morbidity and mortality. Following our report of significantly reduced infection when 320 μg/mL gentamicin in 4% citrate is used as the CVC locking solution (Moran AJKD 2012), this has remained the standard of care in patients dialyzing with a CVC, unless physician order requested otherwise. The infection rates were monitored through an internal QC program developed for National Healthcare Safety Network (NHSN) reporting.
Methods: This study evaluated NHSN data with self-reported infection rates from January 2014 to December 2016 in a non-profit dialysis provider with a total of 57 free-standing dialysis facilities serving more than 5000 HD patients. BSI was reported according to NHSN criteria. Data were audited through comparison to an internal infection control report and discrepancies reconciled prior to final NHSN submission. Blood cultures were mandated before any antibiotic administration for suspected BSI, and 85% or more are sent to one internal lab (Ascend).
Results: The rate of catheter-related bloodstream infection over the three years was 1.00 episodes/100 patient months, 54% lower than the national average of 2.16 for CVC-related BSI (2014 NHSN BSI Pooled Mean Rate/100 patient-months). Monthly BSI rates showed minor fluctuations, however none exceeded the national average in any given month.
Conclusion: Gentamicin 320 μg/mL in 4% sodium citrate as a routine catheter lock demonstrated sustained low CVC-related BSI rates in HD patients, with approximately half the infection rate compared with the national average. Gentamicin-citrate lock should be considered the standard of care in patients with CVC access.
I was invited by the Curbsiders to talk about CKD. The discussion went a little long and our discussin got divided into two podcasts, #67 and #69. Here is the second half. I don’t think I made any major mistakes except when discussing combined ACEi and ARB therapy I said ALTITUDE was a study of RAAS inhibtion and endothelin antagonists. Actually ALTITUDE was RAASi and Aliskiren, the direct renin antagonist. And it was stopped not because of hyperkalemia but due to a CV signal (though the combination did have more hyperkalemia). The trial I was thinking about was ASCEND which added the endothelin antagonist avosentin to an ACEi or ARB in patients with diabetic nephropathy. This trial was also stopped early, again for CV issues after only 4 months on the drug!
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.
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.
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.
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.
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
#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.
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.
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.
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:
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.
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.
I’m addicted to podcasts. One of my favorite medical podcasts is BS Medicine. The hosts have deep medical knowledge and an enviable commitment to evidence based medicine. In addition, they approach the podcast from a clinicians perspective and don’t get so lost in the science that they forget we are here to help patients.
For their 300th podcast they did a special episode surrounding the dorm room question: If you could have only 20 medications, what would they be?
They had an interesting list and they spoke extensively justifying their list. The explanation and the list stretched over two episodes. Afterwards they did a third podcast to go over the next 10 medications that barely missed the cut.
I loved the thought exercise but I thought James, Mike, Tina and Mike really missed the boat on a few. Here is their list and mine:
The list is the same through the first three, but then I added normal saline. How can you include epinephrine and not include normal saline? And don’t start with me that salt water is not a drug. Saline will cure everything from a hangover to cholera. Essential medication.
They included oral contraceptives. My feeling is that 99% of the function of OCPs could be replaced by IUDs so women could continue to have control over their bodies and I get an additional medication. I will give up treating dysfunctional urterine bleeding, PCO and other maladies that benefit from OCPs.
I also skipped diphenhydramine. If the allergic reaction is bad enough, then we’ll give epineprine, otherwise tough tootles.
I used pentoprazole rather than omeprazole because I wanted an IV formulation. I skipped the losartan and added apixiban instead. I just couldn’t leave all those people with pulmonary embolism, atrial fibrillation and DVTs to fend for themselves with aspirin alone. The losartan omission is a bit tough to stomache as a nephrologist but truly most of the advantage of ARBs can be duplicated with good blood pressure and glycemic control (at least in diabetics). And the other renal diseases tend to be rare. Additionally I’m not as convinced as the podcasters that ARBs are just ACEi without the cough. I can’t remember seeing ARB heart failure data as impressive as:
Consensus Trial Grade 4 CHF, 1988
I don’t know enough ID to vet their antibiotics so I accepted their argument and brought in all three of their antibiotics.
That left me with three more medications after I gave the heave-ho to fluconazole and PEG. To fill this I hadded drugs to treat three of the great infectious diseases that plague this earth: HIV, TB and malaria. Seems morally wrong to ignore them. HAART is one of the greatest medical advances in our lifetime. They have an NNT that approaches one. In 1995, 55,000 Americans died of HIV and they died at young, productive ages causing incalculable losses to the nation. Blood pressure and heart failure medications are hugely important therapeutic target but treatment primarily benefits people in the tail end of their lives. Treating infectious diseases needs to be prioritized because of the age of the people affected.
What’s your list?
— Update —
I received this tweet:
I think he is exactly right. I can use heparin IV or subcutaneous. In this 20 medicine restricted world, thrombophilia will be treated like diabetes, all subcutaneous injection, all the time.