Author: Joel Topf

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Collaborative letter about the pandemic

COVID19 is the only thing on people’s minds. Everywhere you turn organizations are trying to create policies to address the crisis and inevitably they are turning to the CDC for reliable recommendations. Unfortunately, the CDC seems to be making scientifically questionable and politically motivated recommendations. News reports keep filing stories of scientists being muzzled so that they only voice the administration’s position. Dr. Paul Sufka was as frustrated as I was about this and wanted my advice about sending a letter to state officials asking for more aggressive measures to be taken to stave off the pandemic. I thought it was a great idea and suggested a joint letter. Later that day he added me to a DM group of physicians working on such a letter. The mission of the letter mutated over the next 72 hours from a plea to government to an informational post for patients.

The final result is now up at Kevin MD and Howard Luks website. Howard was really the driver of the letter. It felt like a productive project to work on as we wait for the disease to wash over our hospital. On Thursday (3/12/20) I was editing an early outline and documented there were 1,200 people in the US with confirmed cases of Corona. Then when re-editing on Friday, that number was up to 1,600. Today it was 2,100. In three days the number almost doubled.

This is going to get rough.

Let’s be careful out there.

Update. Howard Luks’ website is getting hammered. This post is really catching fire. He is asking that people look at the Medium post for now.

Update 2: the post went viral and was read by approximately 8 million people. 5 million on Howard’s site, 2+ million on KevinMD, and 1.5 million on Medium. This is the most reach I have ever been a part of. It speaks to the tremendous hunger people had for unbiased, science-based information in a time when everything seems to be politicized.

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For #WorldKidneyDay 2020: Why Nephrology?

Residents often ask me what is wrong with nephrology? Why don’t residents want to become nephrologists anymore?

I have a number of answers to that question, but explaining the reason means that I am explaining how other people think and make decisions. I’d rather talk about how much I love nephrology and why I find it a fulfilling career. It feels more honest and less presumptuous.

Last week I had a perfect day and it encapsulated what makes me so happy in the medical career I have chosen.

I woke up, walked the dog and headed into the hospital. I had a lecture. I hold a monthly electrolyte session with the fellows. It is scheduled for an hour but we always go long. Usually the lectures last 90 minutes. I start the lecture with a recent electrolyte conundrum that we work out on the white board. Last week’s lecture kicked off with the highest urine sodium I had ever seen.

And after discussing this case of hyponatremia we continued the potassium lecture from the previous month. The way I handle my fellow lectures is I use the slide set from my resident level lecture but instead of going through the slides in an hour, we spend three to four hours unpacking lecture. We discuss the papers and data behind each slide. The original presentation becomes a road map for a meandering discussion-based didactic session. They are among the most enjoyable teaching sessions I do.

After this lecture I went to the dialysis floor where I’m rounding this month. The full team is supposed to be a fellow, a senior resident, and three interns. But this month we don’t have a fellow, and on that Thursday the senior was in clinic and one of the interns was in his weekly lectures (he is an ER intern, not categorical medicine). So it was just me and two of the interns running the show. The service had exploded overnight so we had the work cut out for us. But we buckled down, triaged the list, saw the sickest ones first, got dialysis orders in for the new patients, and saw everyone on the floor. We even did some on-the-fly teaching and the interns got to see a fresh transplant patient who was making urine. This was great because the previous two transplants had delayed graft function and slow graft function. So this one completed the set.

At noon I had a lecture, but this time I was the audience. One of our fellows was presenting on an interesting case. This was his first time presenting the case but he is going to present at the upcoming intracity grand rounds so we essentially got to see his one point oh presentation. It was great getting to see his work because I know he had been working hard on it. How did I know he had done his homework? Because he had been discussing the case and his research on Twitter!

https://twitter.com/TrehanMD/status/1234521551166431233?s=20

Then after lunch I had a meeting with the head of research and our biostatistician to go over three different resident and fellow research projects to see how they are going. This research isn’t moving fast but it is moving forward and it will be exciting. We have some good stuff in the pipeline.

After that I headed back to the ward, but got derailed by the transplant surgeon and spent 20 minutes trading hospital gossip with her. Truly one of the most enjouable diversions you can have. After that I met with my team, now joined by the senior and ER resident to card-round and make sure everyone was tucked in for the night with dialysis orders ready for tomorrow.

I then went back to my office, added a page to the NSMC.blog website for the NSMC interns.

Went home.

Went for a 5 mile run.

Dinner with my daughter and lastly worked on NephMadness until I went to bed.

Does anybody have it better than me?

What a day!

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Mini-Tweetorial on Metformin Associated Lactic Acidosis (MALA)

How small can you make a tweetorial? This one is only 5 tweets.

A lot of patients are on metformin and a lot of people get lactic acidosis. One does not always cause the other.

But in this case I think the metformin did cause the lactic acidosis. The patient did not have sepsis. There wasn’t any dead bowel, shock, or other typical cause of lactic acidosis. And thanks for asking, the thiamine was normal, they were not being poisoned with arsenic. No aspirin toxicity. No malignancy causing an occult type B lactic acidosis.

They had acute tubular necrosis causing acute kidney injury.

The lactate was sky high

Perfusion was intact. Blood pressures were in the 160s.

And they were taking a coupe grams of metformin a day. The thing about a creatinine of 8 is you need to have a GFR of around zero for almost week to get there. So imagine the patient has about 14 grams of metformin on board.

I think this was MALA.

I think this patient should have gotten hemodialysis.

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New tweet, Old presentation

We tweet and think the tweet evaporates after a day or two (actually, that’s particularly optimistic, most disappear after an hour or two) but occasionally a reply can come from the distant past like a message from a deep space probe.

Today, someone replied to a tweet I wrote in May of 2019.

I’m not sure if The Drug Policy Organization ever posted the webinar, but I now realize that I never posted the slides to my website. So here they are:

Keynote | PDF | Powerpoint

I also made a movie of the demo part of the presentation. I tried to show the logic and process of building a visual abstract.

And here is a screencast of the entire presentation:

Thanks for the nudge Salina!

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Contrast Associated or Contrast Induced Nephropathy? Who the hell knows. St John Ascension Grand Rounds

Everyone talks about the importance of mentors in career development, but there is another type of Fairy God Mother that doesn’t get as much press but can be just as important, this is the Sponsor. A sponsor doesn’t give advice and guide you like a mentor does, but when opportunities come up they think of you and put your name forward.

The most important sponsor in my career has been Chief of Medicine at Ascension St John, Lou Saravolatz. As a fellow, Dr. Saravolatz discovered a bug now known as Methicillin Resistant Staph Aureus (remind me, what world changing research are you doing in your fellowship?). But as Chief of Medicine he has been my (and a host of other docs) sponsor. Dr Saravolatz invited me to give my first grand rounds presentation in 2003. A talk on contrast nephropathy.

Today, I gave another talk on contrast nephropathy. Here are the files. I will try to get a video with my narration up in the next few days.

Keynote

Powerpoint (I just export the Keynote presentation to Powerpoint so I suspect many of the animations are crap. It is here just to preempt the chorus of Twitter requests for it)

PDF

Here is a video of this presentation Rutgers Robert Wood Johnson Department of Medicine grand rounds.

I also am posting the talk bit-by-bit as #Tweetorials.

The first:

The second

The third

The fourth

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We need to do it differently

Michael Heung of the University of Michigan tweeted this yesterday

Here is the image again in case Twitter breaks.

This is not an uncommon finding at medical schools around the country. I have been to lectures by Dr. Heung at Kidney Week and he is a gifted teacher. There is nothing wrong with him. The knee-jerk response is to do what Oakland University William Beaumont School of Medicine did and make lectures mandatory. I get a full auditorium for every one of my lectures. It strokes my (already formidible) ego, but I don’t think it is the right response.

The empty lecture hall is because medical students are finding ways to learn that are better for them than sitting in a class room six hours a day. It’s more efficient to stream the lecture at 2x-speed with tabs open to other resources. If this is how they learn best, schools shouldn’t enforce inefficiency by making them attend lectures. Medical school deans should recognize how the material is going to be consumed and then develop curriculum around that consumption.

Every medical student, after paying tens of thousands of dollars for tuition, spends additional thousands of dollars on materials, tutorials, and videos to get ready for the big bad board exam at the end. What is the core competency of medical schools if it is not getting students ready to excel at licensing exams? Every one of those subscriptions is an indictment of the product that medical schools are providing their students.

Here is a list of vendors from the 2018 American Medical Student Association Convention. Check marks indicate vendors that provide services that medical students should be getting from their (wildly expensive) schools.

If we were to start from the position that students are going to consume every lecture on their own time on their own laptop, would we record the same slide show with the same talking head every year? No, that’s an absurd waste of the professor’s time to produce content that is not compelling or a good use of the medium. This is like the first movies, where directors would just film stage productions, ignoring the nature of the novel medium. Instead of seeing the empty lecture halls as a problem it should be viewed as the huge opportunity it is. The students have already moved to the new medium, it is time for medical schools to catch up.

It is time to turn those lecture halls into production studios. It is time to hire professional animators, artists, and video producers, and go from slide shows that need to be performed live every year to tightly produced educational shows that can be created once and shown many times. Let’s teach for the contemporary reality, rather than fight it with rules that serve to waste student’s and teacher’s time.

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Kidney Week 2019

Kidney Week is my favorite week of the year. It’s Kidney Christmas. Kidney Week is the one week when all of the connections I make over direct message, e-mail, and text via the black rectangle in my hand transform into living, breathing people. If you are going to Kidney week, I’d love to meet you in real life.

Here is a rough itinerary

Pre-Conference

Tuesday and Wednesday

Fundamentals of Renal Pathology – Anthony Chang, MD, FASN, Lynn D. Cornell, MD, Mark Haas, MD, PhD

Conference

Thursday:

1:00 to 1:30 pm I’ll be at the ASN Community Booth discussing Leveraging Social Media for Your Career in Nephrology.

6:30-7:30 pm Nephrology Secrets Book Signing at the Elsevier booth (1119) during the ASN Welcome Reception

Friday

10:30 am Join Cathy Quinlan and I on the NephJC Poster Tour. Meet at the Arkana booth (2515)

9:00 pm NephJC Tweet-up

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Pseudohyperkalemia: the tweetorial

Last week I posted a tweetorial on pseudohyperkalemia due to CLL and a high white blood cell count.

This case peaked with a potassium of 9.5. Pretty frightening, but that was nothing compared to the potassium of 15.5 I saw in 2014. Details here.

I had another case of pseudohyperkalemia in 2011. That one was due to thrombocytosis.

In response to my Tweetorial, Yash Chivate shared a case of pseudohyperkalemia of his own.