Tag: Uncategorized

…I’m moving my blog from blogger to WordPress.

Everytime I spend time in WordPress I ask myself, “Why the fuck is PBFluids still on Blogger?”

One of these days…https://t.co/6Jx9vndoPC

— Joel Topf, MD FACP (@kidney_boy) February 27, 2017

Resources

        •  5 Reasons to switch

        •  7 Reasons to switch

        •  How to switch from Blogger to WordPress

I’m going to Mount Everest Basecamp next year to help raise money and awareness for multiple myeloma. Basecamp is at 18,500 feet. In honor of that altitude, here is a review of all the times I have blogged about acetazolamide.

• Altitude sickness and the role of acetazolamide. My first post on acetazolamide in anticipation of my trip to King’s Canyon.
• Acetazolamide was a smashing success. Summary of our experience using acetazolamide to prevent altitude sickness at King’s Canyon.
• More on acetazolamide. A summary of the side effects we experienced.
• Diuretics, MedMastery, and Keurig. A review of my diuretic presentations for MedMastery, which of course included acetazolamide.
• Nephrogenic diabetes insipidus and carbonic anhydrase inhibitors. Review of the data on using acetazolamide to reduce polyuria in nephrogenic diabetes insipidus. 

This seems like a pretty innocent infographic. It is trying to communicate how Canada is doing in preventing and managing diabetes.

Here is the tweet

Canada is average in care for #diabetes but behind peer countries in preventing the disease #CDNhealth https://t.co/ChCzf7iQ6m pic.twitter.com/WdPcLIye5Y

— CIHI_ICIS (@CIHI_ICIS) February 17, 2017

Here is the response I saw in my timeline

.@CIHI_ICIS this image incorrectly groups all types of diabetes & promotes stigma against people with diabetes. https://t.co/kkxAWtETod

— Holly Witteman (@hwitteman) February 17, 2017

This seemed a stretch that this poster was stigmatizing people with diabetes.

This Storify has the entire twitter exchange that follows.

I am gong to highlight a few of the tweets from that exchange here.

One of the first criticisms leveled was that the poster did not distinguish between type 1 and type 2 diabetes. This is important because the advice they were tracking and grading were all techniques to prevent type 2 diabetes: healthy weight, diet and physical activity.

@kidney_boy @WilliamDale_MD @CIHI_ICIS 1/At minimum, be clear about different etiologies of different types of diabetes.

— Holly Witteman (@hwitteman) February 17, 2017

This is a constant tension in building infographics, “How do you balance precision and clarity?” Not specifying type 2 diabetes makes the poster less precise but since type 2 diabetes represents 96% of diabetes in the US (not sure the Canadian data) I agree with the decision to simplify the poster. Type 1 diabetes is small potatoes compared to the public health nightmare of type 2 diabetes. Additionally, because of the potential for diabetes to grow like an epidemic and because we have tools to curtail this epidemic it becomes a good target for public health messaging in a way that type one diabetes does not lend itself.

There was then the argument that the therapy is not that effective and that people who follow this advice often still end up with diabetes:

@kidney_boy @WilliamDale_MD @CIHI_ICIS 3/Second, yes, there is evidence that some cases of type 2 diabetes are preventable.

— Holly Witteman (@hwitteman) February 17, 2017

@kidney_boy @WilliamDale_MD @CIHI_ICIS 4/Those same trials show that despite doing everything “right”, some ppl will still develop type 2.

— Holly Witteman (@hwitteman) February 17, 2017

The problem here is that since people have some agency in their disease, others will blame them for getting diabetes. The patients will be shamed because they didn’t act strongly enough to avoid the disease. By publicizing ways to avoid diabetes you are setting up people with diabetes to be blamed for their condition.

How effective are the items in the poster at preventing diabetes. They are about as effective as any therapy we have in medicine. DPP is the best program to prevent diabetes. See this RCT. What was the interventin in DPP?

The goals for the participants assigned to the intensive lifestyle intervention were to achieve and maintain a weight reduction of at least 7 percent of initial body weight through a healthy low-calorie, low-fat diet and to engage in physical activity of moderate intensity, such as brisk walking, for at least 150 minutes per week. A 16-lesson curriculum covering diet, exercise, and behavior modification was designed to help the participants achieve these goals. 

All three items that are being tracked in the infographic.

So what do you get for that intervention? The DPP trial showed

• 58% reduction in the incidence of diabetes compared to placebo. 
• 39% reduction in the incidence of diabetes compared to metformin. 

In 2014 1.4 million people developed type two diabetes. A 58% reduction in the incidence of diabetes means that over 800,000 people would not develop diabetes in a year.

That compares pretty favorably to the total population of people with type 1 diabetes: 1.2 million.

The problem with arguing the fact that some people progress to disease despite therapy to prevent it is that none of our medications are 100% effective. If I advise patients to take their ARB because it will help their diabetes and then they develop ESRD anyways, did I invite ridicule on them because I gave them an effective therapy? Will people not provide comfort because if they had just tried harder with their ARB they would not have developed ESRD? I hope not. And that concern should not stop me from making it well known that there is an effective drug for diabetic nephropathy, it is also important to remember the treatment effect in IDNT and RENAAL were pretty modest.

Losartan reduced ESRD by 28%, but a quarter of the treated patients still ended up on dialysis by 4 years.

Irbesartan had a similar treatment effect and a similar proportion of patients end up on dialysis despite therapy.

We should not blame people for the diseases they develop but we should not use the fear of that blame to avoid measuring, publicizing, or developing public health initiatives, because it looks like it maybe working.

I gave Dr. Witteman an early version of this blog post and an opportunity to respond.

Thanks for the opportunity to respond to your post. I would like to note the following five points.

1. Type 1 diabetes in Canada is estimated to represent about 9% of all cases of diabetes. That’s more than twice your US estimate. Even if it’s still a relatively small percentage, given the prevalence of all types of diabetes, that’s a lot of people. I am one of those people, so this is personally relevant to me.
2. I think it’s important to note that CIHI is not, strictly speaking, a public health agency. Their role in Canada is more or less to collect, collate and report data on health system quality and population health. The infographic is not intended to motivate individuals. However, when they tweet it out as they did, they’re deliberately seeking a public audience.
3. There is some evidence that blame & shame methods can be not only ineffective as health behaviour change mechanisms, they may be counterproductive. In other words, they may make health-related behaviours worse, not better.
4. A Canadian survey in 2011 conducted on behalf of the Canadian Diabetes Association revealed that 37% of people would hesitate to tell others they have type 2 diabetes. Stigma around diabetes, particularly type 2 diabetes, is a very real issue in Canada.
5. The most concerning cases of type 2 diabetes in Canada occur among people in marginalized populations (Indigenous peoples, immigrants from specific populations known to be at higher risk of type 2 diabetes, people living in poverty, etc.) Promoting the idea that diabetes is completely their own fault may reduce public support for interventions that can help prevent diabetes in these communities, including programs that promote healthy eating and physical activity. Maintaining or increasing public support for such programs is an important consideration in a publicly-funded health system such as we have in Canada.

Thank you for reaching out and offering me the opportunity to engage with you on this issue. As noted in my original 13 tweets, I strongly agree with encouraging healthy eating and physical activity. I also agree with preventing type 2 diabetes and reducing the burden that diabetes can place on people. The problem is that infographics like this typically don’t move the needle, and they can even be counterproductive and harmful. 

Sincerely,
Holly Witteman, PhD

When the Chief Resident calls you up and asks for two lectures in one day I say “Yes sir!”

I did the World’s Greatest Potassium Lecture at 8:00 AM.

Then I did Getting started in social media for doctors at noon.

I’m trying to collect some you tube videos for med students. Send me your favorites. No hour long lectures. Only looking for lessons that are shorter than 10 minutes.

Yesterday, the consult team was evaluating a patient in the ICU and I asked to see the x-ray. A fourth year medical student started scrambling with his iPad to bring up the image. After about 15 seconds he apologized for how slow it was and then a few seconds later the image resolved.

And I just started laughing.

It was just over decade ago that we started daily rounds down in radiology to go over all of the films for our service. Well not all the films because a third of them were always missing, usually the missing ones were in the OR or still on the radiologists light box carousel.

This looks ancient. It was 1999.

I still remember that uncomfortable shame that came from having to tell my attending that I couldn’t get the films. Rounding in the ICU was great because there was a satellite reading room attached to the unit so we could just duck into a room to see the images fresh from the developer. I remember being alone in the University ER when a dying man came in. The story sounded like an acute MI but I was worried about an aortic aneurysm and I was so busy putting in lines and starting pressors I couldn’t get to radiology to take a peak at the mediastinum. Luckily a co-resident wandered by and was able to sprint to radiology to get the answer.

Fast forward to today and I have a kid apologising that his handheld wireless device, that is capable of displaying decades of lab results, all the notes and consults, is going to take anther few seconds to display the x-ray that was taken an hour ago.

We didn’t get flying cars, but we did get a lot more than just 140 characters.

I just saw one of the biggest anion gap of my life and I don’t know the cause. Worse yet, the patient had this occur a few months ago, also with no explanation. So I want to figure out what is going on before admission number three.

Patient presented to the ED obtunded and was unable to give a cohesive history. The admission labs:

Looking at the numbers, the gap gets so large because not only is the bicarb so phenomenally low, but they have a pathologically low chloride and a sodium which is bumping up gainst the upper limit of normal. Additionally the potassium is a bit low, shrinking the other cations box.

We have an ABG done a few minutes after the chemistries were drawn:

• pH 6.94
• paO₂ 179
• pCO₂ 6
• HCO₃ 1

Then we hit that with Winter’s formula: 1.5 * 1 = 1.5 plus 8±2 gives a target CO₂ of 7.5 to 9.5, just a bit higher than the actual pCO₂ of 6. So this patient has a metabolic acidosis with a slight respiratory alkalosis. But who can fault them for hyperventilating with a pH south of 7.

So with a massive metabolic acidosis and a ginormous anion gap, you should be itching to order a toxic alcohol screen. But first check for other causes of an anion gap metabolic acidosis:

• Aspirin: less than 2.0 mg/dl (works especially well with the concurrent respiratory alkalosis)
• Acetaminophen: less than 5 mcg/dL
• Lactic acid: 9 mmol/L
• Ketoacidosis: This hospital doesn’t do real time serum ketones. So we didn’t have data acetone, betahydroxybutyrate or acetoacetate levels. However the U/A showed ketones at 20 mg/dL 

So if we start to fill in the gap:

• A normal gap is 12 mmol/L
• Lactate is 9 mmol/L
• The phosphorus is 7 mg/dL. Four of that is included in the normal gap, the extra 3mg/dl converts to 1 mmol/L
• That comes to 22, leaving an unknown gap of 31. Some of this will presumably be filled by ketones, acetoacetate and betahydroxyburyrate. 

Next step is to look for an osmolar gap, because if you aren’t thinking toxic alcohol you aren’t wired to be a nephrologist, toxicologist or critical care doc. The serum osmolality is 342. Calculated osmolality:

I know that your shitty medical calculator does not include ethanol or if it does it divides it by 4.6 not the correct 3.7. For crap calculators see MedScape, GlobalRPh, (QxMD and UpToDate don’t even include alcohol?!). Even Wikipedia gets this right. Get with the program, get MedCalcX or use MD+Calc.

So the osmolar gap is 342-321= 21. High but not very impressive, especially compared to the anion gap in the stratosphere.

The thing to understand about toxic alcohol’s, anion and osmolar gap is that they move in opposite directions. Ethylene glycol (antifreeze) and methanol (fuel, incompetently distilled spirits) are both neutral alcohols. They are osmotically active so they contribute to the osmolar gap, but since they are not anions they do not contribute to the anion gap. So early after ingestion the osmolar gap is high but the anion gap remains low.

Then the toxins are metabolized (initially and most importantly by alcohol dehydrogenase) into toxic downstream metabolites. Many of these metabolites are acids that lose a proton, and thus become anions. So after metabolism the anion gap will climb as neutral alcohols are converted into anionic acids. Interestingly, the osmolar gap falls. Even though the metabolites are low molecular weight and osmotically active, they do not contribute to the osmolar gap, because the equation includes them in the calculated osmolarity. When you multiply the sodium by two, you are covering all anions in solution. Since the acids are anions they are covered by the calculated osmolality and don’t contribute to the gap.

So our patient with the big anion gap and the modest osmolar gap could just be a late presentation of a toxic alcohol. Once that has happened and the osmolar gap has retunred to normal. Even if there is a large anion gap it is probably too late to intervene with fomepizole to block alcohol dehydrogenase. Once the osmolar gap has closed the toxin has moved downstream of the alcohol dehydrogenase.

But our patient still had an osmolar gap. So we gave fomepizole and dialyzed the patient. The next morning the osmolar gap had closed and the anion gap was nearly normal. We stopped the fomepizole and dialysis. On the third hospital day we got back the toxic alcohol screen. 

• Acetone 31 mg/dl
• Methanol: not detected
• Ethylene glycol: not detected
• Isopropanol 12 mg/dL

Isopropanol, is commnly called isopropyl alcohol, rubbing alcohol. It will increase the osmolar gap but is not converted to an acid and does not cause anion gap metabolic acidosis. Divide the level by its moleculatr weight, 60, and then multiply by ten to convert “per dl” to “per liter.” So the level of 12 accounts for 2 of our abnormal osmolar gap of 21.

The Acetone is interesting. It is also not a charged molecule so will not account for the anion gap, but it is in equilibrium with two charged molecules that can generate an anion gap: acetoacetate and beta-hydroxybutyrate. 

I looked but could not find the expected ratio of acetone to the other two ketones in order to extrapolate from the acetone level to the concentration of the anions. I couldn’t find a reference, but I found a number of documents that said acetone was a definite minority. So if we estimate that each ketones is at 2-3 times the concentration of acetone we have a 20-30 mmol/liter combined concentration of acetoacetate and betahydroxybutyrate. (Molecular weight of acetone is 58, so 31 mg/dl is 5.3 mmol/L). This essentially fills the unknown gap.

Could this just be alcoholic ketoacidosis? The patient had a triglyceride level of 600 mg/dL which is consistent with alcoholism? The serum glucose on admission was 57, also consistent with alcohol induced ketosis. 

I personally am not very satisfied, because I see drunks all the time (at work, not socially) and nion gaps this high are very unusual. I personally think there is some other ingestion stimulating the massive ketosis. Looking for ideas.

Notes: We have an oxoproline level cooking, but the negative acetaminophen level makes this less likely in my mind. No, we didn’t send a D-lactic acid level.

Nothing can accelerate a scientific career like harnessing the work of lots of scientists by creating a new paradigm for thinking about old research. We have long known that gastric bleeding and kidney disease are often seen together, but no one has been able to harness them together in a cohesive theory, So in the hopes of greatness (and many international speaking gigs), I introduce a schema to understand the many manifestations of renal dysfunction and gastric bleeding: Gastrorenal Syndrome (GRS)

GRS Type 1. 
Acute kidney injury leading to gastric bleeding.
Acute kidney injury can causes increased sympathetic nervous system activity, increased cortisol release and alterations in the platelet function. All of these contribute to an increased risk of upper GI bleeds. In addition drugs, such as NSAIDs, increase the risk of both AKI and GI bleeds. If the kidney gives out before the stomach you have GRS type 1. If the stomach starts bleeding before the kidney goes let me introduce you to GRS type 2…

GRS Type 2. 
Gastric bleeding leading to AKI.
It has long been noted that sudden drops in hemoglobin can cause ischemic acute tubular necrosis. But previous authors have failed to properly place this in the syndrome of gastrorenal disease.

GRS Type 3. 
Chronic kidney disease leading to gastric bleeding.
CKD has long been recognized as an important risk factor for GI bleeds and now we have a schema to organize that in its proper place.

GRS Type 4.
A history of GI bleeds and peptic ulcer disease that leads to CKD.
This was just a hypothetical entry until the blockbuster news last year that chronic use of proton pump inhibitors is associated with CKD. Now we know that the mythical GRS type 4 is no figment on anyone’s imagination, but rather a real entity.

GRS Type 5. 
A separate disease leading to both AKI and gastric bleeding. Think of the acutely ill patient with sepsis who develops AKI and a GI bleed. Don’t make the rookie mistake of seeing two separate diseases, you are actually witnessing CRS 5!

Look for many review articles in Seminars of Nephrology and other closed access journals in the near future.

This post is getting a bit of traction on social media and I fear some might not get the joke. See this link for my feelings on cardiorenal syndrome that I was trying to spoof.

Hot take: journal club shouldn’t change the way you treat patients because most articles exciting enough for journal club need additional data, replication and time to mature. By the time the data is compelling enough to justify changing your practice the data comes via a boring meta-analysis that you read and remark, “I knew that, we read about it in journal club like 3 years ago.”

See: Medical Reversal: Why We Must Raise the Bar Before Adopting New Technologies Link