Monday, May 31, 2010

Holiday Quick-Post


Things are not quite as dire as the photo, but I really need some treadmill time before another afternoon lounging by the pool.

Of course, this provides another opportunity to watch an episode of Glee.

So enjoy the holiday. Enjoy your family and friends.

Image courtesy of PhotoXpress.

Friday, May 28, 2010

Bacon Makes the World a Brighter Place

Photoxpress_3373434This week a few of my OTI colleagues began #baconblogwars.

A moment of silence to dream of bacon… that smoky flavor and the soft parts that melt on your tongue… with those little crunchy bits that make it sing while you chew.

Is there any meal that cannot be improved simply by adding bacon?

So today, a friend sent me this ad that pretty much says it all:

I have a pound of thick sliced peppered bacon in the fridge, awaiting my skillet. Maybe Saturday morning with some honey-wheat pancakes…

Top image courtesy of PhotoXpress.

Thursday, May 27, 2010

Like My Page, Please!

We have a problem.facebook

No life endangered, no major economic threats. Nothing that will alter the course of history. Just something awkward.

See, back in the old days of 2009, you became a fan of pages on facebook. You set up a page for a business or an organization, and you could say “become a fan.”


Now, when you want to show your support for such a page, you click on a link that says you “like” this page.

In some ways this makes sense. You are showing your approval for a business or organization or other entity, giving it the old “thumbs up.”

It’s the language that gets clunky.

See, you need 25 people to “like” your page so you can get a “vanity” facebook address. Instead of a string of letters and numbers following the facebook url, you can then be, for example (yes, we made the count yesterday). While trying to make that hurdle, I had a dilemma. What should we call these people? Fans? Gee, facebook went to all that trouble to change the process name… Should we really tweet that we only need one more fan? Perhaps they should be called “likers?” Although that sounds really, really weird. And, it is only 1 small typo away from lickers, which could get even weirder.

How do you recruit these people? Some say “follow us on twitter (@KidneyNews) and facebook (, although my own preference is to use the verb “follow” specifically for twitter. Yes, saying “fan us on facebook” sounded wrong, but so does “like us on facebook.” Nothing is quite as good as “become a fan.”

And saying “we need one more person to like us on facebook to meet this goal” sounds pitiful. Won’t someone like me, please?

I have no wise Solomon-like solution. But I am feeling awkward. And I am open to suggestions.

Tuesday, May 25, 2010

Keeping My Foot On The Gas Pedal

FrenchFlappers 1920 began with Babe Ruth moving to New York, but this proved a small event in the course of the year (unless you talk to my husband or other rabid baseball fans). The world powers continued to deal with the aftermath of “The Great War.” The League of Nations formed without the US. Adolf Hitler presented his National Socialist Program in Munich.

On August 6, the 19th Amendment guaranteeing women’s suffrage, was certified.

Now, 90 years after gaining the right to vote, women have achieved much; however, there are still gaps in our status in this country. Men still earn more for comparable work. Men dominate board rooms. Men dominate politics. Men dominate academic medicine and science, my own field.

Vision 2020 calls for a decade of discussion and action about these ongoing inequalities:Vision

Vision 2020 is a national project focused on advancing gender equality by energizing the dialogue about women and leadership. Its first public event takes place on Oct. 21-22, 2010, when a congress of national delegates, representing all 50 states and the District of Columbia, will meet at the National Constitution Center in Philadelphia to launch an action agenda to move America toward equality by 2020, the centennial celebration of the 19th Amendment.

“What is Equality?” Vision 2020’s Anthem poses some provocative questions.  Watch, think and engage by clicking here.

My favorite description of Vision 2020:

Vision 2020 will develop and launch its decade-long action agenda to move America toward equality by inspiring and engaging new generations of women and men to finish the work of the suffragists

[Emphasis mine]

I am delighted to represent the state of Nebraska in this important endeavor. All of the delegates can be found, by state, here. We represent every field of human (not just feminine) endeavor, with a wide range of backgrounds and goals.

Vision 2020 may will be one of the coolest things I get to do.

I hope we can advance the work of the suffragists. I hope we can work toward a country where a woman will be elected president. I hope our conversations and actions can drive pay equity. After all, I have a daughter.

Equality: Are we there yet? No. That is why we must keep driving forward.

Follow Vision 2020 on twitter, and “like” it on facebook.

Postcard of French Flappers, circa 1920, via Flickr.

Monday, May 24, 2010

Neckwear Discrimination?

Last week my husband and I travelled together. On the final day, wePhotoxpress_4778471 both found ourselves flying in serious business attire. My ensemble included a lightweight scarf, about the weight of the one in the photo.

My scarf must be placed in a bin and xrayed as we go through security.

What I do not understand is why his necktie can be adequately screened while still on his body.

detail of a business man with coloured tieSeriously, how would I hide a significant deadly object in a sheer scarf that could not also be obscured by a silk tie?

This may just be one of those mysteries we never understand. I would love to understand the rationale. If you know anyone from TSA, have them wander by and explain this policy to me.

In the meantime, I guess scarves are one more thing I will try to avoid on travel days.

Pretty soon I will be avoiding so many items that I may end up flying naked.

Images courtesy of PhotoXpress.

Friday, May 21, 2010

Everyone, at All Times

Having Rand Paul as a candidate won’t be boring. You would think by now everyone would be over stuff like the Civil Rights Act (passed during my childhood) and Women’s Suffrage (before my time), but Paul seems to believe that federal laws protecting the rights of all Americans somehow trample on the rights of someone or something else (I’m sort of fuzzy on exactly what he is thinking; Pal over at White Coat Underground has a better handle on the views).

I must admit there are times when I feel out-of-sorts with “others.” Usually this happens when I am in clinic and I have multiple Spanish-speaking parents and too few translators. Or I am trying to schedule a meeting and I have to work around a whole bunch of religious holidays. I curse those who are not like me, although I do feel bad about it later.

It would never occur to me to insist that those who are different from me cannot learn, eat, work, or seek medical assistance alongside me. Like those on Avenue Q, I misjudge some people based on external factors. When push comes to shove, we are ALL in this together.

Rand Paul’s views go beyond the “little bit” standard. His legal viewpoint could return us to “separate but equal.”  Should a private restaurant really not be required to adhere to the Civil Rights Act?

Now that would be a little bit stupid.

Thursday, May 20, 2010

Words of Wisdom from Danae

Last week DrugMonkey posted that the NIH ain’t doin’ it right if a certain portion of grants do not fail. In a time of tight paylines, a back-the-sure-thing, nobody-ever-got-fired-for-choosing-Microsoft mentality prevails, and science gets more of the same. Big labs get more grants to grind out lots of incremental papers (“so productive”), while smaller labs get less, thus assuring inadequate productivity for at least another funding cycle (hey, bitter is the new black, so don’t judge me).

In my experience on study sections, reductionist proposals receive the most enthusiasm. Drilling down into a specific cell/pathway/molecule appeals more than looking at the whole animal or tissue level. Apparently, “mechanism” can only be truly delineated at the cellular level. Never mind that no one in my clinic exists as an isolated packet of cells.

I am not saying that such very basic, mechanism-of-life work is unimportant; this type of science has driven a whole world of biomedical advances in the last few decades, and we need to keep funding it. We just should not lose sight of the bigger picture and the need to keep our minds open.

I just got back in town, and I need to catch up on things. This blog post did not top my To-Do List. I was delighted to see this when I logged on this morning, and just had to write:


The motto of science should be “expect the unexpected,” yet reviewers of grants want “the sure thing.”

OK, you should have enough preliminary data to show that you can perform any new or unusual technique (this generally does not include anything in a kit). You should have data to show that you are facing west, so to speak. Not necessarily a peer-reviewed paper, but something supportive (although at least one peer-reviewed paper supporting your idea is generally necessary for an R01 in the present funding climate).

Just don’t forget to look east occasionally, because that might be even more interesting than the sunset. And reviewers, please do not kill a proposal for looking east as well as west.

The next big advance in any field will be completely unexpected – or we would have found it already.

Saturday, May 15, 2010

What I'm Reading

A couple of weeks back, while at Experimental Biology, I saw Denialism displayed in the exhibit hall. I read the book jacket, whipped out my Kindle, and downloaded the book (immediate gratification). I did not start it immediately (delayed gratification), but I have now made my way about 3/4 through it.
Michael Specter examines many issues in modern society where belief trumps rational thought, including the anti-vaccination movement, genetically-modified foods, and dietary supplements. He presents the science, and the facts, as well as the viewpoints of the opposing side.
Unfortunately, many of the people who need to read this book will not. They do not seek facts or the truth; they believe what they want, and rational arguments will not sway them.
For the next few days I will be out and about with little time to blog. If you need to read something in my absence, buy Denialism.

Friday, May 14, 2010

Maternal Remembrance

A few years back I was working frantically to finish a grant proposal. My husband was out-of-town, my daughter was at dance class, and I really needed to write. I parked my almost 8-year-old son in my office with a GameBoy© and tried to work. Every 5 minutes, I would hear a chorus of “Mommy! Mommy!”

About the time I began plotting where to hide his body, he cried for me again and handed me this sheet of paper, now carefully laminated and preserved:


Kids seem to know when you feel like eating your young. Then they do something cute so you won’t. He has survived to the age of 17 now. In another year he will leave my home.

10.  I love you, too, Tim.

Wednesday, May 12, 2010

Journal Club: Is Saline Toxic?

Outcomes of critically ill children requiring continuous renal replacement therapy
Hayes et al. J Critical Care (2009) 24:394-400;  PMID: 19327959

What was studied?

A number of retrospective studies in children and adults (including one by someone named Lane) demonstrate that volume overload at the initiation of renal replacement therapy for acute kidney injury (AKI) increases risk of death. The study I reviewed for today’s Photoxpress_3018802journal club examines a single-center (Children’s Hospital of Alabama) series of pediatric AKI patients treated with continuous renal replacement therapy (CRRT) from January 2000 through September 2005. In addition to examining predictors of mortality, a variety of secondary outcomes are included in the study (duration of mechanical ventilation, length of intensive care unit stay, days of hospitalization, and time to renal recovery). The investigators predicted that greater fluid overload at the time of initiation of CRRT would produce more adverse outcomes.

How was it studied?

After appropriate human subject protection review, charts of all CRRT patients were examined for standard demographic and diagnostic information. Fluid overload (FO) was calculated from admission to the intensive care unit until CRRT initiation:

(Total Intake Liters – Total Output Liters)/Admission Weight Kilos

I have one complaint with this score; if the patient were significantly volume depleted at the time of admission, it could overestimate volume overload. Given that a true “dry weight” would not be available for most patients, this is probably the best measure they could use.

Pediatric Risk of Mortality 2 scores (PRISM) were calculated for admission and onset of CRRT. Appropriate statistical analysis is described.

What was found?

Over this almost 6 year period, 76 courses of CRRT were studied, including 42 survivors and 34 nonsurvivors. The groups were similar for age, race, and sex. PRISM scores of “sickness” were similar, as were the requirement for blood pressure support mediations and level of kidney dysfunction. The number of hospital days before starting CRRT did not differ between the groups, nor did the type or dose of CRRT. Nonsurvivors were more likely to require a ventilator at the time of CRRT initiation, have higher airway pressures 24 hours into their course of CRRT, and had greater FO before starting CRRT.

If FO was above 20% of admission body weight when CRRT began, the odds of dying during the illness were increased 6-fold (95% confidence interval 2.2-17.0, p=0.0006). Risk of mortality also increased with sepsis (odds ratio 12.9, p=0.0001) and multiple organ dysfuntion syndrome. If only the kidneys had failed, all patients survived.

So they have confirmed the prior literature; what was new? For the 42 survivors, FO above 20% associated with longer need for a ventilator (16 v. 7 days), length of intensive care unit stay (21 v. 14 days), length of hospital stay (57 v. 27 days), and time to renal recovery (26 v. 8 days).

What does this mean?

This study confirms FO as a marker of mortality in children requiring CRRT for AKI. In addition, it shows worse outcomes for children who survive their illness, with longer time on a ventilator, on dialysis, and in the hospital.

Because of the retrospective and descriptive nature of the study, the major question remains:

Why is volume overload associated with worse outcomes in AKI?

When my own work found this association in bone marrow transplant patients, we hypothesized that sicker patients received more fluid for blood pressure support; our population also required more drugs to keep blood pressure up. In this study from Alabama, drugs for blood pressure support did not differ between these groups, nor did PRISM scores to estimate the level of “sickness” of the patients.

What is the alternative to FO as a marker, an epiphenomenon? Perhaps FO itself is toxic. Extra fluid may complicate ventilation and other body systems, especially if it leads to compromised nutritional support. Would earlier intervention with CRRT (perhaps at 10% FO) lead to better outcomes? Only a prospective multicenter study will answer this question.

Take-home message

Many physicians see fluid therapy as a completely benign thing to do, with little potential for adverse outcomes. Certainly, patients should receive fluid resuscitation, as noted by the study authors:

…it is vitally important that critically ill children in shock receive adequate treatment; we do not advocate withholding fluids from children during resuscitation.

This study provides one more piece of evidence that we need multicenter studies of earlier CRRT initiation. Only then will we know if saline is the bad guy or an innocent bystander in the morbidity and mortality of the critically ill.

Image courtesy of PhotoXpress.

Tuesday, May 11, 2010

Excuses and Delays

Yesterday my first PhD student’s comprehensive exam kept me from blogging (she passed, of course), and today I must finish a journal club presentation. Journal club sounds like it might be some sort of fun, exclusive activity for which you wait in line; if you aren’t dressed correctly, the boPhotoxpress_5528831uncer may not let you participate.

Of course, I would be dressed correctly for any occasion!

In reality, journal club provides an important piece of biomedical training, honing skills in critical appraisal of the literature. Participants (me, this time around) select an article to critique.

The process proceeds similar to manuscript review. We discuss the experimental question, the methods used to collect and analyze the data, the interpretation of the data, and how it all fits together with everything else we know. For established physician-scientists such as myself, journal club is a good way to review a topic and discover something new. For trainees, critiquing studies helps develop a sense of “the way things are done.” Science and medicine, especially when written, have their own language and conventions. Learning how to fit into this culture is part of the training- along with learning how to conduct and critique research. Oh, and picking up a bunch of facts as well.

Tomorrow I will provide a brief post on my article.

Image courtesy of PhotoXpress.

Sunday, May 9, 2010

Culture Clashes and the AAP

Last week the American Academy of Pediatrics (AAP) released an updated version of its position statement on ritual genital cutting of minor females. It is telling that the original statement from 1998 addressed female genital mutilation; this change is language is not accidental. And the change in tone of the position statement produced much controversy in its wake.

Female Genital Cutting/Mutilation (FGCM)

Some describe FGCM as female circumcision, although the procedures are not analogous. Removing the foreskin does not render the penis inoperable. The World Health Organization classifies FGCM into 3 levels, most of which involve removing the clitoris.

FGM Male circumcision produces no benefit for most, but also yields no harm. Some evidence of medical benefit exists in regards to urinary tract infections and HIV transmission. FGCM may leave women with significant health problems, especially in regards to future fertility and urinary function.

FGCM is practiced in some regions of Africa and Asia, as documented at the WHO site.

What has changed

The title of the new AAP statement provides the first clue to changes in the document apparently driven by physicians working with immigrant communities. The abstract would lead one to believe that little had changed in the recommendations:

The traditional custom of ritual cutting and alteration of the genitalia of female infants, children, and adolescents, referred to as female genital mutilation or female genital cutting (FGC), persists primarily in Africa and among certain communities in the Middle East and Asia. Immigrants in the United States from areas in which FGC is common may have daughters who have undergone a ritual genital procedure or may request that such a procedure be performed by a physician. The American Academy of Pediatrics believes that pediatricians and pediatric surgical specialists should be aware that this practice has life-threatening healthrisks for children and women. The American Academy of Pediatricsopposes all types of female genital cutting that pose risks of physical or psychological harm, counsels its members not to perform such procedures, recommends that its members activelyseek to dissuade families from carrying out harmful forms of FGC, and urges its members to provide patients and their parents with compassionate education about the harms of FGC while remaining sensitive to the cultural and religious reasons that motivate parents to seek this procedure for their daughters.

Later in the discussion, issues of cultural sensitivity arise:

The American Academy of Pediatrics policy statement on newborn male circumcision expresses respect for parental decision-making and acknowledges the legitimacy of including cultural, religious, and ethnic traditions when making the choice of whether to surgically alter a male infant's genitals. Of course, parental decision-making is not without limits, and pediatricians must always resist decisions that are likely to cause harm to children. Most forms of FGC are decidedly harmful, and pediatricians should decline to perform them, even in the absence of any legal constraints.However, the ritual nick suggested by some pediatricians is not physically harmful and is much less extensive than routine newborn male genital cutting. There is reason to believe that offering such a compromise may build trust between hospitals and immigrant communities, save some girls from undergoing disfiguring and life-threatening procedures in their native countries, and play a role in the eventual eradication of FGC. It might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick as a possible compromise to avoid greater harm.

The 1998 statement was easy: FGCM is medically wrong and illegal; don’t do it! The current document provides final recommendations that read almost the same:

The American Academy of Pediatrics:

  1. Opposes all forms of FGC that pose risks of physical or psychological harm.
  2. Encourages its members to become informed about FGC and its complications and to be able to recognize physical signs of FGC.
  3. Recommends that its members actively seek to dissuade families from carrying out harmful forms of FGC.
  4. Recommends that its members provide patients and their parents with compassionate education about the physical harms and psychological risks of FGC while remaining sensitive to the cultural and religious reasons that motivate parents to seek this procedure for their daughters.

Only in the discussion do they discuss offering a “ritual nick” as an alternative to a riskier procedure, recognizing that even this alternative remains illegal. My question: will the “ritual nick” eventually lead to more significant procedures to appease parents?

FGCM is illegal for a reason. I recognize that other cultures are as valid as my own, but we have outlawed these procedures for very good reasons. Other cultures permit “honor killings;” would we tolerate these in this country just to be culturally sensitive? I know we do not! When you choose to immigrate, you choose to make changes in your life. Eliminating FGCM is one change that must be made.

Thursday, May 6, 2010

Jumping Through the Hoops to Make Bones Better

My nurses do a great job keeping the clinical service running, especially handling prescriptions and the nonsense sometimes required by insurers. Treating children with chronic kidney disease means prescribing a lot of medications not approved specifically for use in children. Sometimes we must jump through flaming hoops to get the job done.

hyperparathyroidism-718x567 Today, they had a new issue.

We prescribed calcium acetate, a medication used to bind phosphate. As the kidneys lose function, they cannot eliminate phosphate from the body. Dietary reduction helps, but since most organisms store energy in phosphate molecules like ATP, it cannot be eliminated entirely. Patients can take calcium or other medications with meals to bind to the phosphate in the gut. Calcium phosphate cannot be absorbed into the body. Instead, it is fecally excreted (or pooped out, as I tell my patients). Excess phosphate (along with lack of the active form of vitamin D) causes bone problems in many patients with chronic kidney disease, including secondary hyperparathyroidism (shown in x-ray).

Being generally cognizant of insurance limitations, we generate most prescriptions for the generic drug, in this case:

Calcium Acetate 667 mg three times daily with meals

Today, we received a fax:

Patient must fail a 2-week trial of PhosLo before calcium acetate can be prescribed.

PhosLoSo what is PhosLo? The trade name of calcium acetate 667 mg tablets.

Yup, same stuff. So we wrote back and gave permission to prescribe PhosLo. Duh!

Thank you, Nebraska Medicaid, for providing today’s blog fodder. And a lot of head-shaking in our office!

Wednesday, May 5, 2010

A Good Example

Photoxpress_612445 Today I am reviewing a manuscript that includes a qualitative research component. A while back some bad qualitative research rocked the blogosphere, so I thought I would strip the identifiers and provide an example of what good qualitative research sounds like in the methods section:

Two of the authors independently reviewed the open-ended responses to questions…/… and developed a coding scheme. After discussion, a common coding scheme was developed and subsequently reviewed by a third author... The original two authors then independently coded the database.

So scheme developed, confirmed by another researcher, and then applied. That is the way you do a qualitative study.

Art courtesy of PhotoXpress.

Monday, May 3, 2010

Can 10 Minutes Be “The New Black?”


New England Journal of Medicine runs a column on “Becoming a Physician.” In the April 29, 2010 issue this piece by Susan Mackie, MD, explores “The Value of DNKs.”

For non-clinician readers:

DNK (pronounced "dink" and always uttered wistfully by the residents in my program) is the abbreviation that appears on our online schedule when a patient "did not keep" an appointment.

Dr. Mackie goes on to compare two clinics during her primary care residency at Beth Israel Deaconess Medical Center in Boston:

I thought about the previous day. Then, my clinic had felt frenetic, I had felt cynical, and I know that my patients had left dissatisfied. What had changed? There were many possible factors — from what I had eaten for lunch to the traffic my patients had fought on their journey in — but one difference stood out in my mind: DNKs.

…I began to suspect that the reason I felt I was a good doctor was largely the result of my two DNKs. DNKs create time.

She goes on to discuss the techniques her preceptor teaches to “make a 10-minute visit feel like a 60-minute visit.” Even though this doctor is merely a second-year house officer, she is not fooled:

Either I am not skilled enough to make 10 minutes be 60 minutes, or there is something real about clock time. I suspect it's the latter.

The real question, one that Mackie eventually touches: why would anyone consider a 10 minute visit adequate? No physician, no matter how experienced, can take any sort of history, do a meaningful exam, and provide treatment and advice in 10 minutes! When I started at my current institution, we scheduled 20 minute return appointments in our Pediatric Nephrology clinics. By the third appointment, we were late. Parents and children were cranky. Hell, I was cranky. We saw everyone, and eventually gave them the time they needed. But the schedule was, frankly, more of an ordered list than time slots.

We changed our return patients to 30 minute slots, extending the clinic day (on paper) by a bit. We marked charts with special considerations. Non-English speaking needing a translator? Anxious mom who will want to talk about everything at least twice? Child accompanied by a biological parent and foster parents? Longer slot or, even better, the final slot- when only my staff and I will  be inconvenienced. There are still days when the proverbial shit happens and we get delayed, but they are few and far between. We still see the same number of patients, generating the same revenue, but we do it much closer to the scheduled time. We all feel better!

Of course, I am in a subspecialty in an academic medical center. I am not in the position of running a private practice. Susan Mackie envisions her future in primary care:

Enthusiastically, and perhaps naively, I have mentioned to my mentors that I look forward to a future in which I will be able to share responsibilities with nurse practitioners and physician's assistants in such a way that my appointments with patients will be fewer, more thorough, and more satisfying for everyone involved. None of the experienced physicians I've talked to have confidently embraced this vision. Perhaps they have seen too many changes for the worse to believe that a change for the better is possible.

The problem with her vision? First, one has to generate sufficient income to cover all of the expenses for those NPs and PAs. Also, adding extenders may increase individual visit time with Patient X on a given date, but it means you are not seeing Patient Y. Many patients feel slighted if they do not see the doctor. And if you just stick your head in the door after an extender does the real visit, well, we are back to the 10 minute paradigm.

Like Dr. Mackie, I have no solution. The economics of current reimbursement policies mandate a certain number of visits each day to cover the costs of a business like a private practice. As patients become more complex, with more chronic diseases, these issues will only worsen. We keep expecting more for less in office practices; soon we will hit the wall.

In Harry Potter and the Prisoner of Azkaban, Hermione can manipulate time. Until we muggles can bend the laws of physics, we have to value the time a doctor needs with patients. 10 minutes can never be “the new hour.”

Image courtesy of