The Fix for Bad Slides: MORE SLIDES!

(by Pascale Lane) Aug 28 2014

I love this slide-show about breaking dense slides into "layers of slides." I have been trying to get some colleagues to do something like this for awhile.

Enjoy and please take this advice!

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"Happy" Women's Equality Day

(by Pascale Lane) Aug 26 2014

94 years ago, the 19th amendment to the Constitution was ratified, giving women the right to vote. Our fore-mothers fought for this right, believing that without political power any other rights could be denied. They also believed that with political voices we could achieve true equality.

Their belief in the vote sustained them through public humiliation, beatings, starvation, jail, forced feedings, and a number of other indignities.

Despite the passage of nearly a century, women still have not achieved full equality. We make less than 80% of our male counterparts in similar jobs. We are underrepresented in the best -paid careers, and even when we enter those fields we are marginalized. Corporate boards, congress, and other decision-making bodies rarely demonstrate gender equality, despite the evidence that more women in those positions increases profits and other measures of efficacy.

Today we see rights we thought were won under attack. It's time we used that vote, the political voice our ancestors fought for. Learn the issues and make your choices. Run for office, or at least support those you like in whatever way you can.

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Another Topic to Video: Thrombotic Microangiopathies

(by Pascale Lane) Aug 25 2014

My conversion of resident lectures to self-study videos continues with Thrombotic Microangiopathies.

These disorders are characterized by consumption of platelets and red blood cells with resulting anemia and blood clotting problems. Other organs can be affected, particularly the kidneys (duh-why else am I talking about it?). These disorders include hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP).

I would enjoy hearing your comments about the video. Would an adapted version (with less attention on specific doctor-level stuff) be good for parents?

Let me know in comments below, please!

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Final Friday Thoughts

(by Pascale Lane) Aug 22 2014

I just read a post about the sexual and racial politics of the latest videos from Taylor Swift and Nicki Minaj. The author saw waaaaay more in these presentations than I did, although I found both songs and videos entertaining.

  1. "Shake it Off" is pretty much what you would expect from Taylor Swift if you have ever encountered her stuff before EXCEPT it is clearly not a country song.
  2. "Anaconda" may set a record for most phallic symbols in a video.
  3. How do they do that with their butts?
  4. While both tunes are catchy, it is unfortunately the work of Ms. Minaj that has provided today's earworm.

I will be off in a bit to do whatever it takes to get the phrase "My anaconda don't" off of continual replay in my head. I think I pulled a muscle trying to emulate some twerk moves as well.

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What I Am Reading: Dystopian Future

(by Pascale Lane) Aug 21 2014

CircleRemember reading 1984 in high school? Big Brother is watching you so you must conform to society's standards! The Circle tells the story of the genesis of an internet-age totalitarian society much like the one Orwell created.

I doubt that this one will make the jump to "literature that should be taught, but I might be wrong.

What is The Circle? Imagine that Google, Facebook, Twitter, Paypal, and every other major internet service were mashed up into one giant corporation. This company controls an online identity system that keeps people from participating anonymously or pseudonymously online. This led to complete internet civility (of course!). It also allowed more secure payment systems, even leading some to suggest that all cash be eliminated for Circle-based payments. Employees at the company propose new uses of The Circle to make life more pleasant and secure all the time. The one thing no one seems to do at The Circle is code or actually do computer stuff. Hmmmm.

The story focuses on Mae Holland, a new employee at The Circle. Through a friend who is in The Circle's inner circle, she secures an entry-level customer experience job that allows her to escape a mind-numbing position at a local utility company. The Circle resides on a California campus with all the bells and whistles we expect from an internet company: game rooms, free cafeterias, gardens, sports fields, the works. In addition, their seems to be multiple social events for employees every evening, some of which are mandatory. The campus also boasts beautiful dorms where employees can stay and give up life outside The Circle all together.

May starts out treating her employment like a job. As time goes on, she discovers that she is expected to participate in The Circle's ongoing social media (internal and external) as well as "extracurricular" activities or she will be viewed as "antisocial" and "not part of The Circle." May succeeds, and rises in her department, eventually resulting in 6 or 7 separate screens on her desk for various components of her work. Eventually, events occur that prod May to become "transparent." This means wearing a live web cam at all times so her life while awake becomes an open book. Nothing can be deleted from her video feed (even when she catches her parents having sex).

The leaders are intent on "Closing the Circle" which should make May ask some very critical questions. However, despite the obvious impending loss of freedom (and the reader screaming at her on the page), May seems disinclined to see anything but the rosy picture her supervisors paint. Even when someone brazenly spells it out for her, she fails to see the danger of the situation.

The use of tiles at the company echos parts of 1984. Instead of "Big Brother is Watching," we have "Secrets are Lies" and "Privacy is Theft."

We often look at totalitarian states and wonder how the regular people let this obviously bad government happen. This book tries to explain that, and does a reasonable job. I wish there had been a few more examples of resistance, other than an ex-boyfriend who I found generally unappealing. If anyone else has read this book, I would love to hear your thoughts in the comments.

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Change, change, change

(by Pascale Lane) Aug 14 2014

More and more learning requirements have been added to the curriculum for medical students and residents. Advocacy, quality improvement, and communication skills are all worthy subjects for the house officers learning a specialty, but it has cut the availability of slots for didactic teaching.

Good. Lectures mostly bored me silly; I learned more from reading about patients and thinking on my feet than I ever did from a talk.

This does not eliminate the need for we faculty members to provide appropriate information for our trainees. We just have to figure out other ways to do it. To that end, I am converting my lectures to short videos (amazing that something I spoke about for the better part of an hour can be condensed to 7 minutes) with accompanying handouts. These will be posted online so that whenever the resident needs the topic they can access it in the manner they prefer. Eventually we hope to have a series of online assessments as well.

I just finished my first conversion, Pediatric Acute Kidney Injury. Closed captioning is in progress (it's the slowest bit of YouTube). I've also embedded the video here for your "entertainment."

Things I learned:

  1. You can never practice your narration and cues too much
  2. An expensive microphone beats a cheapie every day
  3. It's amazing how long it takes to make a 7 minute video
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What I Am Reading: Blast From My Past

(by Pascale Lane) Aug 11 2014

First, Some Background

I come from a family of non-athletes. In high school, my interest in sports mostly involved cute boys playing them. I had to learn about basketball in gym class, but watching my tiny high school football team taught me little about the game.

I then left for Kansas City. As part of the University of Missouri system, my boyfriend, an actual athlete, took me to football games at Mizzou. I began to appreciate the strategy of the game. The Chiefs were pretty bad in the early 1980s, so tickets could be bought at reasonable prices. I loved sitting in that bowl at Arrowhead as part of the crowd in red and gold, even if victory often fell out of reach.

In 1984, that same boyfriend (now my spouse) moved to Chicago to start his residency. The Bears were coming of age that year, especially dominating with their 46 defense. I moved to the Windy City in the summer of 1985, ready to cheer on a new team.

MonstersThe Book

Monsters: The 1985 Chicago Bears and the Wild Heart of Football occupied two evenings of my vacation. I could not put this book down, although I do not know if someone without the type of background above would love it as much. The author, Rich Cohen, grew up in Chicago and during his senior year in high school managed to get SuperBowl XX tickets and make his way to New Orleans for this big game. He captures the mood of the city at that time perfectly, and provides great background for those of us (like President Obama) who were new to the way of "Da Bears."

Yes, there is a component of memoir to this text, but also of history. I knew Papa Bear Halas, thanks to his obituaries, had been instrumental in founding the National Football League, but I never realized how much the game owed him. He was the first coach to use the "eye in the sky." One game an assistant took a message to his wife in the stands. He came back to the sidelines in awe of what that view afforded him. What looked like guys grinding it out in the mud took on patterns and logic when seen on high. The next year Halas stationed an assistant at press box level and installed a phone from there to the sideline.

Even after he "retired" from coaching, he often hung around the facilities. One day in the locker room, some players recall him beginning to lecture them on varying strategies depending on where the ball was being played. He divided the field into blue, white, and - wait for it - red zones, the first time anyone can recall the term "red zone" being used.

We learn a lot more about Iron Mike Ditka (other members of the family had simplified the Polish surname to Disco, if you can imagine that) and Buddy Ryan. The latter, of course, brought us that amazing defense that never quit. At the time, I knew these men did not like each other; I never realized how much they disliked each other until reading the book. The details also seal my everlasting admiration of Samurai Mike Singletary, a guy tough enough and smart enough to run that defense.

McMahon salutes authority

McMahon salutes authority

Cohen does not shy away from the aftermath of the game, either. He discusses the difficulties with injuries many of the players continue to have, including Dave Duerson's suicide in 2011 while suffering from chronic traumatic encephalopathy and Jim McMahon's ongoing issues with mental function. As he finished his interview with the forgetful but still punky QB, he asked the money question: Was it worth it? McMahon said, "I'd do it all again in a heartbeat."

Postlude

I still remember that Sunday morning. I took call overnight in a now gone Chicago hospital that Saturday, caring for sick infants in the neonatal intensive care unit (NICU). I was anxious to get home because we had friends coming over for the game. All that stood between me and departure were handoff rounds. As we entered the NICU, we were delighted by every infant having a piece of tape (paper or adhesive, as tolerated) with "Rozelle" or a player's name or just "Bears" written across it in marker. Just remembering it brings a smile to my face and makes me want to dance the SuperBowl Shuffle.

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Vacation!

(by Pascale Lane) Aug 02 2014

I am off to enjoy some time with my spouse, my son, my brother, and assorted critters in the woods and waters of Oklahoma. Feel free to make snarky comments below while I have another cocktail...

Photographic evidence of this endeavor will likely be available on my twitter feed.

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What I Am Reading: Free Market Edition

(by Pascale Lane) Jul 28 2014

Click for Amazon

Sigrid Fry-Revere is a lawyer and a medical ethicist. She has played an advisory role to organ donation organizations in the US. Her latest work explores the kidney "exchanges" in Iran where a very different approach to organ donation has produced a surplus of living kidney donors.

The approach in most of the world has been to use deceased donors for transplantation as much as possible. Kidneys provide a unique opportunity for living donation, since most people have two and can live nicely with only a single organ. Our system requires these kidneys be donated from purely altruistic motives, usually because of relationships between the parties involved: husband - wife, parent - child, or other relations. When relatives or other close parties cannot donate, a donation "circle" can be set up. In this, one party cannot donate to their loved one, but they are a match for someone else whose relatives cannot donate. In the simplest setting, the donor exchange is paired; however, chains of up to 19 donors and recipients have now been orchestrated to give dialysis patients a better life.  While many donor expenses are covered by medical insurance, donating may have unseen expenses, including weeks out of work and the potential for complications of anesthesia and surgery.

Despite harvesting deceased organs, matching services for donor chains, and availability of dialysis, 20 to 25 people in the US die every day awaiting a kidney.

Iran has taken a different tactic to alleviate kidney shortages, namely paying organ donors. The powers that be in the US have assumed that this system is coercive and unfair. Dr. Fry-Revere decides that a program this successful is worth learning about. She spends several months on the road in Iran with an expatriate nephrologist, Dr. Bahar Bastani, a former colleague of mine at Saint Louis University. They bravely recorded video and audio interviews with doctors, nurses, donors, and recipients throughout Iran, generating the first account of this system by Western experts. The resulting book is The Kidney Sellers: A Journey of Discovery in Iran.

In Iran, the national government provides a cash payment for a kidney. Additional compensation varies by region. Most regional centers provide health coverage for a period of time for donors. The donor can then negotiate with the seller through the regional bureau for additional cash; if the recipient has no means to pay, the center can often tap donations for the funds needed.

Procedures vary from region to region. In the best situations, donors are carefully screened to make sure that their financial issues cannot be solved through other routes.  Potential donors interviewed in the book often had a debt to retire or needed capital to start a business; marriage often necessitated a cash infusion. Donors often expressed mixed emotions about the procedure. Many got their money, fixed their financial issues, and moved on with no regrets, but some felt guilt or shame that they had to sell an organ to make their lives better.

Recipients sometimes formed bonds with their paid donors, but for the most part this was a market transaction that ended when it ended. Many stated that they preferred a paid donation to an altruistic one from a relative; the latter would have left them indebted for life, while paying cash let them feel the debt was paid. They could then move on with better health and less guilt.

The book can be a bit repetitive at times, but it paints a wonderful picture of a society and system we know very little of. As I watch my own patients on dialysis, waiting months for a deceased donor kidney, I wonder if the Iranians just might have a good idea. I recommend reading this work for a thought-provoking take on our organ donation system.

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Is the Answer at the RIVUR? #NephJC

(by Pascale Lane) Jul 16 2014

This study will be discussed as part of the online, twitter-based Nephrology Journal Club on July 22,2014. More information about the workings of #NephJC can be found here.

The Problem of Reflux

Vesicoureteroreflux (VUR) occurs in approximately 10% of children overall, but about one-third of those with a febrile or otherwise symptomatic urinary tract infection (UTI). VUR is associated with an increased risk of renal "scars." Since it was first described in the 1960's, treatment of this backflow of urine from the bladder to the ureter has been recommended for all affected children. Surgery can create a competent valve at the vesicoureteral junction during voiding, but an early randomized trial showed that prophylactic antibiotics to prevent infection were just as effective as surgery in the scarring outcome.

Despite the recommendations for treatment for 50 years, permanent kidney failure attributed to VUR has not declined in the end-stage database of any country. Improved prenatal diagnosis of infant renal anomalies have allowed us to diagnose VUR in the first weeks of life, prior to any UTIs. Some children without UTIs still get renal scarring, leading some to suspect that "scars" may actually be areas of hypoplasia or other abnormal development due to an abnormal ureteric bud.

The original study showed equivalent results from surgery and antibiotic prophylaxis, but it included no untreated control group to assess the strategy of intermittent treatment of  UTIs when they occurred. The Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial set out to determine if long-term prophylaxis prevented recurrence of UTIs, occurrence of "scars," or contributed to antimicrobial resistance.

The Study

The study was a randomized, double-blind, placebo-controlled trial of prophylaxis with trimethoprim-sulfamethoxazole (TMPS). Children were screened and enrolled after 1 or 2 febrile or otherwise symptomatic UTIs, including positive culture. Bagged urine samples were not allowed. Children in the study ranged in age from 2 months to 6 years and had grades I to IV VUR (severe grade V patients were excluded). Exclusion criteria included other urinary abnormalties, chronic kidney disease, inability to take TMPS, and other selected medical issues.

Studies included dimercaptosuccinic acid (DMSA) scans at baseline and 1 and 2 years later. These scans (the gold standard for kidney scars) were read and scored centrally by two pediatric nuclear medicine radiologists.

Treatment failure was defined as:

  • 2 febrile UTIs
  • 1 febrile and 3 symptomatic UTIs
  • 4 symptomatic UTIs
  • New or worsening "scars" at 1 year

The Results

Baseline characteristics of the children enrolled can be seen here. No significant differences on any parameter existed between the treatment and control groups. Time to first febrile or symptomatic UTI after trial enrollment is shown below:

Figure2

As shown in the paper’s figure 2 above, the two groups separated significantly within the first 6 months of treatment, with TMPS prophylaxis clearly preventing UTIs. By the end of 2 years, approximately one quarter of the placebo group had experienced an infection, while only half that many in the prophylaxis group had fallen ill.

A number of potential modifying factors were assessed for impact on the results, shown in the figure below:

Figure 3

As shown prophylaxis was more valuable for children who presented with febrile, as opposed to symptomatic but afebrile, UTI. Bowel and bladder dysfunction, determined via a standardized survey, also favored the use of TMPS.

Renal “scars” showed no difference throughout the study. Rectal swabs showed no significant difference in the rate of resistance of E. coli to TMPS between the prophylaxis and control groups.

Remaining Questions

Clearly antibiotic prophylaxis reduces the risk of recurrence of UTIs in children with VUR. However, about 75% of children receiving placebo had not suffered a recurrence after 2 years of study. UTIs cause discomfort, school absence, and lost work for parents; even after this trial we have no evidence of long-term damage prevention through the use of TMPS. Antibiotic resistance does not seem to be a big problem in this patient population.

So the question remains: what should we do about VUR?

In my mind, the question is still open. Many families today have qualms about long-term exposure to these medications. Other families dread missing a UTI and would far prefer to take the antibiotic. The tolerance of the family for illness vs the small risks of prophylaxis often prove to be a big factor driving therapy.

That leaves us each a lot of flexibility in our approach to VUR. My personal preference is to watch most cases without prophylaxis initially. Those who have further UTIs in the first few months after diagnosis are encouraged to start prophylaxis and consider surgical treatment. Those without significant recurrences receive follow-up on a regular basis. All of this requires ongoing discussion with the parents and input regarding their tolerance for urinary symptoms.

The pediatric nephrology community hoped that RIVUR would answer our managment questions about VUR. It would appear that we still have more we need to know.

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