Author: admin

PBFluids has been quiet. Took awhile to just clear the cobwebs to get this post up.

One of the things that has kept me busy has been a project with a company called MedMastery. Franz Wiesbauer was a fan of my fluids book and reached out to me. We worked together to create a curriculum covering body water, diuretics, IV Fluids, sodium and potassium. The full course is about 1,000 slides. But the genius of MedMastery is how they edit and craft the course so it is broken up into an odd fifty 6-minute morsels. It is medical school for Generation Keurig.

MedMastery has opened up a few of the K-cups for promotion. 

Take a look at two of my diuretic lectures:

Philosophy of diuretics

 Loop Diuretics

Thiazide diuretics

Acetazolamide and potassium sparing diuretics

Overcoming diuretic resistance

Some photos from the recording studio

Art Levinson is the current Chairman of Apple. He was brought on to the board in 2000 during Job’s second act and was present for the introduction of the iPod, iTunes and iPhone.

Art Levinson is always introduced as the former CEO of Genentech but I didn’t know his story until I read the Herceptin story in Emperor of All Maladies. Turns out Levinson was trained by Nobel Michael Bishop of oncogene fame. In the late 80’s Levinson was leading a group pursuing treatment for breast cancer by doggedly tracking a gene called HER-2.  Genentech’s executives turned away from cancer research after some high profile failures in the 80’s. This should have been the end of genentech’s role in HER-2 except for the leadership of Levinson. He dodged the bureaucracy, pursued resources and lead a small team to continue work on HER-2. The group produced Herceptin, one of the most important breakthroughs in chemotherapy in the molecular era in, a jaw-dropping, 3 years.
Laureate

Reading that story I can see why Jobs would want him on the Apple board.

As we were gearing up for NephMadness Mealnie Hoenig mentioned that she loved working with the Nephmadness crew because they were “her people.” This resonated with me and has become my latest way of looking at the word. This particularly resonated with me when my college roommate introduced me to Public Broadcast Service.

Gene Kranz

There best song is “Go” which samples Gene Kranz dialog with his flight controllers during the Apollo 11 lunar lander landing. I love this because though I have heard the story of the Apollo mission a 100 times I had never thought of it from the perspective of the flight controllers.

This struck me as a great example of my people. While I never could imagine myself as Neil Armstrong, I could imagine me, and my ilk, being a flight controller in Houston. Which one would I be? flight SURGEON, of course.

Summary of the different flight controllers can be found here.

Transcript from the song:

Narrator (NASA Spokesman?)
This is Apollo Control 102 hours into the flight of Apollo 11.
It has grown quite quiet here at Mission Control

A few moments ago Flight Director Gene Krantz requested that everyone sitdown and get prepared for the events that were coming and he closed with the remark “Good luck to all of you.” [Ed. not quite One small step for man; one giant leap for Mankind]

12 minutes now until ignition for powered descent. Everything still looking very good at this point

Gene Krantz
Okay all flight controllers, “Go” “No go” for powered descent.

Or if you prefer, the Ed Harris version

RETRO?
      Go!
FIDO?
      Go!
GUIDANCE?
      Go!
CONTROL?
      Go!
Deltcom? [can’t quite tell, maybe INCO?]
      Go!
GNC?
      Go!
EECOM?
      Go!
SURGEON?
      Go!

CAPCOM we are go for powered descent [CAPCOM, capsule communicator, was an astronaut in Houston responsible for communicating with the mission astronauts. At the time of the landing it was Charlie Duke]

We are off to a good start.
Play it cool.

Okay all flight controllers, I’m going around the horn

RETRO?
      Go!
FIDO?
      Go!
GUIDANCE?
      Go!
CONTROL?
      Go!
Deltcom?
      Go!
GNC?
      Go!
EECOM?
      Go!
SURGEON?
      Go!

60 seconds [This is the amount of fuel that is left before they must abort]

Transcript of Apollo 11 landing.

David Goldfarb has written a sternly worded letter to the ACP in response to their clinical practice guideline, Dietary and pharmacologic management to prevent recurrent nephrolithiasis in adults. The guidelines took positions that seemed to make no sense when looked at as a whole. Due to insufficient evidence the guidelines recommend:

• no need to determine stone composition prior to treating stones
• no need to analyze blood chemistry before treating stones
• no need to do 24-hour (or 48-hour) urine collections before treating stones

None of the authors of the paper have a single other co-authorship in PubMed relevant to kidney stones, other than the AHRQ review. I believe that none of the authors are nephrologists or urologists, none have a kidney stone clinic, none appear at, or present research at, kidney stone meetings, none have any experience regarding management of kidney stones

And this doozy, in response to a comment of the paper from the lead author:

As we point out in the guideline, we are aware that many physicians do select medications based on stone type, for example, allopurinol for uric acid stones, and we do not discourage that practice. 

Physicians who regularly treat stones or who played NephMadness (2014 edition) know that allopurinol is used to prevent calcium stones not uric acid stones which are best treated with alkalinization.

Read Goldfarb’s letter. It is excellent.

Minor updates.

PDF (7.6 mb)

Pages (8.7 mb)

I think this covers all the high points that residents need to know about calcium. Please send feedback of what is missing.

The blog turns 7 on May 30th. But tonight we flipped the odometer.
One million page views.

I bet we never see ten million.

PBFluids.com Established 2008

The push to one million. Blog post about Twitter (NephJC) and Twitter mention of an old post on MDRD and protein restriction. A PBFluids deep cut.

The first NephJC chat was April 29th 2014, so the official birthday went unrecognized a couple of days ago. Such is the way of academic medicine.

I’m very busy. On an unrelated topic, I have questionable time management skills and difficulty saying no.

— Shit Academics Say (@AcademicsSay) May 1, 2015

Swapnil and I are delighted with the success of the endeavor which launched with humble beginnings on Medium aweek before the first chat with this manifesto:

Coincidental to the calendar turning over, NephJC is being recognized in two articles in the medical literature. The first is the first systematic review of microblogging journal clubs. It is an interesting and thought provoking article. NephJC takes a victory lap in Table 2:

It’s been whirlwind first year and I’m looking to see what new boundaries NephJC can stretch in year two.

This is my go to video for helping patients make decisions on what modality to choose.

I was invited to speak at the Canadian Society of Nephrology last fall. Swapnil set up a talk on social media. My first international speaking gig. Very cool.

We have two associates out on Maternity leave and another key partner retired a couple of months ago, so practice is tight. No way I could take half a week like I do for Kidney Week. I left for my 1:30 talk at 8:30 that morning. Direct flight from the D to Montreal. As I’m walking through the airport I’m looking for nephrologist ads. During Kidney Week there will always be a big a pharma company advertising in the airport. I love seeing those ads and trying to imagine wha percentage of the general population have any idea what Samsca™ or Aranesp™ are. Montreal had none of these advertisements. I took a taxi to the Hotel Bonaventure.

Found my way to the conference center and registered for the conference. The conference had about 450 people in total, about one 30th the size of Kidney Week. It is like Kidney Week Mini Me. Same clothes, same attitude but smaller. In this case a lot more than just one eighth the size.

Kidney Week is a major international conferences. I heard more foreign languages in Philadelphia last Novemebr than I heard at CSN which was being held in Montreal. We often associate size with quality but thie would be totally unfair to CSN. The lectures were amazing. They absolutly stand toe to toe with the quality you get at Kidney Week. Of course, there are some Canadian specific lectures that didn’t interest me, but the general nephrology content was excellent. Five lectures in particular were amazing:

1. Patient oriented symptoms of ESRD

emolients weak data but little down side. Baby oil, primrose oil. #csn15
— Joel Topf (@kidney_boy) April 25, 2015

newest evidence for Nalfurafine 5 mcg IV after HD 3x/wk. http://t.co/aHW2Si1mER and http://t.co/OzmBTZjs8C #csn15
— Joel Topf (@kidney_boy) April 25, 2015

Uremic Pruritus: other possible txs SSRI, Ondansetron, granisetron, thalidomide, activated charcoal 6g daily. (Never duplicated) #csn15
— Joel Topf (@kidney_boy) April 25, 2015

2. Conservative care With Dr. Fliss Murtagh

Murtagh is quite prolific. Is planning an RCT to look at onservative care vs dialysis in edge cases. http://t.co/IlP4czPkKq #csn15
— Joel Topf (@kidney_boy) April 25, 2015

#CSN15 murtagh survival data pic.twitter.com/91tBCuLDB1
— Joel Topf (@kidney_boy) April 25, 2015

3. Membranous nephropathy with Daniel Cattran

4. FSGS with Dr. Hladunewich

Proof. It really happened. #CSN15 #thingsYouDontSeeAtASN pic.twitter.com/i2FrGX8qHa
— Joel Topf (@kidney_boy) April 25, 2015

5. Screening cancer tests in dialysis patients. Dr. Zimmerman gave an excellent and practical talk.

Things you see at #CSN15: speakers wearing hockey sweaters. Oh Canada. pic.twitter.com/1FyhhXHhtq
— Joel Topf (@kidney_boy) April 24, 2015

If your dialysis pt is/has: age >80, CHF, CAD, CVD, PVD, or BMI<19 they get all the risk of the screening and none of the benefit. #csn15
— Joel Topf (@kidney_boy) April 24, 2015

Stop doing screening mammograms in ESRD #Csn15 pic.twitter.com/1oK5CWXW8R
— Joel Topf (@kidney_boy) April 24, 2015

Their were also a few debates. I was disappointed that I had to choose between GN and the hypertension debate. It sounds like it was outstanding:

Next up at #CSN15: Debate on should BP target in proteinuric CKD be 130/80? @NavTangri vs Rob Quinn pic.twitter.com/kYgtFrcojF
— Swapnil Hiremath, MD (@hswapnil) April 25, 2015

Pro: @navtangri cites AASK fu in @nejm (free) http://t.co/Qlzqi4EUmF of subgroup data to support his position #csn15
— Swapnil Hiremath, MD (@hswapnil) April 25, 2015

#CSN15: @NavTangri referring to a sub-group analysis on a surrogate outcome in ACCORD. Quinn looking more confident….
— Scott Brimble (@S_brimble) April 25, 2015

Pro: @navtangri attempts a pre-emptive strike against Quinn by trashing REIN-2 http://t.co/99SqdSH9w1 (in @thelancet) #csn15
— Swapnil Hiremath, MD (@hswapnil) April 25, 2015

Con: Quinn: MDRD study primary and secondary outcomes were actually all negative. So was AASK. (proteinuria was only +ve outcome) #csn15
— Swapnil Hiremath, MD (@hswapnil) April 25, 2015

Con: Quinn demolishing AASK: if U ACHIEVE a low BP (regardless of Rx) less progression. But if U TARGET lower BP, there is no diff. #csn15
— Swapnil Hiremath, MD (@hswapnil) April 25, 2015

Con: Quinn uses http://t.co/8A4UcGTgKI from @thelancet to make gr8 point of subgroup analyses interpretation #CSN15 pic.twitter.com/lrkzietZY2
— Swapnil Hiremath, MD (@hswapnil) April 25, 2015

Swapnil and I did our social media session.

👏 2 @hswapnil 4 a terrific lecture on social media
— Tejas Desai, MD (@nephondemand) April 24, 2015

`

Thanks, Tejas! #CSN15 especially @kidney_boy killed it! And gr8 job by @brownpa79 to @periscopeco it https://t.co/Hk00Wqtwnm
— Swapnil Hiremath, MD (@hswapnil) April 24, 2015

The talk was broadcast live on Periscope. So 21st century.

LIVE on #Periscope: #csn15 @hswapnil and @kidneyboy social media talk https://t.co/T0r0cwwRV1
— Pierre Antoine Brown (@brownpa79) April 24, 2015

The plan was a one-two punch, where Sawpnil presented why you should engage with social medi,a and I followed with a “how to” engage in social media. It went well. I had some trouble using Keynote on the iPhone app to advance the slides. I used Keynote on the iPhone to control Keynote on my computer. It worked perfectly during my (admittedly abbreviated) practice sessions and for about half my presentation before it crapped out. I need a more reliable solution, please tweet recommendations. The AV-guy was pretty good at picking up my signals to advance the slides but it wasn’t natural and threw my rhythm off. I’m Sorry Canada, I could’ve done better. That was another difference from ASN. At CSN they had no trouble wiring in my MacBook Air to their AV set-up. Much slicker than the MUST USE POWERPOINT party line from ASN.

I’ll post the slides when I get a chance, but first I need to add a slide crediting @Doctor_V and Howard Rheingold, who involuntarily donated ideas to my talk. And I want to pump up the Who to Follow section with a description of mining Symplur to find thought leaders. I also need a slide telling people about Twitter4Nephrons.

In the end, I had a great time at CSN and would definitely go again; maybe not next year in Halifax, but why don’t we meet the year after in British Columbia?