Golden Thoughts

Moving On

2010-08-02T07:30:00.000-07:00

So the first fork in the road is past; my new blog is WhizBang over on the all-new Scientopia Network. Check it out! And bookmark it.

The Fork in the Road

2010-07-30T15:10:00.001-07:00

Only rarely does a free photo service provide an image as perfect as the one shown.

My life lately has presented a whole drawer of silverware in the middle of the road. I find myself contemplating a choice of paths almost daily.

Taking one or the other is mutually exclusive. The wrong choice may lead to the wrong destination. It may be an express route, or it could be a long, tiresome detour.

I keep telling myself that life is a journey, not a destination.

Some of these choices belong to me alone. Others involve my family. Some are completely out of my control.

Over the coming months a number of these choices will be revealed. Monday, August 2, the first choice becomes public. I hope you will stroll with me a bit along this new road.

Enjoy the weekend. More to come soon!

Image courtesy of PhotoXpress.

Daughter of Shoe-fari

2010-07-28T05:00:00.000-07:00

Today’s post provides a happier note, a wearable yet attractive item for the foot:

Queen by Moda Spana costs $49.95 at DSW. Its 3-inch heel provides a modest bit of lift, and the wrap-across-the-forefoot leaves a peep-toe and a D’Orsay effect on the instep. These beauties are elegant yet practical for most of my workdays.

They come in the metallic shown and in black.

I promise I will post something besides shoes later this week, but I have to admit this Shoe-fari has been a load of fun!

Shoe-fari: A Pair Not Worth The Ammo

2010-07-27T03:00:00.000-07:00

I don’t get peep-toe boots. Being from the midwest, boots are for cold, slushy weather. Leaving the toe open defeats their general purpose.

Add an ugly design that resembles nothing more than a neutral bowling shoe with a heel, and you have something not worth my hard-earned cash. Maybe someone out there can explain the appeal of the Buren to me ($139 at Nine West).

Because I really don’t get it.

More Shoe-fari: Wild Bargain Edition

2010-07-26T01:30:00.000-07:00

Today we stalk the great cats, but not just any cougar. No, today we find something closer to a snow leopard:

Embry 2, shown in white leopard, features printed pony hair with leather trim and soles. Its original price was $198, but you can now snatch these up from the Via Spiga shop for $79.

Makes me want to purrrrrrrrr.

Shoe-fari 2010 Part 3

2010-07-25T04:00:00.000-07:00

We continue our footwear adventures with a trip to DSW, my personal favorite store, and one of my favorite brands, Steve Madden.

As I mentioned with Friday’s selection, I have a desire to feel tough, wicked, even bad-ass right now. Friday’s shoe took that desire over the top; today’s version reflects a more subtle take. Kallie ($59.95 at DSW online) restricts the studs to a small platform. This caramel brown version looks more “I mean business” than “I’m going to hurt you.”

As the new fall fashions hit the magazines, I will share more of my finds during Shoe-Fari 2010.

Shoe-fari Continues!

2010-07-24T10:37:00.001-07:00

This weekend the Nebraska State Legion Baseball Tournament is in full swing. In turn, this means heat and humidity and catching rays in the bleachers. For your consideration, I present the following shoe:

http://www.zappos.com/product/7660830/color/1394Nieti, by Donald J. Pliner, costs $235 at Zappos. These Italian beauties rock several trends that work now and into autumn, including statement hardware and, for the Ocean colored ones shown, bright sandals. When temperatures drop, these will slip over a pair of black tights.

I have to go to a baseball game now, but I’m dreaming of heels even though I’m wearing Fit-Flops!

Shoe-fari for the #sbFAIL Diaspora

2010-07-23T11:41:00.001-07:00

As you may have heard, ScienceBlogs had some issues last week. Bloggers have been changing sites faster than I can edit my links. We have finally heard from the pseudonymous goddess who got me hooked, Isis the Scientist:

So, after the events of the last couple weeks, what is the reality of Isis the Scientist?
I've had a lot to consider. But, after speaking with Adam Bly today, I get the impression that he is still passionate about trying to continue this conversation and I believe that he is engaging with us, the folks who provide content to the site, in good faith. I think he is vested in seeing this enterprise succeed and in working together collaboratively. I can only take him at his word, and so On Becoming a Domestic and Laboratory Goddess will remain at Scienceblogs. Here, I'll continue to blog about the practice of being a woman in science. After all, science is culture and all that. If some of the ideas discussed today with the powers that be come to fruition, this could still be a groundbreaking place to watch.

Just as I have felt the need to have two creative outlets, the goddess has chosen a similar path. However, she still hasn’t blogged any shoes for a couple of weeks. (I know she has been distracted by pepsigate and shitbubbles and all…)

Today I am feeling particularly bad-ass, so I offer these to my online community:

Lorissa, by Sam Edelman, sells for #200.95 at Zappos. They also come in white. My husband would absolutely FREAK about what those studs could do to the carpet floor mats in my car. But they do look tough. Think what you could do to someone with a backward kick! Hmmmm. Maybe my daughter needs a pair…

Shameless Self Promotion

2010-07-22T10:47:00.001-07:00

So today I posted over on pascalelane.net about a study that just started up, Open Notes. A perspective on this experiment, based on interviews with participating physicians and patients, is published in the current Annals of Internal Medicine.

So click on over and tell me what you think. Should patients have unfettered access to their clinic visit notes?

Image courtesy of PhotoXpress.

Seeing the Opportunity in Human Execution

2010-07-21T11:11:00.001-07:00

The current issue (16 July) of Science includes an article on mutations that protect from sleeping sickness but promote kidney disease in people of African descent. As a nephrologist, I know this is a BIG STORY. Several press releases have made their way to my editorial in-box about this cool and significant genetic-association study.

I am going to blog about something else in the issue (full article here).

Anatomy sometimes seems like the poor stepchild of the medical school. You have to keep it around, but it lacks the sexy research found in biochemistry or cell biology. When medical schools combine departments to save resources, anatomy often goes under the axe.

Turns out, a lot of what we know about anatomy may be ethically tainted. In the early 20th century, Germany and Austria produced some of the world’s finest scientists in many disciplines (rocket science, anyone?). As the Nazis rose to power, anatomists developed arrangements with executioners to obtain cadavers for dissection, instruction, and research.

In 1938, senior anatomists at the University of Vienna beganan unusual arrangement: They worked closely with local Naziofficials to obtain corpses for teaching and research, receivingthe bodies of prisoners shot in the Gestapo rifle range or guillotinedin Vienna's assize court building. So many corpses were transferredthat Viennese authorities ran a special streetcar, dubbed the"Death Transport," between the court and the medical schoolin the early morning. If the medical school morgue was full,court officials postponed the executions. Viennese physicianssecured at least 1337 bodies of Nazi victims this way, accordingto a report issued by the University of Vienna in 1998.

I have emphasized that one sentence because this degree of coordination between executioners and medical schools amazes me, even given the atrocities of the era.

The article goes on to describe other ethical breakdowns during the Nazi years, including studies by Hermann Stieve on the effect of stress (scheduling of one’s execution) on ovulation and menstruation:

He sent an assistant to Plötzensee to obtainfrom prison doctors the women's medical histories, as well asdata on their menstrual cycles and reactions to the announcementof their execution date. He also persuaded Plötzensee'sdirector to continue conducting executions in the morning, despitethe daylight air attacks in Berlin, so tissue samples couldbe processed the day of the execution.

A sidebar article discusses Pernkopf’s Atlas, considered by many the gold standard of anatomical illustration; however, Pernkopf and his artists were avid Nazis. Many of these dissections and illustrations came from the executions described above.

Should we still use these illustrations given their tainted past?

I say no. The examples shown are gorgeous, no doubt, but I managed to learn enough anatomy to practice medicine via other sources. Today, Amazon lists 41,906 results when I searched “anatomy” in their books section. We can live without Pernkopf.

I encourage everyone to read the original articles by Heather Pringle, author of The Master Plan: Himmler’s Scholars and the Holocaust (2005).

What are you waiting for? Click those links and READ!

World’s. Toughest. Pedicure. Period.

2010-07-20T02:00:00.000-07:00

Please forgive the photo of my toes, but I had to demonstrate the power of the Axxium pedicure. I had this UV-light-cured gel pedicure done 4 weeks ago today. My nails have grown out, so I will get it re-done this week, but THERE ARE NO CHIPS. I have worn nothing but sandals since having this done, and I was at Walt Disney World on vacation for one of those weeks.

My toes above sport Cajun Shrimp. I haven’t decided where to go next; probably a deep purple-y color.

I tried a manicure which lasted a whole week. Unfortunately, I accidently cut into the polish on a sharp edge while I was doing some kitchen work. Removing this stuff is, well, a bitch. I may keep doing my hands with traditional polish most of the time, and save this procedure for travel.

Joys of Parenting

2010-07-19T08:34:00.001-07:00

Being a mom is never boring, although sometimes I could use a bit less excitement. Even now, with my “baby” scouting out universities for 2011, he can still provide moments that remind me not to take anything too seriously.

Last week I was up to my eyeballs in clinic patients when I realized I had not turned the ringer off on my BlackBerry. I realized this because it was ringing, of course, and my son was calling. Tim is a texter, not a caller, so I answered. If he wanted verbal communication, fire or massive blood loss was probably in progress. The conversation went something like this:

Tim: “ Mom, I have a hypothetical question.”

Me: “OK. Make it quick. I am working.”

T: “Suppose someone cut off my left sideburn. How can I make it look even with the right one?”

M: “Well, I would cut off the right one even with the left. And what do you mean by ‘hypothetical?’”

T: “OK, so technically this isn’t a hypothetical question. Is there anything else I could try besides cutting off the right one?”

M: “Who the hell is cutting your hair?”

T: “A friend. She, I mean he or she, forgot to put the guard on after cleaning out the clippers and whacked off the sideburn accidently.”

M: “Look, I think you will have to cut the other one off even and let them grow back. Maybe you should go to the barber and get it done. I have patients to see. Talk to you later.”

T: “OK. Bye, Mom.”

About 30 minutes later he shared his solution with me:

I took the guard off and buzzed my head. I am officially bald.

He also posted the “officially bald” part on his facebook wall. I knew it must be true.

Of course, we have to get senior photos done soon. His father felt doing this just before their college tours may not have been his best idea. I’m hoping they will assume he had chemo recently and come up with more scholarships, but I have always been a dreamer.

It’s only hair. It will grow back. And I have had a great story to share.

Image courtesy of PhotoXpress.

Sweating It Out

2010-07-18T19:40:00.001-07:00

At left is an artistic rendition of how I spent most of my weekend. See, my son’s American Legion Baseball team, the Deeb Mustangs, lost their first game. They then proceeded through the loser’s bracket, in significant heat, to face another team for the regional/area championship tomorrow.

I have spent much of my weekend hot and sweaty. Not in a good way. Not in a bloggy way.

Tonight, I finally finished a post over at Stream of Thought. I really had planned to do something else here at Golden Thoughts, but I don’t have the energy right now.

Tomorrow night we play a much-favored team at 5pm. If we win that game, we have to beat them again at 8 to win the tournament. No promises for tomorrow, but I will share more Golden Thoughts this week.

Image courtesy of PhotoXpress.

Kidneys Down Under

2010-07-15T03:00:00.000-07:00

Yesterday I got distracted here by a bit of nonsense from a member of the Tea Party. I did end up reviewing the IDEAL trial over at my serious, professional blog, Stream of Thought.

The IDEAL trial (Initiating Dialysis Early and Late) is a prospective randomized trial of initiating dialysis in adults early (eGFR 10-15 mL/min) and late (5-7 mL/min). It’s also an Australia and New Zealand study, so I get to use this cool satellite image (click it to see its full-screen glory).

While the study reveals no advantage (or disadvantage) to early initiation of dialysis, only 102 of the 424 patients assigned to the late-start group made it to the target range of eGFR. Yup, 76% of patients started dialysis before planned, presumably because of uremic symptoms. And no analysis of these 102 patients who really waited late is presented.

Click on over to the full post.

And enjoy that cool image.

Distracted By So Much Wrong

2010-07-14T06:59:00.001-07:00

I planned to discuss a recent study publication today.

I also considered some sort of tribute to Bastille day. When your dad’s a French historian (who gives you a French name), you grow up celebrating such things.

Then I heard something on the radio. The National Association for the Advancement of Colored People (NAACP) passed a resolution calling for the Tea Party movement to expel the racists and bigots in its midst or take responsibility for them.

I am sure we all remember the signs at the demonstrations, and the slurs yelled at people of color, in particular African-American members of congress and President Obama.

The Tea Party response requires some attention:

"I don't recall the NAACP speaking out when George Bush was portrayed as curious George or as the Joker," said Mark Williams, a national spokesman for the Tea Party Express.

I really don’t see that these were racial slurs against George W. Bush. If they somehow disrespect caucasians, I would greatly appreciate an explanation. I thought these characterizations questioned his intelligence and motives, both fair-game for public figures. Unfortunately, Williams goes on to say even more:

"You're dealing with people who are professional race baiters, who make a very good living off this kind of thing. They make more money off of race than any slave trader ever. It's time groups like the NAACP went to the trash heap of history where they belong with all the other vile racist groups that emerged in our history,"

The NAACP is a vile racist group making big bucks?

Nowhere in the response does Williams address the overtly bigoted nature of some Tea Party demonstrators. He never describes their activities as unfortunate or a small minority, nor does he try to deny their existence. Instead, he attacks the NAACP and their lack of response to someone comparing Dubya to the Joker.

You could get the feeling that he condones the sort of behavior the NAACP protests. But I am sure that interpretation makes me some sort of vile racist.

Read/listen to the entire NPR story.

Teacup courtesy of PhotoXpress.

I’m Too Old For This Now

2010-07-13T19:54:00.001-07:00

Today brought many good things.

YouTube removed the offending still shot from my iGoogle page.
Clinic finished early.
One of my patients was waiting for a possible transplant when I left.

The latter, unfortunately, led to a multitude of pages overnight, leaving me a bit sleep-deprived. I used to be able to stay up 36 hours straight without a problem, back when I was a resident and a new mom. Now, not so much.
The All-Star game is not helping, either. More appears to be happening than in a World Cup match, but not much more.
I am ready to lie back and relax. I will opt out of the flowers in the hair, though. They just seem like too much work.
So goodnight, all. I read an article to blog today, but I just cannot do it justice right now.
Sweet dreams.

Image courtesy of PhotoXpress.

OH NO, MY EYES…

2010-07-12T07:50:00.001-07:00

For the last 48 hours, every time I pull up the internet, the YouTube gadget on my iGoogle home page has featured the following image from some World Cup video:

I really wish this would go away now, since yesterday is impossible.

Now, I have to go see patients. I hope something on rounds can remove this image from my retinas.

The Big FAIL

2010-07-09T12:59:00.001-07:00

For those of you in the real world, you may not have noticed when the proverbial shit hit the fan at ScienceBlogs last week. Being on vacation, I discovered the controversy a few days late myself, when the flotsam and jetsam started hitting my twitter feed (#sbFAIL if you want to search for comments there).

ScienceBlogs, a subsidiary of SEED Media Group, provides an aggregation of 80 bloggers interested in science and associated issues: working in academia, women in science, science-based medicine, and assorted other topics. I follow a number of blogs there regularly and link to them in the blogroll in the right column.

Some of them may be changing their blog sites soon.

ScienceBlogs provided what I believed was an ideal model of an online “magazine.” Bloggers provided independent content that was fresh, interesting, and (sometimes) controversial. By virtue of the traffic this collection of individuals attracted, ScienceBlogs could get advertising to support the site and its authors. Many of these authors write under pseudonyms [can you call it a pen name in this digital age?], so they could have bias or conflicts of interest we know nothing about. Others could be Googled so we could know their issues. I mean, Google sees everything.

Seems a new blog popped up recently in the health and medicine channels. Food Frontiers turned out to be a paid blog; not ScienceBlogs paying the blogger, but Pepsico paying to post material on the site. Food Frontiers departed abruptly from the ScienceBlogs model. Many bloggers felt it compromised the reputation they had worked so hard to build for themselves and for their site.

Many of them fled.

Some of the Sciblings (what the ScienceBloggers call themselves) wrote about the whole mess. One of my favorites was posted by Abel Pharmboy who addressed the way the whole episode could have been approached without the ensuing failure.

And failure is the only word strong enough for this fiasco. The offending blog has now been removed from ScienceBlogs (although it still lives on at the Pepsi website). Stories started circulating about behind-the-scenes issues and complaints (poor technical support and late payments), including other ethical problems with SEED magazine, the parent company. It seems the wall between advertising and content never was particularly strong. As a magazine editor myself, I know the pains we take to keep editorial control isolated from those who sell the ads. SEED allowed those barriers to break on several occasions.

I thought about presenting the ScienceBlogs model to groups to convince them to become blog aggregators. Go out on the web, find the bloggers writing about your area, and invite them to post at your site. The group can generate enough traffic to interest advertisers. Now, I would be hesitant to present ScienceBlogs as anything but a warning to others.

Once your reputation goes down the toilet, it can be almost impossible to scrape it out of the sewer.

I had once applied to write at ScienceBlogs, but they never invited me into their fold. And now I’m pretty glad about that. Could this bias what I’m writing today? Yes- but I’m telling you that. Blogger transparency in practice here.

There is still an air of chaos among the Sciblings, especially those whose choice to stay or go has not yet been made. One thing is for sure: ScienceBlogs is irrevocably changed by this episode. And probably not for the better.

Exit sign image courtesy of PhotoXpress.

HUS and The Good Life

2010-07-08T09:58:00.001-07:00

Today I posted my first disease-specific piece over at Stream of Thought. This post addresses hemolytic uremic syndrome:

Hemolytic uremic syndrome (HUS) flourishes in the summer, for reasons we do not understand. This common cause of acute kidney injury in children also demonstrates geographic hot-spots, and the disorder can reach epidemic rates in July and August.

Yes, Nebraska seems to be one of the hot-spots.

As promised, I am linking to my “professional” posts from the new site.

The new web site gives me a place to publish all sorts of information about my interests, including save-able/print-able PDF’s (no downloadable files here on Blogger/Blogspot).

So click on over and enjoy. Oh, and let me know if you have any thoughts for topics or for the website.

Half a Century Later

2010-07-07T12:00:00.000-07:00

During my morning ablutions, I listened to my local NPR station per my usual routine (and yes, I am a member of KIOS). Lynn Neary reported on the 50th anniversary of publication of a favorite book, To Kill A Mockingbird:

Fifty years ago, Harper Lee had the kind of success that most writers only dream about: Shortly after her novel, To Kill a Mockingbird, was published on July 11, 1960, it hit the best-seller lists. In 1961, it won a Pulitzer Prize, and in 1962, it was made into an Academy Award-winning film. It has never gone out of print.

Reading this book is a rite of passage for most adolescents in the US. Mary McDonagh Murphy interviewed writers, journalists, historians, and artists to collect their impressions in her book, Scout, Atticus & Boo. The NPR story also includes thoughts from students who recently read the book.

Many women identify with feisty Scout. My spouse sees Atticus, especially in Gregory Peck’s movie portrayal, as the ideal father. In the NPR story, Joanne Gabbin, a professor of English at James Madison University in Virginia, saw her own father and grandfather mirrored in another character:

In Tom Robinson, the African-American man unjustly accused of rape, she saw not a victim, but a hero. He reminded her of her father and grandfather — African-American men who put up with untold humiliation in order to take care of their families.

To Kill A Mockingbird touches so many people in so many ways. For me, it illustrates the power of stories. Statistics may demonstrate racism or sexism or poverty other iniquities, but even with glitzy animated graphics they cannot enthrall us as plot and people do. Stories may be fictional, like To Kill A Mockingbird, or completely true, like The Immortal Life of Henrietta Lacks. In either of these cases, the way we come to know the characters and care about them (even if we hate them) helps the lessons stick.

Beautiful, poetic prose helps as well. NPR includes an excerpt from the book. My own favorite image arises when Scout describes grown ladies dealing with the heat of an Alabama summer. They add layers of talcum powder throughout the day, so by nightfall they resemble a frosted pastry. I am paraphrasing, but that picture embedded in my brain over 30 years ago. Every summer it flits through my neurons again during hot spells.

To Kill A Mockingbird hit bookstores a year before my birth. By the time I read it, much had changed in race relations and our attitudes toward mental illness. We still have progress ahead, since iniquities still plague the world.

But I have faith in the power of stories to help us mend our ways.
Click on the images above to see their source.

Random Thoughts On The World Walt Built

2010-07-06T11:12:00.001-07:00

The Lane family vacation ended yesterday, with relatively uneventful flights back to Omaha. Today I am back at work, reviewing my data that no trip goes unpunished. I am still rejecting the null hypothesis on this one…

Our sojourn began 12 days ago with the husband and I attending the scientific sessions of the American Diabetes Association. We then moved to Walt Disney World for 6 days of complete escapism.

The parks were not without dangers. Oh, the fierce beasts in Animal Kingdom remained safely out of reach. No one fell out of rides. No food poisoning either. No, the main danger in theme parks is…

strollers.

Parents with a child in a stroller (or even pushing the thing empty) seem compelled to use it as a plow in the parks.

We were that couple once. We lugged our son around Walt Disney World when he was 2 years old. He spent, perhaps, 30% of his time in it. Our next trip, when he was 4, did not require the device. He felt “too big” to need a stroller; he could walk!

Last week, I saw kids in strollers who must have been 7 or 8 years of age. Seriously, these children were lapping over the sides of the strollers. Kids that age should be walking! If they are too tired, you need to rest them or leave the park! If they cannot walk for medical reasons, they need a different sort of conveyance that fits them.

Or you just want to use the damn stroller as a weapon.

I wish Magic Kingdom had a special attraction. One you were invited into after super-secret personnel saw a stroller ram your legs or knock your elderly mom down (again). You could enter an area with other adults and beat old strollers into oblivion with baseball bats.

Now that would be magical.

Image courtesy of PhotoXpress.

Unfaithful?

2010-06-28T18:46:00.001-07:00

I have a confession.I have been seeking satisfaction elsewhere.

No, nothing like that.

See, for a variety of reasons, I started another blog. It can be accessed from my website, pascalelane.net, or via pascalelane.wordpress.com. Stream of Thought, as I’m calling it, will focus on professional material such as healthcare and diseases. A lot of posts will be geared toward parents and children with kidney disease. See links to my current posts below:

The Biomedical Fair

From Orlando: Improving Your Child’s Future Health

Golden Thoughts will remain for another audience. Humor, wardrobe advice, and other topics near and dear to my heart will have this venue for discussion.

For a few days I will be spending time with my family and not posting at either location. Don’t worry- I’m not fooling around with a third blog.

Tee-Hee-Hee: Bp Edition

2010-06-26T07:18:00.001-07:00

Had to crop it to fit my layout, but the essentials remain. Click the image for the full strip.

Up, Up, and Away

2010-06-24T06:00:00.000-07:00

Today I venture to Orlando for the annual Diabetes Meetings. For the next few days communication will be erratic as one thing or another catches my fancy.
Today involves multiple airports. Rest assured that I am efficiently packed with an exquisite collection of appropriate warm-weather meeting clothes. And lovely shoes.
I wonder what Mickey’s background strain could be? C57 Black?

Things You Can Learn Online: TSA Edition

2010-06-23T13:33:00.001-07:00

Tomorrow I fly again, through the hot muggy skies of Omaha to the hot muggy world of Orlando. As I wait for my flip video camera to upload, I trolled through the TSA site. Omaha’s airport now has one of those fancy imagers. I don’t think it’s on the set of gates I use, but it could be.

So here are potential images from these machines as stolen acquired from TSA:

Images above used backscatter technology; the ones below were generated with millimeter wave:

The images cannot be seen at the screening checkpoint, only at a remote site.

I also learned that my netbook may be screened in its case:

Electronics: Electronics the size of a standard laptop or larger, such as game consoles and full-size DVD players, and video cameras that use video cassettes must be removed from their carrying cases and submitted separately for X-ray screening. Smaller electronics such as e-readers, netbooks and iPads typically do not need to be removed from carry-on baggage for screening.

I have always removed my netbook from the case for screening, but not my Kindle, phone, or iPod. I’m not really clear on why a netbook or iPad can be screened through a layer of neoprene, but a 13” laptop cannot.

My download is almost complete. That’s my cue to go home and pack!

Goodbye, Johnny! You Will Be Missed.

2010-06-22T11:13:00.001-07:00

Help! Fearsome Frogs have invaded Omaha!

Once again it is College World Series, Omaha’s annual block party. Last night I saw the TCU Horned Frogs succumb to the Bruins of UCLA. Once the sun set, the evening breeze cooled us in a pleasant way. The evening was lovely, yet bittersweet.

This was the final CWS game that I will see in Rosenblatt Stadium.

The Johnny, as locals call it, hosts its 61st and final CWS this year. The facility is showing its age (aren’t we all?), and it would be nice to see the field of play from the concession area, as in most modern ballparks.

Johnny Rosenblatt was an athlete and local businessman and political figure who brought the CWS to Omaha:

Johnny Rosenblatt (1907-1979) whose name graces this ballpark, played amateur, semipro, and professional baseball before entering a life of public service. He located this hilltop site and pushed for its construction. It opened in 1948, and two years later, attracted the NCAA College World Series. Rosenblatt Stadium has won the hearts of those who have attended the College World Series.
Johnny, ebullient and upbeat, served as mayor of Omaha from 1954 to 1961, but was stricken with Parkinson's Disease in the prime of life. Omaha's Rosenblatt Stadium, also home to the Omaha Royals, has carried his name since 1964. Thanks to the dedication of the city of Omaha and countless benefactors, the stadium has evolved into a representation of what college baseball is all about -- teamwork, dedication and camaraderie.

More about the stadium and its history can be found on the CWS website.

Lots of traditions do not make the cut for the NCAA’s history. Every game, the general admission folks begin to chant “Right Field Sucks” and “Left Field Sucks.” Back and forth the verbal volleys fly, often for an entire inning. Contraband, highly illicit beach balls bounce throughout the stadium, although primarily in these outfield “cheap seats.” Last night, in addition to the occasional ball ponging about, left field got organized in this misdemeanor activity. They managed to keep about 40 inflated beach balls (and one inflated whale) hidden until the middle of the fifth inning. At that point zombie beach balls attacked. THEY WERE EVERYWHERE. Security and ushers rushed to remove errant balls from the field and delayed the game to expell at least two purported masterminds. Frankly, I found it delightful! To organize this crowd of strangers into an inflatable-toy flash mob required an impressive skill set, especially given the amount of beer some had consumer prior to entering the stadium.

A few years back, I bought tickets to the finals at a charity auction. My son, then in middle school, and I were in town without sister or father, daughter or husband. We attended every minute of the 3 game final series, including one which required 45 minutes huddling in the concourse during a thunderstorm. The temperature, about 95 when we entered the Johnny, dropped to 70. The souvenir shop sold out of sweatshirts in about 10 minutes. I did not rush to leave, even though I had to work the next morning. We stayed so he could see the victory dog-pile when the Oregon State Beavers claimed their title. My dedication to baseball during that series impressed my son, possibly more than anything I have else I have done.

I understand the shortcomings of Rosenblatt. The CWS deserves a shiny new facility, although I wish it would still bear the name of the man who brought this event to Omaha, rather than the corporation who paid for naming rights. They can move the “Road to Omaha” statue there, but it won’t be the same.

Goodbye, Johnny. I’ll always love you.

From Sex and the City to Animal Farm: Voices of Women

2010-06-18T15:05:00.000-07:00

This week brought aggravation. Not just the I’m-on-call-and-everybody-wants-a-piece-of-me-now stuff, but a lot of committee meetings. As I sat through these “events” I felt angry.
I am not opposed to what we were discussing; much of it makes a lot of sense. So why did I want to shout “No,” and do a Diva-stomp out of the room?
I finally figured it out. For several years I have wanted to make our section better, starting with another faculty member. A salary line received approval a few years back, but we were not allowed to recruit. Even when we confirmed increases in our patient volumes, we were told to wait, to be patient, to be team players. For years our opinions and desires have been ignored or minimized.
Now, a lot of other people are telling us what we must do. They don’t necessarily listen to our input, even when it might be in a patient’s best interest. They have their own agenda, and if we are in the way, well, too damn bad.
We have lost our voice. This theme recurred throughout Sex and the City 2: Miranda’s new boss, Carrie’s bad book review, and the veiled women of the middle east. All literally or symbolically suffered a blockade of their mouths.
I wonder if this could have anything to do with the composition of our section; after all, we are two women. Would a group of men be this disenfranchised? Ever?
In Animal Farm, society initially regulates itself by the Seven Commandments, summarized as all animals are equal. By the end of the book, the powers in charge have changed the most important commandment:

All animals are equal, but some animals are more equal than others

Yup, I know how they feel. My section, my specialty is definitely less equal these days.
And it’s damn irritating. Maybe I should practice my Diva-stomp.

Sorry I Have Not Written

2010-06-17T18:21:00.001-07:00

Change is the only constant.

The week proved more interesting than I hoped. Anger and irritation dominated my thoughts the past couple of days, gnawing through my best intentions.

While such a situation can produce much blog fodder, a coherent post requires more self-indulgent rumination about, well, everything. I need a few days removed, a bit more perspective.

In other words, what I thought about writing… I’m not. At least not today.

My online life will be undergoing reorganization soon. Don’t worry; I will still spew Golden Thoughts.

So stay tuned; the best may be yet to come.

Image courtesy of PhotoXpress.

Ethical Doctor Blogging

2010-06-15T13:17:00.001-07:00

PalMD (of the White Coat Underground) tweeted a link to a 2008 post calling for a code of ethics for MD blogging. A study under review showed:

17% of the blogs include enough information for patients to identify themselves or their physicians

I occasionally blog stuff inspired by my patients. I never worry that they will identify me- if they don’t, I would be really worried! I use my real name and image, after all.

Most of the time I am blogging a condition, such as volume overload or neonatal hypertension. While these posts may have been inspired by one or more in my care, the posts reviewed the conditions; no patient data of any sort were shared!

Could my patients identify themselves from my posts? A number of parents of hypertensive neonates probably believe their child inspired me to put fingertips to keyboard, but they cannot tell from that post. Only one post comes to mind in which the patient concerned would know for sure it came about because of him: the post on Page kidneys. Given the date of the post, the few vague items presented, and the fact that this patient knows he has the honor of being the first and only patient I have treated for this condition, he would figure it out.

I do not feel this post is unethical. Only someone who knows this person’s diagnosis and that I am his doctor can identify the patient. If they already know that much about him, they will learn nothing new from the post! The pathophysiology of Page kidneys, not the patient, remains the focus of the blog.

I ~~would never~~ try not to moan about inappropriate or inconvenient patients in a public forum. All physicians have “war stories” that we share; this blog is not the time or place. Occasionally I write about colleagues when either (1)I do not care if they read it and know it is about them; or (2) I have no clue who it is. Either way, no ethical issues apply. These situations are like complaining about jerks in traffic.

I have to go see a patient now. I am not going to say who, where, or what, though. And this kid will never know s/he inspired my closing today!

Image above is my daughter about 20 years ago. No patients were compromised in the creation of this post.

Saturday Night at the Movies

2010-06-14T10:21:00.001-07:00

Over the weekend I finally saw Sex and the City II. Clearly, this flick targets me, a huge fan of the original show. The movie also touched on issues discussed in the blogosphere last week.
Charlotte, at the end of the first movie, held her newborn daughter. Rose has now moved into the “terrible twos,” and Charlotte is overwhelmed, even with a full-time nanny. The nanny, a young hot Irish woman, eschews certain items of lingerie; she becomes “Erin Go Braless,” as a result. When first we meet Ms. Erin, Samantha suggests Charlotte should keep an eye on her husband around the nanny.

Between Rose, who cries and fusses constantly, and Lily, her adopted daughter, Charlotte has her hands full (although why she tries to ice cupcakes in a cream-colored vintage Valentino pencil skirt is beyond my understanding). After the action moves to a luxury resort in the middle east, Charlotte and Miranda, the other mother in the group, commiserate about raising kids. Charlotte’s big confession? When Samantha said something about her husband and the nanny, her first thought was, “Oh my god, we can’t lose the nanny!” Remember, Charlotte stays at home with the children and has full-time help.
These mothers have not forgotten that they are wealthy and have excellent support. Their assets do not keep them from feeling overwhelmed by caring for their offspring! They cannot figure out how women do it without their resources – and finally they drink a toast to those moms.
Miranda finds herself “between jobs” at this point in the movie. She makes another confession in this scene. Although she loves her son more than anything in the whole world, she misses working. She is a lawyer, and she wants to retain her sense of herself. Motherhood and her career are both parts of her, and neither should be excluded from her life.
I remember when my son was born; he also fussed a lot, and he slept no more than 2 hours at a stretch for the first 3 months of his life. I sent his older sister to daycare (we had to pay for it to keep her spot), even though I was on leave. I do not know how all of us would have survived if I had her at home, waking me up every time I finally got Tim to doze.
Later that night, I toasted all those moms who raise kids without my resources- I don't know how they do it!
My 22-year-old daughter accompanied me to the movie; she turned to me as the lights came up and said that it was worth every minute and every penny we spent on it. “And I know you have blog ideas for the next week or so.”
Yup. Stay tuned.
Click on photos to see on original sites.

Guess This Lesson Didn’t Stick

2010-06-12T09:57:00.001-07:00

My friend, Dr. Isis, raised some hell over on ScienceBlogs last night, suggesting that – gasp – men ~~may need to~~ should do their fair share of the housework! It may be Mr. Clean, but we can tell who really uses those products- I know that this concept is still a a pipe dream for most women; I am, after all, the person who arranges the home appliance repairs, the housekeeper, the veterinarian, and the sports physicals (even, sometimes, when I am in a different time zone from my spouse).
The post did tickle some synapses and bring a poem from Free to Be You and Me to mind. Below, I present Housework, originally read by Carol Channing. Lyrics here were shamelessly cut and pasted from LyricsZoo.

Housework

You know, there are times when we happen to be
Just sitting there, quietly watching TV,
When the program we're watching will stop for a while
And suddenly someone appears with a smile,
And starts to show us how terribly urgent
It is to buy some brand of detergent,
Or soap or cleanser or cleaner or powder or paste or wax or bleach,
To help with the housework.
Now, most of the time it's a lady we see,
Who's doing the housework on TV.
She's cheerfully scouring a skillet or two,
Or she's polishing pots till they gleam like new,
Or she's scrubbing the tub or she's mopping the floors,
Or she's wiping the stains from the walls and the doors,
Or she's washing the windows, the dishes, the clothes,
Or waxing the furniture till it just glows,
Or cleaning the fridge or the stove or the sink,
With a light-hearted smile, and a friendly wink,
And she's doing her best to make us think
The her soap, or detergent or cleanser or cleaner or powder or paste or wax or bleach,
Is the best kind of soap, or detergent or cleanser or cleaner or powder or paste or wax or bleach,
That there is in the whole wide world.
And, maybe it is, and maybe it isn't,
And maybe it does what they say it will do,
But I'll tell you one thing I know is true.
The lady we see when we're watching TV,
The lady who smiles as she scours or scrubs or rubs or washes or wipes or mops or dusts or cleans,
Or whatever she does on our TV screens,
That lady is smiling because she's an actress,
And she's earning money for learning those speeches
That mention those wonderful soaps and detergents and cleansers and cleaners and powders and pastes and waxes and bleaches.
So, the very next time you happen to be
Just sitting there quietly watching TV,
And you see some nice lady who smiles
As she scours or scrubs or rubs or washes or wipes or mops or dusts or cleans,
Remember, nobody smiles doing housework but those ladies you see on TV.
Your mommy hates housework,
Your daddy hates housework,
I hate housework too.
And when you grow up, so will you.
Because even if the soap or cleanser or cleaner or powder or paste or wax or bleach
That you use is the very best one,
Housework is just no fun.
Children, when you have a house of your own,
Make sure, when there's house work to do,
That you don't have to do it alone.
Little boys, little girls, when you're big husbands and wives,
If you want all the days of your lives
To seem sunny as summer weather,
Make sure, when there's housework to do,
That you do it together!

Free to Be You and Me now has a 35th anniversary edition in print. I guess ~~some~~ many of its lessons didn’t get learned.

Have A Good Weekend

2010-06-11T14:25:00.001-07:00

I will be on call the next couple of days and may not take time to blog. After back-to-back business trips, a few piles of laundry call out for my attention as well. Oh, yeah, I have to work at a baseball game tonight and perform parental duties.

If you haven’t seen it yet, head on over to The Scholarly Kitchen for a 10 minute video on the power of time perspectives. The real-time drawing is cool on its own; the information presented raises the cool factor to ice!

What are you waiting for? Click the link already!

Image courtesy of PhotoXpress.

Why I Read Non Sequitur

2010-06-10T07:23:00.001-07:00

Can’t add much to this one. I certainly have no desire to return to the days when, as a woman, I was less than a person.

I just wish “non sequitur” were easier for me to spell!

From Cowboys to Equity: Children in Clinical Trials

2010-06-08T16:00:00.000-07:00

Today’s post presents the challenge of writing when beach and ocean lie just across a boulevard. Yours truly sat in a subterranean conference room all day, learning about a clinical trial protocol, while the paradise that is beachfront Fort Lauderdale beckoned. The tribulations I endure for my patients!
Events such as this were distinctly uncommon in years past. Today we will stroll through a brief history of pediatric clinical trials in the United States. After this walk in the woods of regulatory affairs, you will agree that my current endeavor amazes!

All about white males

For a long time, medical care and clinical experimentation had no regulation! Children were subjected to experimentation without consent or assent during this time, as were adults. The best history of the evolution of clinical research regulation can be found in The Immortal Life of Henrietta Lacks (which I previously reviewed). Over the years, the public demanded better protection for human research subjects; vulnerable populations, including women, children, prisoners, and the mentally incapacitated, presented special problems for enrollment. Women could become pregnant, resulting in an “adverse event” with a fetus, perhaps yielding death or life-long disability, a risk not many drug companies are willing to bear. Most children enjoy good health, so marketing chronic medications to them provides little financial benefit to a drug company (certainly not enough to justify study as required by regulatory bodies). Thus, through the 1970s, women and children had few studies performed, aside from drugs directed specifically to their group.
Ethnic and racial minorities presented other challenges (once again, see the HeLa book for more discussions; I can't imagine why you haven't read it yet, really). Investigators often excluded minorities because a large enough population could not be recruited in any study to make the confounding variables worth examination. So most clinical trials included only white men.
In 1983, the NIH adopted a policy requiring inclusion of women and minorities in clinical research, particularly phase III clinical trials, a policy made law in 1993. You could still exclude women or minorities (for example, you would not include women in a prostate study), but you had to have a really good reason if you wanted federal funding. As a study section participant for the Veteran's Administration, I know many of their studies exclude women and children because they simply are not available in the VA population. Participating in research was redefined as an opportunity that could not be denied at the whim or convenience of an investigator.

What about kids?

Children took more time, in part because a paternalistic attitude seemed more appropriate to offspring. In the 1990s, some patent extensions became available for testing in pediatric age groups. The Pediatric Pharmacology Research Units (PPRU), 13 sites coordinated by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), proved that children could participate in pharmacologic research. Based on success with the PPRU, the NICHHD gained additional powers with the Best Pharmaceuticals for Children Act (BPCA), initially signed into law in 2002. Almost 2 years later, the Pediatric Research Equity Act became law, requiring pharmaceutical companies to provide timelines for pediatric testing or request a waiver or deferral if appropriate. [Note: if you search for PREA on Google, at least the first 2 pages of results are various Prudential Realty groups or the Prison Rape Elimination Act; spell it out if you search to learn more] Children could no longer be ignored because their market was small; pediatric use had to be considered by companies preparing new agents.
Congress amended the BPCA in 2007 to increase the scope of NICHD’s responsibilities. Specifically, the institute was granted power to identify gaps and needs in the pediatric therapeutic armamentarium and to target studies to those areas.
A flurry of studies in the 1990s (of drugs we already used) has proceeded to prospective planning of pediatric clinical trials, thus, my presence near the sandy shores of Fort Lauderdale.

How did we test drugs before?

About 1500 children develop chronic kidney disease in the US each year; obviously, this number does not provide a viable market for most drug companies to develop and test an agent. How did we get agents to treat these children before the present day?

A new drug would be approved for adults.
The pediatric nephrology “cowboys” would try it in bigger patients (you know- those early adapters who will try anything); if nothing bad happened, they would use it in smaller kids, especially if the pharmacy could cook up a liquid formulation.
Those of us with a bit more caution would have a patient where we really needed to use the drug; we would contact our “cowboy” friends to see what they had learned about dosing.
Eventually, enough of us would use it that it was generally accepted; someone might even publish dosing guidelines based on their empirical use.

We generally got away with this approach. Of course, a lot was learned through trial and error rather than really scientific study. Many drugs used once daily in adults must be given twice daily in kids. We don’t really know if this reflects less absorption, faster metabolism, or some of each, because we have no pharmacokinetic/pharmacodynamic data, just our clinical observations.

Testing now

The drug in the present study, aliskiren, directly inhibits the enzyme renin. It is the first drug in its class, and the pediatric studies have been prospectively planned. We used to believe that angiotensin II (AngII) was the only active component of the renin-angiotensin-aldosterone system. As shown below, we were wrong!
Various components of the system have their own receptors that may induce beneficial or detrimental effects. Our present agents inhibit ACE, preventing AngII formation, or block the AngII type 1 receptor. Both of these approaches increase renin via a feedback loop. We now know it has its own receptor, and elevated renin could produce fibrosis and hypertrophy, both detrimental to the kidney and other organs.
Aliskiren reduces renin and AngII. The current trial will examine its efficacy and safety in children with hypertension, but I foresee a role for this drug in many chronic kidney disease situations. It also cheers me to know that we are testing children with this agent as we should, even though the studies required are complex and expensive.
I’m sure some of my “cowboy” friends have already used this drug in their patients. I am happy to help provide data to do these studies the right way. Yes, a PHARMA company will make some bucks off of this effort; but we will have a novel therapeutic agent for children.

Image of children courtesy of PhotoXpress.com.

Image of renin-angiotensin system courtesy of Pamela Carmines, PhD.

Finally: Homeopathy for the Kidney!

2010-06-07T07:16:00.001-07:00

I am seriously considering a homeopathy web start-up.

See, a bunch of my friends have recently “passed” kidney stones. Really, “passed” is too gentle a term for what these small but mighty gravel bits inflict on their hosts.

Now, based on the composition of the stone and/or analysis of what a person excretes in their urine, we have a number of therapeutic options to prevent stone recurrence. But the mainstay of all therapy remains water. Lots and lots of water. The more water is in the urine, the less likely other molecules are to come together and rock on.

So, you take a stone (or, if you can’t get it when it passes, substitute a garden rock) and put it in your drinking water. The teensiest bit of it will then be in the water. Drink 3 or more quarts of this liquid each day, and your stone formation will decrease dramatically.

When I searched kidney stones and homeopathy earlier today, Google found more than 3 million sites. Most of these would love to separate you from your hard-earned cash. I have just given you an excellent, nephrologist-certified homeopathic kidney stone preventative FOR FREE.

If this tonic fails to prevent stones, please see your doctor. You may have a more serious disorder requiring different treatments. Don’t worry- they will continue to encourage this “natural” remedy (albeit without the stone or rock).

Image from Wikipedia Commons.

I Heart Word Clouds

2010-06-04T06:52:00.001-07:00

As a visual person, I love both written words and images. Books-on-CD will never cut it for me. Word Clouds make me smile. Wordle, my favorite word cloud site, will let you create clouds from any web site with an RSS feed.

Today’s image comes from the wisdom of Dr. Isis:I really thought other synonyms would trump “penis,” if nothing else from their inclusion in “cockweaseldouchemonkey,” athough that appears to be a single word. Enjoy!

Serving with Pride

2010-06-03T07:20:00.001-07:00

Once again I write my update from the Omaha Airport. Today I fly to Washington, DC, for a study section for the Veteran’s Administration research program. Physicians and scientists with appointments to a VA hospital can apply for grants to support research that betters the lives of veterans. Since veterans are generally people, much of this work will benefit everyone.

The process began several months ago with an email. I had finished a regular term on this study section last May, but they needed me again for the session tomorrow. Over the next couple of months I signed agreements about confidentiality, ethical conduct, and travel reimbursement. I then received a spreadsheet with information about who submitted a proposal and what it was about. Based on that information, I could declare a conflict if I had collaborated with someone on the grant. I could also indicate applications I really wanted to review and those that I did not wish to consider. About 2 months ago I received my assignments and the current scoring guidelines.

I generally read all of my applications through once for a general feel about them; you might be surprised how well this first impression correlates with the final score generated by the group! Then I read each in more detail and evaluate each of the following areas:

Significance: Does the study address an important problem? If not, then why should limited resources go to it?
Approach: Will the proposed experiments address the problem? Are they the best way to address the problem?
Innovation: Are the studies novel, or do they merely replicate earlier work?
Investigators: Are the investigators well-trained and capable of performing the experiments based on their prior accomplishments?
Environment: Does the VA Hospital and associated university have the facilities necessary to perform the studies?
Feasibility: Can this be done?
Overall Evaluation: Will the proposal lead to important new knowledge? Do its significance and strengths outweigh any identified weaknesses?
Ethical/Safety Issues: Could anyone be harmed by these studies? Have appropriate institutional oversight procedures been followed?

After writing up each of my assignments, I then assigned them a score from 1-5 using defined criteria. Three of us reviewed each proposal and posted our scores and critiques on line. On some of them, all three of us gave nearly the same score; others have a bit of spread that will have to be resolved when we discuss them face-to-face tomorrow.

Study sections can be inefficient and unfair, but thus far they are the best system we have for doling out limited funds. I am proud to participate.

I hope the people reviewing my current proposal today and/or tomorrow feel as positive as I do right now.

Piggybank image courtesy of PhotoXpress.

Holiday Quick-Post

2010-05-31T08:18:00.001-07:00

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.

Bacon Makes the World a Brighter Place

2010-05-28T12:40:00.001-07:00

This 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.

Like My Page, Please!

2010-05-27T11:01:00.001-07:00

We have a problem.

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 www.facebook.com/ASNKidneyNews, 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 (www.facebook.com/ASNKidneyNews), 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.

Keeping My Foot On The Gas Pedal

2010-05-25T14:46:00.001-07:00

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 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.

Neckwear Discrimination?

2010-05-24T08:00:00.000-07:00

Last week my husband and I travelled together. On the final day, we 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.

Seriously, 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.

Everyone, at All Times

2010-05-21T11:14:00.001-07:00

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.

Words of Wisdom from Danae

2010-05-20T08:20:00.001-07:00

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.

What I'm Reading

2010-05-15T19:13:00.000-07:00

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.

Maternal Remembrance

2010-05-14T13:34:00.001-07:00

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.

Journal Club: Is Saline Toxic?

2010-05-12T11:24:00.001-07:00

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 journal 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.

Excuses and Delays

2010-05-11T17:24:00.001-07:00

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 bouncer 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.

Culture Clashes and the AAP

2010-05-09T10:49:00.001-07:00

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.

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 thegenitalia of female infants, children, and adolescents, referredto as female genital mutilation or female genital cutting (FGC),persists primarily in Africa and among certain communities inthe Middle East and Asia. Immigrants in the United States fromareas in which FGC is common may have daughters who have undergonea ritual genital procedure or may request that such a procedurebe performed by a physician. The American Academy of Pediatricsbelieves that pediatricians and pediatric surgical specialistsshould 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 risksof physical or psychological harm, counsels its members notto perform such procedures, recommends that its members activelyseek to dissuade families from carrying out harmful forms ofFGC, and urges its members to provide patients and their parentswith compassionate education about the harms of FGC while remainingsensitive to the cultural and religious reasons that motivateparents to seek this procedure for their daughters.

Later in the discussion, issues of cultural sensitivity arise:

The American Academy of Pediatrics policy statement on newbornmale circumcision expresses respect for parental decision-makingand acknowledges the legitimacy of including cultural, religious,and ethnic traditions when making the choice of whether to surgicallyalter a male infant's genitals. Of course, parental decision-makingis not without limits, and pediatricians must always resistdecisions that are likely to cause harm to children. Most formsof FGC are decidedly harmful, and pediatricians should declineto perform them, even in the absence of any legal constraints.However, the ritual nick suggested by some pediatricians isnot physically harmful and is much less extensive than routinenewborn male genital cutting. There is reason to believe thatoffering such a compromise may build trust between hospitalsand immigrant communities, save some girls from undergoing disfiguringand life-threatening procedures in their native countries, andplay a role in the eventual eradication of FGC. It might bemore effective if federal and state laws enabled pediatriciansto reach out to families by offering a ritual nick as a possiblecompromise 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:

Opposes all forms of FGCthat pose risks of physical or psychological harm.

Encouragesits members to become informed about FGC and its complicationsand to be able to recognize physical signs ofFGC.

Recommendsthat its members actively seek to dissuade familiesfrom carryingout harmful forms of FGC.

Recommends that its members providepatients and their parentswith compassionate education aboutthe physical harms and psychological risks of FGC while remainingsensitive to the cultural and religious reasons that motivateparents to seek this procedure for theirdaughters.

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.

Jumping Through the Hoops to Make Bones Better

2010-05-06T08:40:00.001-07:00

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.

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.

So 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!

A Good Example

2010-05-05T12:42:00.001-07:00

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.

Can 10 Minutes Be “The New Black?”

2010-05-03T19:27:00.001-07:00

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 whena 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 thatmy patients had left dissatisfied. What had changed? There weremany possible factors — from what I had eaten for lunchto the traffic my patients had fought on their journey in —but one difference stood out in my mind: DNKs.

…I beganto suspect that the reason I felt I was a good doctor was largelythe 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 minutesbe 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 lookforward to a future in which I will be able to share responsibilitieswith nurse practitioners and physician's assistants in sucha way that my appointments with patients will be fewer, morethorough, and more satisfying for everyone involved. None ofthe experienced physicians I've talked to have confidently embracedthis vision. Perhaps they have seen too many changes for theworse 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 PhotoXpress.com.

What’s In a Name? Uremia, for Example

2010-04-30T22:01:00.000-07:00

Uremia (or uraemia for my friends from the Empire) results from kidney failure. Accumulated wastes build up in the blood, resulting in a number of symptoms; these symptoms include loss of appetite, vomiting, headache, rashes, abnormal body odor, bleeding (due to platelet problems), and coma. The term “uremia” comes from “urea" which is a nitrogenous waste product measured in the blood. Elevations in urea usually reflect poor kidney function, but a number of other conditions may raise blood urea nitrogen (BUN) levels independent of kidney function. These include high protein diets, catabolic states such as sepsis, gastrointestinal bleeding, and a number of drugs (glucocorticoids most notably).

In general, BUN correlates well with uremic symptoms, but urea is not the cause of these symptoms itself. Supporting data comes primarily from a study of urea loading in chronic dialysis patients. Patients studied still had abnormal kidney function, so while high levels of urea did not result in “uremia” in otherwise well-dialyzed patients, other abnormalities could not be studied.

Thanks to a Brief Communication in the May issue of Journal of the American Society of Nephrology (JASN) we now know that uremic platelet dysfunction is not due to urea.

Linthorst, Avis, and Levi studied platelet function in vivo and in vitro from 3 family members with familial azotemia. In this rare inherited disorder, blood urea levels rise to levels consistent with uremia but without reduction in glomerular filtration rate or accompanying uremic symptoms. All platelet studies fell within the normal range, ruling-out urea itself as the cause of platelet dysfunction.

Sometimes I am asked to dialyze patients with high BUN levels but relatively normal glomerular filtration rates to help with bleeding or other uremic possibilities. Now we know that lowering BUN is not itself beneficial because it is merely a biochemical epiphenomenon, not the real toxin. All thanks to an experiment of nature.

To Whoever Just Paged Me

2010-04-30T08:50:00.001-07:00

Dear You Know Who You Are:

Right now, you are cursing me for not answering your summons immediately. Your emotions will rise over the next few minutes as I continue not to call, then you will calmly document my failure in a chart and on evaluations of my performance.

It is you who deserve the FAIL.

You paged me to 4 digits. At some institutions this is sufficient information for a page, but not in my professional life.

The Nebraska Medical Center includes prefixes 552- and 559-. Either of these is possible.

Children’s Hospital and Medical Center of Omaha uses 955- numbers.

I also get paged to other hospitals in town and dialysis units. And right now, I am not the doctor on call.

Short of trying every permutation with these 4 digits (which are not familiar to me), I cannot know where you want me. And I do not feel obliged to try.

Is your life really so onerous that you cannot punch an extra 3 digits into the phone when you page me? Really? REALLY? I guarantee it will take less time than waiting for my answer to your insufficient request.

Sincerely,

Pascale H. Lane, MD

Photo courtesy of PhotoXpress.

Wisdom from the Swarm

2010-04-29T09:16:00.001-07:00

I received the following in an email from my father, with several previous forwards in the headers. I have no idea who initially wrote it, so I cannot give proper attribution. What I can do is post it here as a more permanent source of edification.

Please note, I do not wish to imply anything negative about unemployed alcoholics. Alcoholism is a disease/disorder with genetic and societal components in its pathogenesis. I have nothing but compassion for those addicted to the demon rum and its cousins.

On the other hand, bankers…

An Easily Understandable Explanation of Derivative Markets

Heidi is the proprietor of a bar in Sydney . She realizes that virtually all of her customers are unemployed alcoholics and, as such, can no longer afford to patronize her bar. To solve this problem, she comes up with a new marketing plan that allows her customers to drink now, but pay later. She keeps track of the drinks consumed in a ledger (thereby granting the customers loans).

Word gets around about Heidi's "drink now, pay later" marketing strategy and, as a result, increasing numbers of customers flood into Heidi's bar. Soon she has the largest sales volume for any bar in Sydney .

By providing her customers freedom from immediate payment demands, Heidi gets no resistance when, at regular intervals, she substantially increases her prices for wine and beer, the most consumed beverages. Consequently, Heidi's gross sales volume increases massively.

A young and dynamic Vice President at the local bank recognizes that these customer debts constitute valuable future assets, and increases Heidi's borrowing limit. He sees no reason for any undue concern, since he has the debts of the unemployed alcoholics as collateral.

At the bank's corporate headquarters, expert traders transform these customer loans into DRINKBONDS, ALKIBONDS and PUKEBONDS. These securities are then bundled and traded on international security markets. Naive investors don't really understand that the securities being sold to them as AAA secured bonds are really the debts of unemployed alcoholics.

Nevertheless, the bond prices continuously climb, and the securities soon become the hottest-selling items for some of the nation's leading brokerage houses.

One day, even though the bond prices are still climbing, a risk manager at the original local bank decides that the time has come to demand payment on the debts incurred by the drinkers at Heidi's bar. He so informs Heidi.

Heidi then demands payment from her alcoholic patrons, but being unemployed alcoholics they cannot pay back their drinking debts. Since Heidi cannot fulfill her loan obligations, she is forced into bankruptcy. The bar closes and the eleven employees lose their jobs.

Overnight, DRINKBONDS, ALKIBONDS and PUKEBONDS drop in price by 90%. The collapsed bond asset value destroys the banks liquidity and prevents it from issuing new loans, thus freezing credit and economic activity in the community.

The suppliers of Heidi's bar had granted her generous payment extensions and had invested their firms' pension funds in the various BOND securities. They find they are now faced with not only having to write off her bad debt but also with losing over 90% of the presumed value of the bonds. Her wine supplier claims bankruptcy, closing the doors on a family business that had endured for three generations, and her beer supplier is taken over by a competitor, who immediately closes the local plant and lays off 150 workers.

Fortunately though, the bank, the brokerage houses and their respective executives are saved and bailed out by a multi-billion dollar, no-strings attached cash infusion from their cronies in Government. The funds required for this bailout are obtained by new taxes levied on employed, middle-class, non-drinkers who have never been in Heidi's bar.

Now you understand!!!

All photos courtesy of PhotoXpress.

So Long, Anaheim

2010-04-28T11:01:00.001-07:00

Check-out time nears, and my laptop has to find its safe case for the trip home. Tomorrow I will be back in Omaha, checking in with my lab peeps and seeing patients all afternoon.

Today’s post was going to be about the Renal Section Dinner last night, with video of the undergraduate and post-doc award presentations. Watching these folks try to line up for a photograph is hysterical; you will have to trust me for now.

I plugged my flip into the laptop this morning and started the upload to YouTube. Everything went well for over an hour. At 95% things were still going smoothly. Then, the message: problem with download.

I do not have time to start over now. Tomorrow I will try again with my hard-wire connection. I will make this available (because everyone’s parents deserve to see this sort of thing).

So stay tuned. I will prevail over my gizmos.

Congratulations Darwin (Not That Darwin)

2010-04-27T12:43:00.001-07:00

Meeting fatigue has set in, and I am almost looking forward to the trip home tomorrow. Hot science still rules the Anaheim convention center, and there will be a tweet-up to celebrate the tweet-off tonight.

This morning I dragged myself to an 8am session because a friend, P. Darwin Bell, PhD, of the Medical University of South Carolina, gave it.

The Gottschalk Distinguished Lectureship of the APS Renal Section is the highest award a physiologist can receive (unless the Nobel committee comes calling). We are talking scientific rock-star status. And I know this guy! I had to rouse my sorry butt out for this one.

Carl W. Gottschalk, the namesake of the lectureship, came from Virginia but accomplished his breakthroughs during 41 years as a faculty member in the College of Medicine at University of North Carolina. Although he started out to be a cardiologist, the kidney grabbed his attention. Using micropuncture, he studied urine concentrating mechanisms and developed the countercurrent multiplier theory.

These scientific contributions alone would warrant naming stuff for him; however, Gottschalk also worked for patients with kidney disease. In 1967 he chaired the government panel that guaranteed payment for dialysis and kidney transplantation, at the time novel therapies, via the Medicare program. Millions of patients, including my own, are living productive lives because of these efforts by Gottschalk.

Focusing on tubuloglomerular feedback during his career, Darwin has changed many views of this process. The field of patch-clamping amazes me, and the technical stuff Darwin performs sometimes seems like science fiction. Clamping the macula densa? A bioprobe to confirm ATP secretion? Wow. A PubMed search reveals 113 publications today, a number that will rise in the future.

So once again, congratulations to Dr. Bell for a well-deserved and well-delivered lecture.

By the way, don’t forget the tweet-up to celebrate the tweet-off between Executive Director of the APS Marty Frank and Dr. Isis, 10:30 tonight in the bar at the Anaheim Hilton. I will announce the official winner about 6pm via Twitter. Good luck to all!

Translational Research Needs

2010-04-25T18:49:00.001-07:00

The critical first step in a research project occurs when the investigator chooses a model. Can the experiment be performed in cultured cells? Is a clinical trial in people necessary? Or will something in between be needed?

Something in between often means an animal model. I spent my training studying kidneys from people. The next questions I asked could not be studied that way; they required a setting with more control of variables, one in which the basic workings of the tissues could be dissected and explored. Would cell or tissue culture do? Perhaps for some of it, but I wanted to examine puberty. This complex physiological period involves sexual maturation and the acceleration then cessation of linear growth. Our understanding of all its processes is elementary at best, so they cannot (yet) be modeled in vitro or in silico. I had to find a model.

At that time, a search of PubMed revealed a whole bunch of animal models of diabetes and its complications. The array of species and variables sent my head spinning. Now, genetically altered mice flood the field, each with its own particulars! On Tuesday mouse models of diabetic kidney disease will occupy 2 hours of symposium time at Experimental Biology. New models are published every month.

Sunday I learned about LAMHDI , the initiative to Link Animal Models to Human DIsease, while strolling the exhibit hall. This emerging resource results from efforts of the National Center for Research Resources of the NIH. The goal is a simple yet comprehensive catalog of animal models, including the gene(s) affected (when available) and phenotype information. Similarities and differences from human disorders will be included as well.

Services available include the following:

LAMHDI Database Search - The LAMHDI Database Search is a search of data from partner websites. Currently JAX Mice and ZFIN have made their databases available to LAMHDI. A search returns pertinent information about animal models. Other websites with information about animal models are welcome to join as LAMHDI partners. We also invite you to share your feedback.

Animal Model Web Search - The Animal Model Web Search is a Google-like search of select websites that contain information about animal models. Currently LAMHDI indexes more than 75 sites with over 1.2 million pages that you may search with a single search strategy. Search results take you back to the originating site. Please suggest other sites that LAMHDI might include.

Featured Resources - Eventually LAMHDI will link all appropriate animal model databases in a single search. In the meantime, several additional resources have been identified as most useful to animal model researchers to supplement LAMHDI today. If you have other resources to suggest, please let us know.

LAMHDI may accelerate translational research by allowing the best model, not merely the one most familiar to the investigator, to be used. Right now the searches are dominated by rodent and zebrafish models. Eventually, the developers plan to include all species, and the nation’s leading primate centers are participating.

In addition to its potential to speed up bench to bedside, the database might also reduce the number of animals used in a given line of research. By selecting the best possible model for the experimental question, a series of less relevant experiments may be eliminated. Faster, better, and lower costs (in both dollars and animal lives)- sounds like a winner to me.

LAMHDI is described as a prototype. The developers want scientists to use it and give feedback. How is it working? What other resources should be included? How can we make this thing rock? So click on over there and try it out.

I will update the EB tweet-match throughout the day; my twitterfeed can be found in the right-hand column above.

Update on the Race

2010-04-25T08:35:00.001-07:00

The first day of EB provided some sciencey razzle-dazzle and a whole lot of fun. The symposium on animal rights groups and the Pro-test movement produced lively discussion and useful information.

The Cannon lecture, given by Jeffery Fredberg, convinced me that a cell would feel like toothpaste if you could stand next to it and poke it with your finger. Of course, my favorite part of the talk was hearing my name over and over, since the unit of force is the kilopascal (after Blaise Pascal, not me).

Then the fun began with the Cannon reception and the President’s reception. I also got to meet a number of my online acquaintances face-to-face, which is always a treat.

Now, for what you clicked by to see. We are 24 hours into our tweet-match. Marty Frank made appeals to the masses for new followers, using his public persona and the authority that 25 years as Executive Director of the APS brings. He now has 154 followers for a net gain of 12. Dr. Isis countered by promising $1 for every new follower, up to $500, to the Porter Minority Development Fund. Dr. Isis really, really wants to win. As of 8am today, this effort will cost her $94.

So the goddess leads, 94 to 12. The final count will be made Tuesday evening, and a lot could change in 2 days and 10 hours. It’s up to you- go, follow, and tweet!

And have a great EB if you are with us in Anaheim.

Lost in the Performance

2010-04-24T22:01:00.000-07:00

Last week NPR ran a story about a poem, reportedly one of the first pieces of animal rights literature. Ann Barbauld, an assistant in the lab of Joseph Priestly, penned it:

It was, after all, 1773, just a few years before Lexington, Concord and the Declaration of Independence. On both sides of the Atlantic, "inalienable rights" were a rallying cry, and Anna, a young wife and poet, decided to write a protest poem. She called it "The Mouse's Petition to Dr. Priestley, Found in the Trap where he had been Confined all Night."

NPR included commentary from a historian on the concept of “inalienable rights,” and an actress read the poem with great emotion.

Priestly himself gets a bit lost in their discussion:

There were lots of mice in Priestley's lab. He had made his reputation as one of the first scientists to identify oxygen. He studied mice to figure out what happens inside animals as they breathe. This meant he regularly opened them to examine lungs, veins, arteries, to see that blood changed color when it moved through lungs. And since tuberculosis -- or "consumption" -- was the scourge of that era, lung research seemed like a valuable thing to do.

Priestly described oxygen, photosynthesis, and carbonation. He also founded Unitarianism. His support of controversial ideas often necessitated moves to other countries or even continents; he died in the United States because he supported both the US and French revolutions.

Some of his most famous experiments are detailed at this web site. He collected oxygen and found that a container of it burned longer and kept mice alive longer than an identical container of air. He also demonstrated that plants can produce oxygen; a closed container would kill a mouse, but a plant in the same closed container allowed the mouse to live.

Priestly’s ongoing belief in phlogiston theory kept him from developing his observations to their full potential and eventually excluded him from mainstream science. Antoine Lavoisier eventually “discovered” oxygen as well and recognized it as an element, discrediting phlogiston theory along the way. These events led to the development of modern chemistry. The American Chemical Society arose from a commemoration of Priestly’s work a few years after his death.

Today, combustion is a chemical reaction. Air contains oxygen that enters our blood through our lungs. Plants renew oxygen in the air. All of these facts result, at least in part, from Priestly’s experiments with mice.

People and animals still die of lung diseases. We still have much to learn about the way bodies work. There are still questions we cannot answer without using animal models. Today, though, our animals get much more protection. Institutions that perform animal research supervise scientists and require protocols that use the lowest number of animals possible. Most laboratory animals come from commercial sources and are bred solely as research subjects; rats and mice are generally not trapped in the wild as they were in the 1700s. Experiments expected to end in the death of an animal, such as Priestly’s, require extra levels of justification and supervision. While most animals do succumb to experimental efforts, death most often occurs under anesthesia or via another approved method of euthanasia. Food and water are provided. Environments are enriched. Pain and distress are minimized, as required by law.

Animal research remains an important tool for understanding biology and disease. Without it, progress in a number of disorders will be slowed or stopped. I am glad NPR told me about this historically important piece of literature; I just wish they would have pointed out the importance of Priestly’s experiments; surely they justify the loss of some mice.

And They’re Off…

2010-04-24T08:02:00.001-07:00

This morning Experimental Biology began officially, as did the tweet-off between Marty Frank, Executive Director of the American Physiological Society, and Dr. Isis, the shoe-loving, smoking hot science blogger.

I have blogged the rules on multiple occasions, most recently here. In short, the participants will try to sign up the most new followers on twitter between 8:00am PDT Saturday and approximately 6:00pm Tuesday. The winner receives all due accolades at a tweet-up in the Hilton bar at 10:30pm Tuesday evening.

So where is our starting gate?

@ExecDirectorAPS: 142 followers
@drisis: 1,115 followers

What do you need to do? If you have a twitter account, follow one or both of the contestants. If you don’t have a twitter account, what are you waiting for? Click on over to twitter and set one up; it takes about 2 minutes and a valid email address. Twitter identities are ExecDirectorAPS and drisis. Click on the links and then click the “follow” button. Really, they cannot make this any easier.

Either way, don’t forget to follow me (@PHLane) for updates on this horse race! Or, if you prefer a less “real-time” experience, I will blog updates at this site as well. Also, any tweets related to the meeting will carry a hashtag: #EB10. You can see what everyone is tweeting about EB by searching for this identifier; don’t forget to include it in your own updates!

Also, feel free to say hello if you see me in real life (IRL) at #EB10. I am easy to identify because I am not anonymous or pseudonymous, and my real photo appears on this site. My name badge has been blinged, including a cool pair of martini-sipping kidneys. Furthermore, I use a BlackBerry case that looks like what happens when a leopard gets bedazzled.

Who will win? Will the credentials of an Executive Director draw more followers? Or will the new, improved pants-free goddess prevail?

It’s up to you… Go tweet!

Paging the Page Kidney: Biomedical Musings

2010-04-22T08:58:00.001-07:00

I recently saw a medical condition I had never encountered before. A teenager had been diagnosed several months ago with hypertension (high blood pressure) by his primary care physician. After dietary modifications failed to lower his readings to acceptable levels, an ultrasound showed an abnormality in one kidney. MRI further defined a mass within the kidney consistent with a resolving hematoma, or subcapsular bruise.

Irvine H. Page demonstrated that tightly wrapping a kidney with cellophane would induce hypertension in 1939; in his honor, this type of kidney problem is called a Page kidney. More information, including an MRI and pathologic specimen, can be seen in this feature in New England Journal of Medicine.

So how does wrapping a kidney in cellophane or adding a subcapsular mass cause high blood pressure?

The left image shows a diagram of a normal kidney with its artery entering and branching. Repeated branches occur until each vessel ends in a filtering unit or glomerulus. The capsule forms the large border around the pink “meat” of the diagrammed kidney; this firmer scar-like structure holds the organ in place. If bleeding occurs within the kidney, from a blow to the flank or a kidney biopsy, a bruise may form under the capsule as in the image on the right. This bruise or hematoma cannot push the firmly made capsule out, so it squishes the working part of the kidney, including blood vessels in the region.

When the kidney sees a reduction in blood flow, it cannot tell if low blood pressure in the body or compression by a hematoma (or some wacky scientist wrapping it in cellophane) has caused the problem. The blood vessels near the glomeruli respond by pumping out a hormone called renin that turns on the angiotensin-aldosterone system, raising blood pressure throughout the body).

Thus, a squished kidney causes high blood pressure. This form of hypertension can often be cured by draining the hematoma or removing the offending kidney.

And 25 years after completing medical school, I still see new things!

Maternal Pride and Organ Donation

2010-04-21T08:15:00.001-07:00

Organ donation is a topic near and dear to my heart, as I have blogged before. I am quite proud of my daughter’s efforts on behalf of organ donor registration this year. As a PR major at University of Nebraska – Omaha, she has chaired a group of students organizing a major transplant awareness event. A local TV station featured her event on last night’s news (doesn’t she look good on TV?):

She has worked her ample butt off for this event, even talking me into donating prizes for a “pin the organ on the body” contest [Note to I Heart Guts: if you offered express shipping, your stuff would have been the prizes, but I could not get it here in time].

Jennifer is on track to graduate next December; if anyone wants to hire her, feel free to contact me!

More EB Wackaloonacy

2010-04-21T02:00:00.000-07:00

Experimental Biology, formerly known as the FASEB meeting, draws all sorts of life-scientists. Virtually anyone with an interest in something biological can find something of interest at this meeting.

To better demonstrate what happens at #EB10, I made a word cloud out of this year’s program (free service at wordle). I used the cross-society program, so only session titles and not individual presentations are included:

The meeting occurs in April, so the month is fairly prominent. Obviously, the group is big on regulation, metabolism, and disease.

I have enjoyed using wordle; it proves that a picture is worth 1,000 words, even when that picture consists only of words.

Fight Club Meets EB

2010-04-20T10:46:00.001-07:00

As you may have heard, the amazing icon of hot science and shoes, Dr. Isis, and the fearless leader of the APS, Marty Frank, will start a twitter-war for ~~world~~ EB 2010 domination this Saturday morning. In earlier posts this event was described in terms of boxing matches or mud wrestling. Of course, #EB10 is in Anaheim, CA, a kinder, gentler place (even if it does have a professional hockey team nearby). Therefore, my final imagery for this challenge is one that seems much more California-like: tofu wrestling. Folks, you can’t make this stuff up (click on the photo and follow the link if you doubt me).

I am not going to repeat the rules in this post because I did that recently here (and originally here). Today you get to hear about the winning event!

The winner will be determined by yours truly at ~6pm PDT (just before the bar opens at the Renal Section Banquet at EB). The winner will receive accolades in the bar at the Hilton beginning at 10:30 pm PDT that evening. Look for me or Marty Frank (the goddess will be wearing an invisibility cloak). Hijinx and shenanigans should follow!

Keep following me (@PHLane) on twitter for updates throughout the meeting. And let the games begin!

More Pre-EB Wackaloonacy

2010-04-19T09:03:00.001-07:00

Last Friday I blinged my namebadge for #EB10 (that’s the meeting’s twitter hashtag for those of you who do not yet tweet) with the usual stuff. To the left of my name is my twitter name (you can tell because @ precedes it). Below the word “University” lies the Nebraska “N” with the Cellular and Integrative Physiology logo superimposed. Completely against University Stylebook, but much cooler than anything official. In the lower right corner I stuck the APS logo to augment the boring “APS” printed below the barcode.

By far the best image falls to the right of my name; a larger version is shown here. These toasting kidneys were “appropriated” from a cool web site, I Heart Guts.

Here is the site’s own description:

I Heart Guts is the brainchild of an anatomically obsessed illustrator who loves internal organs and all they do. Founded in 2005, our little family operation (heh, heh, heh..ugh) strives to offer the best in stoopid slogans paired with happy gloppy guts. We like to think of the Guts as what you might find inside a dissected Hello Kitty.

The guts grew from a single drawing of a broken heart, after a string of bad hookups, dead-end relationships and lame-o boyfriends. At the time, I was also doing a lot of drinking and smoking, so a sad liver and bummed-out lung followed. Years later, my wonderful husband wondered, “Why don’t you do something with those darned guts?”

The site includes a lot of useful information about the function of various organs and glands, as well as a store with plush organs, tee shirts, and lapel pins (all of us bio-geeks need these; perhaps they should sell them at EB). The free e-cards just rock, especially this one featuring the bladder:

I will not have my plush kidney in time to take it to Anaheim (the site has a gallery for guts on vacation). But I will be wearing those kidneys over my heart.

More on the Twitter smack-down between Isis and Marty Frank in tomorrow’s post.

Countdown to EB2010

2010-04-16T07:32:00.001-07:00

One week from today I fly from the home quarters in Omaha to Anaheim, home of the original House of the Mouse and site for this year’s Experimental Biology (#EB10 for you twitterati).

In addition to the usual scientific stuff, the twitter smack-down between Dr. Isis (@drisis) and Marty Frank of the APS (@ExecDirectorAPS) begins at 0800 PDT on Saturday, April 24. Isis currently claims 1105 followers, while Dr. Frank has 139 followers. For those of you who do not wish to follow the link above for the rules, here they are:

The challenge: sign up new Twitter followers (Tweeple or Tweeps) during Experimental Biology in Anaheim.

I will certify the number of followers each has at 7:59 am PDT on Friday, April 23, just before on-site registration opens at the meeting. When a predetermined deadline has been reached, I will once again check the number of followers for each. Whoever has the most new followers will win. For those of you more mathematically inclined:

New followers = N(deadline) – N(start)

I am letting the fighters determine the “prize” which may also determine the deadline. For example, if a tweet-up with the loser buying drinks is involved, we should probably end on Tuesday to allow that event to occur. If clown services at some point in the future are involved, well, we can go to the last minute on Wednesday.

For those of you who have never experienced twitter, well, it’s about time! After all, the EB program is available for iPhone/iPad/iPod touch. Go to the app store and download Echofon, set up your account, and get ready to pick sides.

There may also be a tweet-up. What’s that? Someone will tweet a location and time to congregate. If you’re not tweeting, looking for that #EB10 hashtag, you may get left out of some fun!

So get ready, Anaheim- scientific gizmo geeks are on the way!

Selling Yourself (No, Not THAT)

2010-04-15T07:40:00.001-07:00

Medical and scientific degrees give a surprising range of career options. My own path courses through academia, but careers in a variety of businesses present other options.

Jobs outside of the ivory tower, and sometimes within it, require different documentation than a faculty position.

A number of documents summarize careers, including our qualifications, experience, and fit with various positions. For faculty, the gold standard is the curriculum vitae followed closely by the NIH biosketch. The business world relies more on resumes and shorter documents that must be focused to the desired position.The curriculum vitae or CV is an all-inclusive document. Most institutions of higher learning have a preferred format. Anything can be included on this document; if in doubt, list it. This is one time when less is not more! Your CV should be ready to print at all times. Also, include the print date on your CV so outdated copies can be readily identified. Do not obfuscate on this document; if required, separate peer-reviewed and invited papers and presentation, and make sure your status on grants is clear. Use standard fonts, minimal color, and no pictures. Any of these items may limit scannability of your document!

The NIH biosketch is a bit less complete than the CV, but far more manageable for grant applications or speaker introductions. The format changed recently, adding a “personal statement” block (ridiculed here) that lets an investigator focus their biosketch on a specific proposal. Keep this document ready-to-go as well, other than customizing the statement section. Be sure and download the latest form and instructions from nih.gov; you never know when those crazy federal employees will change things up again!

An executive summary supplements a traditional CV. This brief, 1 or 2 page synopsis document, provides a snap-shot of stuff tailored to your current career objective. The summary is always printed in portrait format. Following contact information, the objective statement is a brief (2-3 lines) description of what you wish to do, your top strengths, skills, or talents, and a summary of results that can be expected if you join an organization. Qualifications follow in a short paragraph or a few bullet points. This section in why you can do what you say you will do. The achievements statement is a priority list, tailored for the position you seek, of accomplishments that illustrate your objectives and qualifications. This section should be constructive strategically, not exhaustively (your CV will do that). Use action words and quantify results when possible:

Bad: Profits appeared to improve after my actions.
Good: My actions increased profits 25% over 12 months.

The final document, the prospectus, also supplements a traditional CV. This instrument is very focused and limited to a single page printed in landscape format. Contact information and objective statement are similar to those of the executive summary. A profile section is similar to the qualifications statement of the executive summary. The difference is the final section, areas of expertise, which highlights skills, accomplishments, and personal characteristics applicable to the desired position.

Example of an Executive Summary:

Example of a Prospectus:

Providing summary documents appropriate to your job search can highlight relevant accomplishments. Their inclusion may help your new boss find that critical factor that gets you hired.

Photo courtesy of PhotoXpress. Other materials created by Pascale H. Lane, MD.

Free To Be… Whatever

2010-04-12T18:45:00.001-07:00

Last week Isis and Zuska both addressed the perception that women should be women, even at work in male-dominated fields. I wonder if a male scientist has ever been chided for failing to nurture someone? Of course, it would be labeled a failure of mentorship; dudes would never be accused of “nurturing,” even in a professional sense. Do random strangers ever ask my husband to smile because he would be so cute? He is adorable when he smiles, but I don’t see that happening more than once… even though I hear that request several times a year, even though I am closing in on half a century of life.

About the same time, my daily update from Pink, an e-zine for women in business, addressed balance. Not in the usual, “home vs. office” way, but in a more “personal style” way:

“Research shows that women who behave in too masculine a way are respected but not very well liked by their colleagues, while women who are too feminine are well liked but not well respected,” says Robin Ely, Professor of Business Administration at Harvard Business School.

Damned if we do. Damned if we don’t. Women must choose between respect and likeability.

The Pink post goes on to discuss books, videos, and other blogs with advice on finding the right balance of our “feminine” and “masculine” sides. We are encouraged, as we climb the power ladder, to allow our femininity (those nurturing instincts and decorative capabilities) to reemerge and become more valued in the workplace.

What if we don’t want to do that?

I will never be mistaken for a guy. I shave my legs. I wear makeup. I love heels. I usually smell good. I read fashion magazines! But I am not a touchy-feely-kumbaya kind of person. A number of times in my professional life I have been expected to take on this role; it is not who I am. I did not do well.

We need to move beyond stereotypes based on gender, ethnicity, sexual orientation, or anything else. Every person is a unique blend of personality traits and talents. We should value each person for who they are, not who we expect them to be. That is the world I want for my children.

Now that sounded touchy-feely-kumbaya. Maybe I do have it in me. After all, I am a woman.

Image courtesy of PhotoXpress.

A Time to Fly (Again)

2010-04-08T06:59:00.001-07:00

Once again, I am blogging from the Omaha airport. Today I am on my way to Washington, DC, for the Publication Committee of the American Society of Nephrology.

I attended this meeting last year, when ASN Kidney News had published a mere 2 issues. Tomorrow I will regale them with tales of our transition to a monthly publication. We have new columns and features. We respond to current events in a more news-like manner; the renal community’s response to the earthquake in Haiti was covered in the March issue.

Monthly publication does bring a downside, even beyond the added workload. When we cover “breaking” stories, like Haiti or healthcare, requested articles may be delayed in publication. My apologies to those who wondered why their articles don’t appear on schedule, but it happens. We also suffer from the advertising cycle now. Our very first issue, January 2009, had little trouble attracting ads. This year, things became a bit tighter. It turns out that advertising budgets are uncertain for the new year, and companies are hesitant to buy space for a January issue. I had always noticed that trade magazines were smaller in January, but I attributed that to content. Turns out if you have fewer ads, you can run less content, and this cycle is true across most publication categories. Makes me feel a bit silly. I should know that most things are about money!

After the January slump, things are looking up. We ran special sections in February and March. The April issue is up online in flash or PDF files. It features multidisciplinary care of kidney patients, and the articles presented rock! Hard copies should hit mailboxes the third week of the month.

We are always looking for good content ideas. It may be a special section with several featured articles, or just a single column. Nothing is too weird or silly for our consideration, as long as it somehow connects to the world of kidneys.

It is almost time to hit the security line. Later, nephrons!

Anaheim Get-Together

2010-04-06T18:19:00.001-07:00

Greetings! Experimental Biology officially gets underway on Saturday, April 24, just over 2 weeks from now. Shenanigans must be planned!

This year I do not have a poster or other presentation, giving me the time to plot capers. We already have the Marty Frank – Dr. Isis twitter match (as close to scientist mud wrestling as we will ever get). What more could you want?

How about a tweet-up?

On some day, we tweet a location for a meet and greet. It could be at a poster, a bar, or even DisneyLand. I am open to all ideas. We could even schedule the event ahead of time. It wouldn’t be a real tweet-up then, but we could get the non-twitterati involved that way.

So give me some ideas. I can get it organized, but I need a little help.

California, here we come!

Next Year Begins Tomorrow

2010-04-05T18:35:00.001-07:00

I write this as the nation’s collegiate basketball championship game occupies our television. In 40 minutes- that will take roughly 2 hours of real time- a champion will be crowned.

Will it be perennial powerhouse Duke, even though they had a “down year” according to many talking heads?

Or will the upstart Bulldogs of Butler fuel the dreams of every mid-major team across the US?

Time will tell (and the score is pretty even after ~5 minutes of play), but at least we will have an outcome determined on the court.

If basketball had a BCS system, we would be watching Kansas vs. Kentucky right now.

Why can’t we do this for football?

Faux Mouse From E. Bunny

2010-04-04T20:08:00.001-07:00

We enjoyed a lovely lamb dinner at my parents’ home, with a relaxing family afternoon. My son and I once again won at cards.

Now, I am watching Dottie, the cat.

See, the Easter Bunny brought her a new toy. She found the FeatherMouse while still attached to its cardboard holder. The added packaging did not prevent her from trying to play with it. Now it is detached, and she is going at it with insane abandon and glee.

The toy has no catnip or chemical enhancement. It is merely a fabric mouse with a feather tail.

This could keep us all entertained for hours.

First Quarter Grades Are In

2010-04-03T08:25:00.001-07:00

At the end of December I made my blogolutions. I gave myself an A for following them at the end of January. Have I kept up my grade average?

January 19 posts
February 23 posts
March 19 posts

Grand total: 61 posts in 14 weeks for an average of 4.4 posts per week.

My goal was 3 to 5 posts each week.

I have exceeded my expectations about serious, sciencey blogging, with multiple posts each month on biomedical science or other healthcare issues.

I have earned a nice bottle of zinfandel, I believe.

Image courtesy of PhotoXpress.

Flippin’ Cool

2010-04-01T14:24:00.001-07:00

I now have videos in my YouTube account.

I started my account a couple of years ago. You had to register in order to sign in and email people hilarious videos of guys getting hit in the groin and other stuff.

Oh, we had a video recorder. About the size of a Kleenex box, I found it annoying to use. When taping with it, I felt excluded from the action. I was recording the festivities rather than participating.

Uploading videos required special software, cables, and an adapter. I figured out how to do it for dance audition tapes for my daughter, but overall it was not worth the hassle.

Two weeks ago I acquired a flip video recorder. I went with the minoHD which records 2 hours of high-definition video on internal memory- no tapes or cards to lose or destroy! This camera is also smaller than my BlackBerry, so light and unobtrusive that I think I may actually record more events!

Uploading is a breeze as well. Slide a switch on the side and out “flips” a USB port. Plug it into your computer; the first time it installs FlipShare software and lets you make an online Flip account. Click on an icon for “Share Online” and video can download directly to YouTube, Facebook, and other social media sites.

I have not yet tried to do any fancy stuff or video editing. But I do have two videos in my YouTube account, one of which is the new feline member of the family. Her name is still a source of intense discussion, but she doesn’t seem to care:

I have to go now for my son’s baseball game; maybe I will post some video of that event tomorrow. You never know, now that I am flipped out and dangerous!

Four Decades of Change

2010-03-31T11:43:00.001-07:00

Even though my flights last Saturday night all came with first-class upgrades and early arrivals, snuggling under the covers still presented the most attractive option Sunday morning. My husband had other ideas – we were going to church on Palm Sunday.

I am truly grateful that he dragged my ample butt out of that bed.

When I was 11, the ordination of women caused much controversy within the national Episcopal church. The controversy divided my own church which had never allowed female acolytes (alter girls). Hours of coffee- and beer-fueled debate ensued. Ultimately, practicality won the day. The upcoming confirmation class included no male children, and the parish needed new acolytes. They trained two girls.

Lightening did not strike. The sanctuary walls remained upright.

Today it is difficult to remember that ordaining women was controversial, especially since the head of the American Episcopal church is a woman.

The Most Rev. Dr. Katharine Jefferts Schori presided at Palm Sunday services at Trinity Cathedral in Omaha. She delivered a beautiful sermon about helping others in the world as the route to peace.

In my lifetime we have advanced from ordination of women being “illegal” to a woman running the church. More than any passage in the bible, this gives me hope.

So thanks, honey. It’s retrospective, but sincere.

Sleeping woman photo courtesy of PhotoXpress.

More On Personal Branding and Platform

2010-03-30T09:08:00.001-07:00

Once again, my daily email from Pink Magazine proved timely and informative. Today’s topic, personal branding, fits well with all the talk about platform development in last week’s workshop.

One informative link was to an online identity calculator. This short query uses a Google search of your name to determine your digital distinctness.

It helps to be “Pascale Lane” and not “Jane Doe.” It also helps to be online actively managing what people associate with you. Owning your own domain, blogging, and other digital interactions will help increase your digital brand immensely. Most importantly, you can move your brand in the direction you desire rather than passively allowing others to determine your image.

In this day and age, when a Google search about you may make or break a job search, overlooking your online brand would be short-sided. I encourage everyone to use the link and determine their online identity score.

Think it doesn’t matter? Better think again.

Then Color Me Pinko

2010-03-29T14:51:00.001-07:00

I have friends and relatives living in terror. They fear that they will lose their health care coverage to “Obama’s socialist agenda.”

Of course, their primary coverage is via Medicare, a government program. One could say a socialist program.

What is socialism? According to Wikipedia:

various theories of economic organization which advocate either public or direct worker ownership and administration of the means of production and allocation of resources.

In short, public ownership constitutes socialism. I live in Nebraska, a generally red state, where “socialist” is considered a major insult, yet I purchase my water, gas, and electricity from publically-owned utilities with elected boards. Looks like socialism to me.

My children attend excellent public schools and universities. An educated electorate is essential to democracy, and most education in the US is subsidized by the public one way or another. More socialism in action.

Early intervention is another service readily available through our socialist education system. Every state in the union put these programs into place during the 1990’s to target children with special needs. Their development improves with programs implemented before the traditional school age, sometimes during the first year of life. Most parents would not be able to afford the intensive behavioral and occupational therapy provided by these publically-funded programs.

Yup, early intervention programs are another example of pooling public resources to provide a public good. More of that “S” word.

Sarah Palin denounces socialism every chance she gets. She attended several public universities, though, and has thus benefitted from educational socialism. Yes, you pay to go to university, but it is highly subsidized via tax dollars, even for out-of-state students. State universities are big-government at work.

Palin claims to have turned down government handouts. Will she become even more suspect of public and government funding as the tea-party movement gathers steam? I hope not; for the sake of her son, Trig, I hope she accepts those socialist early intervention services.

Just say thanks- the American public does this because it is the ~~right~~ correct thing to do. We all want Trig to have the best life he possibly can. I personally want every child to have nutritious food, educational opportunities, vaccinations, and adequate healthcare, even though it means higher taxes for me. Even though it means a larger government. I would like every US citizen to have guaranteed health care, whether or not they are employed or have pre-existing medical conditions. I do not see how these changes to healthcare threaten individual freedoms in any way.

Guess that makes me a socialist. Please don’t shoot me.

Increasing Sensations of Incompetence

2010-03-27T06:47:00.001-07:00

I am learning to write creative nonfiction.

I have this book idea. I finally “gave” myself this conference to try and get my act together and WRITE THE DAMN BOOK!

Among this group of mostly middle-aged healthcare workers, I am way ahead of the online media curve. I have a blog (no link because you’re reading it right now). I am on FaceBook. I am on LinkedIn. I even Tweet!

The first day of the conference discussed preparing the book proposal and pitching it. I felt smug then because I had began developing “platform” with my traditional and social media work (see Thursday’s post).

Yesterday we talked about actual writing. Michael Palmer presented his insights from the beginning and growth of his writing career.

This morning focuses on public relations for budding authors. And I feel so far behind. I just now registered my domain name. I just signed up for HARO (help a reporter out). I have bought my Flip videocamera, but have yet to upload to my YouTube Channel (no link because THERE IS NOTHING THERE YET). So much to do… and I haven’t yet factored in the book proposal! Or actually writing THE DAMN BOOK! Or my day jobs.

Sigh!

The good news is I have a lot of new blog fodder. And I have to write; I don’t know why. It is part of who I am. So hang on- it may be a bumpy ride, but it won’t be boring. At least not every day…

Building a Platform

2010-03-25T17:04:00.001-07:00

When I hear the word platform, something like these Madden Girl beauties comes to mind.

So why was I listening to “Platform: What It Is and Why You Need One” in a writers workshop this morning? Would hot shoes and a taller appearance make publishers like me better? If so, then my decision to bring a single pair of low wedges might bring me down, and not merely in physical stature!

Turns out that one’s platform consists of professional credentials, media work, and other writing; the stuff that lifts you above the waves of others out there, sort of like an oil platform in the ocean (once I came up with the analogy I had to use it).

Turns out that blogging, podcasting, twittering, facebooking, and other social media help build that platform.

Now when my husband asks me if I’m screwing around on the computer/Blackberry/iPod again, I can honestly tell him no; I’m building my platform!

APS vs. Isis Slam-Down

2010-03-24T06:00:00.000-07:00

No, the above photo is not a depiction of this year’s Experimental Biology meeting in Anaheim. It is labeled on Flickr as a Biker Mud Wrestling Party.

As of today, EB is one month away. I am awaiting official updates from the training camps of Dr. Isis, the Domestic and Laboratory Goddess, and Marty Frank, Executive Director of the American Physiologic Society. The contest will see which of these icons of physiology can enroll the most new Twitter followers during the meeting. The rules and other details are outlined here.

Dr. Isis recently acquired an iPhone; her daily tweets show increasing proficiency with the touch-screen keypad. The Frank camp is maintaining silence on his training regimen.

Only one month till EB; let the shenanigans begin!

Trip Time

2010-03-23T17:00:00.000-07:00

Tomorrow I leave the homestead in the heartland for a workshop in Boston.

I have wanted to attend one of these writing courses since I first saw the brochure. I am finally making it happen. Maybe, just maybe, I will write my book one of these days.

So tonight I will pack 3 days worth of clothing in a carry-on bag. And I know my readers are asking, “What will you pack?”

2 pairs of dress trousers in wrinkle-resistant blends
3 tops
1 jacket
Undies and accessories and other necessities
PJs

I will wear my best pair of jeans with another top and jacket; the jeans will make the trip home as well. I have a pair of neutral metallic 1.5” wedges, that will serve me well through airports and along city streets, as well as complimenting every outfit in the suitcase.

The usual electronic devices want to come along for the ride: BlackBerry, Netbook, iPod, and Kindle.

It is time to do those things I love, travel and write.

I am so glad I gave myself this trip!

Making and Breaking Rules

2010-03-22T19:46:00.001-07:00

A couple of weeks ago I posted on neonatal hypertension. In the course of that piece I commented that I had made a rule about when I would recommend treatment for this condition. A commenter, Dr. Isis, asked the following:

I am interested in the "I decided to make a rule..." part of it. Can you tell us more about how you made this decision?

I posted an answer about my review of the literature and other considerations, but that really does not address the root of the issue; why did I feel the need to make a rule?

So I reviewed a relatively recent book, How Doctors Think. This read from 2007 examines the ways physicians deal with uncertainty in medicine. We learn to recognize patterns, and respond to them accordingly. Neonatal hypertension bothered me because of the uncertainty, the lack of data to drive decisions. We usually cannot identify a cause, we cannot determine which tiny minority of patients will not do well, and yet we hope to do no harm using drugs not approved for use in infancy.

In my case, I wanted a rational approach to the common neonatal hypertension patient who had no evidence of kidney or vascular problems to explain the hypertension. I picked a level of blood pressure that seemed significant, and I decided to treat at that level.

Physicians deal with uncertainty on a daily basis. We rarely know everything about a patient (not until the autopsy, anyway), and our patients rarely fit the textbook completely. Recognizing patterns and responding to them makes practice possible, although numerous examples in Jerome Groopman’s book illustrate the dangers of these thought processes.

Lots of doctors proclaim that they do not practice “cookbook medicine.” In other words, they treat each patient individually rather than relying on rules, flowcharts, and other “cookbooks.” Of course, they all do rely on rules to some extent- the important thing is to realize when the pattern and response to treatment vary in some important way that will influence the patient’s outcome.

As I noted at the end of my earlier post, my rule seems to be serving me well. I spent far more time considering why I formulated it than I took to create it.

Fuzzy Women

2010-03-20T11:58:00.001-07:00

First, I am pre-menopausal. Still cycling, thank you very much.

Peri-menopausal? Can’t deny that. I mean, you expect that when your next birthday puts you at the half-century mark.

But I have had excessive facial hair for a long time. Since puberty. A mustache. It’s been bleached, dissolved, shaved, and waxed.

I put patients, including teen-age girls, on medications that increase hair growth. I am able to discuss various forms of hair removal with them from my own personal experience.

So when this video showed up in my twitter feed this morning, I really appreciated it:

H/T to @dikeough via @RebeccaSkloot.

By the way, my husband is an endocrinologist. The Gland Man. He thinks facial hair on a woman is a good thing because it means the androgens are working, pushing our sex drives. He probably just says that to make me feel better, but feel free to quote him if you need to put a positive spin on facial hair sometime.

Remember: You are not alone.

A Major Award and a Major Headache

2010-03-18T15:06:00.001-07:00

Last night, my husband won Specialty Physician of Distinction for The Nebraska Medical Center. He poses with his plaque and Beth Pfeffer, the nurse manager of the Diabetes Center and Service Line who nominated him.

One bonus of the evening was the keynote address by J. D. Kleinke, medical economist extradordinaire. His views on healthcare reform provided further support for my own, and one of his books sounds like a must-read: Oxymorons: The Myth of U.S. Health Care System (2001).

I hoped to post this morning so my husband’s achievement could be easily shared with friends and family; unfortunately, my patients did not allow it. When I finally got to a computer, I skimmed one of my regular reads, White Coat Underground. The post today raised an interesting question: would health care reform cause physicians to leave medical practice?

I will let you read the original post, because the question (and supposed answer) are not, well, real.

I do know something that will make physicians consider leaving medical practice, though: Maintenance of Certification (MOC).

In the old days (before 1985), a medical student graduated and took one of two courses of action. After 1 or 2 years of rotating internship, most states would license an MD for general practice. Alternatively, one could pursue residency training for a number of years and then sit for board certification examinations in specialties. These specialties included primary care (Internal Medicine, Pediatrics) and more specialized fields (Endocrinology and Pediatric Nephrology for my household). Once you passed the test, you were board certified forever.

A few years back, someone decided that certification should not be forever. Boards should have processes to certify that a physician’s knowledge and skills remained current. I was in the first group in pediatrics that could not get permanent certification (we became board eligible in 1988).

It sounds reasonable to require continuing medical education (CME), and state licensing boards have required documentation of such coursework for years. Sitting through a lecture did not insure learning, though. This new process would assure specialty-specific CME, along with the examination to document the accomplishment. So far, so good.

But then the powers that be decided that knowledge alone does not a physician make. Practicing medicine requires skills not tested by traditional multiple choice exams. Thus, MOC was born.

MOC includes (1)maintaining unrestricted medical licensure; (2)completing qualified education modules; (3)practice improvement projects and patient surveys; and (4)secure examination.

My husband is currently performing a practice improvement module. A quality measure has to be first defined, and then measured via a chart audit. Once measurements are made, an improvement project can then be implemented. This takes time and person-power to accomplish. In academia, he has time to pursue this, along with support staff to help carry it out. Those in private practice will have to clear patient schedules to perform these tasks (loss of revenue), and/or hire personnel to perform them (increased costs). Either way, these requirements have negative economic impact on a practice.

Will physicians continue to practice after a couple of rounds of MOC? I believe most will; after all, taking care of patients drives most doctors to “doctor.” Will doctors maintain certification? A number of insurers require MOC for reimbursement of specialty services, so I suspect many will. I guess a fair number will not, especially in primary care. Once your patient base is set, they are unlikely to ask if you have maintained certification. Many doctors may find that patients prefer to have them more available, rather than working on MOC.

I recertified in general pediatrics once. At the time recertification was an open-book exam via personal computer. I learned a lot of things that I had missed while devoting myself strictly to my subspecialty. It was a great experience, and I had no ill will about doing it (not even the cost). I will no longer be maintaining this certification for a number of reasons, especially the fact that I have no general pediatric patients for the required survey. I am enrolled in the Pediatric Nephrology MOC program.

MOC looks good on paper, but it will not be easy to complete, especially in a clinical practice environment. Only time will tell if physicians maintain certification and if MOC makes any difference in physician performance or patient satisfaction.

Lack of data never stopped anyone from enforcing a course of action.

Qualitative Quap

2010-03-16T13:38:00.001-07:00

The blogosphere has been buzzing about a recent publication on science blogging. The study by Inna Kouper is “an attempt to understand current practices of science blogging and to provide insight into the role of blogging in the promotion of more interactive forms of science communication.”

She examined eleven blogs.

I must admit I have trouble getting my brain around qualitative research. To my mind, research should provide information that can be generalized or applied in some way. Many forms of qualitative research cannot be used this way.

I asked one of my colleagues who really likes this sort of analysis what he thought of a sample size of 11 for this study. He said that was a reasonable number depending on the goals and methodology of the study. A qualitative study would not necessarily require a random sample of a certain percentage of blogs; that’s quantitative research thinking!

So I sent him the paper.

He was not impressed.

[One] disturbing part of this is that the methods do not mention how or why the particular blogs were chosen. There is no consistency and no specific criteria that is detailed. That is important for any qualitative analysis because there should be a specific phenomenon that is being analyzed. This author very loosely commented that the purpose was to look at science-related blogs and the responses. That is very broad and does not guide one to believe looking at only 11 blogs is useful data....even in qualitative studies.

He also comments that the qualitative analysis theory the study used was exceedingly difficult to find within the manuscript. His most damning criticism:

[More detail is needed on the] data reduction that was done. Yes, the author details how items were coded. However, this coding process was not validated by an independent reviewer to ensure they were coding in a similar manner. That is the one way to ensure reliability and credibility of the data collection and data analysis process. This was not done at all from what I read.

Qualitative research is a different world, but even in that world there are problems with this work.

For earlier posts on this study see:

A Blog Around The Clock

DrugMonkey

On Becoming a Domestic and Laboratory Goddess

I realize I have not credited my qualitative statistics expert; I will let him “out” himself, if he desires, in the comments section.

Membership Has Its Benefits

2010-03-12T12:06:00.001-08:00

I remember joining a sorority in high school. After pledging, we had secrets to learn. Rules, colors, and goals were memorized and recited, the exact texts never to be shared outside of our sisterhood. OR ELSE…

Dan Brown makes a pretty good living writing about secret societies. People keep joining these groups, even though death seems to be the price of holding their secrets.

Biomedical and scientific societies are not quite this secretive. Or dangerous.

In an email on March 10, The Scientist linked to an essay on membership in scientific societies. Steven Wiley briefly discusses the origins of scientific societies and their vanishing benefits. Most journals are readily available online or through a university library. Opportunities to present work flourish. Groups can be powerful advocates for funding as the NIH budget seems to be driven and targeted more and more by special interests. Networking and career advice also provide value.

Some of these groups have trouble:

many of the larger societies are struggling with stagnant or declining memberships, especially among young scientists. Although it is the youngest scientists who potentially have the most to gain from a scientific society because of networking opportunities, they are the ones who usually are most poorly served by those societies. This is because scientific societies generally cater to the status quo…

It does not have to be this way.

As a nephrologist, my strongest allegiance is to the American Society of Nephrology. I joined after completing fellowship because it was the “thing to do.” It got me a bit of a discount on registration for the annual meeting, and I could submit my abstracts without having to track down a sponsor to sign the submission form (yes, it was that long ago). Over the years, ASN has published two journals (JASN has the highest impact-factor of nephrology journals; CJASN has grown into a monthly publication), an update and self-assessment program publication (NephSAP), and a newsmagazine (which I edit). The society maintains several grant programs for research funding, and it leads advocacy efforts to maintain adequate federal funding for kidney disease research and treatment. Full benefits of membership can be found here.

ASN maintains relevancy with some less traditional output as well. Highlights of the annual meeting become RenalWeekends for members unable to attend RenalWeek, the big annual meeting. Members also work closely with the certification boards on the development of Maintenance of Certification (MOC) coursework and criteria. Board Review Courses provide another membership benefit. In the last few years, web-based learning and podcasts added to the society’s offerings.

The American Physiologic Society also impresses with their efforts to provide relevant services to members (click here for the full benefits page). For example, students and young investigators awarded travel grants for Experimental Biology are paired with “meeting mentors.” Mentors and mentees (is that a real word?) are corralled together during EB. Advice imparted includes getting the most out of a huge meeting and the power of networking. APS provides much needed career support for those pursuing careers in academia or industry, research or teaching. Advocacy and public relations on a number of topics are another service provided by the organization that make my dues worthwhile.

One reason I feel these are value-added organizations is that I have been behind-the-scenes working on committees and projects. I have seen the effort that goes into making the world, at least from the members’ perspective, a better place. Their offices are not just a clearinghouse to process membership fees.

Some of the groups that get my dues do not impress me that much, and I maintain membership because I should. Others, like ASN and APS, are making a difference. If you belong to a group that is underperforming in your eyes, perhaps you need to get involved and make something happen. Most big organizations seem to need volunteers for committees and advocacy (what they call unpaid lobbying), and they welcome junior member participation, at least in my experience.

When you come right down to it, organizations are their members.

Happy World Kidney Day 2010!

2010-03-11T08:49:00.001-08:00

Once again the second Thursday in March has rolled around, bringing celebrations of all things kidney with it! World Kidney Day, for ye of little faith, is a real event (go ahead and click the link if you don’t believe me), but it really needs better PR.

This year’s theme reminds folks to protect their kidneys by preventing and controlling diabetes, a disease near and dear to my heart both personally and professionally. Today should be doubly festive in my household.

And that is the problem. We have no generally recognized festivities for World Kidney Day.

No songs.

No gifts or cards.

No activities or foods.

In the spirit of the day, I invite people to suggest ways to make the second Thursday in March more festive. Christmas has candy canes and cookies. Easter has Cadbury eggs and Peeps. What special foods should we have for World Kidney Day? Please do not suggest anything containing actual kidney; that would be (1)too literal to be clever and (2)something I do not like (and yes, I have tried steak and kidney pie; IMHO, a waste of steak).

Next week a whole bunch of people will become Irish for a day; beer would be an appropriate beverage for today without even dying it!

Come on! We have a year to make World Kidney Day 2011 unforgettable!

Pee on Earth, Goodwill to Urine!

Top image created by Pascale Hammond Lane.

Other images courtesy of PhotoXpress.

del.icio.us Tags: world kidney day

Primer on NICUs

2010-03-09T13:38:00.001-08:00

Last week I posted on neonatal hypertension. This week I am reminded that not everyone appreciates the level of care some newborn infants require, nor that nurseries are rated for the level of care that they may provide.

The American Academy of Pediatrics describes 3 major levels of newborn nursery care, with 4 sublevels for those serving the sickest infants as outlined below:

Basic neonatal care (level I)

    Well-newborn nursery

    Evaluation and postnatal care of healthy newborns

    Neonatal resuscitation

    Stabilization of ill newborns until transfer to a facility at which specialty neonatal care is provided

Specialty neonatal care (level II)

    Special care nursery

    Care of preterm infants with birth weight at least 1500 g

    Resuscitation and stabilization of preterm and/or ill infants before transfer to a facility at which newborn intensive care is provided

Subspecialty neonatal intensive care (level III)

Level IIIA

        Hospital or state-mandated restriction on type and/or duration of mechanical ventilation

Level IIIB

        No restrictions on type or duration of mechanical ventilation

        No major surgery

Level IIIC

        Major surgery performed on site (eg, omphalocele repair, tracheoesophageal fistula or esophageal atresia repair, bowel resection, myelomeningocele repair, ventriculoperitoneal shunt)

        No surgical repair of serious congenital heart anomalies that require cardiopulmonary bypass and /or ECMO for medical conditions

Level IIID

        Major surgery, surgical repair of serious congenital heart anomalies that require cardiopulmonary bypass, and/or ECMO for medical conditions

I visited a shopping center yesterday that was plastered with posters about a new Women’s Hospital nearing completion in Omaha. According to these posters, this place will provide comprehensive service for mothers and infants, including the first level III NICU in west Omaha. On their website they describe the design and engineering that will make their facilities wonderful:

Unfortunately, the subtlety of “virtually all” critically ill neonates may be lost on a lot of laypeople. Many of them will see the following still on the landing page and assume that “everything” means, well, everything:

I am one of two Pediatric Nephrologists in this region. We currently see patients, including sick newborns, at 3 hospitals in the Omaha area, all with level III NICUs (2 are IIID; the other is IIIC or D). I also have a lab and a bunch of other job responsibilities, so I am seeing patients about one-third of the time. Essentially, a single kidney specialist serves the state of Nebraska and other nearby areas (western Iowa and the Dakotas). Covering the hospitals we currently serve is difficult at best. Another level III NICU in Omaha (covered by our neonatologists) wants us to provide services, but we do not have the personnel to do it. They show similar ads for their NICU around town, and I shudder when I see the billboards.

Adding yet another NICU to our coverage is not in the cards right now. In other words, if your baby encounters problems with its kidneys, pediatric subspecialty care will not be available at this shiny new neonatal unit. I am sure it is a beautiful unit, with everything new parents could want. But not a nephrologist.

I cannot speak for all pediatric subspecialists in Omaha, but it is not clear which, if any, of them will be covering the new hospital.

Parents need to understand these issues (if they are not having an absolutely uncomplicated pregnancy) and discuss the best place to deliver with their perinatologist. Ask if the appropriate pediatric specialists will be available immediately, if needed, or if the baby will have to be transferred to get all the care it (probably) needs. Ask if you can talk to these specialists before planning your delivery. Some abnormalities may not require immediate care, allowing mom and dad more choices about where baby is born. Other conditions will limit options; transporting the baby in a uterus is generally easier than moving a critically ill newborn in an ambulance.

del.icio.us Tags: Clinical,Medicine,NICU,Omaha

More On Money

2010-03-08T17:02:00.001-08:00

A few days ago I posted a query about raises with promotions in academia. I queried some other sites as well, ones with readers with experience in the whole promotion thing.

I am dismayed.

Most of those who answered pointed to educational salary sites. One can presume, based on the increase in median salary from rank-to-rank, that there is that level of increase. Some schools have rules, generally a set amount based on the tabular data from AAMC or other standard sites.

Many schools have no increase in salary with rank. Promotion occurs through acquisition of grants or clinical work. These activities may make one eligible for incentives that increase salary as well as resulting in promotion.

But no increase in base pay.

So even though one gets promoted with tenure, and a guaranteed salary line, the amount guaranteed remains low. Many who have responded report never receiving any raise to base pay besides small cost-of-living boosts.

I expect more answers will be coming in, and I will update if I get any novel information.

I didn’t realize how good I had it.

del.icio.us Tags: academia,promotion,salary

Ignore or Engage?

2010-03-06T09:49:00.001-08:00

Last night my daughter called to talk to her brother with an unusual question:

Who were those people dressed like fairies outside of your high school?

Seems Westboro Baptist Church has been making the rounds in Omaha. Yup, the “god hates fags” people targeted a high school for the unforgiveable sin of putting on the school edition of Rent (last month) and having a Gay-Straight Student Alliance. My daughter was in the group of students that put together that alliance. I am pretty proud of that.

Other high schools in the area have been targeted recently. The schools know when the protesters are due, since they are “kind” enough to post a schedule online (Academy Awards, you have the next one). The local schools have not engaged the protests; I guess fairies are like trolls and go away if you withhold food. Or publicity.

No mention made of the activity on the local news or in the paper this morning. Maybe if we ignore them they will go away. Maybe the schools have it right. I just hate to do that; when we do not actively fight hate and ignorance, I feel like we give it approval. Writing this blog may be the wrong thing in the eyes of some, but I feel better letting the world know that at least one family at our high school disagrees with these bigots.

Note: I included the link to the church’s website above, but I don’t recommend clicking on it unless you want to see a whole lot of offensive ignorance in full-color html.

How Much To Request, How Much To Expect

2010-03-05T12:10:00.001-08:00

A question arose in discussion earlier today:

When being promoted in academia, what sort of performance raise should one request or expect?

In biomedical specialties in centers that include medical schools, there are standards for salary by region and rank available through the Association of American Medical Colleges. There are a couple of problems with relying on these data to determine your salary goals.

First, they report median and various percentiles for your department, rank and administrative title, and region of the country. Years in rank generally are not filtered in, so knowing an appropriate “starting salary” is more difficult. Second, these are lag data, reported after the fact. Salaries (should) already be higher than what is reported.

Some institutions use the median for rank and region as a base, adding in fudge factors for years in rank, productivity, and other variables. While this approach seems fair, it means there is really no market working in academic medicine. Basing salaries on regional medians works to keep everyone in the same range, even in short-supply specialties like my own.

The only guide I have ever received was 10%. If you get a promotion or tenure, you should receive at least a 10% raise. If you change institutions, even without change in rank, you should get at least 10% more in salary than in your old position.

Since most of my promotions occurred within a single institution, there was no “request” for a raise with promotion; I knew my chair would make it 10% since he gave me the above guidelines. However, what if you have the opportunity to request a performance raise. How much should you request? Is there a limit to how high you can go without looking like a greedy, ungrateful wretch?

I am looking for experiences. Please leave your comments, opinions, gripes, etc, along with your general area (basic science department, clinical science, whatever). I realize this is an extremely unscientific survey, but we have to start somewhere.

Photo courtesy of PhotoXpress.

Hyper-what? In the NICU!

2010-03-02T13:24:00.001-08:00

I get consulted a lot for neonatal hypertension.

In actuality, most cases I see are not really neonates but premature infants who are nearing their due dates. They often have chronic lung problems or other major health issues and a history of umbilical vessel catheterizations.

Because of issues with measuring and confirming blood pressures in this age group, our practice is to rely on the systolic measurement (SBp). A variety of studies address normal blood pressure in neonates, with most showing a value of approximately 110 mmHg as the 95th percentile after the first 2 weeks of life. Elevated blood pressures in these infants rarely cause detectable end-organ damage such as cardiac enlargement. Virtually all infants with blood pressures above the 95th percentile have complete resolution of this condition by 2 years of age. Risks and benefits of treatment or non-treatment remain unclear.

Values repeated greater than the 95th percentile for age warrant a work-up that includes estimated glomerular filtration rate via serum creatinine measurement; a urinalysis and culture; and a renal ultrasound with doppler bloodflow studies. Echocardiogram may show a cause for the SBp elevation, or may indicate end-organ damage. We rarely find a secondary cause for the blood pressure elevation.

The question remains whether to treat or not to treat. No studies provide concrete evidence of benefit of treatment. Major risks of medications include dropping the blood pressure too low. Occasional reports of death, heart failure, and encephalopathy associated with high blood pressure warrant careful consideration of treatment benefits, though.

About 10 years ago, I decided to make a “rule” about how I would handle these babies. SBp of 110 seemed the critical value. Since most of these infants were still in neonatal units, we generally had access to multiple readings over several days. If the SBp were greater than 110 on more than half of the readings, treatment with an angiotensin-coverting enzyme inhibitor was recommended. Otherwise, ongoing observation of SBp occurred.

My last call week included several infants with SBp elevations, so I pulled more recent articles on this topic. While no definitive randomized trials or other evidence-based studies have been published, the overall recommendations remain consistent with those I created a decade ago, as far as I can tell.

I feel better now. But I wish we knew more.

References:

Arch Dis Child Fetal Neonatal Ed 2002;86:F78-F81 doi:10.1136/fn.86.2.F78

Pediatr Nephrol. 2009 Jan;24(1):141-6. Epub 2008 Jul 9 doi:10.1007/s00467-008-0916-9

del.icio.us Tags: Clinical,medicine

When Kidneys Fail: A Brief Glossary

2010-03-01T11:16:00.001-08:00

One of my current projects centers on the rebuilding of the continuous renal replacement therapy (CRRT) program at Children’s Hospital and Medical Center in Omaha, NE. Last week I blogged from a CRRT meeting on Coronado Island, and more posts will include these topics as the project progresses. Definitions seem in order.

When kidneys fail, some form of dialysis must be performed to replace their function. Most people have heard about hemodialysis, illustrated in the photo, in which blood is pumped out of the body, run through an artificial kidney, and then returned to the circulation. Another form, peritoneal dialysis, uses the blood vessels that run through membranes in the bowels to filter blood. A tube inserted into the abdomen allows fluid to surround the bowels. After time for wastes to enter the fluid, it is drained and replaced.

CRRT is a continuous form of hemodialysis. Some forms of CRRT use primarily hemofiltration to remove water and wastes from the body. Blood passes through the dialysis cartridge as in hemodialysis, but no dialysate passes around the blood filters. Instead, large amounts of filtrate are removed and then replaced with an appropriate sterile solution. In many cases, patients require both this type of clearance as well as dialysis to maintain appropriate biochemical balance; these therapies are collectively called hemodiafiltration.

CRRT removes fluid and wastes continuously, thus providing gentler shifts in balance than traditional hemodialysis. This therapy class most frequently benefits unstable intensive care patients who would not be able to tolerate hemodialysis and in whom peritoneal dialysis may not be feasible.

A pediatric CRRT program faces special challenges. First, virtually none of the devices have been FDA-approved for use in children; pediatric CRRT is not a huge market. Second, we are dealing with a much wider range of patient size than the adult market, with weights ranging from 5 to 300 pounds. Scalability becomes much more of an issue.

The process of rebuilding a program can be tedious, but we will develop state-of-the-art capabilities. Next step? Reviewing hardware.

Stay tuned!

Goodbye Coronado, Hello Home

2010-02-27T06:00:00.000-08:00

Today I will leave the San Diego area for uncomfortable airport seats, and then the colder climes of home. I have survived my 5 day adventure with the contents of my computer tote and a standard roll-aboard suitcase. These included:

2 pairs of dress trousers
1 pencil skirt
4 knit tops
2 knit cardigans
1 denim jacket
2 pairs of shoes (1 worn Tuesday en route)
1 pair of jeans (worn Tuesday)
1 additional top (worn Tuesday)
1 trench coat (worn Tuesday)
1 nightshirt
Assorted cosmetics
Appropriate undergarments
Netbook, Kindle, and Blackberry with their chargers

I could easily have packed two more tops to get another day’s wear out of each pair of trousers. So, in theory, I could have gone a week with just the contents of allowable carry-on bags.

That is the art of packing. For other upcoming trips I will not be quite as condensed (mostly because I have already been discussing footwear with other meeting attendees; I have a reputation to uphold, you know).

Photo courtesy of PhotoXpress.

Update on ZZZZ$

2010-02-26T19:34:00.001-08:00

So yesterday I posted my disappointment that a daily email newsletter was pushing a probably harmless but unproven sleep aid.

So what did Google AdSense place with this post?

Wait for it…. You got it!

Catching Some ZZZZ$

2010-02-25T20:35:00.001-08:00

This morning I received an email update from Pink magazine about sleep. This email article discussed and linked to a site for Alteril, “the sleep aid that can make all the difference in your sleep.”

So what is this miraculous substance?

Alteril is an all natural sleep aid formula that contains the ingredients shown to help you sleep. If you are one of the millions of people who have trouble falling asleep, get up in the middle of the night, or wake up groggy in the morning, Alteril may be the solution for you.

Many people have taken sleep aids that contain the ingredients found in Alteril for years for good, sound sleep and now it is available to you for only a fraction of the cost of prescription sleep medications.

Alteril contains three primary ingredients, L-tryptophan, melatonin and valerian, along with additional ingredients believed to help calm and relax you.

Alteril may help you get the deep, restful sleep you need and lets you wake up energized for the entire day. This combination of nutraceuticals interact with brain receptors and is believed to help produce deep restful sleep.

L-tryptophan is the amino acid metabolized to produce serotonin and melatonin; it is frequently blamed for the post-Thanksgiving nap, although this effect remains unproven and controversial.

Melatonin, produced endogenously, promotes sleep. The effects of exogenous melatonin are less clear. According to the government’s evidence report:

Evidence suggests that melatonin is not effective in treating most primary sleep disorders with short-term use, although there is some evidence to suggest that melatonin is effective in treating delayed sleep phase syndrome with short-term use.
Evidence suggests that melatonin is not effective in treating most secondary sleep disorders with short-term use.
No evidence suggests that melatonin is effective in alleviating the sleep disturbance aspect of jet lag and shiftwork disorder.
Evidence suggests that melatonin is safe with short-term use.

Valerian, the final ingredient, is the root of a plant used to “treat” insomnia and anxiety. Few studies of sufficient quality exist to judge its efficacy. Few reports of side effects or drug interactions exist, but, once again, it has not been rigorously studied.

Thus, this box appears on the Alteril site:

When I review those bullet points from their web site, it sure sounds like Alteril is intended to treat something; sleeping problems, for instance.

The Alteril site has some great suggestions for sleep hygiene that may be sufficient for most people with occasional insomnia. It reminds me of diet aids that are most effective when used with a prescribed diet and exercise program.

I realize that sponsors and promotions are part of the Pink business plan. I don’t mind getting a pitch for a book or service; I have actually bought some of this stuff. I do mind getting ads for a non-drug that at best can be said to be harmless. Because not everyone is going to look up other sources of information, like I just did.

Sleeping child courtesy of PhotoXpress.

PowerPoint Notes

2010-02-25T11:42:00.001-08:00

So, still at my conference. My morning “workshop” on extracorporeal treatments for sepsis was not particularly enlightening.

Sepsis syndrome is associated with eleventy-billion evil humors in the blood and tissues
Clearing evil humors in controlled experimental models appears beneficial
Even though we can really only clear the central circulatory compartment (~30 m^2) while the capillary/lymphatic compartment that communicates directly with tissue is pretty much inaccessible (and huge at ~300 m^2)
But nothing yet seems to make much of a difference in humans, probably because we are genetically heterogeneous and are comparing real-life sepsis, not controlled, defined models

What did I learn? Well, if you want to use a figure in a slide, try to get it from an online source like a web version or computer generated PDF. If you must scan a printed copy, don’t start with a photocopy, and jack the resolution up higher than your scanner’s default.

Cause what appears minimally jaggy on your computer is damn well unreadable when projected on a conference wall screen.

Learning New Stuff

2010-02-24T22:46:00.001-08:00

I have lived a busy meeting day with sessions on acute kidney injury (AKI) stretching from 8am until 7pm. I learned a lot; as I noted on twitter, friends and colleagues greeted me as follows:

Pascale, what are you doing here?

See, my research has focused on diabetic kidney disease and kidney growth. Most recently a project on kidney development has, well, developed. AKI was not in my repertoire.

It is now. Our clinical service needed work, and I needed to learn more. Today helped, although I must admit that my brain was full a couple of hours before we quit meeting for the day.

I have 2.5 more days of workshops and symposia. I hope to bring home lots of information to help my patients. I hope to be refreshed by the sight and scent of azaleas and other flowers in bloom.

And maybe next time I hit this meeting no one will ask why I’m here.

Photo courtesy of PhotoXpress.

OMG It Is Lovely Here

2010-02-24T04:00:00.000-08:00

So I am in the Hotel Del Coronado. Ocean breezes scented with some flower that doesn’t live in Omaha waft through my room.

I will spend all day in a conference room discussing acute kidney injury.

Today’s wardrobe items (photo available via the twitter feed) include a pair of black pants with subtle white and blue pinstripes. A wild-print tee in shades of blue, white, and black is up on top with a black cardigan. My black shoes will finish the outfit; if space had been less of an issue, a pair of cobalt blue patent pumps would finish the look.

The trousers are neutral enough that after 24 hours on a hanger I could wear them again with a different top, extending my carry-on wardrobe another day.

Later today I will discuss the sciencey stuff going on at the meeting. In the meantime, at least I see no dirty snow outside of the window.

And that’s a very good thing.