My Grand Rounds

For the last 6 weeks I have been pounding the computer finishing and perfecting my lecture which I gave at Grand Rounds at both Providence Hospital and St John's Hospital.

I delivered the second one yesterday.

Here is the lecture with an audio track. My presentations are not self-contained most of the important data comes from me presenting. I hope you like it. (.zip file of native Keynote file)

Uric Acid, Fructose and Hypertension

View more presentations from Joel Topf.

Reading Atul Gawande's Checklist Manifesto

Reading The Checklist Manifesto is a mind expanding experience. I can't stop thinking about its implications and how I can help my patients by eliminating "errors of ineptitiude." (Which I learned as the difference between errors of omission as opposed to errors of cognition, where the latter is an error because the condition requires care beyond the skill level of the individual and the former is when the patient is harmed because of a lapse in applying standard care.)


Good blog post on the Gawande. A negative review of the book in the Wall Street Journal. A positive review on Amazon by Malcolm Gladwell.

My emphasis on teaching as my personal niche in medicine is from the idea that more important than pushing boundries of science is to learn the lessons of what has already been discovered.

After reading a couple of chapters I searched for Gawande in the NEJM and was delighted to see the breadth of contributions he has made as either scientist, editorialist or subject.

Right now I am busy crafting checklists for nephrology. I am focusing on the outpatient CKD care and routine admissions for hemodialysis patients.

Is anyone aware of checklist implementation in nephrology?

From the department of: He's a better doctor than you

So, you think you're a pretty good doc? You think you could remove your own appendix?

Leonid Rogozov was the only physician at an Antarctic research post and developed appendicitis. Since he was the only doctor he administered local anesthetic and operated on himself using "feel" and a mirror.

Must read article. Via Kottke

Great post on the demonization of high fructose corn syrup

High fructose corn syrup is not the enemy; fructose is the enemy and HFCS has about as much fructose as table sugar.

Nice article highlighting this issue as it pertains to diabetes.

For the relationship of fructose to the epidemic of hypertension and chronic kidney disease, come to my Internal Medicine Grand Rounds at Providence Hospital in Southfield Michigan on January 28th.

Monitoring therapeutic Dilantin in renal failure requires looking at the free not total Dilantin.

My fellowship director was the Great Brain, Dr Patrick Murray. Pat is quadruple boarded:

1. internal medicine
2. critical care
3. nephrology 
4. clinical pharmacology

Pretty intimidating. (If you have the time, check out his 179-slide presentation. Wow!)

One of the side effects of doing my fellowship under a professor in clinical pharmacology is that I learned more about drug monitoring in renal failure than any innocent nephrology fellow should.

One of the pearls he taught regarded the monitoring of therapeutic Dilatin (phenytoin) levels. the Renal Fellow Network discussed Dilantin pharmacokinetics twice but neither of the posts noted the change in protein binding that occurs with renal failure.

Dilantin is highly protein bound (90%) and only the free dilantin is therapeutically active. Uremia is associated with plasma molecules which displace Dilantin from albumin. This increases the active fraction of Dilantin, so sub-therapeutic total levels of Dilantin may represent appropriate free levels in the presence of renal failure.

I currently have a dialysis patient in the ICU who was seizing following a cardiac arrest. He was loaded with Dilantin and a few days later his labs showed:

Total phenytoin level of 5 mcg/mL, below the therapeutic target of 10-20. Simultaneously his free level was 1.14 mg/L. (Rant: How can the EMR express the total level as mcg/ml and the free level as mg/L. THEY ARE EQUIVALENT. Don't hide it.)

So in this case the free dilantin is 23% of the total, rather than the normal 10%. Note that the total level appears sub-therapeutic but this patient would be poorly served by a re-loading of Dilantin as his free level is therapeutic.

Summary: in uremia always use the free dilantin level and don't trust the total Dilantin level.

Funniest thing a patient sent me

I just got this e-mail from a patient and felt compelled to share one short bit:

...i consider you a good friend and the
greatest doctor of all time (well, maybe
Dr. Frankenstein was a little better.  he
did after all assemble from corpse parts
a human entity and brought it to life.
trying topping that one Dr.Topf).

Webservice to strip passwords from PDFs

Some journals will allow you to download PDFs but they will not allow you to copy text from them (I'm looking at you Nephrology Dialysis and Transplantation).

FreeMyPDF strips this restriction.

Thanks SniperGirl. Nice find.