Category: Commentary

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List of therapies that reduce cardiovascular mortality in diabetes

I’m giving grand rounds on Tuesday on SGLT2 inhibitors and I’m trying to come up with a list of therapies that lower CV death in diabetes.

Here is my list:

  • Blood pressure control
    • UKPDS
    • ADVANCE All-cause mortality was reduced with a near miss on CV mortality (P=0.041)
  • Empagliflozen
  • Canagliflozin
    • CANVAS Only partial credit here. CV death was part of the composite outcome, but CVD was not significant on its own
  • Semaglutide
    • SUSTAIN-6 Weak. Hit the primary outcome but CV death was explicitly identical between groups
  • Liraglutide

Drugs that have run the FDA CV disease gauntlet and that are non-inferior to standard of care:

  • Exanatide
  • Rosiglitazone
  • Pioglitazone
  • Alogliptin
    • EXAMINE (This is a secondary prevention trial. As far as I can tell it is the only FDA mandated outcome trial that is specifically designed as a secondary prevention. Not sure why.)
  • Saxagliptin
  • Degludec

 

I’m sure I’m missing some. There must be a statin trial of diabetics. Right?

 

Swapnil was first with the statin answer:

And Edgar came up with a great visual from a review paper:

And Szymon came up with the Steno trial. I can’t believe I forgot about that one.

 

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Mistakes in medical education social media

I am in page proof hell.

The two year slog from from gleefully saying “Wow, that sounds like fun” to a published book is wrapping up. I am working with Edgar Lerma and Matt Sparks on Nephrology Secrets fourth edition. It is an amazing amount of work.

Yesterday I was proofing a chapter and found a pretty profound error.

Not a typo.

Not a misspelling.

Not an awkward turn of phrase.

This was a hardcore, error-of-fact that would have confused readers that didn’t know better and cause significant loss of authority for the book by the readers that did.

This error had travelled a long and perilous editing river to finally arrive intact at the final page proof.

I don’t know how the authors proofed their own chapter, but I assume it went through multiple drafts and rewrites. Then the chapter was sent to the editors and for Secrets, each editor read and commented on each chapter. After each editor the chapter was sent back to the authors for revision. This rinse, wash, and repeat went through three cycles. One with each editor. Then the text was turned over to Elsevier and they converted it into a book. The publisher returned proofs to the authors with specific questions that came up during the page layout. Another independent set of eyes. And then the authors signed off on the proofs.

And after all of that I found the error. A significant error.

This error came within one-step of being a permanent, written-in-ink error in the book. That chain of revisions and proofs is what makes books as good as they are. What type of checks are there in social media delivered medical education? How do we assure that the lectures and pearls we push through our blogs and tweets do not contain subtle (or not so subtle) errors. Very little social media has anywhere close to the editorial infrastructure that an Elsevier textbook enjoys.

In my post about Kidney Week I received three different DMs and @s notifying me of 3 different typos and misspelling. Fix and move on.

Typos are easy. There is more embarrassment than ego in those mistakes. Mistakes of content are harder to accept. The instinct is to defend our work, push back against the unsolicited peer reviewer. But we need to keep our ears to the crowd and our minds open so that…

If we are wrong

It is not for long.

Because the strength of social media is using Linus’s Law to uncover mistakes and then it is up to us to put away our egos and make it right.

given enough eyeballs, all bugs are shallow

I really feel the success of FOAMed depends on the crowd notifying authors of mistakes and then the authors fixing those mistakes. A failure on either side of that equation (either side means that if you are reading FOAMed and see a mistake you have an obligation to point it out. Noticing a mistake in medical education material and moving on without notifying the author is like seeing a discarded pistol by the playground and not telling the authorities. That dead seven-year-old is on you) and FOAMed becomes a joke as it morphs into a minefield of crappy, error filled resources.

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The Nephrology Social Media Collective internship is accepting applications

The NSMC internship was created a few years ago to assure that nephrology had a surplus of dedicated people creating varied, compelling, and creative FOAMed resources. In the early years of Social Medicine, I believed that digital natives would join #NephTwitter and quickly and effortlessly create original content without guidance.

The medical school class of 2016 began high school the same year Facebook was launched. They literally have been using social media for their entire adult life.

However after a few years I became impatient with how fast young doctors were joining #NephTwitter and wanted a way to incubate these digital natives so that they could become contributors quicker.

The Digital Native Myth is the belief that young people will intuitively understand how to contribute to FOAMed.

The 90, 9, 1 rule is that for any social media experience 90% of people just consume, 9% will comment on other people’s content, and only 1% will contribute content. The idea behind the NSMC Internship is to move as many people as possible to the right. We want to move doctors from the 90% to the 1%.

A few weeks ago in New Orleans we graduated our third class of interns.

This class was our largest yet and some of the graduates are already standouts on #NephTwitter.

The interns provide us with detailed feedback to further develop our internship. Based on that feedback we are going to be adding a new module to the curriculum to teach interns how to build a website as part of a complete social media presence. One of the roles that our graduates have repeatedly been asked to fill, is to develop a social media presence for various projects. This may be for a large study, or an institution like a division or fellowship program. Our feeling is that many programs created twitter handle and that is where they stop. In order to have a real social media presence, Twitter needs to be backed up by by a website and a blog. We are now going to teach our interns how to do that in either WordPress or SquareSpace. Additionally we will teach them how and when to use Medium.

So drop an application and join us. It will be great.

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In defense of live Tweeting at meetings

Skeptical Scalpel has re-upped his on going war on Live Tweeting or, as Alex Djuricich used to say, Tweeting the Meeting.

Scalpel and I have sparred about this in the past, and I have flipped and flopped quite a bit. Here is my first post on live tweeting:

And the flip flop

If you look at the blog posts linked in that second post you will see posts written largely from the notes created and archived on Twitter. For a more contemporary example take a look at the post I wrote about the late breaking and high impact trials at this year’s Kidney Week. This post uses the Tweets written during the session to tell the story of the session. I think it does a far better job of conveying the mood of the audience during the session than other posts about the session that I have read.

My other post for KidneyWk (#KidneyWk: Serum and Dialysate Electrolytes and the Risk of Sudden Cardiac Death) was also based on tweets but since there were fewer tweeters in the audience the post relies on their voice less and reads like a more traditional post. But don’t be fooled, it was also largely a product of the notes I took as a damned live tweeter.

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Kidney Week is facing an existential crisis

Painting faced an existential crisis with the invention of photography. The platonic ideal of making a picture that fully represented reality was made meaningless by the invention of photography. The goal of painting pivoted from realism to impressionism, surrealism and subsequent movements. Painting faced its crisis by changing the definition of what it strived for. And to be clear artists that spent their career mastering realism didn’t covert to the new movement. New artists came along to fill the niche that had growth and potential despite photography.

Medical education is facing a change in the way students digest information.

Go to a pre-clinical lecture at any medical school in the US and you can find yourself a seat. It doesn’t matter the size of the lecture hall or the size of the med school class, students don’t go to class. Lectures are videotaped and streamed. Students gravitate to the most efficient way for them to learn and surprise, it is not sitting in lectures watching slideshows. If the students likes slide shows they will watch it at double speed with the PowerPoint open in front of them, available for them to make notes. This is nothing like the lectures I attended in med school.

Slideshows are tired, shallow, and inefficient. Students are routing around them. Good for them. I love that students are finding ways to learn in ways most efficient to each individual’s mind.

ASN’s problem is that Kidney Week is slideshow-learning. Selling slideshow-learning to millenials who don’t go to slideshows even when they paid tens of thouands of dollars is going to be like selling sand in the Mojave.

ASN has to make like 19th-century painting and pivot to a different platonic ideal.

What do I mean?

I mean a Shark Tank with real money on the line

I mean TED-like talks

I mean an American Idol-like competition for the best educational lectures.

Have educators around the country compete to make the best lecture on the same subject. Have them compete with the finals at Kidney Week. Rotate the subject every year, but make it a fundamental lecture that everyone needs to give:

  • Acid-base
  • Hyponatremia
  • CKD
  • AKI
  • Dialysis for the internist

Pathology lecture that uses microscopes rather than slides

Simulations

Biopsy training with cadavers

Ultrasound training with patients

A recreational run

With pre- and post- sodium levels and AKI biomarkers

Cooking classes

Panel discussions with patients

ASN is using a fifty year old model of what makes a medical meeting and if they don’t adapt there will be fewer and fewer, and older and older, people attending. The ER and critical care crew have layed the blue print with SMACC, nephrology should be the first specialty to follow it down the rabbit hole.

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When the GFR is zero how fast does the creatinine rise?

 

How do you get a GFR of zero?
Bilateral bathtub nephrectomy
NephrO-kleptO-mainia

In my clinical experience as the GFR approaches zero the creatinine goes up between 1 and 2 mg/dL everyday.

However I was working out a story problem for an acute renal failure and when I calculated how much the creatinine would rise it was 3.3 per day. Here is how I calculated this:

  • Total body creatinine: 420 mg
    • This assumes that creatinine is equally distributed through out total body water. So 42 liters (60% of 70kg) times 1 mg/dl times 10 dL per liter
  • New creatinine: 1400 mg
    • 20 mg of creatinine generation per kg body weight, 70 kg body weight
  • New total total body creatinine 1820 mg
    • add the first two figures
  • New creatinine: 4.33 mg/dL
    • Divide the total body creatinine (1820 mg) by total body water (420 dL):

Did I do my calculation wrong? The total body creatinine calculation of 420 mg seems awfully low, especially if muscles create 1400 mg of new creatinine everyday.

Picture by The Doctr

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Lecture Schedule

March 21 Providence MS3: Acid-Base

February 28 Providence MS3: Sodium

January 24 Providence MS3: Body Water
January 3 St John Hospital Residency: Potassium

2014

December 12 St John Nephrology Fellowship: ASN Kidney Week: reviewed.
December 11 Mclaren Macomb: potassium and alkalosis
December 6 St John Hospital Residency: AKI
December 5 St John Nephrology Fellowship: NephSAP

November 26 Providence Hospital Internal Medicine: Potassium
November 22 Providence MS3: Acid-Base
November 13 Mclaren Macomb: Potassium
November 8 ASN Kidney Week, NephMadness
November 7 ASN Kidney Week, Introduce KDIGO Mobile App

October 24th St. John Hospital MS3: Acute renal failure
October 22nd: Providence Hospital Internal Medicine residency: Acute Kidney Injury
October 17th St John Nephrology Fellowship: Fellow level hyponatremia part 2
October 10th St John Nephrology Fellowship: Fellow level hyponatremia part 1
October 9th Mclaren Macomb: Acute Kidney Injury
October 3 St John Nephrology Fellowship: NephSAP Fluids and Electrolytes

September 27 ACP of Michigan: Uric Acic, Hypertension and Gout
September 17 Beaumont Hospital and Medical Center: Acid Base
September 11 Mclaren Macomb: Fluids and Electrolytes
September 12 Providence Hospital MS3: Acid-Base
September 6 St John Hospital Residency: Sodium

August 29 St John Nephrology Fellowship: Anemia
August 27 Oakland University Beaumont School of Medicine 2nd years: Potassium, alkalosis and secondary hypertension
August 27 Providence Hospital Internal Medicine residency: Acid-Base
August 19: Oakland University Beaumont School of Medicine 2nd years. Acid Base
August 15 Oakland University Beaumont School of Medicine 2nd years. Na and water TBL
August 3 Providence Hospital MS3: Sodium
August 2 St John Hospital Residency Acid Base

July St John Hospital Residency
July Providence Hospital

June 14 Providence Hospital MS3: Potassium
June 11 St. John Hospital MS3: Acid-Base

May 16 St. John Hospital MS3: Fluids and Electrolytes
May 13 William M. Davidson Medical Education Week: NephMadness recap
May 10 Providence Hospital MS3: IVF and sodium
May 8 Mclaren Macomb: NAGMA
May 3 St John Hospital internal medicine residents: Board review
May 2 Providence Hospital Grand Rounds: Social Media in Health Care

April 23 St John Hospital ID Fellowship: HIV and the Kidney
April 12 Providence Hospital MS3: Acid-Base
April 10 Mclaren Macomb: Acid-Base part 2
April 9 St John Hospital MS3: Acute Renal Failure
April 5 St John Hospital internal medicine residents: Metabolic alkalosis

March 22 Gift of Life Minority Organ and Tissue Transplant Education Program: Social Media in Transplant
March 15 Providence Hospital MS3: Potassium
March 14 St John Hospital internal medicine residents: How to give a Lecture Lecture
March 21 St. John Hospital MS3: Acid-Base
March 13 Mclaren Macomb: Acid-Base
March 1 St John Hospital internal medicine residents

February 15 18 Providence Hospital MS3: Fluids and Electrolytes
February 14 St. John Hospital MS3: Fluids and Electrolytes
February 13 Mclaren Macomb: Hyponatremia

January 18 Providence Hospital MS3: Acid-Base
January 17 St John Hospital MS3: Acute Renal Failure
January 9 Mclaren Macomb: IV Fluids
January 3 St John Hospital Nephrology Fellowship: NephSAP divalent ions part 2

2013

December 13 St John Hospital Nephrology Fellowship: NephSAP divalent ions part 1

December 11 St. John Hospital  MS3: Acid-Base
December 7 Providence Hospital MS3: Sodium and Water
December 6 St John Hospital Nephrology Fellowship: Renal Week Recap

November 27 St John Hospital and Medical Center Grand Rounds: Medicine and Social Media
November 13 St. John Hospital  MS3: Fluids and Electrolytes
November 9 Providence Hospital MS3: Potassium
November 9 St John Hospital internal medicine residents: Diabetic Nephropathy, A New Hope

October 24-28 Michigan State Medical Society: Diabetic Nephropathy, A New Hope
October 24 Providence Hospital MS3: Acid-Base
October 26 Providence Hospital MS3: Sodium and Water
October 9 St John Hospital MS3: Acute Renal Failure

September 11 St. John Hospital third year medical Students: Fluids and Electrolytes
September 7 St John Hospital internal medicine residents: Non-Anion Gap Metabolic Acidosis

August 31 Oakland University Beaumont School of Medicine 2nd years. PBL: Glomerular Disease
August 24 Oakland University Beaumont School of Medicine 2nd years. PBL: Acute and Chronic Kidney Disease
August 21 Oakland University Beaumont School of Medicine 2nd years, Acid-Base
August 20 Oakland University Beaumont School of Medicine 2nd years, Potassium Balance Disorders
August 17 Oakland University Beaumont School of Medicine 2nd years. PBL: Sodium and water

August 16 Providence Hospital 3rd year medical students: Potassium
August 3 St John Hospital internal medicine residents: Acute Kidney Injury
August 2 St John Hospital Nephrology Fellowship: Anemia and lack of placebo controlled trials
August 1 Providence Hospital internal medicine residents: Acute Kidney Injury

July 25 St Mary Hospital Grand Rounds: Acute Renal Failure, an update
July 24 St John Hospital internal medicine residents: Acid-Base
July 19 Providence Hospital 3rd year medical students: Sodium
July 17 Providence Hospital internal medicine residents: Water, IV Fluids, Sodium, Diuretics

July 13 Providence Hospital 3rd year medical students: Acid-Base

July 10 St John Hospital third year medical Students: Acute Renal Failure
July 3 St John Hospital internal medicine residents: Water, IV Fluids, Sodium, Diuretics

June 12 St John Hospital third year medical Students: Acute Renal Failure
June 8 Providence Hospital 3rd year medical students: Potassium

May 24 Providence Hospital 3rd year medical students: Sodium
May 15 St. John Hospital third year medical Students: Fluids and Electrolytes
May 4 St John Hospital internal medicine residents: Renal Anemia

April 19 Providence Hospital 3rd year medical students: Acid-Base
April 18 Providence Hospital Resident Reasearch Day: Judge
April 10 St John Hospital third year medical Students: Acute Renal Failure
April 6 St John Hospital internal medicine residents: HIV associated nephropathy

March 20 St. John Hospital third year medical Students: Fluids and Electrolytes
March 13 St. John Hospital third year medical Students: Acid-Base
March 2 St John Hospital internal medicine residents: board review

February 24 UIC/Advocate Christ Medical Center Residents: Non-Anion Gap Metabolic Acidosis
February 10 Providence Hospital 3rd year medical students: Potassium
February 9 Providence Hospital 3rd year medical students: Sodium and Water
February 3 St John Hospital internal medicine residents: Tolvaptan is effective in which patient and metabolic alkalosis
February 2 St John Hospital Nephrology Fellowship: Board Review NephSAP CKD and Progression part 2

January 19 St John Hospital Nephrology Fellowship Initiation of Dialysis
January 17 St John Hospital third year medical Students: Acute Renal Failure
January 12 Providence Hospital 3rd year medical students: Acid-Base
January 5 St John Hospital Nephrology Fellowship: Board Review NephSAP CKD and Progression part 1

2012

December 13 St. John Hospital third year medical Students: Acid-Base
December 8 St. Mary’s Hospital in Saginaw: Fructose, CKD and Hypertension
December 2 St John Hospital internal medicine residents: Severe lactic acidosis and electrolyte disorders of the drunk.

November 29 Providence Hospital 3rd year medical students: Potassium
November 17 Providence Hospital 3rd year medical students: Acid-Base
November 15 St John Hospital third year medical Students: Fluid and Electrolytes
November 15 St John Hospital and Medical Center Grand Rounds: Diabetic Nephropathy, an Update
November 11 U of C Alumni Reception. Marriott. 6:45pm
November 11 Blogger get together McGillins Olde Ale House. 8pm
November 11 AJKD Editorial Board Meeting Franklin 4 Room Marriott. 12:45-1:45
November 4 St John Hospital internal medicine residents: Non-anion gap

October 28 Providence Hospital 3rd year medical students: Sodium and Water

October 27 Providence Hospital Grand Rounds: Anemia and lack of placebo controlled trials

October 26 Michigan State Medical Society: Fructose, CKD and Hypertension
October 25 Providence Hospital Residency Program: What’s New in Potassium
October 22 Lupus Alliance of America: Panel discussion
October 20 Providence Hospital 3rd year medical students: Acid-Base

October 12 St. Mary Mercy Hospital: Fructose, CKD and Hypertension

October 11 St John Hospital third year medical Students: Acute Renal Failure
October 6 St John Hospital Nephrology Fellowship: Dialysis Kinetics

September 30 Providence Hospital 3rd year medical students: Acid-Base
September 22 St John Hospital Nephrology Fellowship: Physiology of Sodium and Water Handling
September 20 Royal Oak Beaumont Internal medicine residency: Acid-Base Disorders
September 13 St John Hospital third year medical Students: Acute Renal Failure
September 2 St John Hospital internal medicine residents: Potassium

August 30th Providence Hospital Residency Program: Potassium
August 26th Providence Hospital 3rd year medical students: Acid-Base

August 9th St John Hospital third year medical Students: Fluid and Electrolytes
August 5 St John Hospital internal medicine residents: Acid Base

July 26th St John Hospital third year medical Students: Acid-Base
July 22nd Providence Hospital 3rd year medical students: Fluids and Electrolytes
July 22nd St John Hospital internal medicine residents: Acute renal failure
July 21st Beaumont Family Practice Residency: Acute renal failure
July 21st St John Hospital Nephrology Fellowship: Anemia and lack of placebo controlled trials
July 19th Providence Hospital Residency Program: Body water, IV fluids and diuretics
July 1st St John Hospital internal medicine residents: Body water, IV fluids, diuretics and dysnatremia

June 14th St John Hospital third year medical Students: Acid-Base
June 9th: Abbott pharmaceuticals secondary Hyperparathyroidism: FGF-23
June 8th: St John Hospital and Medical Center: Update in CKD: Anemia
June 3rd: St John Hospital internal medicine residents: a case of Milk-Alkali syndrome and Fructose, Hypertension and Uric Acid
June 2nd: St John Hospital Nephrology Fellowship Program: NephSAP Fluids and Electrolytes
June 1st: Grand Rounds Beaumont Hospital: Fructose, Hypertension and Uric Acid

May 26th St John Hospital Nephrology Fellowship Program: Hyponatremia
May 17th St John Hospital third year medical Students: IVF and Hyponatremia
May 6th St John Hospital internal medicine residents: Nephrology board review
May 2nd: Michigan CRN meeting: Fructose, Hypertension and Uric Acid

April 29th: Providence Hospital third year medical students: Sodium in the morning, potassium at 11
April 20th: Providence Hospital third year medical students: Acid-Base
April 18th: St John Hospital cardiology fellows: Cardiorenal Syndrome
April 14th: Beaumont Gross Point family practice residents: IVF and Sodium Part 1
April 12th: St John Hospital third year medical Students: Acute Renal Failure
April 8th: St John Hospital internal medicine residents: How to give a lecture: Keynote Tutorial

March 29th: Providence Hospital internal medicine residents: hypernatremia and hypercalcemia
March 17th: St John Hospital third year medical Students: Acid-Base
March 4th: St John Hospital internal medicine residents: Cardiorenal Syndrome

Feburary 18th: Providence Hospital third year medical students: Potassium
Feburary 16th: Providence Hospital third year medical students: IVF and Na

Feburary 11th: Providence Hospital third year medical students: Acid Base
Feburary 8th: Providence Hospital internal medicine residents: Hyponatremia, hypokalemia

January 18th: St John Hospital Grand Rounds: Dialysis for the internist, an update

2011