We just got our microscope serviced. It works great.
– Posted using BlogPress from my iPhone
Hyaline casts
Must read article on funding for antibiotic resistance
Maryn McKenna
The investigators looked at funding into Enterobacter species, MRSA and other resistant staph, C. difficile, Acinetobacter baumanii, Klebsiella pneumoniae, Pseudomonas aeruginosa and Enterococcus faecium as the definition of resistant organism research. In 2009, the NIH spent $398 million. For comparison, in 2007 the NIH spent $1.24 billion dollars on HIV research.
Perecevich and Scweizer then compared the mortality from the different diseases and the relative amount of money spent on them (see graph at right).
Though 95% confidence intervals or P values were not provided, the difference appears significant.
The easy explanation is to blame the politics of AIDS. HIV infection, like breast cancer, is a disease with a well organized and loud constituency and they have labored hard to get funding. Unfortunately that funding comes at the expense of other diseases that may be less visible despite having equivalent impact.
The other cynical answer is to blame capitalism. The fact that HIV treatment is lifelong makes it very profitable for drug companies to focus their research on anti-viral treatment, especially compared to acute bacterial infections that may require only 10 days of treatment. I have secondhand knowledge that in the world venture financed early drug research this is very important, however, these are NIH dollars, which should not be influenced by potential profit.
I think the answer is that the market for drug resistant infection is driven by the availability of good grant requests and interested researchers. For 30 years the best and brightest ID researchers have been going into HIV research, it will take a while to turn that battleship to other areas of interest. Supporting this theory is the fact that research on resistant organisms increased from $180 million to $398 million from 2007 to 2009. So interest and money are being directed to this field but it will take time.
Stupid iPhone tricks: auto-dialing into a phone maze
The phone system in my office allows patients, hospitals and practitioners to leave messages and then calls to alert us about new message. Retrieving the message is a multistep process:
- call the main office number
- dial a prefix plus my extension
- dial my password
- enter the code to play back my messages
You can program an iPhone to playback a telephone script to do this. This is a huge aggravation saver.
Create a new contact with an appropriate name
Enter the voicemail number and then tap the bottom left button
This brings up an alternate keypad with 5 buttons
The wait button inserts a semi-colon and the pause botton inserts a comma.
A “wait” will delay sending the next numbers until you tap a button, a pause will delay the next numbers by a second or two. This is what a semicolon looks like when dialing a number:
I use a pause until the phone picks up and then insert a pause after each step so the phone number looks like this:
(313) 886-8787 ; extension , passcode , play-back code
This trick works great.
I love the smell of July 1st in the morning
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:
- total body water and how to choose an IV fluid
- diuretics
- dysnatremia
There is no way I could get through the deck in the 50 minutes of time we had. It probably would take 90 minutes to cover it all. In delivering the talk I focused on the mood of starting this great adventure.
Here are some tips to using this presentation:
The first slide has Munch’s Skrik, which I explain translates as July 1st
Slide 4 has my favorite quote about kidney function. Homer Smith essentially uses 150 words to explain the point that the job of the kidneys is not to make urine anymore than the job of a factory is to make smoke.
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.
Slides 5-9 emphasize that this topic is not a niche topic, the issues of fluids and electrolytes comes up everyday, on every patient.
Slide 11, warn everyone that the unfortunate person who gains 30 kg in this slide is a medicine resident gorging on donuts at morning report.
Slide 18, remind everyone that LR is for surgeons. Deny any knowledge of the reason for this peculiarity. Explain that this is further evidence that they are an alien species unrelated to hard working, honest IM docs.
Slide 27 Explain that the question, “Would you give a drowning man a glass of water?” was taught to me by one of the most foul-mouthed senior residents when I was an intern. I want to show that the lessons learned this year will be the stories you tell interns decades later. Interns will learn more this year than any other year of their life, except their first year of life.
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Here is the lecture in PDF and Powerpoint
Muddy brown cast via iPhone 4
Using the instructions from the NEJM I captured this muddy brown cast in a patient with acute on chronic acute kidney injury. I love this new tool.
The new definition of a rock and a hard place–Updated
The rock would be Amgen with their newest prescribing information for Epogen and Aranesp. The recommendations for dialysis patients can be summarized as:
Specifically, for patients on dialysis, the label advises physicians to initiate ESA therapy when the hemoglobin level is less than 10 g/dL and guides physicians to reduce or interrupt the dose when the hemoglobin approaches or exceeds 11 g/dL. So target a hemoglobin higher than needed to prevent transfusions and no higher than 11 g/dL.
The hard place would be the federal government whose Quality Improvement Plan (QIP) for dialysis units states:
The intent is to control anemia and maintain optimum hemoglobin levels within the range of 10-12 g/dL (grams per deciliter). Anemia management will be assessed by two separate measures:
- CMS will assess the percentage of patients whose hemoglobin levels dipped under 10 g/dL. The program assigns this measure the greatest weight in facility performance calculation, because numbers under 10 g/dL are highly undesirable. (Weight = 50%)
- CMS will assess the percentage of patients whose hemoglobin levels exceeded 12 g/dL. Numbers greater than 12 g/dL could suggest unnecessary or excessive administration of certain drugs. (Weight = 25%)
There is little air to breathe between 10 and 11 g/dL. Something has got to change and my guess is by the end of the year QIP will be suggesting hemoglobins between 9 and 10.
UPDATE: CMS has proposed new rules that remove the lower limit for hemoglobin as a quality measure. Here is some news coverage and here is the PDF.
I think its crazy to remove the lower hemoglobin limit. When CMS introduced the bundled payment system they turned anemia management from a profit center to a cost center for dialysis units. The Quality Incentive Plan was designed to prevent dialysis units from minimizing costs by denying patients adequate treatment. It seems that with the 2013 proposal, a Machiavellian dialysis unit could eliminate anemia management completely and reap financial rewards without penalty.
This can’t be right, at the least CMS should add minimizing transfusions as a quality measure, that would reconcile the prescribing information and the quality goals.
Hat tip to the anonymous first poster.
Using an iPhone for capturing urine microscopy
From the NEJM:
The authors describe their technique:
When microscopy revealed a field of interest, the camera was placed about 0.5 to 1.0 cm over one of the eyepieces, allowing optimization of the image and light intensity by means of the camera’s digital display. The auto-focus and exposure features generally produced a circular image surrounded by a black rim…
Can’t wait to try this.
Hat tip Pediatric Nephrology
Article on aging I want to spend some time looking at
From the American Scientist: Aging: to Treat or Not to Treat?
Patient called me with a blood pressure of 170
He has resistant hypertension that has been well controlled since we added spironolactone. He reported that his systolic blood pressures were between 170 and 205 over the last three hours. In the morning his blood pressure was 120 and for the last week he had been getting blood pressures of 115 to 135, trending toward the lower end of that range.
I told him that I wasn’t worried about the isolated spike in blood pressure. The goal of therapy is to get the average blood pressure down and that chasing individual isolated episodes of hypertension becomes a hopeless game of whack-a-mole.
The treatment of hypertension is like trying to change the climate, not control the weather.
What do you do when they get this phone call? Do you chase after elevated blood pressures with prn clonidine? Is there an evidence based approach to this?
How many cancers have you caused from ordering CT scans
It feels like if a patient coughs they get a CT angiogram to rule-out pulmonary embolism. How many patients would defere that test if they had to sign off on the following chart:
Makes you think twice regarding the CT for stone-profile that some patients get yearly “just to make sure the Urocit-K is working.”
Hat tip to Academic Life in Emergency Medicine blog.