Month: January 2012

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Apple predictions for 2011. How did I do?

Last year I posted my Apple predictions for 2011. Here is the report card.

iPad
The iPad 2 comes out in April after being announced 2-3 weeks earlier.  Not a lot of surprises. It has front and back face-time cameras, weighs less, goes faster and is thinner. It will have a higher resolution screen that Apple will brand a Retina Display but it will not have the same pixel density of the iPhone 4. There wil be three versions, WiFi only, a 3g version with CDMA and a new 4G LTE version from Verizon, AT&T and eventually Sprint.

So three weeks earlier than April 1 is March 11, So I missed the announcement date by 9 days and the release date by 20 days. Yes on cameras, weight loss, thinner, faster, CDMA, GSM and WiFi. No on Sprint, 4g and improved screen resolution
The current iPad, with the low resolution screen, no camera will live on as a low cost model at $399. With the upcoming entry of Palm, RIM and Android in to the tablet space Apple will try to suck all the atmosphere from the room by lowering the entry level price as aggressively as possible. This will upset all the other competitors pricing plans and provide less maneuvering room in the price umbrella under the iPad.
The current iPad did go down to $399, but only to blow-out existing inventory. So no.
By the end of the year Apple will have sold 70 million iPads (total 2010 an 2011 sales) and have a market share of 70+%.
Cumulative sales were 55 million by the end of 2011, so I was over-optimistic by 15 million.


iPhone
iPhone 5 is introduced in June and goes on sale in July. It sports the same form factor as iPhone 4 but has a faster processor, longer battery life, and better front and rear camera. The major new feature is near field communication. Apple sticks with 16 and 32 gb memory options. Prices remain the same.
The Verizon iPhone is introduced with the iPhone 5, the first iPhone 4 for Verizon is the $99 8 gb model introduced along with the iPhone 5.
Verizon introduced the iPhone 4 in February and there was no iPhone 5. The successor of the iPhone 4, the iPhone 4s did indeed share the form-factor of the iPhone 4, had a faster processor, better battery-life and improved back camera. No near-field communication and Apple did add a 64 gb memory option.
The white iPhone makes it first appearance since the 3gs as an iPhone 5.

April 27th the white iPhone 4 is released

Apple will sell a 65 million iPhones in 2011.

Pessimist. Apple sold 93 million iPhones in 2011. I can’t believe they moved nearly a 100 million phones.


My iPhone score card looks like this:

  • iPhone 5 in June/July          No
  • Same form factor                Yes
  • faster                                   Yes
  • better battery                       Yes                                 
  • better cameras                     Yes on back / no on front
  • price remains the same        Yes
  • Verizon iPhone                   Yes
  • Verizon with iPhone 5        No
  • White as iPhone 5               No
  • NFC                                    No
  • Memory remains the same  No
  • 65 million phone                 No
iOS
iOS 5 focuses on the cloud. Music and movies purchased through iTunes can now be streamed over the net. All devices tied to the same apple ID can stream the content, iMacs, Apple TV, iPods, iPads and iPhones.

Pretty much nailed it, except the movies and TV shows.

iOS 5 also gets over the air updating of the OS and over the air continuous back-up, a internet enabled Time Machine back-up service. This major update will better allow iPads to be used without a computer to tether to.

Nailed it

Document management moves forward allowing seamless management of a single document on an iPad then desktop mac and then an iPhone. The document lives in the cloud with synced copies on all of your apple devices.
Nailed it

iOS 5 also adds new APIs that allow software developers to accept voice control and voice feedback for applications.

Voice did debut but it was an iPhone 4s feature not a general feature of iOS. Also it’s a private API that only Apple can access so no public APIs for developers to hook into.

iOS 5 allows FaceTime over 3g.
Nope

I also missed iMessage.

Macintosh
The big story for Mac hardware will be the addition of Lightpeak to replace firewire and display port. By the end of 2011 all Macintosh’s will ship with Lightpeak. RIP Firewire.
Light peak is introduced in Febuary but it did not replace Firewire, it does replace the display port.
MacBook Pros will all go SSDs. There maybe an option for a second drive, a magnetic spinning hard drive but the primary drive will be an SSD. The MacBook will continue to have a spinning hard drive further differentiating the Pro models form the baseline MacBook. This trend will continue across the iMac and MacPro lines both of which will be updated to include an SSD as the primary drive with spinning hard drives as additional drive options.

Not yet. I will include this as one of my 2012 predictions.

Video professionals and HD enthusiasts looking for Macs to ship with Blu-Ray will continue to be disappointed. No Blue-Ray drives will ship in any Macintosh’s.

Yup

MacOS 10.7 Lion will be announced at WWDC to be introduced in the Fall. 10.7 will introduce a new look and feel with a more iOS-like theme.

Yup

The Mac App Store will be a huge hit and will reinvigorate innovation on the PC. The amount of money most people spend on desktop apps will rise and this will intropduce many people to the creativity of the independent Mac Software developer. This will further loosen Microsoft’s and Adobe’s hold on the software market as people get exposed to a myriad of less expensive, less complex and more focused single purpose applications.

Yup

iLife 2011 will add a new application. This application will allow hobbyists, enthusiasts and educators to create interactive content for the iPad. A Hypercard for a new era. See this post.

Nope, not in 2011 and I lost hope and did not include it in my 2012 predictions and then Apple introduces iBook Author. So I had the right prediction but I was early by a couple of weeks.

iPods
In September the big announcement will be that the iPod Nano adopts iOS and becomes the smallest general purpose computer. Apple will open the Nano to a specialized corner of the App store where developer focus on voice and speech for much of the interface.
Wishful thinking.

iPod classic goes away and along with it the last click wheel iPod. The iPod Touch gets a version with 128 gb to replace the lost Classic.

Nope. None of the iPods, not the classic, not the Touch or Nano saw any meaningful upgrade.

Apple TV adds apps that primarily function as channels. So there is the National Geographic app which allows you to view NG video content on your TV.

This looks like a 2012 prediction rather than 2011.

Apple
Apple will not release a release a large screen TV or any other sized TV.

Yup

They will not make a major acquisition, though they will continue to gobble up small, engineering-focussed companies with core technologies.

In 2011 Apple purchased the 3-D mapping company C3 Technologies for 267 million and the Israeli flash memory company Anobit for 390 million dollars. The Anobit purchase was the second biggest purchase in Apple’s history (only NeXT was bigger). I guess this counts as big but I was thinking of a purchase in the billions, like a Yahoo! or other frontline consumer facing company. So I am going to give me a “Yup” for this one too.

The Apple-Google tussel. Apple will not jettison Google or Google Maps.

Yup.

AAPL will hit a high of $415 and finish the year at $395.

Year-end price of 405.00, with a high of 426.70. Missed it by just 2.6% and 2.2%.

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I’m reading the Disappearing Spoon, It’s Nerdtastic

This is a tour through the periodic table. The author is blowing me away with interesting trivia while teaching me chemistry.
Today I learned about the world’s most powerful acid, a super acid with a pH of -31, 1032-times more powerful than stomach acid. He then dazzled me describing the properties of boron based carborone (HCB11Cl11) which is simultaneously the most powerful and gentlest acid. Crazy stuff. The book takes the best anecdotes that professors add to lessons to give context or spice, but its just one anecdote after another, none of the dry, difficult and boring stuff.  A perfect string of pearls.

From The Dynamic Periodic Table

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Acid Base for Med Students, a free iBook. Updated x2

Back in August of 2010 I begged for a content creation system for the iPad and last week Apple delivered iBooks Author.

I just finished converting my Acid-Base handout to the iBook format and the authoring software fits into the rest of the iWork suite. If you know how to use Pages, you will be an iBook Author wiz. The program was solid for a 1.0 release with only one crash in about ten hours of work and I didn’t lose any data. I can’t wait to dig a little deeper and really build some interactive content. I have a feeling, going forward, that iBook Author is going to be my primary content creation tool. For now check out my first iBook. 

Update: Some notes on how to use this file:
  1. You can only use the iBook on an iPad
  2. The iPad must have at least iBooks 2.0 to load the book
  3. The file can be downloaded to a computer and side loaded to the iPad through iTunes, but that seems overly complex compared to just downloading it right from the web sight right on an iPad

Update 2: version of 1.5 is now live with added interactivity.

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New Lecture: Initiation of Dialysis

This is a fellow level lecture. I built it off an old lecture from 2003 or 2004. It is remarkable how much data has emerged since then. Of coarse the IDEAL Trial has put a dagger in the heart of early initiation but the observational data in agreement with abandoning early initiation has also turned.

To fortify this lecture it needs the data on nursing home residents and dialysis outcomes and I’d like to add the recent data on dialysis mortality after the week-end.

All-in-all, its a good foundation.

Initiation of dialysis (PDF, Keynote)
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Crazy numbers: largest drop in hemoglobin without a transfusion

A drop in hemoglobin on 9 grams brings to mind the old surgical maxim “all bleeding stops” but I just had a case of a drop that big that includes three other confounding factors:

    1. He is a dialysis patient
    2. He didn’t died 
    3. He didn’t required a transfusion
He is a 58 year old patient with ADPKD, as part of this disease he had polycythemia and the day he was admitted with a chief complaint of dyspnea he had a hemoglobin of 19 g/dL. He had been advised that this was dangerous and he should go for phlebotomy. Sure enough he had a bilateral PE and multiple DVTs.


We started unfractionated heparin and ordered phlebotomy. So the next morning when we saw the decrease in the hemoglobin from 19 to 14 I was satisfied that he had a good response to phlebotomy. In reality, he never received the phlebotomy.

On that next hospital day he reported worsening flank pain. We ordered a CT to evaluate this and to help evaluate why his PD was failing. Turns out the pain and falling hemoglobin were due to a large bleeding renal cyst and renal hematoma. We stopped the heparin. The hemoglobin fell to 10 g/dL, a tidy 9 gram drop. We transferred him to the MICU. The initial plan was to embolise the bleeding kidney but the hemoglobin stabilized after stopping the heparin. After a few days of expectant testing and nervous observation we resumed the heparin and the hemoglobin held.
While we initially attributed the DVT solely to the erythrocytosis, he has a troubling family history (in addition to the ADPKD) that suggests thrombophilia.
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Crowd sourcing nephrology and IgA resources

I received this letter:

Hi,
I am a patient with IgA nephropathy, (current serum creatinine around 3.7, eGFR around 18ish).  I also have an MD from the University of Washington in seattle.

I love your blog. I was wondering if you could recommend books or review-type  journal articles on two topics of interest to me. With my MD background I can read fairly technical material, although sometimes get a bit lost in some journal articles. Wanting some overview material to bone up on a few topics.

I just haven’t been able to find book titles that seem spot-on. I have a great nephrologist here in Seattle who is very busy at the moment and I can’t seem to get his attention via email, etc. to provide these kinds of recommendations. I thought you might be able to help.

  1. 1. IgA nephropathy – overview of pathological mechanism, current research areas, etc. 
  2. 2. A good article/book on reading kidney biopsy results. 

Any information would be very much appreciated.

I didn’t have anything to suggest. Anyone have any good sources to recommend?

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Crazy Medical Presentation, or Craziest Medical Presentation?

Giles Brindley, the man who
gave whole new meaning to

PowerPoint.

In 1983 Professor Brindley presented his findings on papaverine injection and erectile dysfunction. His presentation was a bit unconventional as recounted by (PDF) Laurentz Klotz, a senior resident who attended the presentation.

…four or five of the women in the front rows threw their arms up in the air, seemingly in unison, and screamed loudly. The scientific merits of the presentation had been overwhelmed, for them, by the novel and unusual mode of demonstrating the results.

via Andy Ihnotko. Additional and comprehensive coverage at AlignMap

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Salty dog, the highest sodium I ever saw.

A series of sodiums from 176-188 mmol/L

Those are not glucoses. They are Sodiums. And, except for maybe an infant with congenital adrenal hyperplasia when I was a resident, those are the highest sodiums I have ever seen.

The primary management concern was the speed of correction. The first Na at 188 was drawn at 4:32 pm. Four hours later it was 177, a change of 11 mEq. Too fast. Here is the salient section from UpToDate:

Rate of correction in chronic hypernatremia — There are no definitive clinical trials, but data in children (particularly infants) suggest that the maximum safe rate at which the serum sodium concentration should be lowered in patients with chronic hypernatremia is 12 meq/L per day. To be safe, we suggest a maximum rate of correction of the serum sodium of 10 meq/L per day in patients who have had hypernatremia for at least 24 hours. The following findings provide support for this conclusion:

  • A retrospective case control study included 97 children with hypernatremia and dehydration; the mean baseline serum sodium was 165 meq/L. The rate of reduction in serum sodium was significantly faster in the children who developed cerebral edema compared with children who had no complications following correction of the hypernatremia (1.0 versus 0.5 meq/L per hour).
  • Similar findings were noted in another report in which the rate of reduction in serum sodium was 1.0 meq/L per hour in the nine infants who developed seizures compared with 0.6 meq/L per hour or less in 31 infants who did not develop seizures.
So Bud Rose, the dean of electrolytes, says 12 mEq per day.
Burton Rose

My patient moves 11 mEq in 4 hours after receiving 500 mL of normal saline. Now what? I was convinced that continuing normal saline would perpetuate the overly rapid correction of the sodium and put the patient at risk of cerebral edema. But since the patient was still in hypovolemic shock, I couldn’t just stop the fluids.

I ordered 3% saline. I ran it at 100 mL/hour and 5 hours later the sodium was back up to 186. I was going in circles. I then changed back to normal saline and over the subsequent 48 hours we corrected the sodium at roughly 0.5 mEq/l/hr. The whole time I was going through this I was wondering is it all necessary? Is rapid correction of hypernatremia as dangerous as Rose said it was? Is half a miliequivalent/L/hr a real evidence based speed limit?

I put this question to a fourth year medical student and he did an excellent job diving into the evidence (or lack there of) on the topic. Here is his analysis:

docx | pdf 
I think he is a little hard on Rose’s guidelines. The student’s analysis criticizes one of 4 references that are provided in UpToDate (though his criticism is appropriate and is the sole reference in Rose’s landmark Clinical Physiology of Acid Bas Disorders) to support of the 0.5 mEq/L/hr speed limit.
The four UpToDate references are:
  1. Rose’s own textbook, Clinical Physiology of Acid Bas Disorders. The page to look at in my 5th edition is 777.
  2. Kahn et al. Controlled fall in natremia and risk of seizures in hypertonic dehydration. Intensive Care Med (1979) vol. 5 (1) pp. 27-31
  3. Fang et al. Fluid management of hypernatraemic dehydration to prevent cerebral oedema: a retrospective case control study of 97 children in China. Journal of Paediatrics and Child Health (2010) vol. 46 (6) pp. 301-3
  4. Blum et al. Safe oral rehydration of hypertonic dehydration. J Pediatr Gastroenterol Nutr (1986) vol. 5 (2) pp. 232-5
I will look at each reference in detail.
The section in Rose’s text is very similar to the UpToDate card. The relevant paragraph is on page 777 in my 5th edition (black cover). The sole reference in this paragraph, is the 1986 Blum article (number 4 from the above list).
iPhone, a surprisingly effective photocopier.
Kahn retrospectively looked at the care of infants. They used half normal saline and gave it at 160 mL/kg/day (6.7 mL/kg/hr). All of the patients were 0-5 months, so maintenance fluids would have been 4 mL/kg/hr.

What book did this great page on maintenance fluids come from?

Nine of the first 47 patients developed seizures that could not be explained by other etiologies (fever, hypocalcemia, hypoglycemia) and so were ascribed to rapid fluid restoration, Group I. They matched these nine to 22 age-matched children who were treated contemporaneously but did not have a seizure, Group II. The investigators then changed the protocol for treating infants with hypernatremia to 120 mL/kg/day and included data on 9 patients under 5 months who were treated this way, Group III.

Here is the primary data on the three groups:

All three groups had similar sodiums but Group I had significantly higher BUNs than Group II, with I +II vs III and I vs III being non-signifigant.

The protocol called for patients in Group I and II to get only 160 mL/kg/day. Both groups significantly exceeded this. Group III hit its fluid goal nearly on the nose. They blamed the excess fluid on oral replacement and volume resuscitation with sodium bicarbonate.

The net result was a wide spread in the rate of correction of sodium:

  • The kids that seized: 1.02 mEq/L/hr
  • The kids that did not seize but were on the same treatment protocol: 0.62 mEq/L/hr
  • The kids on the conservative protocol, also without seizures: 0.35 mEq/L/hr

Fang looked at 97 children with hypernatremia. Mean sodium was 164.5. Mean age 13 months. He performed a case-control study with the cases being patients who developed cerebral edema. Manifestations included seizures, eyelid edema, papilledema in all the patients and bulging fontanel in 36 and pupillary abnormalities in 9 cases.

The data shows cerebral edema was more common with bolus therapy, especially when the bolus was faster, higher sodiums were associated with cerebral edema but much of that disappeared in multivariate analysis as higher sodiums were also associated with increased rate of correction and ind increased bolus rates. Using ROC the investigators found a rate of fluid administration of 6.8 ml/kg/hr was safest. And the average decrease in serum sodium in the cerebral edema group was 1 mEq/L/hr and 0.5 mEq/L/hr without cerebral edema.

The final reference is Blum’s study of oral rehydration, this is the reference my med student was upset with. As he outlined, this was a study of oral rehydration rather than a study of rates of treatment. The cohort was composed of eighteen infants, 6 months or younger admitted with hypernatremia (Na > 150) and treated with oral fluid resuscitation. They compared the hypernatremia outcomes to a second cohort of 26 infants who received IV rehydration for hypernatremia. Average sodium for both groups was 160.

In both groups the reduction of sodium was slow (0.3 mEq/L/hr) and no patient developed seizures.

In Burton Rose’s Clinical Physiology of Acid-Base and Electrolyte Disorders this observational study with no seizures is the sole reference behind the recommendation for a slow restoration of normal sodium. Weak sauce. Of note Androgue’s review of hypernatremia in the NEJM from 2000 references the same Blum and Khan articles to support its recommendation of slow treatment.

So in the end, the recommendation for slow normalization of sodium is based on a handful of studies in infants with no randomized or even prospective studies. What is unbelievable to me is no one references a study that reviews the functional/neurological outcomes of patients with the highest sodiums admitted to a large hospital based on the speed of correction. Seems like an easy study and in its absence we are left to trust in the physiology of babies.