I love NephSAP. It is the greatest life long education product that I use. In my mind, it is the crown jewel of an ASN membership. Thank-you Bob Narins.
We have embedded it into our fellowship curriculum. When I do the questions I get blown away. They are really hard. I have to go searching hard to answer them. I figure I’d get aroound 50% without access to Dr. Google and the Preview Search box. The only exception is the fluid and electrolyte issues. I can handle those pretty well. This month’s NephSAP I nailed with only two misses. One of those misses annoys me. Here is the question:
So the TL;DR summary is you have a transplant patient with some graft dysfunction likely due to the concurrent volume depletion. His potassium is elevated and he has some worrying ECG changes (peaked Ts and a prolonged PR interval). Of note, he is on two medications that can provoke hyperkalemia: tacrolimus and trim/sulfa. This month’s NephSAP has a great section on why tacrolimus causes hyperkalemia. Tacro causes a drug induced Gordon’s syndrome:
Gordon Syndrome (pseudohypoaldosteronism type 2) is a gain-in-function mutation of the thiazide sensitive NaCl co-transporter in the distal convoluted tubule. The increased sodium resorption means there is no/little sodium available for the eNaC in the cortical collecting duct. No sodium resorption means no negative charge in the tubule driving potassium and hydrogen excretion.
The clinically relevant pearl is that calcineurin inhibitor induced hyperkalemia is particularly sensitive to thiazide diuretics. So I was hunting for some HCTZ or indapamide among the foils.
Nope.
Then I went looking for some saline to correct this patient’s hypovolemic acute kidney dysfunction and increase kaluresis.
Nope.
So I was left with the unenviable position of picking among choices that I would not actually do in this circumstance.
Fludrocortisone. I am a big fan of fludro in the treatment of hyperkalemia. But in this situation where there is both eNac antagonism by the trim/sulfa and tacro blocking distal sodium delivery, this did not seem like an effective treatment.
Patiromer. No data on patiromir for acute management of hyperkalemia, but not a bad option and this NephSAP did show some data on speed of treatment so I went with this.
Hemodialysis. This seems a bit extreme for an increase in creatinine from 1.2 to 1.4. But if the patient had a functional hemodialysis access, this is something I could be convinced to do.
But the right answer was our old friend bicarbonate. I thought we killed this one in the 90’s.
The answer key says:
A sodium bicarbonate infusion would not only correct the hypovolemia, but would enhance lumen electronegativity in the cortical collecting, thereby facilitating potassium secretion.
Reference 76 sounds intriguing. It is a KI article from 1977. It was an uncontrolled, but still somewhat convincing study. See the full open access manuscript here.
My beef comes from the NephSAP authors taking their eye off the ball. We don’t want to lower the potassium, we want to avoid arrhythmia. The consensus in nephrology is that IV calcium is the best way to avoid arrhythmia and the NephSAP authors specifically state that IV calcium is given. My concern is why should we then give a treatment that will counteract the antidote to hyperkalemic cardiotoxicity? Raising the pH decreasea the ionized calcium. Will that precipitate arrhythmia? I don’t know. I’m not sure anyone does. Without convincing prospective data I’m sticking with saline.
I love podcasts. I listen to them on my commute and when I walk my dog twice a day.
Bo the Dog
In the last year I have become addicted to The Curbsiders, what I consider the best internal medicine podcast. These three guys get interesting experts and interview them on topics with a primary care angle. They do a good job of digging deep to get good engagement from them and though they are respectful they do ask challenging questions (though honestly, I thought I got all softballs, listen to the podcast on coronary calcium scores for some probing questions).
Most importantly they are entertaining. I don’t need NephSAP audio digest. That stuff kills me. Never absorbed a sentence of it. The Curbsiders make listening to medical science fun.
Looks like they stopped doing these in 2013. Anyone miss them?
And this week they had me as a guest. I enjoyed the experience immensely, but in an hour of talking off the cuff I made some embarrassing mistakes:
In describing water reabsorption I said it occured in the cortical collecting duct rather than the medullary collecting duct.
In describing my cure for cramps I tell the story of Gitelman’s and say it is like congenital loop diuretics rather than congenital thiazide diuretics
I mucked up the story about MRFIT and how it allowed a head to head comparison of HCTZ and chlorthalidone. I really oversold what happened.
it was observed that in the 9 clinics that predominately used HCTZ, mortality was 44% higher in the special intervention (SI) group compared with the usual care (UC) group.10 The opposite was true in the 6 clinics that predominately used chlorthalidone. The MRFIT Data Safety Monitoring Board changed the protocol near the end of the trial to exclusively use chlorthalidone. In the initial clinics that used HCTZ that had a 44% higher mortality in the SI group, the trend was reversed after the protocol was changed to chlorthalidone, and they then had a 28% lower risk (P=0.04 for comparison of coronary heart disease mortality at the 2 time periods).
Like sending out newsletters, in Podcasts (especially when you are the guest) once it is recorded, you own your words with no chance to edit them.
Give The Curbsiders a listen, I think you’ll enjoy them.
The reason I knew that nephrology is Greek goes back to the early days of the The Fluid and Electrolyte Companion. We were planning the book and Sarah Faubel and I wanted to have a lot of little icons for little interesting factoids for the book. Here is the key for what made the cut:
But in earlier versions we had a lot of other icons. And one of the ideas was to have an icon for medical Latin but quickly we found that most words we wanted to define were actually Greek. We created a Medical Greek Icon, but it didn’t really work so we ended up using the light bulb. Here is an example of Medical Greek as found in the Book.
This is what the unused medical Latin icon looked like:
The other problem are the names on this picture, everyone of them has the spelling squiglies under the names. Here the problem is that the screen shot was taken in editing mode The two solutions are to export the document to images or put the document in Show Mode and take the screen shot. Demo time:
NephMadness launched today for the fifth consecutive year. The fourth sequal to an original is a precarious place to be. Exhibit A: Fast and the Furious resorted to bringing in Dwayne Johnson. We looked into it and sadly, he was not available.
So it was with this ominous precedent that we began the journey to NephMadness. In our fifth year we were able to get 31 completely fresh concepts, with the only repeat being antiPLA2r which showed up in the inaugural NephMadness in 2013.
The regions have a few more repeats as we revisited Dialysis, Nutrition, Genetics and Biomedical Research. The theme for the year is Old versus New. More on that in an upcoming editorial (just one of a number of posts that didn’t quite get finished for the launch).
If you are not familiar with NephMadness, these two videos maybe helpful.
I was invited to talk to the Internal Medicine Interest Group at Wayne State Medical School. Here was the deck I used, but to be honest it was mostly a discussion. Much more two way communication and less top down.
Many people say information is power. I don’t believe that. Information sharing is power. People are more than willing to share information not because they are being paid but because they get a feeling of satisfaction that somebody else found their information useful. — Vint Cerf, Chief Internet Evangelist, Google, Inventor of TCP/IP
In this quote, Cerf was describing the value of sharing in order to explain the phenomenal success of social media sites like Facebook and Twitter, but I found that it explained much of my own Internet behavior. I think the principle is so useful: People should optimize their online creative output in order to make the content more useful for others.
Facebook has a billion people on a single network. This is unprecedented in human history, and the incentive to be part of this network comes from friends, relatives, and acquaintances volunteering information to be shared. Everything people add is effectively controlled by a third, profit-motivated, party. One would think this would paralyze sharing, yet 293,000statuses are updated and 136,000 photos are uploaded every minute. The biggest mystery surrounding Facebook is why so many donate their time, energy, and privacy to this endeavor. The reason is not magnanimous generosity, but rather that these hundreds of millions of people are getting satisfaction from sharing.
I am a teacher and blogger. I teach nephrology to medical students, residents, fellows, and an occasional attending physician. I share all of my teaching materials on my blog. When I share these materials, I share them in a way that makes them most useful for the reader. Handouts should not be limited to PDFs but should be available in their native, editable, word processing files. How is this more useful? If you are a student and want to get my lesson, grabbing the more versatile and lighter-weight PDF makes sense; however, if you are a teacher and want to adapt a figure, or a small segment of the handout, having access to the native files is critical. The greatest satisfaction I get as a networked teacher is when I get an e-mail or tweet from a colleague thanking me for making a handout or presentation.
What was so enlightening about the explanation from Cerf was seeing that sharing is not strictly generosity but is powered by self-interest: By increasing usefulness of the resource, I get more satisfaction.
PowerPoint presentations can be distributed multiple ways over the Internet: Presentations can be exported as PDFs, SlideShare presentations, PowerPoint shows, or as native .ppt or .pptx files. Some of those formats are Read Only: PDFs, SlideShare presentations, PowerPoint shows, in that they cannot be edited or remixed by the user. Native .ppt and .pptx files are Read/Write formats that allow the user to see the presentation and freely edit, copy, and reuse parts of it.
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 solely 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 Keynotepresentations) 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.
Medicine and medical education need to abandon the Read Only assumptions about teaching materials and embrace a Read/Write culture: Students can become participants in their own education, and authors of a personalized textbook. This is how I post presentations on my web site:
I first have a picture of one of the slides; this helps me fly through the growing list to find a specific presentation.
Then I have the title and links to the native format and the PDF. The PDF is useful for people who are looking for the Read Only experience and for people without the software needed to read the native file. It is important to provide both.
After that, I have a few bullet points about the scope of the presentation: when it was last updated, weaknesses that need to be fixed. In this case, it has links to a supplementary handout, again as both native file and PDF. Other useful metadata includes how long the presentation is, and the size of the files.
One of the foundations of academic tradition is the ethic to attribute everything. I have seen professors seethe in national meetings as their slides or figures are used without attribution. I want to stress that providing easy ways for people to adapt and remix material in no way relieves them of the ethical obligation of attribution. In fact, attribution is another way to increase the usefulness of the work. Credibility is a primary ingredient in the usefulness of medical material, so a thorough chain of references is seen in the best medical adaptations of source material.
Putting up electronic locks in hope of dissuading people from using material without attribution is a failed strategy. It punishes the lawful without stopping the ruthless. And — importantly — if your effort to lock down your materials means that it is less useful to your audience, you get less satisfaction from sharing.
The currency of social media is sharing. If you want to build an audience and add value to whichever social media realm you occupy, you need to provide content that others can share.
If you create content, you want that content to be in the form that is most shareable. We live in a remix culture. People see content and they want to take it, change it, make it their own, and reshare it. Operating in the social media realm of medical education requires doctors to adapt to the customs of the realm and that means disposing the handcuffs of academic ownership and embracing the reason we are all educators: the dissemination of knowledge.
This post was originally published at Wing of Zock
