Category: Commentary

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#NephMadness Editorial in AJKD

Matt and I wrote an editorial on NephMadness. Last year was the fifth year of NephMadness and Matt and I felt it was time to pass the reigns to some new blood. Tim Yau came on board last year and got a lot of experience. Anna Burgner was added to the executive team this year. They are doing a cracking job.

As Matt and I move to lesser roles, Feldman, Dember, and Sterns invited us to review our experience with the first five years of NephMadness. It was very kind of them. The editorial is out now. Take a look.

My favorite part of this is that when you type NephMadness into PubMed, you will get two hits. (As of writing this, the new article is not indexed. Awkward.)

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Cardiorenal conference in New York: #NephCards2018

You probably know Kenar Jhaveri. He is the founder of NephronPower and the first editor of AJKDblog. He is a professor of Medicine at Hofstra Northwell School of Medicine on Long Island. Kenar is a good friend and one of the great nephrology educators.

He is sponsoring a cardiorenal symposium in March. I’d love to go but I’ll be most of the way to Everest Basecamp at that time. If you have some spare conference time, you should check out The Heart-Kidney Connection.

There will be mad tweeting so in mid-March tune your Twitter machine to #nephcards2018

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The Everest Itinerary

I am so excited to go to the Top of the World with MM4MM to help raise money and awareness for the multiple Myeloma Research Foundation. If you haven’t already, please take a look at my fundraising page.

The trip is being guided by Embark. They seem quite professional.

Here is the itinerary. From what I understand this is just provisional as all plans in the mountains must be.

 

Day 1. We meet in Kathmandu (4, 593 feet).

Day 2. We fly from Kathmandu to the world’s most dangerous airport in Lukla (9,383 feet).

Day 2. After landing in Lukla we hike to Phakding (8,563 feet).

Day 3. From Phakding we trek to Namche bazaar at 11,290 feet. Namche is in a bowl in the hill side, it is a commerce center. Will arrive in the afternoon and may need to climb up to our hotel.

Day 4. We have a rest day in Namche to help with acclimitization. We won’t go any higher to sleep but we will do day hikes. We should have the opportunity to go to Kumchong to see a Hillary School.

Day 5. The next day we will go to Tenboche (12,687 feet). This hike starts by going down and then up. We will be going to the Tanboche monastery, one of the largest in the area. Namche the crowd thins out and the villages are farther apart.

Day 6. The next day is at the Pheriche (14,340). We should get a view of Everest from here.

Day 7. Above Pheriche we encounter the glacier and go to Lobuche, 16,700 feet. We will be walking on the terminal moraine of the glacier.

Day 8. Biggest day is from Lobuche to Gorakshep. We will dump our gear and then climb up to the Everests Basecamp (17,598 feet). We will head back to Gorakshep to sleep (16,942 feet).

Day 9. The next morning we will get up early and head to the summit of Kalapathhar, the highest point of the trip (18,514 feet) and what should have a spectacular view of the glacier and Everest.

Day 10. We then go all the way to Pheriche (14,340 feet)  that night. Long day.

Day 11. The next day we go from from Pheriche to Namche where we will catch a helicopter to take us to Kathmandu.

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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