Category: Lectures and Presentations

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Lecture on Herbal Medicine and Kidney Disease

In August of 2013, I went to Chicago for the ASN Board Review Class. The week long class was filled with great lectures and compelling teachers, but it was a review and I had solid knowledge of most sessions, but one session was different. Warren Kupin (Hey, Warren, we are still waiting for your first tweet!) of the University of Miami gave an inspired lecture on interstitial nephritis and the dangers of herbal medications. It was one of the most interesting lectures I have ever seen and I decided that I would remix his lecture for my February grand rounds.

I gave this grand rounds at St Johns and Providence Hospital last week (two grand rounds, same subject, same week, that’s lecturing like a boss).

Here is a link to see the presentation with me narrating.
Same presentation but higher quality.

The original Keynote file is available here for remixing and editing.

A PDF of the presentation is available here.

Notes on the presentation

Much of the information on sulfanilamide comes from this article by the FDA.

The picture comes from an ad on Etsy. I didn’t get permission to use the photo, but I did buy the bottle, so that should be cool.

Harold Watkins committed suicide after the sulfonilamide disaster, though the owner of the Messengill Company never showed any regrets: Dr. Samual Evans Massengill, the firm’s owner, said: “My chemists and I deeply regret the fatal results, but there was no error in the manufacture of the product. We have been supplying a legitimate professional demand and not once could have foreseen the unlooked-for results. I do not feel that there was any responsibility on our part.”

Diethylene glycol, though it contains two molecules of ethylene glycol there is no evidence that it behaves like ethylene glycol in a poisonong and no evidence that fomepizole would be protective. Contemporary experience with diethylene glycol comes from the Haiti Contamination disaster and a PDF from JAMA.

There are various reports for how much was shipped and how much was confiscated, I took one set of data and ran with it. If I’m wrong, shoot me.

The Kelsey information is almost entirely from Wikipedia.

@kidney_boy One (minor) thing – McGill University is in Montreal, not Toronto. Can get folks upset here in Canada. 🙂 (McGill grad here)
— Michelle Gibson (@MCG_MedEd) March 4, 2014

Getting reliable data on the size of the herbal supplement business was nearly impossible, I found sources that used anywhere from 5 billion to 100 billion. Most sources were around 26 billion so that is what I used. I imagine it depends a lot on what you includein dietary supplements and herbal medication. Of note, GNC alone does 2.6 billion dollars in revenue.

I like this slide, but it doesn’t really fit into the lecture. I bet it gets cut in a future presentation.

The tag line that people take the drugs for years, what they may take changes but they will take something for years, comes almost verbatem from Kupin’s lecture.

I really like the chart styles I used in this lecture. One of the problems with pie graphs is trying to associate a color to a trend. what part of the pie is attached to what is happening. By making one color with maximum contrast and the other with no contrast (transparent), it becomes much clearer. If I were to change anything I would get rid of the title of the slide and increase the typeface over the pies. Kupin’s slide with the same data for comparison.

The silicate stone story is a little weak and could be cut.

Love this slide. Kupin’s idea to leverage physician familiarity with Grapefruit interactions with how St. John Wort interacts. He is really clever.

The Metabolife story is so good it should be made into a movie. And the only reason there is an anvil animation is so you can drop the bars over some guy. Love this slide.

The Seville Orange and synephrine works great. The Blue Cohosh data is a little light and the fact that there aren’t a million weight loss agents using it makes me suspect that it is not a very powerful alpha agonist. May need to research this herb more thoroughly.

I need to include the incredible aspect that Patrick Arnold was the guy who brought DMAA back from the dead. Patrick Arnold was the chemist behind BALCO and inventor of The Clear.

Wife helped me with this slide, the first version had patient temperatures and ambient temperatures on a single thermometer.

The Cheerios story is cute, and illustrative but it could be sacrificed.

One of the funniest parts of Kupin’s talk is when he goes off on the crazy ridiculous packaging of herbal medications (American products waving the Dutch flag, etc.). I couldn’t pull it off and added this single slide. I may talk a bit more about the packaging requirements of DSHEA.

This slide worked as well as I hoped it would. Big risk talking about erections for a slide with 43 builds. It worked.

Weight loss supplements, go home, you’re drunk.
Phenolphthalein. Really?

The Glycyrrhiza glabra joke? It’s Kupin’s. The guy is really funny.

The 11beta-hydroxysteroid dehydrogenase story comes from my metabolic alkalosis, potassium and monogenic hypertension lecture.

It’s principal cell not principle cell. Thanks Matt.

Love this twist to the Aruvedic medicine study. I find it so funny, it is the kind of thing that usually doesn’t make it into the methods. #OverlyHonestMethods

Kupin spent a lot of time in his lecture talking about this. I blew through it pretty quickly. I may make time for this in a future version.

Love the way I told the Aristolochic Acid story. And this story board where I select the different countries turned out just like I hoped it would.

The most important slides in the deck?

This slide didn’t work as well as I would like.

The next version should add some of the data I started to put together on vitamins, especially the SELECT trial and the USPTF statement saying that vitamins have no role in the prevention of cancer of cardiac disease.

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hypokalemia and metabolic alkalosis

A few years ago I was talking one of my mentors at Kidney Week, John Asplin. He mentioned

that he taught an integrated lecture on metabolic alkalosis and hypokalemia. I thought this was an inspired idea.

Teaching separate classes on both subjects results in a lot of overlap because the renal mechanisms for both disease are the same, this means that many of the diseases that cause one, also cause the other.

Additionally hypokalemia can cause metabolic alkalosis and metabolic alkalosis can cause hypokalemia, so it makes sense to teach both of these conditions in an integrated lecture.

Lastly, teaching each electrolyte individually in isolation from each other is a missed opportunity. One can only appreciate the beauty of electrolyte physiology when one understands how each electrolyte fits together and how abnormalities in one is associated and affects all of the other electrolytes.

Unfortunately, I botched the lecture. I gave this lecture for the first time for the Oakland University Beaumont Medical School this past August. I knew it didn’t go too well, but this week I received the class feedback. Overall my statistical evaluations were excellent but when I read the comments the students were jackals. They savaged this lecture.

Timing was on my side, I was scheduled to give this lecture the day after I received feedback. I’m not done tweaking it but what I did for my Tuesday lecture was add more connective tissue between the concepts, and fill in with some additional summary slides.

Right now, I’m using it as a lecture to follow-up my potassium lecture, but at OU the students didn’t have any baseline potassium knowledge. In order for this lecture to work the students must already understand the basics of potassium, especially the central role that renal potassium handling has in potassium homeostasis. Hopefully I will be able to negotiate another hour into the GU schedule for this lecture.

My next plans for this lecture is to cut out a lot of the opening slides. The purpose of those slides is to quickly move from introducing potassium and hypokalemia to getting to the truth that hypokalemia is almost solely a disease of increased renal losses.

I want to add a slide about disease opposites:

  • Pseodohypoaldosteronism type 1 and Liddle syndrome
  • Godon’s syndrome and gittleman’s syndrome
  • Adrenal insufficiency and AME

I want to add some slides on how hypokalemia causes (specifically, maintanes) metabolic alkalosis and then how metabolic alkalosis causes hypokalemia.

Here is the lecture (Keynote version | PDF)

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App.GoSoapBox.com. Three times a charm.

I have been trying to use GoSoapBox to add some interactivity to my lectures. My first attempt did not work out at all like I wanted it. I used quizzes instead of polls. Then I added  GoSoapBox elements to my non-anion gap lecture and I tried to use it at McClaren Macomb a couple of weeks ago. McClaren built this beautiful auditorium under the hospital. It is state-of-the-art in every way except it has no way to plug in your laptop. My Kingdom for a free VGA cable. So I had to run the lecture off Dropbox on the Window’s machine they had available. Not surprisingly it looked like ass. Then, when I tried to use GoSoapBox, I found that the auditorium had no cell signal penetration (basement) and no wifi (whiskey-tango-foxtrot). Who builds a modern auditorium like that? Total Fail.

On Tuesday I gave the same lecture to the Internal Medicine Residents at Providence. This time the system worked great.

Non-anion gap metabolic acidosis (Powerpoint, PDF)

As the residents were getting food I was joking with a few them and we were stuck on what Batman’s father’s name was. The residents found the Social Q&A section and used it to provide the answer.

I started the lecture with a couple of slides walking them through logging in and getting familiar with the system.
Then I had them do a pre-test to assess what their baseline knowledge of the subject was
Then I posted an ABG and asked them to interpret it.

Use of Winter’s Formula

I had a series of questions on the proper use of the urinary anion gap.

And the lecture finished with a series of quick case vignettes designed to test knowledge of NAGMA.

The feedback on the system I received from the residents was excellent. They loved it. I made a mistake of using my laptop to both run the presentation and manage GoSoapBox. GoSoapBox requires the presenter to open the polls at the appropriate time so students can’t see the poll until the appropriate time. Powerpoint got cranky when I would bounce to my web bowser and then back. Next time I will manage GoSoapBox on my iPad.

Disclaimer: I was given a free 6 month trial of this product. I have received no additional payment or inducement for promotion. I was looking for a system like this and Gary Abud, a friend and Michigan Teacher of the Year, suggested I give this a try. He arranged the free trial.

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HIV renal disease

I gave a lecture on HIV renal disease to the ID section yesterday. I give this lecture every couple of years. I swear that lecture changes more from year to year than any subject I talk about.

  • The lecture was about one hour. 
  • The section on APOL1 is rough.
  • I would like a slide describing the transgenic mouse model studies by Klotman that showed that transcription of nef and pol are central to the disease.
  • I need some notes on why I have 2 graphs on slide 16.
  • Add some highlights to table in slide 23.
  • Loved how slide 26 and 27 worked.
  • I think there might be better data on steroids in HIV. Slide 51.
  • Need to flush out IRIS and DILS from slide 67
  • Add comment on adefovir slide mentioning that the hep B dose is a sixth of the anti-HIV dose

Keynote
PDF

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Grand Rounds: Social and Health Care

On Tuesday December 4, I will be presenting grand rounds for St John Hospital and Medical Center. This page has the references, lecture notes and a copy of the slides.

PDF of the slide deck (17.3 MB)

One of the gimmicks of the talk was that a scheduled tweets to drop during the presentation. I also peppered my tweet stream with my talk’s hashtag in the 2 days leading up to the talk. This resulted in a nice little buzz of social activity. Looking over the hashtag (#SJHMCsmhc) a day later I found 20 retweets, 14 replies, 11 favorites. This was spread-out over 17 different tweets All way above normal activity for @kidney_boy.

This only captures activity with the hashtag #SJHMCsmhc

I used HootSuite to schedule the tweets.

Notes and References

Picture of Me and Bud
    1. Shame on You… Facebook page
    2. Preemie Primer post by Dr. Jen Gunter the queen of OB/GYN on Twitter
    3. Forbes blog post, Is KV Pharma Evil?
    4. Eli Reschef, OB/GYN leading charge agains Makena pricing
    5. Academic OB/GYN on the Makena Controversy

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July 3, first lecture of the year

For the past few years I have had the honor of giving the July 1st morning lecture for the internal medicine residents at St John Hospital and Medical Center. Unfortunately, July 1st was a Sunday and Monday mornings are dedicated to a formal sign out rounds in our division. So July 3rd was my first lecture.

I gave my Fluids, Diuretics and Sodium for the Terrified Intern lecture. You can down load it here: