Category: Commentary

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Happy Birthday PBFluids: A decade of Blogging.

Me: PBFluids turns 10 years old this month.

Wife: You going to throw a party?

Me: No, but I’m going to write a blog post.

May 30, 2008, my first post at PBFluids.

Ten years. That’s a long time in  career. At the speed of social media, it’s an epoch. 

Defining moments from PBFluids’ first 10 years

The Beginning

When I started PBFluids, the there were two other nephrology blogs out there, Joshua Schwimmer’s Kidney Notes (March 7, 2005!) and Nathan Hellman’s Renal Fellow Network (Nate started his 5 weeks before PBFluids). Comparing PBFluids to Renal Fellow Network feels a bit like saying between me and Michael Jordan we have 6 NBA championships. But nonetheless, ten years ago we were the first few pebbles which started rolling down this mountain which has become an avalanche of online nephrology education.

Though there was Nathan and Schwimmer, and a year later Kenar (December 7, 2009, talk about a day that will live in infamy) and Tejas (NephOnDemand is a lot different today than it was in the early days), we were all pretty independent. I rarely interacted with them and they rarely interacted with me. I read their stuff and was influenced by what they were doing, but blogging was largely a solo affair. Now every post I write is either inspired by an interaction on Twitter; vetted, reviewed and proofed on Twitter; or has Twitter generated follow-up. The blog and the #NephTwitter community are inseparable.

At Kidney Week 2008 (the first after launching PBFluids)  I live blogged some of the lecturers. Essentially I was live tweeting, but with Blogger. The results were not pretty (see this, and this, and this). I knew what I wanted to do, but Blogger was the wrong tool. I joined Twitter a month later.

For the first two years on Twitter I barely used it. This was largely due to the lack of a community online. It wasn’t until 2011 that #NephTwitter started to become a thing. The blog was important, but Twitter allowed for the interactivity and collaboration that no other platform could provide. Twitter was the essential trigger for nephrology’s social media awakening.

Turning the microphone on.

In October of 2008, 5 months after starting PBFluids, Dr. Schwimmer linked to my blog. Getting a link from KidneyNotes turned the microphone on. It turned the blog from an ego project with an audience of one into a (very) limited publishing platform. Joshua made me a public physician.

monthly page views for the first year of PBFluids

The Smartphone Wars

PBFluids is older than the App store. So a lot of early posts looked at smart phones and how they were going changing medicine. At first it was iPhone vs Blackberry and soon after that, iPhone vs Android (I might have been premature when I called the results of this one).

In March of 2009 I had my first breakout post that received real traffic. It was a review of medical calculators for the iPhone. Don’t miss the follow-up post on MedCalc, which is still my go to medical calculator.

Best story of the blog

October 2010: ‘Meeting’ Margaret Atwood on Twitter.

The story was so cool it got picked up by the Guardian. If you ever wanted to know happens to traffic to your personal website when a post you wrote gets covered by The Guardian, take a gander:

The Madness begins

In March of 2012 I made this video for World Kidney Day.

I wanted to recreate the spirit of Shit Nephrologists Say for the following World Kidney Day. In February of 2013, Matt and I were brainstorming ideas and NephMadness was conceived.

NephMadness

My favorite line from that post:

I had my partners and fellows fill out brackets today. They all had a lot of fun doing it. There is something light and joyful pitting these heavy topics against each other in totally absurd ways. Take a crack at it, have fun.

Seeing Twitter nephrology get into NephMadness and care about it made me understand what was possible with FOAMed. It made me see that we could change medical education so it was woven into your online-life. We could make medical education feel less like the lonely library on a Friday night and more like a raucous but productive study group with your med school friends. It could connect nephrologists so that we could learn together, be smarter together, be stronger together, and have fun together.

The DreamRCT flash in the pan

In a fit of insanity I tried to shoe horn DreamRCT between the new year and NephMadness. Here was my entry in the first contest.

#DreamRCT: Prove the uric acid-CKD connection and win Richard Johnson a Nobel

The following year we moved it to the fall and partnered with MedPage Today. We had a great panel of judges and amazing entries. The reason there was not a year three of DreamRCT was not due to lack of great content. DreamRCT was a victim of trying to do this social media education in the cracks between clinic and rounds. Sometimes there are just not enough h=nights or weekend.

Here is my entry for DreamRCT 2: An EBM take on one of the fundamental problems with hyponatremia.

Please fund my #DreamRCT, it is just embarrassing how little evidence is found in hyponatremia

The second DreamRCT was also the capstone project of the first year of the NSMC. Four of the sixteen studies in DreamRCT 2 were written by our first four interns. Looking at the list of DreamRCTs it is amazing how many questions they brought up that are still taxing us. I particularly loved Scherly’s MIND study and Chi Chu’s RCT on contrast nephropathy.

NSMC

Speaking of the NSMC, it was also was launched on PBFluids:

The first Nephrology Social Media Internship

NephJC

Actually it was launched on NephJC.com, but NephJC.com itself was launched here:

#NephJC is coming

While writing this post I came across a lot of PBFluids deep cuts that I haven’t thought of for years. A few gems:

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

Another Twitter collaboration that turned into a fun post

There once a dialysis patient from Nantucket…

In the last year Twitter has really shake off many of the ancillary companies and services that grew-up around it to support the service. FavStar going away in a few weeks. Storify is gone. We have seen TweetChat and TChat.io lose so much functionality to be unusable. But the blog marches on. After a decade of change and innovation in the social media space there is still room for the blog. And more importantl,y the blog, with its dependence on simple HTML, the portability of its data, and its ability to reform itself (see my transition from Blogger to WordPress this year), has a durability that is valuable in Medical Education. I may not be publishing new content to PBFluids in 10 years, but the work that is here, will remain.

Happy Birthday PBFluids, it’s been a great ride.

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New types of scholars for Generation FOAMed

Interesting article on new roles for scholars to play in the promotion of evidence based medicine. (PDF)

All star team of writers too:

If that interests you, take a look at the role of Medical Journals in the Age of Ubiquitous Social Media by again by Trueger. The article has this line that hit particularly close to home:

some journals take the “meta” step of publishing articles about physicians’ social media use, which are often then shared to great acclaim on social media

Something we have seen with our recent Social Media paper in Kidney International Reports.

 

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Spooky Sodium, the Lecture

Last year’s NephJC on Jen Titze’s study on simulated Mars missions and sodium handling really baked my noodle.

Titze’s arm of research breaks the foundational laws of body fluids. Partly to help myself grasp the information, and partly to help spread this paradigm shifting research I created a 1 hour lecture on his work. I have given the lecture a few times, but I’m still not sure I have it right. I am offering the lecture to the internet to solicit comments. What did I get wrong? What is unclear? And I would like to add my outrage that when I went to the update in fluids and electrolytes pre-course that the ASN offered at Kidney Week this entire angle of sodium was completely ignored, except for one derogatory, snide comment. The legends of sodium, fiddling while their Rome burns .

One thing I am still having trouble with is the increased urine output at the highest sodium intakes. I get that free water clearance generates solute free water and this dilutes total body sodium decreasing the need to drink but this free water is only a hypothetical construct, it is not actually available to increase urine output. Right?

Here is the lecture:

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Antibiotics and AKI for #MADID18 (now with video)

Last fall, Dr. Davis (@IDPharmProf) asked if I would be interested in speaking about antibiotic induced AKI. She was thinking of submitting an idea for a session on kidney disease and antibiotics. Later, she told me I would be sharing the stage with Bruce Mueller (@BAMPharmD), who would be talking about antibiotic dosing during AKI and CRT. This felt like agreeing to doing some Karaoke and then being told you are being paired-up with Frank Sinatra.

I did my best, but compared to Dr. Mueller, the only difference between me and Bozo was the red nose and floppy shoes.

Here is a screencast of the presentation and the slides for you to peruse. But if you ever get a chance to hear Dr. Mueller, don’t miss it. He is really good.

 

 

Keynote: MAD-ID Antibiotic Induced Acute Kidney Injury

PowerPoint: MAD-ID Antibiotic Induced Acute Kidney Injury

PDF: MAD-ID Antibiotic Induced Acute Kidney Injury

 

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The Dark Side and Light Side of Social Media

This is the topic that I was asked to speak about at the International Society of Peritoneal Dialysis meeting in Vancouver. I have never had to speak specifically about the negative aspects of social media in medicine, though I have addressed in previous lectures. I thought it was a good exercise. Here is the talk:

Here are the presentation files:

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Amazon, Sales Rank and Nephrology Secrets

I am reading the  biography of Jeff Bezos, The Everything Store by Brad Stone.

And as I’m reading about Amazon’s innovation after innovation, one jumps out as being particularly relevant to me: Amazon Best Sellers Rank.

I’m not surprised that Secrets is the best selling new release in Nephrology. The series is very popular and the last edition is 10 years old. I suspect there is significant pent up demand.

What shocked me is where the Fluid Electrolyte Acid Base Companion is on the Nephrology Best Seller List:

Fluids came out in 2000. I think we printed 1,200 copies and never did a second printing. We sold out the last of our inventory over a decade ago. If Amazon is telling the truth about their sales either someone has counterfeited the book, these are used books that are being sold over and over again, or this is new old stock that someone found at the back of a warehouse.

My daughter suggested another possibility, that all nephrology books sell like crap. (I’m beginning to come around to this theory as I see how much the sales rank jumps around.

Here are the current sales ranks for some nephrology books of note:

Secrets

Acid-base, Fluids and Electrolytes Made Ridiculously Simple 3rd Edition

Fluids, Electrolytes, and Acid-Base Companion

Handbook of Dialysis Fifth Edition

Clinical Physiology of Acid-Base and Electrolyte Disorders (Rose and Post)

The rankings look funky because I wrote this post in two sessions, separated by a number of hours. Apparently at these sales volumes the the ranking are pretty erratic.

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We are looking for Alport Syndrome patients for a study

I am a primary investigator of the Regulus RG012 study using RNA inhibition to treat Alport Syndrome.

Here are some good resources that I used to brush up my Alport and RNA inhibition skills.

First a video review of Alport

https://www.youtube.com/watch?v=mJ6ULJrdW7I

The best part of the video is the detailed description of collagen IV at 4 minutes. This finally allowed me to understand the multiple mutations that cause Alport.

This video is grand-rounds length description of Alport with a focus on how it affects women by my friend Michelle Rheault.

RG-012 uses a drug that is a oligonucleotide that inhibits the activity of miR-21. miR-21 is a micro RNA which affects the translation of mRNA to protein. In high school biology I learned about messenger RNA, transfer RNA, and ribosomal RNA and that was enough RNA for anyone. But then the Nobel Prize guys had to go and give a prize for the discovery of RNA interference in 2006. Here is a basic explainer about RNA interference.

Here is Regulus’ presentation on RG-012

If you are a physician in Michigan with a patient with Alport Syndrome (needs to be pre-dialysis and per-transplant) or a patient with Alport Syndrome please get in touch, we want to hear from you.

Joel Topf (jtopf@mac.com)

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Adrenal insufficiency and hyponatremia

Every intern knows that the evaluation of hyponatremia includes a TSH and a cortisol level to rule out hypothyroidism and adrenal insufficiency as occult causes of euvolemic hyponatremia.

The mechanism of adrenal insufficiency is a bit confusing with some sources stating that these patients are volume depleted while others are euvolemic.

In some patients without aldosterone, the patients develop severe salt wasting, become hypotensive and get a non-osmotic release of ADH resulting in hyponatremia. These patients will respond to saline. Treat the hypovolemia and the sodium will go up.

Hyponatremia is a common manifestation of adrenal insufficiency even in cases without adrenal crisis. Giving saline to these patients is not effective at correcting the hyponatremia. Giving cortisol, however, results in a brisk water diuresis and rapid correction of the serum sodium (Oelkers, NEJM, 1989).

In addition to being resistant to saline, ADH antagonists (think tolvaptan) protect against this type of adrenal insufficiency-induced hyponatremia.

This means cortisol corrects an abnormality that is due to excess ADH. 

Here is the explanation from the late 90’s from The Fluid, Electrolyte and Acid-Base Companion. 

Bartter and Schwartz original definition of SIADH required a normal cortisol specifically to exclude patients with hypopituitism and primary adrenal insufficiency. In primary adrenal insufficiency, in addition to loss of cortisol there is an aldosterone deficiency which can result in sodium wasting, volume depletion and a non-osmotic (decreased perfusion in this case) stimulates for the release of ADH. In this scenario, the patient should appear salt/volume depleted and would not be considered euvolemic.

A nice review of secondary adrenal insufficiency and hyponatremia was done by Sven Diederich.

Remember:

  • Primary adrenal insufficiency: destruction of the adrenal glands leads to loss of endogenous cortisol. These patients typically also have aldosterone deficiency, so they will be salt wasters, resulting in hypovolemia. They will also have hyperkalemia.
  • Secondary adrenal insufficiency: decreased ACTH (from pituitary or hypothalamic disease, or from pharmacologic steroids) prevents secretion of cortisol

In Diederich’s review they pulled 139 cases of hyponatremia that were referred to endocrinology. (Clearly this study suffers from profound selection bias. Here is a a cleaner study on the epidemiology of hyponatremia by Schrier, from back in the day.) They found 28 cases of hypopituitism leading to hyponatremia. Patients tended to be older (average age 68) and more female (75%). In 25 cases the hypopituitism had not previous been diagnosed and 12 patients had previously been admitted (between 1 and 4 times) for severe hyponatremia without an adequate diagnosis.

Basal cortisol levels were as follows:

  • Below 100 nmol/L (3.6 mcg/dL) in 7
  • Below 200 nmol/L (7.2 mcg/dL) in 21
  • The mean level was 157 nmol/L (5.7 mcg/dL)
  • The highest basal level was 439 nmol/L (16 mcg/dL)

Imaging results:

  • Twelve patients had an ‘empty sella’
  • Six patients had pituitary tumors

  • One had secondary adrenal insufficiency due to chronic treatment with prednisolone because of ankylosing spondylitis

Don’t be the doctor that corrects the hyponatremia but fils to diagnose adrenal insufficiency and discharges and sends the patient home only to redevelop hyponatremia another day. Turn over every stone, especially in patients with SIADH of undetermined etiology.

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The mentor keynote

Matt Sparks gave KidneyCON keynote on Friday night. It was an amazing talk.

Things you don’t see at #KidneyWK

John Arthur asked Matt to talk about his career and how he navigated medicine to become an accomplished scientist, clinician, and educator.  Matt organized his talk around the mentors that guided him. The theme was that the way he made his way forward was by finding the best mentors available and learning as much as he could from them. It started with Wynton Marsalis

Though he went to the University of Arkansas to play trumpet he transitioned to biomedical science and found Dr Jeannine Durdik, an inspiring basic science professor, who taught him the scientific method.

After flirting with a career in basic science he went medical school at the University of Arkansas and matched at Arkansas where also did a chief resident year. The chair of medicine was Dr. Andreoli. I never knew Andreoli, but he sounds like the type of physician they don’t make any more…and you are simultaneously saddened and relieved by that fact. Andreoli was a giant in nephrology and Sparks worked close with him as a resident and closer during his chief year.

Andreoli directed Matt to Duke where he mentored by Tom Coffman. Coffman taught Matt how to write and directed him on his scientific career.

Then Matt talked about going to Mount Desert Island and meeting Nate Hellman. Matt was already an avid reader of the Renal Fellow Network, and Nate invited Matt to contribute. Matt really didn’t get involved until after Nate passed away and this ignited his desire to contribute to the Renal Fellow Network. This is how Matt got involved in and ultimately helped forge what would eventually become our online tribe of nephrologists.

It was fascinating to see the people that mentored Matt, because he is a mentor to so many right now.

Matt seems to know every nephrology fellow in the country and he takes an interest in promoting them and getting them involved. He is a strong advocate for fellows, both in and outside of Duke.

Even though Matt is younger than me, he is one of my important mentors. He has a wisdom that I don’t have and I often go to him with questions. I also trace my success with social media to his reaching out to me back in 2010. He guided me and really transformed my efforts from a solo project to one that recognizes that we can go further and do better by working together. Its a simple lesson but it has been critical to all of the successes we have found in social media.

Matt,

Congratulations on the Keynote.

Congratulations on putting together an amazing conference.

I am honored to be your friend and mentee.

Joel