musings of a salt whisperer
My family took a vacation to Chicago and a friend asked if I could give an acid-base lecture. So I dropped in as an electrolyte sharpshooter and delivered my non-anion gap metabolic acidosis lecture. The revised lecture is in the usual place.
This is a fellow level lecture. I built it off an old lecture from 2003 or 2004. It is remarkable how much data has emerged since then. Of coarse the IDEAL Trial has put a dagger in the heart of early initiation but the observational data in agreement with abandoning early initiation has also turned.
To fortify this lecture it needs the data on nursing home residents and dialysis outcomes and I’d like to add the recent data on dialysis mortality after the week-end.
All-in-all, its a good foundation.
I reworked an old lecture from ’05 on urea kinetics. The old lecture had a hideous purple background, so changing that to black would have been enough but I added a number of cool touches to fully update it. It worked pretty well, though the end’s pacing is off.
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| PowerPoint | PDF |
I especially like the sequence walking through using the iPhone to calculate the simplified single pool Kt/V. Its amazing how many people don’t realize that turning the calculator sideways brings up scientific functions. I love watching their faces light up when I say, “Now turn it sideways.”
As has been the tradition since 2008, I had the honor of giving the morning report on July 1st for the St John Hospital and Medical Center Internal Medicine Residency Program. July one, openning day of the academic year. The conference room was crackling with the energy of fresh interns and the equally excited second years ready to run their own teams.
Giving the lecture was a lot of fun. There were a lot of insightful questions, some because the questioner is terrified and others to show how smart she is. Nobody looked sleep deprived, so the ratio of deer-in-the-headlights to asleep-at-their-desk was unnaturally high.
The lecture covered three topics:
The lungs serve to maintain the composition of the extra-cellular fluid with respect to oxygen and carbon dioxide, and with this their duty ends. The responsibility for maintaining the composition of this fluid in respect to other constituents devolves on the kidneys. It is no exaggeration to say that the composition of the body fluids is determined not by what the mouth takes in but what the kidneys keep: they are the master chemists of our internal environment. Which, so to speak, they manufacture in reverse by working it over some fifteen times a day. When among other duties, they excrete the ashes of our body fires, or remove from the blood the infinite variety of foreign substances that are constantly being absorbed from our indiscriminate gastrointestinal tracts, these excretory operations are incidental to the major task of keeping our internal environments in the ideal, balanced state.
Here is the lecture in PDF and Powerpoint
Today I did a noon conference on sodium for the neph fellows. Instead of a comprehensive sodium lecture I focused on a number of different elements and interesting aspects of hyponatremia. Mostly a deeper dive into aspects that you don’t have time to cover in standard sodium lecture.
I opened with 17 quick slides on free water clearance. These slides are old and I think I could do better. Definitely due for an update.
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| Download the slides here. |
Then I used a slide deck which covers:
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| download the slides here |
I gave the cardiology fellows at St John Hospital and Medical Center a lecture on cardiorenal syndrome this morning. I revised and expanded the lecture I used for the residents:
We also had an interesting discussion on the data suggesting that loop diuretics maybe harmful in acute decompensated heart failure. I should include a couple of slides on that.
Overall a significant upgrade. You can find the lecture in the usual place.
This post really resonates with me: The Ten Commandments of PowerPoint and I wish that I had included it in my lectuer from last week on how to give a lecture.
The chief resident at St John Hospital and Medical Center asked me to do morning report on giving better presentations. It was an interesting project. I have been pretty busy and didn’t have enough time to put together a really polished presentation, but this is what I came up with.
Here is a link to the PDF and Keynote file (130 mb)
iWork documents are a little wonky if you are not using Safari. So the videos I embedded in the lecture are below if you are having trouble looking at them.
Steve Jobs tells it how it is regarding Microsoft
The birth of a morning report:
Screen captures with command-shift-4:
Smart builds
Highlight text:
Mask an image
Improve a crappy figure:
On the first Friday of every month I give a lecture to the residents at St. John Hospital and Medical Center. I like to do an electrolyte lecture but for March the chief resident asked me to talk about cardiorenal syndrome. In researching the lecture I came across this article by Claudio Ronco.
The article defines cardiorenal syndrome as any condition with simultaneous kidney and heart failure. He then goes on to subdivide cardiorenal syndrome into 5 types:
This is terrible. Cardiorenal syndrome used to signify the unique cause of acute kidney injury where the decrease in function is due to apparent volume depletion in a patient that obviously overloaded. It named the only scenario where acute kidney injury responded to diuresis. It was unique and specific. Ronco comes along and says, yes I like your version of cardiorenal syndrome so I will make it type 1 in my new all purpose definition of cardiorenal syndrome. Now whenever there is cardiac dysfunction and simultaneous kidney dysfunction we can just call it cardiorenal syndrome.
It doesn’t have to be this way look at the example of hepatorenal syndrome. The syndrome does not refere to just any situation with simultaneous renal and liver dysfunction. It is a very specific diagnosis that only occurs with chronic liver disease and ascites. The patients must be oliguric, there is no non-oliguric HRS. Patients must be sodium avid and unresponsive to fluids and albumin. Additionally the patients cannot have laboratory or imaging evidence for an alternative cause of renal failure. Because of this definition hepatorenal syndrome identifies a very specific disorder, with a specific pathophysiology and unique prognosis and treatment options.
Ronco takes the beautiful and evocative name cardiorenal syndrome, strips it of all specificity and then tries to restore it by tacking on five different types. The fifth type 5 is the one that makes my brain explode. Sepsis, really? Acute kidney injury from sepsis that happens in the same patient who also suffers from sepsis induced cardiomyopathy should now be considered to have cardiorenal syndrome? Ronco is a man who has spent his life studying sepsis and acute renal failure, I can’t believe he is actually referring to that condition as CRS type 5.
I’m not buying what Ronco’s selling. Cardiorenal syndrome begins and ends with type 1 for me.
FYI: Here is the lecture (Keynote, PDF). It still needs some work. I’d like to add a section on ultrafiltration and I need to include the NEJM article on furosemide that was published yesterday.
The title for the talk was dialysis for the internist and I focused on recent advances in the field of hemodialysis including:
Here is a video of me giving the lecture. I’m working on putting together a formal slidecast but the video was a WMV. What a hassle.
Hemodialysis for the Internist. An Update from joel topf on Vimeo.
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