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The difference between treatment and prevention

The second twitter journal club a classic article by Rose, Strategy of prevention: lessons from cardiovascular disease. Br Med J 1981 282 pp. 1847-51.

My favorite line:

When ordinary doctors do not accept that responsibility then prevention is taken over (if at all) by uncritical propagandists, by cranks, and by battling commercial interests.

And this, on the treatment of hypertension:

A general practitioner, say, makes a routine measurement of a man’s blood pressure and finds it raised. There after both the man and the doctor will say that he “suffers” from high blood pressure. He walked in a healthy man but he walks out a patient, and his new-found status is confirmed by the giving and receiving of tablets. An inappropriate label has been accepted because both public and profession feel that if the man were not a patient the doctor would have no business treating him. In reality the care of the symptomless hypertensive person is preventive medicine, not therapeutics.

A systolic pressure of 160mm Hg may be common at these ages, but common does not mean good.

Remids me of this post from the archives.

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Fix Kidney Wikipedia #fikiWiki

Nephrology is a specialty in crisis. Fewer and fewer internal medicine residents are looking toward nephrology as a viable career. 

In 2011 there were 1.27 applicants for every nephrology fellowship position. In 2013 there were 0.76. http://t.co/3w6C7Cgd9j
— Joel Topf (@kidney_boy) January 9, 2014

The number of applicants continues to plummet. A number of people are looking at ways to increase interest. I’d like to point you to Mark Parker’s work with the ASN and Tejas Desai’s essay for F1000 (comments on the article). 
One of the solutions that people repeatedly return to is the need for better nephrology mentors for medical students and residents. I, like most people who ultimatly pursued nephrology can point to a great mentor. During my fourth year of medical school, I rotated with Dr Shermine Dabbagh, a pediatric nephrologist at children’s hospital of michigan. She was a great teacher and a caring clinician, but she was not my primary influence.
The chief inspiration was not a person at all, it was a book. During my fourth year of medical school, years before I was ready, I read Burton Rose’s classic, Clinical Physiology of Acid-Base and Electrolyte Disorders. It is a wonderful book and it absolutely was the inspiration that launched my career.
While the ASN is working on improving mentors, I think the influence of supportive texts like Rose’s should not be ignored. There are still great nephrology texts, but unfortunately students no longer use textbooks. They use the web and are increasingly depending on Wikipedia. Unfortunately the Kidney Wikipedia is pretty run down. It doesn’t give a reader the impression that the specialty is vibrant, well kept and alive.

Wikipedia is increasingly becoming the initial access point for people to learn about nephrology and we should be better caretakers of it as it is a reflection of our specialty.

I think a great way to revitalize student impression of nephrology is to fix the kidney Wikipedia.
FIx the KIdney WIKIpedia.
FiKiWiki.
Academics scoff at wikipedia, but it will be easier to fix wikipedia than it will be to get a generation of medstudents and residents to stop using it. It is time to stop fighting the Wikipedia and instead we should start refining it, fill it with compelling content that shows off nephrology as the exciting, important and a field that embraces the future of medical education. 
For more information on my opinions about wikipedia check out my editorial at Wing of Zock.

How I learned to stop fearing and love Wikipedia….my latest editorial at Wing of Zock. Go read it: http://t.co/ulIC823p30
— Joel Topf (@kidney_boy) January 23, 2014

@kidney_boy Nice article, biggest limitation is getting trainees to recognize errors? (especially subtly incorrect info)?
— DrWario (@DoctorWari0) January 23, 2014

@DoctorWari0 but isn’t that 1 of the most important lessons we should be treating students, how to recognize when source material is correct
— Joel Topf (@kidney_boy) January 24, 2014

@kidney_boy Loved your write up on @Wikipedia for @wingofzock potential exercise for #flippedlearning: use class time to edit wiki
— Rob Cooney, MD, MEd (@EMEducation) January 23, 2014

@kidney_boy @ShabbirHossain @krw127 We’re all “guilty”(?) of using wikipedia. knowing the limits of your sources is important. Thx for post!
— Charlie M. Wray (@WrayCharles) January 24, 2014

Yep. Also, Wikipedia is a good starting point MT @kidney_boy: How I learned to stop fearing and love Wikipedia…. http://t.co/OxXYzQUgRk
— Miloš Miljković (@Miljko) January 23, 2014

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Twitter, Nephrology and the next version of the KDIGOmobile App

This summer, through luck and/or moxie I was able to land a plum position on the KDIGO team charged with building the mobile app. The team partnered with the crazy effective nerds at Visible Health to push out our initial vision. Our 1.0 for iPad was launched at ASN Kidney Week in Atlanta. Internally, we described the project as building a bridge across a gorge. This 1.0 is like a piece of dental floss connecting the two sides. It is an important step but it we have big plans for future versions.

We have received a lot of feedback on the initial release and the overwhelming requests are: Android, iPhone, Android, iPhone, Android, iPhone.

We are going to do both, but neither are the next step. The 1.0 version is essentially a PDF reader with all 9 KDIGO guidelines pre-loaded. Moving the app to Android and the iPhone will entail porting all of the guidelines to a new data model. We have a big vision for the product and are reworking the infrastructure to get there. Those two updates will come but they need to wait for the new data structure, for now, the only thing I can tell you is: Patience.

The current version of KDIGO Mobile has a community option that is a ghost town. We are going to tear that down and instead adopt the renal community on Twitter. The new social section will have a number of ways to view twitter that are designed to expose new people to the vibrant nephrology discussions that occur in there.

Users will have a number of twitter channels that they can tune into:

  • Current Twitter users will be able to view their timeline
  • Collecting duct: this is a highly selected list of twitter accounts consisting primarily of professional societies, journals and government organizations (Members | Timeline)
  • Proximal tubule: this is a highly curated list of users that typically provide intelligent nephro-oriented discussion  (Members | Timeline)
  • Glomerulus: this is a general list of every nephrologist and nephrology related organization I could find. (Members | Timeline)
  • Hashtags: this will be one or two hashtags that are of interest to nephrologists. For example, during next years Kidney Week, we would push out #KidneyWk14, during NephMadness we would highlight #NephMadness, We might leave #MedEd, #FOAMed, and #HCSM up at other times. etc.

All of these channels are stored on the servers at Visible Health so they can be controlled remotely and are eternally updatable.

Today, we are asking members of the nephrology social media sphere to look at the lists, try out the timelines, explore the hashtags. Tell us if we missed anyone or added someone undeserving.

When evaluating the timelines keep in mind the goal of these Twitter channels. We want to introduce new users to the utility of twitter for nephrology discussions. The timeline that I am most concerned about is the proximal tubule. The collecting tubule is an official channel and will likely be pretty dry. The glomerulus I think will be too much of a fire hydrant and I am thinking about dropping that channel altogether. I’m hoping that the proximal tubule can have relevant, compelling, content to really show off the utility of Twitter to naive KDIGO users.

Any and all feedback would be appreciated.

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Down goes SYMPLICITY.

SYMPLICITY-3 was Medtronic’s play to get into the hypertension business. They have a device that allows physicians to apply burn the sympathetic nerves of the renal arteries and lower the blood pressure. In a previous randomized trial it worked and SYMPLICITY-3 was what they were going to take to the FDA to get approval.

I started the day with our local hypertension guru explaining the inclusion criteria for Symplicity-4. An hour later this hit the wire:

Full press release

I was a huge fan of renal denervation and a bit of me died when the tweets started flying. Our local Symplicity PI says that the follow-up study with looser enrollment criteria, SYMPLICITY-4, has been cancelled. MedTronic supposedly is still going to carryout a trial of renal artery sympathetic nerve ablation in heart failure. If that is positive then it is possible the field will carry on, but if they abandon that, it may be lights out for the entire concept.

First CORAL, now SYMPLICITY 3. It’s been a bad couple of months for the renal arteries. They should get a better PR person.
— Joel Topf (@kidney_boy) January 9, 2014

Some thoughts on simplicity 3. The trial was on patients with severe resistant hypertension: office blood pressure over 160 on three blood pressure medications. These are hardcore hypertensives. This may not be an appropriate crucible to test the hypothesis of weather this works.

Thought two is that sympathetic discharge is thought to drive a lot of the hypertension in CKD and ESRD. (See this, this, and most importantly this editorial review)  So maybe when SYMPLICITY-3 excluded patients with GFR’s less than 45 they were excluding the very patients where the treatment would be most effective.
Thought three is that maybe in an effort to increase enrollment there were more inexperienced doctors doing the ablation. Unlike renal artery and coronary artery stenting there is no convenient sympathetic nerve ablation analog to TIMI-3 flow. At the end of the procedure the team has no idea if they successfully and adequately ablated the nerves. This could be a confounder. 
It will be interesting in subgroup analysis pif they find a signal pointing to efficacy being related to operator experience or a signal to better efficacy with worse GFR.
I blogged about SYMPLICITY here. Here is what Renal Fellow Network wrote about renal denervation when it was one of the top stories on 2010 and in an insightful post by Matt Sparks. 
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Fluid and Electrolyte Curriculum for Residency

I give monthly lectures to the residents at three hospitals. I bill the lectures as a comprehensive, year-long, fluid and electrolyte course. I have never established a fixed curriculum for the lectures, here is one take:

  1. Body water, IV fluids and diuretics
  2. Rapid interpretation of ABGs
  3. Acute Kidney Injury
  4. Osmoregulation and hyponatremia
  5. Hypernatremia
  6. Anion Gap metabolic acidosis
  7. Potassium
  8. Metabolic alkalosis and hypokalemia
  9. Non-anion gap metabolic acidosis
  10. Calcium and phosphorous and metabolic bone disease
  11. Electrolyte emergencies
  12. Board review practice
The curriculum starts with the basic mechanics that interns need to function in the hospital. How to order IVs, and intelligently use diuretics. This includes a review of body fluid compartments so that it is not just practical pearls but is based on physiologic foundation.
Electrolyte emergencies is a lecture that is not entirely written and needs to be. It would be a practical handbook style lecture to walk interns and residents through what I think is the best way to handle: metabolic acidosis and alkalosis, hypo- and hypernatremia, hypo- and hyperkalemia, hypo- and hypermagnasemia, hypo- and  hypercalcemia.
The introductory curriculum ends with the rapid interpretation of ABGs. After that I turn the intensity up a bit and focus on more physiologic based and less practical aspects of electrolytes. This allows deep dives on metabolic acidosis with separate lectures on anion and non-anion gap. I separate out metabolic alkalosis and potassium to provide time to do a deep dive on the monogenic causes of hypertension.
The board review session is a quiz session to review all the concepts of the year.
I have one spare month because a lecture always gets lost along the way.
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Kidney TREKS deadline approaches

Kidney TREKS is a program for medical students who want to learn about nephrology. Here are the components of the program from the website:

  • Attend the Mount Desert Island Biologic Laboratories “Origins of Renal Physiology” course for students, June 6-13, 2014. Tuition, travel stipend to Maine, room and board are paid by ASN.
  • Become connected with a nephrologist-mentor who will interact with the student over the course of medical school training, graduate school or postdoctoral fellowship.
  • Attend ASN Kidney Week during the 3rd or 4th year of medical school or graduate school with travel support (as a part of the ASN Program for Students and Residents).
  • Receive complimentary membership to the ASN with access to website resources for students.

To my mind, the first bullet point stands out as a once in a life-time opportunity. Mount Desert Island (by the way, best name ever: it’s a mountain, and a desert, and an island. Too bad they couldn’t get swamp and archipelago in there somehow) is a research lab where some of the seminal discoveries of renal physiology were made. My understanding is that the students have an opportunity to re-run some of the classic experiments with scientist mentors. Imagine a whole week of Kidney Science Camp.
I have not seen any reviews from participants from last year’s KidneyTreks but the reports from the fellow version make me want to re-do fellowship so I can go.
The deadline for applications is January 24th. Get to the link and apply now.
Imagine hiking around this beautiful island after learning the secretes of glomerular filtration.
Mount Desert Island Biologic Lab, home to the world’s nerdiest fence.
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Pseudohyperkalemia

The highest potassium I have ever seen? That would be 15.5 mEq/L.

It’s not real. It was pseudohyperkalemia from leukocytosis. The patient had chronic lymphocytic leukemia with a white count of 300,000. If you are not familiar with this condition, check out these posts on Renal Fellow Network: Westervelt and Nate. Nice full text references here and here (pdf).

The pseudohyperkalemia merit badge

The first time I saw this was when I was senior resident. I was sleeping in the call room my pager buzzed. It was the oncology floor with a potassium of 9. The patient had CML and was in a blast crisis. His leukocyte count around 100,000. I immediately suspected pseudohyperkalemia and ordered a whole blood potassium from the ABG lab. It was normal so I went back to sleep. The next morning I received an angry call from the Hemo-Onc fellow. The patient was coding and he was furious that I only ordered an ABG instead of treating the hyperkalemia.

I don’t know if the patient coded from hyperkalemia, but I wish that I had gotten out of bed and evaluated the patient. I solved the problem the nurses alerted me to, but if I assessed him, maybe I could of averted an arrest.

Regrets…

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Area Codes, RTAs, and Amphetamine. This is what Twitter is like.

Dallas is Area Code 214. I wonder if they appreciate that 214 really represents the 3 types of RTA in anatomic order?
— Joel Topf (@kidney_boy) January 7, 2014

This morning I was trying to imagine the mad electrolyte gurus of UT Southwestern in Dallas influencing the naming of the RTAs to match their Area code. Well played Donald Seldin, well played.

Not to be outdone, Dalya Munves joined in the area code and medicine game.

@kidney_boy other Dallas area code is 972, which is imprinted on amphetamine/dextroamphetamine tabs! #ADHDpride
— The Health Scout (@HealthScoutBlog) January 7, 2014

@HealthScoutBlog that’s why on the street they are call Ewings #ImMakingThisUp pic.twitter.com/sAVc4Wixvb
— Joel Topf (@kidney_boy) January 7, 2014

Any other area code-medicine mash-ups out there?

Note. The following 5 paragraphs from Douglas Coupland’s Microserfs that I read in 1995 has stayed with me since then. Love this minutia:

“Maybe. But let me digress a bit. Here’s something interesting . . . did you know you can figure out how important your state or province was circa 1961 by adding up the code’s three digits? Zero equals 10.” 

“No.” 

“It’s because zeros used to take forever to go around the little rotary dial-while ones zipped along quickest. The lowest possible code, 212, went to the busiest place, New York City. Los Angeles got 213. Alaska got 907. See my point?” 

Karla always comes up with the best digressions. “Yes.” 

“Imagine Angie Dickinson in Los Angeles (213) telephoning Suzanne Pleshette in Las Vegas (702) sometime before the Kennedy assassination. She dials the final ‘2,’ breaks a fingernail, and cusses a shit under her breath, irritated at Suzanne for being in a location with a loser area code.”