Month: March 2014

Nice lecture that dove tails with my herbal toxin lecture.

I just heard about this yesterday and loved the irony. The NRMP which toys with the emotions of med students everywhere by holding back match results until that wonderfully cinematic moment on Match Day, accidently leaked the match results. Shoddy programming.

Here is the thread from redddit.

Here is a blog post about the slip up:

As you can imagine, this created QUITE a stir, as medical students around the country have been waiting, stressed out of their minds, about where they will be assigned to go to residency for the next 4-7 years. A flurry of online activity ensued, as medical students already pushed to the brink took to their browser’s source codes to figure out their futures. Apparently the programmers “preloaded” the match homepage source code with the information of where people match, so that once the magic time hits on Friday, they can easily change everyone’s NRMP homepages to reveal the new result. What they didn’t realize? That there are medical students out there who are combing every detail of the site to figure out anything they can ahead of time. Several took it upon themselves to poll all of their friends to assess the accuracy of this method.

So today’s match day will have a little less drama, for every fourth year who was not obsessing over the match results.

Happy Match Day. Good luck and “…may the odds be ever in your favor.”

Last year, NephMadness came together in about 4 weeks from concept to Selection Sunday. Because of the short time available, and the fact that we had no idea what we were doing, somethings worked and others flailed. Since we are in the middle of a bracket fever epidemic, let’s take a critical look at last year’s brackets with a focus on the changes we made in 2014.

The most important thing we got right, was dividing the field into 8 regions of 8 teams and assigning unique themes to each of these regions. In 2013 the 8 themes were:

1. Big organized programs like Medicare ESRD benefit and USRDS
2. Research techniques like randomized controlled trials, propensity scoring and epigenetics
3. Randomized clinical trial like TREAT, IDEAL and ALLHAT
4. Molecules and genes, think FGF23, Cystatin C, APOL1
5. Drugs like captopril, cyclosporin and tolvaptan
6. Educational resources like UpToDate, Renal Fellow Network and Wikipedia (yeah, we went there)
7. Equations we use Winter’s formula, MDRD, FENa
8. Renal procedures like kidney biopsy, scribner shunt and plasmapheresis.

An example of this working to perfection was in Kidney Stones.

David Goldfarb, immediately grokked the game and over the course of an hour long phone call filled his brackets with great pairings that hit on stone issues relevant to nephrologists. He selected teams that represented diagnosis, treatment, the future and the past. He built a bracket that we, literally, could not have done without him.

Why I love twitter.

Intermittent HD superior to CVVHD in removing methanol and formate in methanol poisoning. http://t.co/8sHi23RnLu cc: @kidney_boy
— Bryan D. Hayes (@PharmERToxGuy) March 17, 2014

Immediate download.

See if you can get a few more authors next time.

Interesting introduction in the article about the disparity betweeen cases and resources for treating methanol. Most resources  are available in the developed world (dialysis, fomepizole) but most cases occur in the developing world. Also interesting note was that some Islamic Countries have social bans on the medicinal use of alcohol. That could make treatment pretty dicey.

They prospectively observed 24 cases of methanol ingestion out of 121 cases in a mass methanol poisoning in the Czech Republic. Looks like it was due to contamination of spirits with industrial methanol. Apparently this is a relatively common problem.

41 deaths. All patients in the observation cohort were treated with ethanol (17 patients) or fomepizole (4) or both (3) to prevent conversion of methanol to the downstream toxic metabolite, formic acid.

15 years old and this page still stands-up. Some stuff never changes. Page 358 of the Fluids Book. .

The authors present clearance data on 11 patients treated with conventional dialysis and 13 treated with continuous dialysis.

The half life of methanol with conventional dialysis was 3.7 hours and 8.1 hours with continuous dialysis. Not suprisingly all of the componants associated with more efficient dialysis were associated with with faster clearance of methanol: increased dialyzer surface area, increased blood flow and increased dialysate flow. Those half-lifes are remarkably shorter than the half life of methanol in the body using renal and pulmonary clearance.

On the other hand folate supplementation, the pre-dialysis methanol level and the nature of the antidote (ethanol versus fomepazole) made no difference.

The shorter half-life with intermittent conventional dialysis did not transplant into better patient survival.

They turned their math into specific treatment guidelines.

Some interesting tidbits. You know that graft that shows that the osmolar gap falls as the anion gap rises?

Canadian Family Physician

That wasn’t the case so much here, they found simultaneous high anion and osmolar gaps.

Things a re a bit frantic with the start of NephMadness just over 24 hours away.

Sitting on the flight deck of #NephMadness One. Note the glom pic the wife got me for Valentines day! pic.twitter.com/iMLgTlidQR
— Joel Topf (@kidney_boy) March 12, 2014

I posted on World Kidney Day at Medium but I failed to link to on PBFuids. Sorry.

My very optimistic post for WKD

I’m going to be doing more and more of my posts on Medium, it is so much better than WordPress or Blogger for composing and displaying my words.

Dear Dr Topf, 

I congratulate you on assembling and sharing this very nice presentation and, wisely, connecting it to the problems associated with politicians, supplements and DSHEA.  We have written some articles about this connection as well. 

I give a similar lecture to medical students and another focussed on BEN [ed: Balkan Endemic nephropathy] and aristolochic acid nephropathy for Medical and Nephrology Grand Rounds as most of the research being done on that subject since 2005 has been done in our lab. 

A few comments on the historical sequence:

• JP Cosyns is the Belgian pathologist who first recognized the similarity to BEN but did not follow up the lead
• Tjassa Hranjec, a medical student at Stony Brook, doing a summer fellowship conducted the personal  interview with the farmer you attributed to me. She
• was doing a pilot epi study, under my direction, to determine how we should investigate BEN
• The first experimental evidence for the role of AA in AAN and UTUC appears  in our 2007 PNAS paper
• The Serbs and the Bosnians still believed that their BEN was a different disease, so we expanded the number of cases and included those countries in the cover story paper in KI in 2012.  DeBroe wrote a commentary to accompany our paper which convinced any remaining skeptics of the validity of our guiding hypothesis: AAN = CHN = BEN
• Wondering how Aristolochia herbs could have been used throughout the world for 2000 years without one mention of toxicity or urothelial cancer, we conducted the study in Taiwan, where one in three people have ingested the Aristolochia herb according to the prescription database.  The results are in our 2012 PNAS paper.

We continue to work on this fascinating nephrotoxin/carcinogen for which, as you see has a “signature mutation” and is likely to affect tens of millions of people in China.  And the road to its recognition started exactly as you said in your talk, with the two
Belgian women in Vanderwegen’s clinic. He told me that his own clue came when he walked from his office to the clinic and found a number of women talking to each other which was unusual. He asked them how they knew each other which led immediately to the identification of the spa. 

With best regards 

Arthur P. Grollman M.D.
Distinguished Professor of Pharmacological Sciences
Evelyn Glick Professor of Experimental Medicine
Director: Laboratory of Chemical Biology
Health Sciences Center BST-8-160
Stony Brook University

The e-mail included some great images. Two covers from nephrology journals:

Gorgeous picture of DNA Adducts

The NCAA March Madness tournament with a nephrology twist. Get all the details at NephMadness.com

The DreamRCT project launched just over a month ago on January 28th. It has exciting seeing people across the nephrology blogosphere participate in this project. But all good things need to wrap-up. NephMadness is approaching so it is time for everyone to rank their favorite post.

Go to UKidney to view and rank your favorite DreamRCTs

The voting is currently neck and neck, help push your favorite over the top! And if you have a great idea for a DreamRCT, get in quick, the doors are still open. Having trouble coming up with an idea, how about pone of these:

• Systolic blood pressure targets in proteinuric disease less than 140 vs  less than 130. Fill in the hole left from ACCORD BP.
• Fixed ESA dose vs pharmacodynamic dosing (current standard of care). This editorial gets at some of the issues I’d like to explore, but doesn’t fully flesh it out.
• PTH liberal strategy vs conservative PTH strategy. Randomize patients to get PTH lowering therapy based on target PTHs, current standard of care versus only intervene for symptoms such as bone pain and itching. Answer once and for all, is PTH important?