Hanging in the TWiT Cottage with Leo Laporte

My wife and some friends took a trip to Sonoma California to taste some wine and recuperate midway through the winter. Of course Sonoma is only 10 miles from Petaluma, so I needed to make my pilgrimage to the TWiT cottage.

I got to sit in the pole position during The Tech Guy radio show.

Leo crooning for satellite radio.

The left monitor is what was going out live on the internet. The monitor on the right was a preview. 

Leo's Emmy, strategically placed in from of the needlepoint advising him to remain humble. Awesome.

Quotation of the week

I go slow when replacing potassium. I mean, they do use that stuff to execute people.

Jason Ye- orthopedic surgery intern
via Chinita Furiosa

This post from Dr RW is great

Must read post about a recent Lancet paper comparing outcomes for patient treated for health care associated pneumonia (HCAP) and looked at outcomes based on adhering or non-adhering to the ATS and IDSA guidelines.

Spoiler alert: patients treated off guidelines did better.

ASN Renal Week Day 2: Harrisons, UpToDate and the Renal Fellow Network

I grabbed dinner with Matt Sparks, one of the driving forces behind the Renal Fellow Network. It was a great dinner and, for me, was the first time I had a chance to talk shop with another blogger. Very fun. One of the things we discussed was the role of blogs in fellow education (this idea was matured a little with a discussion with Conal O' Seaghdha, the other half of inspiration that drives RFN.

I believe that the primary educational material for medical education has gone through three phases. In the beginning was the medical text book. This was exemplified by Harrisons which rose to ascendancy not by being the first text book but by being the most innovative. Harrison unique innovation was arranging the sections by patient complaint rather than by disease. Here it is described in a fascinating history of the Harrison family of doctors:

PRINCIPLES OF INTERNAL MEDICINE would offer medical students a new way of approaching patients. The Cecil Textbook of Medicine, which had previously monopolized the American medical textbook market, took a less helpful approach. Its author, Russell Cecil, M.D., of Cornell Medical School in New York, had organized the textbook exclusively by disease, offering the definition, cause, symptoms and signs, methods of diagnosis, treatment, and prognosis for each one. This meant, of course, that a student must identify the patient's disease before the book would offer help. Principles of Internal Medicine, on the other hand, began with the patient. Tinsley [Harrison] devoted the first third of his textbook to symptoms and signs experienced by sick people, which included shortness of breath, swelling of the feet, and so on-leading from there to understanding the disease. The text mirrored the ideal practice of a physician. The first edition of his book, published in 1950, proved an instant and major success.

The second phase was UpToDate. Burton "Bud" Rose (how can Wikipedia not have an entry on Dr. Rose?) crushed the primary medical references by creating a comprehensive, readable and searchable reference. He also cajoled his authors to make specific treatment recommendations so Up-To-Date is the only medical reference that actually teaches you to take care of patients. One of my friends used to complain that when she would invest the hours and tears needed to read a chapter of Harrison's she would finish with tremendous knowledge and the ability to shine on atending rounds but have no idea how to treat her patient. UpToDate is not like that and has probably saved more lives than ACLS. I routinely ask prospective fellows about their reference of choice and for three years running every single one of them has answered "UpToDate."

As good as UpToDate is it has some weaknesses. The EBM zealots take it to task for relying on expert opinion but I really don't have too much concern about that (my previous post on that took them to task for saying they are EBM when they are really an expert opinion source. That's why the list of author/editors is so important and impressive. They should be proud of what they are rather than claim to be EBM) .

What concerns me is UpToDate's inability to escape its CD-ROM DNA. I have been a subscriber to UpToDate since I was a resident and Burton Rose was still answering the phone to deal with bad CDs and pimping the still incomplete product in the hallways of Renal Week. The ascendancy of the Internet has allowed UpToDate to get out of the CD shipping business but they still refuse to link out even when it makes overwhelming sense. All of their articles are fully referenced, but not with links to the primary data or the pubmed reference but to an internal database record of the reference.

I get that isn't too hard to copy the PMID and drop it into google and that will pull the article, but why doesn't UpToDate just link-out?

This goes for other area where a link out makes sense. Here is a segment of UpToDates card on "Overview of the management of CKD in Adults"

Wouldn't you expect, reference 8 to take you to the K/DOQI guidelines. They are free and available on the internet. UpToDate instead links to their internal reference of the AJKD supplement with the original publication of the K/DOQI guidelines, which are behind an Elsevier pay wall.

It feels that the editorial rules for UpToDate were created in the CD-ROM era of the 90's and haven't been updated for the internet era.

I beleive that, just as Harrison had an openning in the Internal Medicine textbook space by using patient oriented complaints to organize his text and Rose had an openning by using search and a unique editorial style, the technology of today provides a niche. I want an interactive textbook of medicine with comments, a Facebook "Like" button, a way to connect with other practitioners and share treatment pearls.

The renal fellow network and other knowledge focused medical blogs are early progenitors of this future but some pretty large problems need to be addressed:

• Organization. Blogs are reverse chronologic order by convention but given the random way that topics get posted, it makes for an unorganized structure. Solutions that are being used now include search and tags. Unfortunately, the tag clouds are so huge that they border on the useless. Search is good but a more structured table of contents and/or index would be great. I am delighted with the addition of the lecture and handout tabs on PBfluids, its a step that allows, at least me, to find things I have posted here before.
• Expiration of old data. Medicine is always evolving. Today's truth is tomorrow's MMR-autism fiasco. These medical blogs need a way to mark expired information as such. A perfect example is the ATN trial by the VA and NIH. Prior to that study I was firmly in the more dialysis for acute kidney injury camp. After that was published I marked my acute kidney injury lecture, as being pre-ATN trial. This meant something to me, but my readers likely had no idea what that meant. How many other educational resources were obsoleted by that medical about-face?

Nephrology on demand looks like they are another group making good progress in this mission. Look out UpToDate, Web 2.0 has you in our sights.

- Posted using BlogPress from my iPad

Pregnant Gitelman Patient follow-up

Last week I posted on my pregnant patient who has Gitelman's Syndrome. I am managing her with amiloride and a mixture of oral potassium and a mixture of oral and IV magnesium.

I received the following letter from a reader who went through a similar experience:

I am not a doctor, but I have Gitelman's, and 16 years ago, was pregnant and ended up having to go on amiloride at the start of my second trimester, because my potassium and magnesium levels just tanked.   Being part of proving the track record on the viability of amiloride in pregnancy was a scary time, I tell you what.  Your patient's experiences are similar to mine, though I did not require the magnesium IVs she apparently does during gestation. 

The great news is my son turned out healthy, and without any sign of potassium disorders of any sort, so far as we can tell at nearly 16.  He's healthy, bright, nearly 6 ft - no indication at this time  that he was harmed in any way by the fetal exposure to amiloride. 

And another point to pass along - after he was born, I had my breast milk checked for traces of amiloride, and it passed whatever screens were applied. Therefore I nursed him for about 9 months, though I supplemented with formula.  It was an acceptable risk for me - since I know the literature does not record any data on nursing while on amiloride, I thought I'd pass along one uncontrolled anecdote for you to ponder. [Note: on further communication the patient clarified that she did not take amiloride during breast feeding] 

Anyway, please pass this information along to your patient - I am sure it will help her peace of mind to know another successful long term outcome.  It was a scary time for me, and without the widespread use of Internet back in 1995, the only piece of mind I got was by tracking down Dr. Almeida, who wrote the 1989 paper about Gitelman's in pregnancy.  I spoke to one of his nurses to see if they could give me some info on long term followup on the baby, but the mother had disappeared after giving birth, and they had nothing to report.    

Best of luck to your patient - I know what she's going through. 

Final note for your patient going forward: Getting my levels back up after the birth was a bit of a challenge, I recall.  But many of the details have been lost to time and the fog of war, I'm afraid - I will just say that the first month post-partum was pretty rough on me.

ASN Renal Week day 4: APOL1 the best medical science story of 2010

The Renal Fellow network may have ranked APOL1 as the fourth biggest story of 2010 but I think it is actually the best story in all of medicine, not just nephrology.

When I went to ASN Renal Week I stayed at Castle Marne, an idiosynchratic bed and breakfast about a mile and a half from the conference center. The other people staying at the Castle were a rogues gallery of interesting conference participants.

One of the breakfast crew was David J. Friedman, the second author on the Science paper blowing the lid off of APOL1.

The APOL1 story begins in 2008 with the discovery of MYH9. Scientists were doing whole genome analysis to find a genetic explanation for the excess renal risk African Americans face. This excess risk is seen in the dialysis population, where African Americans are over represented. This is particularly true in patients with ESRD due to hypertension. African Americans represent 13% of the U.S. population but represent 48% of the patients on dialysis due to hypertension (HA-ESRD).

Data from USRDS and US Census

The two other places that the increased renal risk of African Americans is seen is in FSGS and HIV associated nephropathy (HIVAN). FSGS is 5 times more likely in young African American males than in age-matched Caucasians. HIVAN is nearly unheard of among people of European ancestry. The only cause renal failure more specific to black patients than HIVAN is sickle cell nephropathy.

The genetic locus 22q13.1 was found to convey phenomenal excess risk of FSGS. The excess risk was 400-700% (OR5-8). In whole genome analysis, researchers are delighted to find odds ratios of 1.1-1.2. Finding ORs of this magnitude is nearly unheard of. Poking around the genetic neighborhood, the researchers found a likely genetic target, MYH9. 

MYH9 codes for an intra-cellular myoglobin. MYH9 was an especially appealing candidate gene because it is expressed in podocytes and mutations of the gene had previously been found to be associated with glomerular pathology. Quickly MYH9 was declared the genetic explanation for excess risk of renal disease among African Americans and the scientific nephrology community geared up to crack every mystery related to MYH9. 

It was the gene that launched a 1,000 RO1s.

The NIH and NIDDK sponsored symposia to get scientists up to speed with breakthrough discovery

Unfortunately, no one was able to find the specific genetic mutation that led to these renal complications. From the discussion of the original paper:

A limitation of our study is that we have not yet identified the causal sequence variation in MYH9 that is associated with FSGS

Then in August 2010, David Friedman and his team identified APOL1 as the gene that actually was associated with FSGS, HA-ESRD and HIVAN. The association was discovered after new genetic material was made available in the 1000 Genomes Project, a public database of genetic information from individuals around the world including a number of Africans.

APOL1 lives just to the centromere side of MYH9. Friedman et al showed a tighter association with APOL1 than MYH9 and when they controlled for APOL1, MYH9 was no longer significantly associated with renal disease.

As the scientific community began to feel the rumbles of truth emerge about MYH9 and APOL1, researchers hitching their wagon to MYH9, prayed they were funded before the NIH scorers realized that MYH9 was the wrong gene. Scientists with research proposals on MYH9 that were too late would have to rewrite the grant to focus on the new target, APOL1.

Friedman's team didn't just identify APOL1 they told a fascinating story involving parasitology, evolution and human migration.

In 2003 APOL1 was identified as the genetic source for an immunity factor which protected people from African sleeping sickness. 95% of African sleeping sickness (I refuse to use the 3-letter acronym) is caused by Trypanosoma brucei gambiense.

Trypanosomes cause the mortal disease African Sleeping Sickness

Trypanosome lytic factor (TLF) protected humans from sleeping sickness until Trypanosoma brucei rhodesiense and gambiense evolved a protein, Serum Resistance Associate Protein, that deactivated TLF. This adaoptive response by the trypanosome made humans susceptible to infection. This was the state until about 10,000 years ago when variants of APOL1 appeared and restored the protective action of TLF and made the carrier of even a single copy immune to African sleeping sickness.

These genetic variants of APOL1 appeared in Africa 10,000 years ago, but much of the human race had already left Africa to spread across six continents. Additionally, regions that did not have the Tze Tze fly didn't have trypanosomes and hence didn't have selective pressure for the APOL1 variants. In regions endemic to Tze Tze fly, the selective pressure for these mutations was immense. In the U.S. 30% of African Americans carry APOL1. Heterozygotes are immune to trypanosomes and may have a modest increase in the risk of HA-ESRD (OR 1.26, no risk for FSGS) . Homozygotes for APOL1 are equally immune to trypanosomes but unluckily have a sky high risk of renal disease.

So APOL1 behaves like sickle cell anemia and malaria. Heterozygotes are immune but homozygotes suffer from  devastating disease. Balanced polymorphism.

The last twist is the mystery of HIVAN in Africa. HIVAN is found in western, Sub-Saharan Africa. Eastern Africa has a lower rate of HIVAN than would be expected. This data comes from cohort studies done in Kenya and Ethiopia. The risk of HIVAN is associated with APOL1. The Tze Tze fly is not endemic to Eastern Africa, hence no trypanosomes, so no selective pressure for APOL1, so few people are homozygotes for the variant of APOL1 that predisposes to HIVAN.

This story was one of many that were batted around the breakfast table at Castle Marne and served to show that I found the perfect place to stay during ASN Renal Week.

That's a really low fractional excretion of sodium

Patient with acute renal failure and constipation. Normal saline to the rescue.
That's a low FeNa, but not the lowest I have ever seen.

- Posted using BlogPress from my iPhone

Gitelman syndrome and Pregnancy

One of my Gitelman patients (whom I kidding, "one of my Gitelman patients", how about "my only Gitelman patient") finally got pregnant. We had been managing her with amiloride and a truck load of oral potassium and magnesium supplements. I was shocked to find that amiloride is acceptable in pregnancy with a track record of successful births. Prior to starting amiloride the patient was taking twenty-eight 20 mEq pills of KCl a day. She abandoned her prior nephrologists when she was told to further increase her potassium pills.

from UpToDate

We are now using magnesium sulfate infusions 4 grams twice a week to keep her magnesium north of zero. She was able to keep her magnesium around 1.4 with oral supplements and amiloride prior to being pregnant but now, despite 8 grams of weekly IV magnesium her magnesium is sitting around 1.1. This probably represents one of downsides of the up-regulated GFR of pregnancy.

Interestingly, she saw her labs and saw that her sodium was 132. Modest hyponatremia is a normal finding in pregnancy, so she decided to increase her dietary sodium intake. Bad move, increased renal sodium loads increases renal magnesium losses. Her serum mag fell 30% to 0.8.

Just gave grand rounds on hemodialysis

The title for the talk was dialysis for the internist and I focused on recent advances in the field of hemodialysis including:

• Plavix for fistula maturation. Doesn't work.
• Aggrenox for graft preservation. Does work.
• HeRO grafts for patients with central venous stenosis
• Poor outcomes for nursing home patients started on dialysis
• Poor outcomes for the elderly on dialysis
• Evidence base for selecting conservative care rather than dialysis
• Early versus late start for dialysis
• Frequent hemodialysis
• APOL1 as the cause of increased risk for kidney disease among African Americans

Keynote has a feature that allows people using Safari to view the presentation. Here it goes. We'll see if this works. Otherwise, the PDF and Keynote files will be available under the Lecture Tab.

Here is a video of me giving the lecture. I'm working on putting together a formal slidecast but the video was a WMV. What a hassle.


Hemodialysis for the Internist. An Update from joel topf on Vimeo.

Get better Steve

Tim Cook, at Apple's forth quarter 2008 earnings call in early 2009, right after Jobs took his first leave of absence to receive a liver transplant:

...There is extraordinary breadth and depth and tenure among the Apple executive team, and they lead 35,000 employees that I would call wicked smart - and that's in all areas of the company from engineering to marketing to operations and sales and all the rest. And the values of our company are extremely well entrenched. We believe that we are on the face of the earth to make great products and that's not changing.

We are constantly focusing on innovating. We believe in the simple not the complex. We believe that we need to own and control the primary technologies behind the products that we make, and participate only in markets where we can make a significant contribution.

We believe in saying no to thousands of projects, so that we can really focus on the few that are truly important and meaningful to us. We believe in deep collaboration and cross-pollination of our groups, which allow us to innovate in a way that others cannot.

And frankly, we don't settle for anything less than excellence in every group in the company, and we have the self-honesty to admit when we're wrong and the courage to change. And I think regardless of who is in what job those values are so embedded in this company that Apple will do extremely well...

Just like everyone, I want Steve Jobs to get better. I want to live in a world where the man who launched the PC revolution is still leading it. All the news today, however, is about how doomed Apple is without Jobs. It's a little over the top. Look at Tim "acting CEO" Cook's words. That is an off the cusp speech and it is pitch perfect. Those words could've come right from Steve's brain. Apple is going to be fine.

Hat tip to Asymco

Found an old lecture

In 2006 I had to give the fellows a lecture on nocturnal dialysis. I remember being delighted with how it turned out. It was a fellow-level lecture that would have little appeal to non-nephrologists. The lecture goes into the different ways to measure dialysis dose and deep-dives into the National Cooperative Dialysis Study and the HEMO trial.

A month or so after giving the lecture I had a hard drive crash. After that, I couldn't find the lecture.

Well, today I was mucking through an old external hard drive and found the lecture! Yay me! I backed it up!

If you are interested the lecture is now resting safely under the Lectures Tab.

HeLa, Salk and the Tuskegee Institute

The Immortal Life of Henrietta Lacks is a multi-headed beast. The story is structured around three discernable plot lines. The first, is the history of the Lacks Family from slavery war up through present day. Another, is the author's story of  how she met the family and uncovered the history. And the last leg is the history of science and how it relates to human cell culture and the HeLa cells.

This last story line is amazing, but I'm a little cooler to the other two. So far I'd say the third line is strong enough to justify reading the whole book but this is no The Checklist Manifesto.

One of the most interesting stories is regarding the first scientific win for the brand new science of human cell culture. HeLa cells were instrumental in the widespread testing of the Salk Polio vaccine. (All of the following excerpts from the book come from here)

“..in April 1952, [George] Gey and one of his colleagues from the NFIP* advisory committee –William Scherer, a young postdoctoral fellow from the University of Minnesota– tried infecting Henrietta’s cells with poliovirus. Within days they found that HeLa was, in fact, more susceptible to the virus than any cultured cells had ever been… they knew they’d found exactly what the NFIP was looking for”… “On Memorial Day 1952, Gey…sent Mary to the post office…When the package arrived in Minneapolis about four days later, Scherer put the cells in an incubator and they began to grow. It was the first time live cells had ever been successfully shipped in the mail.” …”When the NFIP heard the news that HeLa was susceptible to poliovirus and could grow in large quantities for little money, it immediately contracted Scherer to oversee development of a HeLa Distribution Center at the Tuskegee Institute… [p95] …it was the first-ever cell-production factory and it started with a single vial of HeLa that Gey had sent Scherer in their first shipping experiment, not long after Henrietta’s death. [p96]

George Gey was the original scientist who created the immortal HeLa cell line.
*NFIP was the  National Foundation for Infantile Paralysis, the organization now known as the March of Dimes, created by FDR to fight polio.

I had never known that the Tuskegee Institue had a role in the war on Polio and development of the Salk Vaccine. The HeLa cells were used in wide spread testing of the vaccine to make sure it was immunogenic. Since HeLa were able to be infected and killed by the Polio virus, they became a convenient means of testing the vaccine. The vaccine was administered to volunteers and six weeks later if that patient's serum protected HeLa cells from Polio infection that alloquot of vaccine and its administration technique was immunogenic.

The only thing I knew of the Tuskegee Institute was its role in medicine's most horrific racial crime, the studying of 400 African American men with syphillis without telling them they were infected or offerring treatment. This deception lasted for forty years. From Wikipedia:

By 1947 penicillin had become the standard treatment for syphilis. Choices might have included treating all syphilitic subjects and closing the study, or splitting off a control group for testing with penicillin. Instead, the Tuskegee scientists continued the study, withholding penicillin and information about it from the patients. In addition, scientists prevented participants from accessing syphilis treatment programs available to others in the area. The study continued, under numerous supervisors, until 1972, when a leak to the press resulted in its termination. Victims included numerous men who died of syphilis, wives who contracted the disease, and children born with congenital syphilis.[4]

So finding out that Tuskegee had a role in Polio was interesting, but discovering that the technicians and scientists in Tuskegee were all African American and that the Tuskegee institue had won the contract to produce the cultures in a form of proto-afirmative action blew my mind. An afirmative action program was happening at the same place, and at the same time, as one of the darkest moments in the mistreatment of African Americans.

…”Black scientists and technicians, many of them women, used cells from a black woman to help save the lives of millions of Americans, most of them white. And they did so on the same campus –and at the very same time– that state officials were conducting the infamous Tuskegee syphilis studies.

Steven Colbert interviews Rebecca Skloot

Ms. Skloot is the author of the Immortal Life of Henrieta Lack, the book I'm currently suffering through. Steven's line about irony insurance is perfect.

The Immortal Life of Henrietta Lacks by Rebecca Skloot Featured on the Steven Colbert Report

New Lecture Tab.

I gave a lecture to the internal medicine residents of Saint Johns today. The lecture was case based and focused on non-anion gap metabolic acidosis. Later, I received this e-mail:

Dear Dr Topf,

I appreciate your lecture this morning on Non-anion gap metabolic acidosis, I tried to get a copy from your website, but i couldnt find it. I would appreciate if I could get a copy

Thank you,
Saif

Saif, you want it? You got it.

Look above and next the Blog and Handout tabs is a brand new tab, Lectures.

If the presentation is a powerpoint-style slideshow then I'll post it under that tab. If the lecture was paper based then look under Handout for the supporting material.

Enjoy.

Epocrates announces that it is ending support of WebOS

Epocrates got its start in the PDA boom of the late 90's on the backs of the Palm platform. I am surprised that they are pulling up stakes and dumping WebOS. It feels like HP was too slow in releasing new metal or doing anything to show the developer community that there is a reason to stick it out. Could the last WebOS developer shut off the lights and lock the door when they leave.

Sad day. It's beginning to feel like just a two horse race, Apple and Google.

My Apple predictions for 2011

Every year the gadget blogs and podcasts give their predictions for the next year. I'm watch Apple pretty closely and I think I have a pretty good feel for the next year. Here are my predictions for 2011. Let's see how I do.

iPad

The iPad 2 comes out in April after being announced 2-3 weeks earlier. Not a lot of surptrises. It has front and back face-time cameras, weighs less, goes faster and is thinner. It will have a higher resolution screen that Apple will brand a Retina Display but it will not have the same pixel density of the iPhone 4. There wil be three versions, WiFi only, a 3g version with CDMA and a new 4G LTE version from Verizon, AT&T and eventually Sprint.

The current iPad, with the low resolution screen, no camera will live on as a low cost model at $399. With the upcoming entry of Palm, RIM and Android in to the tablet space Apple will try to suck all the atmosphere from the room by lowering the entry level price as aggressively as possible. This will upset all the other competitors pricing plans and provide less maneuvering room in the price umbrella under the iPad.

By the end of the year Apple will have sold 70 million iPads (total 2010 an 2011 sales) and have a market share of 70+%.

iPhone

iPhone 5 is introduced in June and goes on sale in July. It sports the same form factor as iPhone 4 but has a faster processor, longer battery life, and better front and rear camera. The major new feature is near field communication. Apple sticks with 16 and 32 gb memory options. Prices remain the same.

The Verizon iPhone is introduced with the iPhone 5, the first iPhone 4 for Verizon is the $99 8 gb model introduced along with the iPhone 5. 

The white iPhone makes it first appearance since the 3gs as an iPhone 5.

Apple will sell a 65 million iPhones in 2011.

iOS
iOS 5 focuses on the cloud. Music and movies purchased through iTunes can now be streamed over the net. All devices tied to the same apple ID can stream the content, iMacs, Apple TV, iPods, iPads and iPhones.

iOS 5 also gets over the air updating of the OS and over the air continuous back-up, a internet enabled Time Machine back-up service. This major update will better allow iPads to be used without a computer to tether to.

Document management moves forward allowing seamless management of a single document on an iPad then desktop mac and then an iPhone. The document lives in the cloud with synced copies on all of your apple devices.

iOS 5 also adds new APIs that allow software developers to accept voice control and voice feedback for applications.

iOS 5 allows FaceTime over 3g.

Macintosh
The big story for Mac hardware will be the addition of Lightpeak to replace firewire and display port. By the end of 2011 all Macintosh's will ship with Lightpeak. RIP Firewire.

MacBook Pros will all go SSDs. There maybe an option for a second drive, a magnetic spinning hard drive but the primary drive will be an SSD. The MacBook will continue to have a spinning hard drive further differentiating the Pro models form the baseline MacBook. This trend will continue across the iMac and MacPro lines both of which will be updated to include an SSD as the primary drive with spinning hard drives as additional drive options.

Video professionals and HD enthusiasts looking for Macs to ship with Blu-Ray will continue to be disappointed. No Blue-Ray drives will ship in any Macintosh's.

MacOS 10.7 Lion will be announced at WWDC to be introduced in the Fall. 10.7 will introduce a new look and feel with a more iOS-like theme.

The Mac App Store will be a huge hit and will reinvigorate innovation on the PC. The amount of money most people spend on desktop apps will rise and this will intropduce many people to the creativity of the independent Mac Software developer. This will further loosen Microsoft's and Adobe's hold on on the software market as people get exposed to a myriad of less expensive, less complex and more focused single purpose applications.

iLife 2011 will add a new application. This application will allow hobbyists, enthusiasts and educators to create interactive content for the iPad. A Hypercard for a new era. See this post.

iPods
In September the big announcement will be that the iPod Nano adopts iOS and becomes the smallest general purpose computer. Apple will open the Nano to a specialized corner of the App store where developer focus on voice and speech for much of the interface.

iPod classic goes away and along with it the last click wheel iPod. The iPod Touch gets a version with 128 gb to replace the lost Classic.

Apple TV adds apps that primarily function as channels. So there is the National Geographic app which allows you to view NG video content on your TV.

Apple
Apple will not release a release a large screen TV or any other sized TV.

They will not make a major acquisition, though they will continue to gobble up small, engineering-focussed companies with core technologies.

The Apple-Google  will not jettison Google or Google Maps.

AAPL will hit a high of $415 and finish the year at $395.