Precious Bodily Fluids

Here are posts tagged kidney.

I’m trying to generate a master list of renal blogs. I a m looking for blogs that would be of interest to nephrologists, doctors and medical students. I am not looking for patient blogs unless they have significant scientific information. See HemoDoc and Sharp End of the Needle as examples. I am also interested in blogs that are no longer being maintained or may have disappeared from the internet (see Utah Renal Fellows). I am limiting my analysis to English Language, sorry NephroHug.

Here is my list so far:

1. uremic frost
2. PBFluids
3. Renal Fellow Network
4. Utah Renal Fellows
5. Nephron Powers
6. The Kidney Doctor
7. Sharp end of the needle
8. eAJKD
9. uKidney
10. HemoDoc
11. Global Kidney Academy
12. Kidney Notes
13. ACO Blog
14. Mahesh’s Top Reads
15. allen’s Blog
16. Demystifying Kidney Disease…
17. WhizzBang
18. Pediatric Nephrology Blog
19. Nephrology on Demand

Clinical trial day is held on May 20th in honor of the first clinical trial, James Lind’s 1747 Trial on the treatment of Scurvy. The ironic thing is how shoddy the study design was. He took 12 sailors with scurvy and divided them into 6 groups of 2. He then treated each group with a different dietary supplement:

1. quart of cider
2. sulfuric acid
3. vinegar
4. seawater
5. oranges and lemons
6. spicy paste and barley water

‘What the Industrial Revolution Did for Us: Modern Medicine’ from James Lind Library on Vimeo.

Patient comes to the ER. She has a a sodium of 119.

Four days earlier the sodium was 134.

ER provides normal saline and the sodium falls to 114.

This is classic SIADH. If you see the serum sodium fall with normal saline, SIADH is your diagnosis.

The fellow ordered all the right tests:

• Urine Sodium: 81
• Urine Potassium: 87
• Urine osmolality: 583
• Uric acid: 2.6
• BUN: 13
• Cr: 0.95

From the drug insert

So bad you need to read it to believe it. The NKF has this ask the doctor article by

Look at all those paper charts! How 2007 of you.

Dr Spry on the effects of alcohol on the kidney.

His first point is that drinking alcohol suppresses ADH. You know what other beverage suppresses ADH? All of them. Because that’s what drinking does. Alcohol may have some aditional ADH suppressing property but it is not clinically relevent because being drunk doesn’t cause hypernatremia.

Here is what UpToDate has to say about the electrolyte abnormalities of alcohol:

So beyond some increase in thirst from the suppression of ADH, this is a side show.

Then Spry confuses that point by saying that drinking beer to excess can cause hyponatremia as part of beer drinkers potomania (BTW: Best name for a disease ever). To say that beer-drinkers potomania is a consequence of alcohol misses the point, the disease comes from a bizarre diet that is void of protein and salt. These people exist on carbohydrates alone.

Then he mentions that excessive drinking can cause high blood pressure, but fails to mention that not drinking is associated with increased mortality, in fact being a teetotaler has the same relative risk of death as drinking a sixer every night. Seems like an important omission.

For some more on this crazy phenomenon see this post or this one

Regarding his next point, I’m speechless:

Med calc received an incremental update this week to 2.7.1. The purported reason for the update was to fix a crash on start bug. An additional gift was to update the notes to detect UID and create links.

Here is what the notes looked like in my last review:

Here is what it looks like now:

@kidney_boy Notice anything when looking at your transtub K gradient note in MedCalc 2.7.1? 😉
— Pascal Pfiffner (@phaseofmatter) May 14, 2013

@kidney_boy @phaseofmatter Yep. Thanks for the inspiration!
— MedCalc (@MedCalc) May 14, 2013

I recently heard a great example of failed sharing. USMLE World is a question bank designed for students preparing for USMLE Step 1. The questions can be viewed through the website or via an iPad. Here is what the iPad version looks like.

NOTE: Users running iOS 6.0 and higher will need to enable access to ‘Photos’ as all screen captures are automatically stored in that section. The application will track the number of stored images only to determine whether screen captures are being performed and stored while a test is being taken or reviewed. Tests will not launch without this access. USMLEWorld does not sample, transfer, or save images at any time. USMLEWorld is committed to ensuring the privacy of all users, and any identifying information will be used only in accordance with the Privacy Policy as outlined on our website.

You’re the man.  Just as it was done to me, I direct any student on my rotation to “The Whole Enchilada.” (warning 28 mb PDF)

I’m in my second year in private practice, and I get to teach students and residents through the osteopathic school in Philly (PCOM).

As a 4th year student, a renal attending put me onto your book.  I had to special order it from alibris or one of those sites.  My wife also used your microbiology book often when we were 2nd year students in medical school.

Anyways, I’m a big fan and supporter of all your varied output (books, blogs, lectures, etc).  Early on, it made a big difference in how I synthesized a lot of daunting content, and it continues to affect how I communicate and teach others.  But I’m not at the point where I can hand out sodium ninja badges…

Sincerely,

John Fontanilla

A wonderful letter. And it came after he voted for his favorite PBFluids post (Do we need to EVOLVE our views on EBM in dialysis) and collected a free copy of MedCalc. Come on guys vote!

A couple of months ago, Jeff Zonder was stroking my ego telling me how much he loved PBFluids and how it inspired him to begin blogging (check out his blog, Amyloid Planet). One of the aspects of PBFluids that he liked was how I freely shared my teaching materials.

A bit later I was invited to write a post for Wing of Zock, a blog about academic medicine in transformation and decided to write about the the value of sharing. The essence of the post is that it is not enough to just post a PDF of your presentation or paper, what you should post, to be truly useful to your audience, is the native, editable files. From the post:

The NYU Division of Nephrology has weekly renal grand rounds done by the fellows. In the spirit of Internet sharing, they post every presentation on the division’s website. Every presentation is available only as a PDF. This form of sharing is strictly Read Only; providing the information only as a PDF limits users from remixing your content. Posting a presentation as a PDF says to users, “You can use my material, but only if you use all my information. The way I teach this subject is the only way to teach this subject and my information is eternal and infallible.”

However, the Internet is inherently a Read/Write culture. The optimal way to post those presentations is as native PowerPoint files (or Google Docs Presentations or Apple Keynote presentations) so future fellows can leverage previous work, adding new data, correcting mistakes, and reworking the old into the new. Make the materials you provide online flexible to make them more useful, because the source of your satisfaction is usefulness to others. Provide the Power Point file so the user can grab what they like, skip what they don’t and fix the mistakes you made. We should readjust our sensibilities regarding ownership and intellectual property to recognize the Read/Write culture of the internet.

Read the post at Wing of Zock.
Read the story behind the name of the blog.

I am a big fan of MedCalc. I have used it since the early days of the Palm PDA. The program rocks on the iPhone. The authors, Pascal Pfiffner and Mathias Tschopp, have added both the KDIGO AKI and RIFLE criteria for acute kidney injury. But the tentpole feature of 2.7 is the ABG analyzer.

The ABG analyzer uses Androgue’s 2009 review paper in KI to create a mathematical framework to fully interpret ABGs. This has been done before, I recommend ABG in my lectures and there are 6 programs in the iTunes store whose name starts with “ABG” and appear to do the same thing.

MedCalc offers a few features that set it apart. First, data entry is very slick. The keypad is well designed and other programs that use a wheel or + and – buttons are exercises in frustration. 

Lots of clever ideas to speed entering data, MedCalc bests them all with a device called a “keypad.” The other MedCalc innovation is requiring only the pH and pCO2 and then calculating and autofilling the only possible HCO3 for those independent variables. Clever. The Henderson-Hasselbalch equation: not just a good idea, it’s the law.

The other nifty feature is the application is live. You enter the pH and pCO2, and it immediately fills the HCO3 based on a Henderson-Hasselbalch calculation. No calculate button or analyze button. Instant interpretation. It will immediately interpret the ABG and provide:

• the primary disorder
• additional primary disorders, altering compensation
• If you add the sodium it will calculate the anion gap
• It will calculate the delta ratio to determine if there is an additional non-anion gap metabolic acidosis or metabolic alkalosis.

Pretty slick. It is by far the fastest ABG calculator I have seen. My position on ABGs can be summed up here:

Page 13, Acid Base Haggadah

I will update the document to include MedCalc as my suggested tool.

My final thoughts on MedCalc is that it is a delight to use. The keypad can be swept away to see the data underneath. You can get to the supporting data for any equation by tapping on the ‘i” in the upper right corner (a very Palm-esque method) or by swiping to the right. Tap on the wrong formula from a list? Swipe left to go back. Entering multiple variables for a calculation, swiping on the keypad advances you to the next field. If you want to add your own notes on on any formula, you can do that.

My notes on the TTKG formula in the yellow

The handsome and generous authors have given me 15 codes so you can get the program for FREE! The standard calculator is $1.99 and the pro version is $4.99.

Here’s what you need to do:

1. Apologize to Pfiffner and Tschopp for not having purchased their superior program before now. 
   • You can do this by twitter (Pascale and/or Mathias) please tag @Kidney_boy  or use the hashtag #ImOnlyDoingThis4TheFreeSoftware in your apology so I know you did it. 
   • Alternatively you can also apologize by e-mail, remember to cc me (joel.topf at gmail dot com).
2. Then vote for your favorite post on PBFluids. Use the form below. I ask for your twitter name or email just to match it up to the apologies. I have neither the time or inclination to spam you. I will destroy that info after the contest.

• Dialyzing the highest potassium
• There once a dialysis patient from Nantucket…
• Cool Wikipedia page of the day: Hickam’s Dictum.
• When 1A evidence is not 1A evidence.
• Shame on you US News and World Report
• Do we need to EVOLVE our views on EBM in dialysis
• Team based learning, reason for optimism about medical education
• You hear about the kid who sold his kidney for an iPad?
• Three of them with each meal…
• Salty dog, the highest sodium I ever saw
• Dogs, squirrels and evolution
• The agony and ecstasy of of secondary hyperparathyroidism
• How the kidney works, a primer for non-medical folks
• One of my friends had a heart attack
• Celebrity interaction: How I “met” Margaret Atwood on Twitter

I have codes for both the regular version and the pro version. If you are already rocking the original version, mention that and I’ll send you a code for the pro version.