Brain with Atherosclerosis

NCP 1277, originally uploaded by otisarchives1.

A Mindmap Containing All Major Topics in Biology, Chemistry, and Physics.

Structure of the Kidney.

Why Doesn't This Catheter Work?

Have I mentioned recently that you must read Nathan Hellman's Renal Fellow's Blog?

Steve Jobs' Liver Transplant

Image via CrunchBase

Via Daring Fireball:

Yukari Iwatani and Joann S. Lublin, reporting for The Wall Street Journal:

Steve Jobs, who has been on medical leave from Apple Inc. since January to treat an undisclosed medical condition, received a liver transplant in Tennessee about two months ago. The chief executive has been recovering well and is expected to return to work on schedule later this month, though he may work part-time initially.

This must be a deliberate, timed leak from Apple. The timing is simply perfect from Apple’s perspective — midnight on the Friday of what appears to be the most successful new product launch in company history.

Marlo Isis Armstrong

in the middle of the night
Originally uploaded by dooce

Manhattanhenge 2009

manhattanhenge 2009, originally uploaded by mudpig.

© 2009 Steve Kelley, posted using Flickr's "Blog This" feature. Please see the original on Flickr.

Clowns vs. Cops. In a Hospital.

There are no words.

Bizarre Devices from Medicine's Dark Past

From the New Scientist Web site. Not entirely safe for work. (Via Warren Ellis.)

Nephrology Calculators for the iPhone

My colleague Joel Topf over at Precious Bodily Fluids reviews three nephrology calculators for the iPhone. He likes Neph CalcMedCalc the best.

"13 Things I Hate about Nephrology" (by Nephrogirl)

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In a recent post, "nephrogirl" — who is either a nephrology fellow or younger nephrologist — listed the "13 things [she hates] about nephrology." I appreciate that she took the time to vent her unhappiness. And while her experiences with nephrology aren't mine — which might have to do with differences in our patient populations and many other factors — I understand her perspective. Here's the list, along with my comments.

1) The incessant checking of labs, powerlessly watching the kidney function slowly deteriorate. [I'd say the ratio of patients for whom I make a significant difference to patients that I feel powerless to help is well over 50:1.]
2) Sending patients for the critical intervention which you feel is going to make the difference, only to see them suffer a devastating complication from the procedure itself which was worse than the actual disease. [Interventions for renal artery stenosis and coronary artery disease might fall into this category. I've rarely seen catastrophic outcomes from either of these interventions, and the number of patients that I've seen helped far outweighs any of the complications I've seen.]
3) The self-deception involved in thinking you might be slowing the progression of their kidney disease, when their main problem is the cardiovascular death that’s waiting for them in the next 6-24 months. [Interventions to slow the progression of kidney disease, like improving control of hypertension and diabetes, also have the potential to also prevent or delay cardiovascular disease.]
4) The rampant noncompliance of so many patients. [Agreed, this is frustrating. But I've also seen many patients stop smoking, lose weight, begin taking their medications, and change their lifestyles.]
5) Reassuring the dialysis patient that his labs look better, when he’ll be dead in a year. [Again with the fatalism and therapeutic nihilism, which is difficult to argue against, because the prognosis for many dialysis patients is so dismal. Then again, I've seen plenty of patients survive many years on dialysis and eventually get transplanted.]
6) Relying on the creatinine to determine kidney function, a wildly imprecise measure at best. [Agreed, but the MDRD formula is now mainstream and is a more sensitive — though not a specific — measure of kidney disease.]
7) Watching the diabetic dialysis patient slowly losing his eyes, feet, kidneys, heart, and brain…knowing the outcome will not change despite everything that you try to do…watching the health care system spend tens of thousands of dollars on him in his last year of life. [I agree, this happens, and is frustrating, and many nephrologists feel powerless.]
8) Trying to explain kidney disease to patients and to other doctors – it’s a wild mystery to most people that they usually equate with death. [A cardiologist once said, half-jokingly, that "Everyone understands the heart, and no one understands the kidney." The mysteriousness and non-intuitiveness of the kidney is what gets many nephrologists into the field in the first place.]
9) The joylessness of a nephrologist’s life, especially one who feels it is her duty to try to make a difference, despite constant evidence that her efforts are most likely futile. [Most days, I'm very satisfied with my work, and I don't feel this way at all.]
10) The realization that it is easier and more financially rewarding to put a patient on dialysis than to try to preserve their kidney function. [I've suspected this phenomenon might occur, but I don't practice this way.]
11) Knowing that the promise of a kidney transplant is what dialysis patients live for…and knowing that a transplant can in some cases be worse than dialysis, especially when the post-transplant care is handled by an erratic system more interested in doing surgery than in practicing medicine. [In general, it's better to get a kidney transplant than to be on dialysis, even taking into account transplant patients who do poorly.]
12) Not being able to let go…for fear you’ll miss the acute renal failure, the rapid correction of hyponatremia, the diagnosis of RPGN…then when your back is turned, an unexpected catastrophe happens. [Many medical specialties require a high level of vigilance, nephrology perhaps more than most.]
13) The realization that the bill of goods you were sold when you chose this field is far different than the reality. [Personally, more than five years into practice, I still wouldn't choose any other field.]

Thanks again for taking the time to leave your comments.

Electronic Stethoscope Oddities

Happy New Year!

If acoustic stethoscopes — the kind physicians have used for over two hundred years — are the equivalent of typewriters, then electronic stethoscopes are like word processors. Okay, this analogy is non-intuitive, but hear me out. Electronic stethoscopes, like word processors, are newer, more expensive than the previous generation, and are — well — electronic, with all the advantages and disadvantages this implies.

The advantages to electronic stethoscopes are many. As I've written previously in my review of the Littman Electronic Stethoscope Model 3000, it's simply easier to hear heart and lung sounds with an electronic stethoscope than it is with an acoustic stethoscope. (For real-world examples of this, see the previous review.) Plus, some models, like the Littmann 4100 Electronic Stethoscope, allow you to record and playback — think copy and paste — heart and lung sounds for reference or teaching.

But anything electronic is prone to failure, and when electronic stethoscopes fail, they fail spectacularly. Don't misunderstand: I'm a fan of my Littman Model 3000, but it's worth pointing out the oddities you should expect if you decide to purchase one of these things. (Some of these observations are taken from my postings on Twitter.)

First — and this might sound obvious — the electronic stethoscope requires batteries. Eventually, these batteries will die. Unexpectedly. At exactly the wrong moment. Almost certainly, when you're examining a patient. At this time, your electronic stethoscope will make a sad little noise, then — silence. An eerie silence. And unless you're walking around with an extra AA battery in your pocket — which you will suddenly realize is probably a good idea — you will then say, apologetically, "I'm sorry. The battery in my electronic stethoscope just died."

Second, if you carry around an iPhone or a BlackBerry, you will experience intermittently the faint faraway static of your mobile device as you're listening to the heart of a patient. And while this doesn't interfere with your physical exam, it's unnerving.

Finally, if you were planning to place another type of diaphgram on your electronic stethoscope — such as the excellent SafeSeal stethoscope covers by DRG — don't. It will cause unbelievable amounts of feedback. As I learned recently, placing incompatible diaphragms on electronic stethoscopes makes your patients' hearts sound like they're being played by Jimi Hendrix.

(Also posted on Tech Medicine.)

Netter for the iPhone

Would have loved this during anatomy. Looking at the video, I can almost smell the gristle and formaldehyde again. This is one of the few medical apps I haven't used, though — any medical students find it helpful?

Precious Bodily Fluids, a New Nephrology Blog

Image via Wikipedia

Dr. Joel Topf is one of only two or three blogging nephrologists (including Dr. Arnold Kim, who publishes MacRumors.com, so that may not count). Joel writes the excellent Precious Bodily Fluids blog. PBF not only contains a wealth of clinical information, but scores huge points for the Dr. Strangelove banner. He's also the author of The Fluid, Electrolyte, and Acid-Base Companion, perhaps the easiest-to-understand primer on these brain-twisting disorders. Via Precious Bodily Fluids:

Yesterday I gave a great lecture on interpreting ABG results. I added a problems set for gap-gap analysis and added a section on the osmolar gap. I also improved the anion gap section with my new favorite mnemonic. Forget PLUMSEEDS, forget MUDSLEEPS, forget MUDPILES. The new hotness is GOLD MARK:

* G Glycols
* O 5-Oxoproline (pyroglutamic acid)
* L L-Lactic acid
* D D-Lactic acid

* M Methanol
* A Aspirin
* R Renal failure
* K Ketoacidosis

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Urinary Tract Wallpaper

Via the talented Shannon Wright:

Sparklines and Hantavirus Nephropathy

Sparklines and Hantavirus Nephropathy, originally uploaded by KidneyNotes.

How to Blog, by Merlin Mann

How To Blog

View SlideShare presentation or Upload your own. (tags: advice blogging)

And the talk itself, here.

Transitioning Blog Comments to Disqus

I'm transitioning Kidney Notes' blog commenting system to Disqus. The old comments will — hopefully — still be there, but things may look strange for a bit.

Hello Health

Hello Health, originally uploaded by KidneyNotes.

The Controvery Over Cardiac CTAs

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Weighing the Costs of a CT Scan’s Look Inside the Heart - NYTimes.com:

A few minutes later, Dr. Hecht studied the results. As he had expected, the angiogram revealed that Mr. Franks’s arteries were healthy. In some places, plaque had blocked 25 percent of their blood flow, but in general, cardiologists do not consider blockages clinically relevant until they reduce blood flow at least 70 percent.

After Mr. Franks finished dressing, he joined Dr. Hecht, who went over the results, explaining that his heart appeared healthy and that he would not need a stent. Still, Dr. Hecht recommended that Mr. Franks have another CT angiogram next year to check that the plaque was not thickening. Mr. Franks agreed, pronounced himself satisfied and left.

For Mr. Franks, the test was quick and painless. But it subjected him to a significant dose of radiation.

Based on a reporter’s notes about the duration of the scan and the power output reported by the scanner, Dr. Brenner of the Center for Radiological Research estimated that Mr. Franks had received 21 millisieverts of radiation — even more than a typical test, equal to about 1,050 conventional chest X-rays.

Given the radiation risks, Dr. Ralph Brindis, another cardiologist, said Dr. Hecht had erred. Because Mr. Franks had already taken a nuclear stress test with normal results, he did not need a CT angiogram, said Dr. Brindis, vice president of the American College of Cardiology. And particularly because the scan’s results were benign, he said, Dr. Hecht should not have recommended a follow-up test.

“The biggest problem we have with radiation is that the doses are cumulative and additive,” Dr. Brindis said. “So the concept of doing serial CT testing on asymptomatic patients, I think, is abhorrent. I cannot justify that.”

Dr. Hecht said he sharply disagreed with Dr. Brindis. The scan was appropriate for Mr. Franks, despite his normal results from the nuclear stress test, because of Mr. Franks’s other risk factors for heart disease, including his higher-than-average calcium score, Dr. Hecht said. And he said he recommended a follow-up scan next year so he could see how quickly the plaque in Mr. Franks’s arteries was thickening.

The article attempts to reconcile two sharply opposing points of view. In my opinion — and I hasten to add that I'm not a cardiologist or radiologist — cardiac CTAs are at the same level of clinical usefulness and acceptance now that CTAs of the pulmonary arteries were several years ago. It took years for a CTA of the pulmonary arteries to a widely accepted test for diagnosing or excluding pulmonary emboli. Within the next several years, I would expect that CTAs of the coronary arteries will become a well-accepted test for diagnosing or excluding coronary disease.

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Resistant Hypertension: Diagnosis, Evaluation, and Treatment, from the AHA

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Resistant Hypertension: Diagnosis, Evaluation, and Treatment: A Scientific Statement From the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research -- Calhoun et al. 51 (6): 1403 -- Hypertension

Resistant hypertension is a common clinical problem faced by both primary care clinicians and specialists. While the exact prevalence of resistant hypertension is unknown, clinical trials suggest that it is not rare, involving perhaps 20% to 30% of study participants. As older age and obesity are 2 of the strongest risk factors for uncontrolled hypertension, the incidence of resistant hypertension will likely increase as the population becomes more elderly and heavier. The prognosis of resistant hypertension is unknown, but cardiovascular risk is undoubtedly increased as patients often have a history of long-standing, severe hypertension complicated by multiple other cardiovascular risk factors such as obesity, sleep apnea, diabetes, and chronic kidney disease. The diagnosis of resistant hypertension requires use of good blood pressure technique to confirm persistently elevated blood pressure levels. Pseudoresistance, including lack of blood pressure control secondary to poor medication adherence or white coat hypertension, must be excluded. Resistant hypertension is almost always multifactorial in etiology. Successful treatment requires identification and reversal of lifestyle factors contributing to treatment resistance; diagnosis and appropriate treatment of secondary causes of hypertension; and use of effective multidrug regimens. As a subgroup, patients with resistant hypertension have not been widely studied. Observational assessments have allowed for identification of demographic and lifestyle characteristics associated with resistant hypertension, and the role of secondary causes of hypertension in promoting treatment resistance is well documented; however, identification of broader mechanisms of treatment resistance is lacking. In particular, attempts to elucidate potential genetic causes of resistant hypertension have been limited. Recommendations for the pharmacological treatment of resistant hypertension remain largely empiric due to the lack of systematic assessments of 3 or 4 drug combinations. Studies of resistant hypertension are limited by the high cardiovascular risk of patients within this subgroup, which generally precludes safe withdrawal of medications; the presence of multiple disease processes (eg, sleep apnea, diabetes, chronic kidney disease, atherosclerotic disease) and their associated medical therapies, which confound interpretation of study results; and the difficulty in enrolling large numbers of study participants. Expanding our understanding of the causes of resistant hypertension and thereby potentially allowing for more effective prevention and/or treatment will be essential to improve the long-term clinical management of this disorder.

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