Friday, February 26, 2016

Central Pontine Myelinolysis after Slow Correction of Hyponatremia

This week's Images in Clinical Medicine is a case that demonstrates how little we know about hyponatremia.

35 year old alcoholic.
Severe hyponatremia with a sodium of 119.
The sodium was corrected over 5 days from 119 to 135. A rate of only 3 mmol/L/day.
Patient developed CPM on the sixth day.

Kenar has a nice post on this case with an alternative approach to try to protect patients.

Tuesday, February 23, 2016

BS Medicine's top 20 medications

I'm addicted to podcasts. One of my favorite medical podcasts is BS Medicine. The hosts have deep medical knowledge and an enviable commitment to evidence based medicine. In addition, they approach the podcast from a clinicians perspective and don't get so lost in the science that they forget we are here to help patients.

For their 300th podcast they did a special episode surrounding the dorm room question: If you could have only 20 medications, what would they be?

They had an interesting list and they spoke extensively justifying their list. The explanation and the list stretched over two episodes. Afterwards they did a third podcast to go over the next 10 medications that barely missed the cut.

I loved the thought exercise but I thought James, Mike, Tina and Mike really missed the boat on a few. Here is their list and mine:

The list is the same through the first three, but then I added normal saline. How can you include epinephrine and not include normal saline? And don't start with me that salt water is not a drug. Saline will cure everything from a hangover to cholera. Essential medication.

They included oral contraceptives. My feeling is that 99% of the function of OCPs could be replaced by IUDs so women could continue to have control over their bodies and I get an additional medication. I will give up treating dysfunctional urterine bleeding, PCO and other maladies that benefit from OCPs.

I also skipped diphenhydramine. If the allergic reaction is bad enough, then we'll give epineprine, otherwise tough tootles.

I used pentoprazole rather than omeprazole because I wanted an IV formulation. I skipped the losartan and added apixiban instead. I just couldn't leave all those people with pulmonary embolism, atrial fibrillation and DVTs to fend for themselves with aspirin alone. The losartan omission is a bit tough to stomache as a nephrologist but truly most of the advantage of ARBs can be duplicated with good blood pressure and glycemic control (at least in diabetics). And the other renal diseases tend to be rare. Additionally I'm not as convinced as the podcasters that ARBs are just ACEi without the cough. I can't remember seeing ARB heart failure data as impressive as:

Consensus Trial Grade 4 CHF, 1988
I don't know enough ID to vet their antibiotics so I accepted their argument and brought in all three of their antibiotics.

That left me with three more medications after I gave the heave-ho to fluconazole and PEG. To fill this I hadded drugs to treat three of the great infectious diseases that plague this earth: HIV, TB and malaria. Seems morally wrong to ignore them. HAART is one of the greatest medical advances in our lifetime. They have an NNT that approaches one. In 1995, 55,000 Americans died of HIV and they died at young, productive ages causing incalculable losses to the nation. Blood pressure and heart failure medications are hugely important therapeutic target but treatment primarily benefits people in the tail end of their lives. Treating infectious diseases needs to be prioritized because of the age of the people affected.

What's your list?

-- Update --

I received this tweet:

I think he is exactly right. I can use heparin IV or subcutaneous. In this 20 medicine restricted world, thrombophilia will be treated like diabetes, all subcutaneous injection, all the time.

Thursday, February 18, 2016

My #dotMED16 experience

I was on vacation when I got a DM from Ronan Kavanagh asking me if I would be interested in speaking at dotMED. I said yes without really knowing anything about the conference, but a quick glance at the previous speakers convinced me that speaking there would be a once in a lifetime opportunity. A chance to punch above my weight.

Ronan gave me a blank slate to speak on anything I wanted. I chose social media opportunities in medical education.

My wife and I took a red eye to Dublin and arrived on the Tuesday before the conference. We toured the Guiness Factory Store, Kilmainham Gaol, the Modern Art Museum of Ireland and the Irish Museum. On Wednesday night we were invited to the White coat ceremony at UCD. Pat Murray my old program director at University of Chicago is now the dean of the medical school. Friends in high places and all that.


The following day I gave a lecture on social media to the staff and students at UCD. Great response.

And it was great getting a chance to rehearse my dotMED talk in front of a live audience.

The talk went long, about 45 minutes for my 30 minute slot. When I went to the Smockalley Theater later that day for an AV check, I asked Kerry O'Sullivan if a slightly longer presentationwas okay. She turned ashen. I had my answer. So I pulled out the metaphorical scalpel and started my lecture lobotomy.

Thursday night the speakers met at the Shelbourne Hotel for drinks and then went to The Winding Stair for dinner.
Ronan meets Steve Bergman, A.K.A. Samuel Shem. Ronan looks so happy.

The Winding Stair is by the Ha'Penny Bridge, the oldest toll bridge in the world. This was before #FOAB (free, open access bridges)

Muiris Houston, conference organizer at dinner

Monica Lalanda, conference cartooner showing Dr. Bergman his representation. Dr. Leticia Rivera is behind Monica.
Monica and Leticia

The following day we walked from our hotel to the Smock Alley Theater.
Ronan welcomed everybody and then John Greally, pediatrician and geneticist from Albert Einstein, gave the first talk of the day Learning from Artists in the Digital Age. It was an amazing talk. He started with a history of visual representations of data. From primitive maps, to the first histograms, to maps with epidemiologic data. Fascinating. He reminded us that modern radiology images are just visual representations of what is really quantitive data.

The history lesson was a set-up for the fact that all advances in data visualization occurred before 1900 and that with the era of big data we need new data visualization techniques. He is spearheading this effort by bringing together artists, data illustrators visualizers and geneticists to comb through big epigenetic data dumps to find unique and useful ways to present it to clinicians and scientists. (Nice NYT article about Greally's efforts).

I loved John's definition of big data: any data set too large to fit on a laptop.

After John, I was up. I spoke about the evolution of the medical textbook and how social media and mobile will inform future versions.

Best part about the talk? I got to use the Madonna/Astronaut microphone.

After my presentation, Ronan sat down with John and I for a question and answer session. My answers may have been a bit too strongly worded:

One of the best arguments in favor of social media was made by John. He discussed that forensic statisticians do a lot of the post publication peer review of big data research and they typically publicize their work via social media. I did get the final question of the session and my wife says it was the best part of the morning:

Next up was Leticia Ruiz Rivera discussing her photo exhibit, Limits, which explores the brutality of medical training. She takes portraits of residents before and after their 24-hour shifts. She gave a 5 minute introduction and then we went upstairs for coffee where we could look at her photo exhibit.

After the combination coffee break and photo exhibit the conference resumed downstairs with a Pitch off. Four start-ups in the health space competed to win the conference.
The first company was Humane Engineering with their app Cove. Cove is digital diary that allows you to create music to fit your mood and acts as a non-judgmental, always available, grief counselor. It was an amazing presentation and my personal favorite. As we spend more and more time staring at our phones, reimagining them as tools for psychotherapy seems innovative, important and the type of idea that could change the world. One day psychotherapy will delivered via computer and I don't know what it will look like but if it is done well and is effective it will be a great thing.
The next company was N-Silico that had an EMR-like product that focused on a specific type of meeting that seemed to me to be like a tumor-board meeting. They developed software that would help the team mates collaborate. It maybe a great idea, but seemed like JAFEMR (just another fracken EMR). Though he did have the best line of the conference, "Paperwork wouldn't be so bad without the paper...or the work."

The third presenter was the Beats Medical. They have a smart phone app that treats Parkinson's disease. Apparently the shuffling gait and freezing can be ameliorated by a metronome like beat. This company has created an app than takes a 2 minutes walk test (done by shuffling around with the phone in your pocket) and then creates a custom metronome beat for your disease. It is customized for the individual in pitch and tempo. This was my wife's favorite and she was not alone:

The judges were concerned that this was a defensible idea and that copycats would flood the market. Also it is hard to build a business around the App Store. People just don't like to spend a lot of money on apps. 

Concluding the contestants was PMD respiratory. They build a device that you stick on a patient and it records the respiratory rate. The pitch is that respiratory rate is an important vital sign that can predict bad hospital outcomes but since the rate is poorly measured and recorded we need a way to automate it. Myles Murray gave the pitch and the core to the pitch is that if you look at a ward full of 20 patients, 19 will have a recorded respiratory rate of 16 and the last one will have a respiratory rate of 32, and she'll be about to code. There has to be a respiratory rate between 16 and 32.

He sad that measuring the respiratory rate from ECG leads works in health but in sick patients it is not very effective and prone to error.

Later in the afternoon they announced that PMR won

Following the pitch session came a one on one interview of Rory O'Neill, AKA Panti Bliss, by conference organizer Muris Houston.

I had never heard of this Panti Bliss, but the story that I pieced together at the conference is that he is a gay, cross dresser and actor. After one of his performances he came on stage and made a impassioned plea for gay marriage. This video went viral and he became an accidental spokesperson for the ultimately successful gay marriage movement in Ireland.

Muris focused the interview on Rory's HIV status. He turned positive in the mid 90's and lived through the birth and maturing of the HAART era. Rory discussed the wonderful staff at the STD/HIV clinic.

He had some insightful and funny insights on the early days of HAART:

He says that being HIV is now pretty irrelevent to his life, but not completly irrelevent:

There was a lunch break and that we were back to the conference. We started with the dulcet sounds of Colm Mac Con Iomaire. It was amazing and let's face it not many medical conferences can boast a session highlighted by a 300 year old Irish love song.

Colm was a founding member of the Frames, described to me by Suzanne Donnelly as Ireland's greatest band not named U2. 

Following Colm, they announced that PMD won the pitch session and then we were off with Deborah Bowman on Staging Medicine, or an actors perspective on the doctor-patient relationship. She talked about how medicine and theater are related. Her talk was filled with soliloquies taken from the stage. 

Following Deborah, was Ian Williams (@theBadDoctor). Ian is a comic artist and GP. He wrote a graphic novel, which he describes as a comic that requires a book mark. After he wrote the book he noted an explosion of medically themed graphic novels so he started a website to track and discuss them, Graphic Medicine. This website has made the cover of the BMJ and now has a yearly conference. He talked a bit about the history of drawing in medicine. It has until very recently been dominated by the illustrations of other peoples disease. Today we are seeing artists drwing there own illnesses.

I am happy to say that we now own a print of this image. Our souvenir from #dotMED16.
He tells the funny story that he put a barcode in a comic in the Guardian. The barcode resolved as a pretty rude statement. He thought it would take a few weeks to be discovered. The very first comment on the comic spilled the beans.

After Ian, Ronan convened a panel of the two illustrators, Ian and Monica, and Laticcia, the photographer to discuss visual imagery in medicine.
Then to close out the meeting, the headliner, Stephen Bergman, AKA Samuel Shem. The name of the talk, "Staying Human in Medicine in a World on Fire."
Early in his talk he recounted how he was given advice to begin his novel with lots of humor to engage his audience and leave a lot of the punch to the end. Which is exactly how he structured his talk at dotMED.
He started with a charming story about how during medical school he did his OB rotation in Dublin at Hollis Street. He said it was the drunkest period of his life. He says he and his buds would get hammered at a pub then stumble back into OB ward and deliver a couple of kids. The nurses would only give him the easy ones, the moms that were delivering kid number 20. The audience was laughing uncontrollably but looking back it is kind of a horrifying story. Just like the House of God, I guess.

He told the story of how he got House of God published. He wrote the first 50 pages and he sent it off to an agent. He didn't know what he was doing and the drat was single spaced and filled with typos and notes in the margin. A few weeks later he had forgotten all about it and received a call from the agent saying he was either insane or a genius. Later on the publisher asked if anyone in the book was identifiable. Stephen thought, "everybody" but answered just one, the chief of medicine, a renologist, who tucked his stethoscope into his pants. Son the lawyers gave him a large birthmark on his face to vaccinate them from a lawsuit.

He talked about the most important thing in medicine is connecting with a patient.

He elaborated on the healing power of connection by talking about his own alcoholism. He in recovery and a believer in alcoholics anonymous. He wrote a play about the origin of AA called Bill W. and Dr. Bob and explained that the core truth about AA is about connection:

The problem is that meaningful use and modern medicine are separating us from our patients. It is preventing connection.

Closing point of Bergman's talk. So true.

After his talk, Muiris interviewed him. Muiris started by mentioning that peope are always warned against meeting their heroes but meeting his hero, Stephen Bergman, has been wonderful.

Following the interview there was a wine and appetizers mixer. It was great to get a chance to chat with everybody at the conference. One of the remarkable things about dotMED was just how interesting everyone in attendance was. It was great chatting with them.

Then we went off for one last dinner and finally wrapped up up dotMED at Dex.

Just an awesome meeting and a great week in Dublin.

Smoother coverage of the meeting:

The Irish Times

Pat Rich

Marie Ennis-O'Connor put together a storify

Sunday, February 7, 2016

NephJC needs your help!

If you take a look at the side bar you will see I'm a totally pathetic assistant professor. Help me get promoted by filling out the NephJC survey so we can publish!

We actually went through the trouble of getting IRB approval and everything. Get more details (if you care) here, but really just fill out the survey.
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