The Trouble with Travels: #xBio 2014 Edition

(by Pascale Lane) Apr 18 2014

This time of year often makes me crazy.

  • April 25: Fly to San DiegoAirTravel
  • April 26-29: Blog EB
  • April 30: Fly home*
  • May 1: Fly to Washington, DC*
  • May 2: Meeting with American Society of Nephrology in DC
  • May 3: Hang in DC because there is no sense going home for <12 hours
  • May 4: Take train to Philadelphia by 3pm for first event
  • May 4-6: Vision 2020 Congress
  • May 6: Finish Congress and fly home
  • May 8: Fly to Chicago
  • May 9-10: WESH Summit
  • May 10: Finish meeting and fly home
* Please recall that there is no April 31

My spreadsheets for wardrobe planning are going full-time right now. I have to look business casual and/or vaguely professional for at least portions of these events. I have planned my EB wardrobe so it has no overlap with what I am wearing for the next escapade. I will get home, dump the dirties in the hamper, and shove the next trip's stuff in the suitcase, perhaps after a bit of Febreze to keep it all fresh.

Yes, I know I have chosen to do most of this to myself. I really like to travel, but I wish I had a day or two to breathe between some of these events.

Oh, well, if my blogging lightens up after EB, you will know why.

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The Spouse Does Good

(by Pascale Lane) Apr 17 2014

Earlier this week my husband received a small package in the mail. From Scotland.

Click for source

When he got home, he handed it to me to open.

Inside I found a necklace and earrings similar to those pictured.

It seems he caught an episode of How It's Made in which these heathergems were featured. Enterprising Scots take the stems of heather, beat them into submission, and mix them with natural dyes to produce these multicolored "gems" that are then lacquered and set. The Heathergems site includes a bunch of cool brooches and other Celtic themed jewelry.

Cool Flash Design!

Good job, Jim! I got something pretty, and I learned something new today!

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I Got Rhythm, I Got Kidneys

(by Pascale Lane) Apr 14 2014

KidneyClock

It's midnight; do you know where your kidneys are?

Did you know that kidneys can tell time?

Don’t trash your watch just yet. This phenomenon involves relative time, not what the clock says. A number of nephro-centric body functions vary throughout the day. Blood pressure normally dips at night, and salt and water excretion also drop while we sleep. When the latter gets dysregulated, people must get up at night to pee (nocturnia in fancy doctor talk) and suffer from these sleep interruptions. Since such disruptions occur more as we age, these clock issues may contribute to increased cardiovascular disease risk.

How does our body clock get controlled? From a recent paper by Michelle Gumz, PhD, an Assistant Professor of medicine at Florida, comes the explanation of four proteins that control circadian rhythm:

The four core proteins are CLOCK, Bmal1, Period (Per 1-3), and Cryptochrome (Cry 1-2). CLOCK and Bmal1 heterodimerize and interact with E-box response elements to transcriptionally up-regulate circadian target genes, which include Per and Cry. Per and Cry interact and then repress the transcriptional activity of CLOCK and Bmal1 (5). In addition to transcriptional regulation, the circadian clock also undergoes post-translational modifications through the phosphorylation of the Per proteins by the circadian kinases Casein Kinase 1 isoforms δ/ε (CK1δ/ε). Phosphorylation by CK1δ/ε allows Per1 nuclear entry (6,7).

Dr. Gumz has two recent papers examining how the Period proteins regulate other systems in the kidney. Per1 regulates sodium transport in the distal convoluted tubule via transcription of sodium cotransporters. This can help explain why we normally decrease urine output overnight. Per1 also participates in regulation of the endothelin system, with results varying both by time of day and tissue. In addition to downstream effects of endothelin on salt and water transport that help explain other diurnal phenomena, these data may have important implications for the clinical use of endothelin receptor blockers. If peak activity in the organ of interest occurs in the day, then morning dosing may be most appropriate. If an organ active at night is the therapeutic target, bedtime dosing may be key.

I wonder how many other systems have circadian variation that could affect drug dosing? Only one way to find out, and that is to do the experiments.

Of course, the deeper question is why diurnal variation is so important. Health disparities for people doing weird shift work and those with sleep disturbances point toward the importance of our circadian cycles. All of this evidence that our body’s processes are regulated at the cellular level to promote sleep also tell us that this state is pretty damn important…even though we still do not really know why.

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Countdown to #xBio 2014

(by Pascale Lane) Apr 11 2014

Two weeks from today I leave my home and head to glorious San Diego for Experimental Biology 2014, the annual gathering of the organizations that comprise the Federation of American Societies for Experimental Biology, AKA FASEB. My favorite of these groups, the American Physiological Society, once again asked me to blog the meeting. I have finally gathered scheduling information and abstracts to organize my activities.

I will be attending and summarizing Saturday's session on storytelling for scientists, presented by Randy Olson. He has followed that traditional career trajectory from tenured professor to film school, and he wrote two books about scientists and communication skills (or, more accurately, lack thereof). I heard him speak at a screening of his film, Flock of Dodos, a few years back. His latest book, written with Dorie Barton and Brian Palermo, is Connection: Hollywood Storytelling Meets Critical Thinking. I am looking forward to seeing how his message has morphed over time. Obviously, I love communications, so this session is right up my alley.

Saturday also starts more traditional fare, including the Cannon Memorial Lecture. James M. Anderson of the NIH will present his talk, The Contribution of Paracellular Transport to Epithelial Homeostasis. As someone who teaches renal pathophysiology, this topic will be relevant. Look for some live tweets during this session.

Of course I will also attend and discuss the Gottschalk Award Lecture for the Renal Physiology Section on Monday afternoon. Susan Wall of Emory University will present her work on The Role of Pendrin the the Pressor Response to Aldosterone.

I have selected a number of abstracts that interest me; next week I will contact authors about coverage, either through email interviews, conversations on site, or perhaps even videos of them at their posters. See something in the program you think I should explore? Drop me a line via twitter (@phlane) or email (pascalelane [at] gmail...you know the rest).

Be sure and follow me on twitter as well as @expbio, and track the official meeting hashtag (#xBio) while you're at it. You may not be gazing on San Diego harbor in the sunshine, but you can still get a feel for the science at the meeting.

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The American Way

(by Pascale Lane) Apr 10 2014

Today in one of my feeds, someone asked why a woman's employer should pay for her birth control. Seems if we ladies want to make the beast with two backs without creating new little beasts, we should be ready to put up our own funds for the privilege.

When you get right down to it, why should our employers pay for our check-ups? Or our blood pressure control? Or bypass surgery or Viagra for their executives (who are almost universally d00ds)?

Because it's the American Way! Not in a flag-waving, patriotic sense, but because, historically, health insurance became a benefit provided by employers in this country. Like-it-or-not, reproductive care is a major aspect of women's health. No contraception coverage? You'll be paying for babies then. Even women who practice celibacy (like nuns) may need interventions for polycystic ovary disease or other symptomatic conditions affecting those bits down there.*

As long as we have employers providing the bulk of health insurance, they will have to pay for reproductive services for women.

OK, I got that off my chest. I will try not to yell at my screen about it any longer.

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*I personally know of a case where the convent had no trouble buying oral contraceptives to control symptoms of polycystic ovary disease for a young nun. Intent, in this case, trumped the name of the drug. Of course, the Roman Catholic medical center that employed me would not cover the same pills for me.

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My Arch Enemy

(by Pascale Lane) Apr 08 2014

Oklahoma is recovering from an outbreak of Escherichia coli which has kept me away from the blog recently.

E. coli, as we usually call it, lives all around and in us. A good chunk of that microbiome we keep hearing about includes this bacteria. Most strains happily thrive in our guts, living a perfectly benign coexistence with us. At times they may find their way into our urine or other problematic place, but they can usually be rapidly dispatched.

Some strains produce a toxin first noted in the bacteria Shigella, thus named Shiga Toxin. Autocorrect on my iPhone wants to change "shiga" to "shiva." This may not be an error. This toxin causes incredible inflammation within the bowel. When the gut gets inflamed, it lets water and other material flow on through, producing diarrhea. In this case, the inflammation is so intense that the gut bleeds. A bloody gut produces bloody diarrhea. Nausea, vomiting, and intense cramping complete the clinical picture. This is a case of the runs you will never forget.

Click to Enlarge

Click to Enlarge

In a small number of cases of hemorrhagic colitis, the toxin enters the blood stream and produces a systemic response called a thrombotic microangiopathy (TMA for short). In tiny blood vessels throughout the body (capillaries), the toxin damages the inside. Platelets (oblong lavender thingies in the diagram) activate on these areas of damage to begin repairs. These tiny clots get bigger over time and form a mesh or halt blood blow to an organ, impairing or shutting down its function.

Not all organs seem as prone to TMA damage. The kidneys seem to provide a playground for the toxin and platelets; kidney involvement ranges from the trivial to irreversible infarction or scarring of the kidneys. This is why we call this TMA hemolytic uremic syndrome (HUS), uremia being another term for kidney failure. Other organs can be involved, including the brain, pancreas, liver, and heart.

Obviously the kidney provides a major clotting magnet, or I would not be discussing this entity. We do not really know why one child gets colitis and develops HUS while another gets just a horrible case of diarrhea. Using antibiotics and anti-diarrheal drugs during the colitis can increase the risk of HUS, but they do not explain it all.

Since this syndrome was described in the 1950's mortality has fallen from ~50% to <5% just with supportive care. Mortality generally is confined to patients with significant central nervous system involvement. Apparent kidney recovery occurs in 95% of survivors, although most will develop other signs and symptoms of chronic kidney disease over the decades.

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Trying to Stop a Disruptive Train

(by Pascale Lane) Apr 04 2014

My week involved a lot of work with patients as some hemolytic-uremic syndrome came to town. While driving to and fro and using the restroom, I have read some tweets. At one point in a discourse, we talked about "antique" portions of the physical exam.

For example, in medical school they taught us to percuss heart borders. Percussion involves tapping on the chest and listening for the difference between the air-filled lungs and the relatively solid heart as shown in the video:

I cannot remember the last time I percussed a heart. Children do not hold still and quiet for such nonsense, and we get much more information from a chest xray. The latter also provides a lasting objective record of the findings that can be shared with subsequent physicians (or legal professionals). Most of the medical students I queried had no idea what I was talking about.

Many medical schools now incorporate inexpensive portable ultrasound machines into their curriculum. I envy these students who will be able to hear a murmur and figure out what it means on-the-spot. I know several pediatric nephrologists who have trained to perform their own ultrasound exams in the clinic. Unfortunately, its use is not spreading as fast or as far as it should.

Why? Hospital privileges.

When a doctor establishes a practice in a clinical facility, they usually have to be approved by a group at that place to make sure they are competent. I could apply for privileges for many procedures, but then I have to document my proficiency. Generally, they want to know what training you have and how many of the procedure you completed in the past 1-5 years. Imaging studies have fallen under the procedures heading. All those formal ultrasounds in the radiology suite generate lots of income for facilities.

They may not want us doing our own, even when we have the capability to record and store our images for the record.

The nice thing about disruptive technologies is that they are usually hard to stop. Eventually pocket ultrasound may replace even more of those "artisanal" physical exam skills. And that's OK if it makes for better care.

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Physician, Heal Thyself

(by Pascale Lane) Mar 31 2014

I had good intentions to blog last week. I had planned to fill out my #nephMadness bracket and blog about my choices. I had reviewed a topic, ready to discuss some medical science.

Then life interfered.

A bit over a week ago things were in their usual state of disarray for a Friday. I sat in my nurses' office, fiddling with the items on their table, including a wrist blood pressure cuff. I put it on and got a reading of 200/165. Yes, this is really high. After multiple readings with a variety of devices, including the gold standard (manual cuff and my nurse with a stethoscope), it became clear that I now have hypertension.

In retrospect, this should not have surprised me. After all, almost everyone in my family has developed high blood pressure at some point. I believe my mother's onset came during peri-menopause, a phase of life I now "enjoy."

I bought a cuff and picked up my first bottle of hydrochlorothiazide on my way home. The first few days got interesting since I had to fly to a meeting; gosh, diuretics do make you pee! By the end of the first week, my urine output was back to its usual amount. Today my blood pressure was 150/90. Not normal, but much improved and still decreasing daily, and all with a once-a-day drug that cost $3.51 for the first 30-day supply.

By the way, I felt completely fine. Even now that my pressure is down, I cannot point to a single symptom that would suggest my BP was high. Hypertension truly is a silent killer. Don't ignore it, and take your medication(s). It's important for your heart, your brain, your kidneys, and your life.

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Sanity Enhancement

(by Pascale Lane) Mar 20 2014

Often I get a sense of renewal after attending a conference. I see colleagues and learn new things, and I return to my job refreshed and ready to conquer the world.

I cannot always leave town when I need a pick-me-up. We all need things that give us that lift, like No Doz washed down with a 6-pack of RedBull. Following are some of my favorite things:

  • Songza: Sure there are a number of streaming music services, but this one has so many options. You can select from tunes for your time of day, activity, and mood. Most options are safe for work as well. Earlier today I used the "Busy Coffee Shop" as background noise while I did some tasks. Now, while I await the arrival of my first afternoon patient, I chose to go with the Hawaiian genre and Tiki Bar selections (I figure I can blog with Tiny Bubbles playing in the background). I also got a Bluetooth portable speaker so I can stream the sound from my iPhone without any plugs or cords.
  • Cute stuff: Emergency puppy, need I say more?
  • Physical activity: The standing desk helps my back and energy level, but it cannot completely replace a brisk walk around the building.
  • Online shopping: Really bad days call for drastic measures. Sometimes a quick browse through new items at a favorite site provides the lift; other times, nothing short of a new pair of shoes will lift me out of my mood. Yes, this can get expensive; reserve it for the very worst times.
  • Movies: This is mostly an after-work activity, although occasionally I find the need to shut my door and divert to a video that makes me feel empowered. My all-time winner in this category is Fried Green Tomatoes. I would love other suggestions.

What other activities, internet sites, or items help you through slow times at work? Leave your suggestions in the comments, please!

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Back to Reality

(by Pascale Lane) Mar 19 2014

Urologist's ad in bathroom at Traditions Field

Urologist's ad in bathroom at Traditions Field

I have finally returned from a much needed vacation in the sunshine of Florida. We watched six spring training baseball games and saw our daughter. The ad pictured to the right was posted on the back of the bathroom stall doors in Port St. Lucie where the Mets play. My spouse shared that the same practice advertised in the men's room for treatment of erectile dysfunction...something about helping you get to home plate.

Now I must work again. Catching up always challenges me. I have finally learned to do what I can do; the whole backlog does not have to be completed the first day back (even if everyone wants their piece done immediately).

I have some material for posts piling up on my desk, so you should see something science-like in the near future.

In the meantime, I have to see a few patients!

By the way, if you haven't done so yet, go over here and support science education while playing bracketology with Darwin's Balls, our NCAA Basketball group. I have Cinderellas winning a bunch of rounds, so I may be out after the second round!

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