Sketchnote in Nephrology: Medicine

A great read for educators and learners is the book called The Sketchnote Handbook – The Illustrated Guide to Visual Note Taking, a new book released by Mike Rohde.  Sketchnotes  are visual diagrams of a lecture that has some writing and some figures to allow a different form of note taking. 
In physiology, especially complex renal physiology such note taking strategies might be useful for certain type of learners. This allows for a larger bigger overall understanding and can allow for details as well.  Many of us might be doing this already when we take notes( perhaps draw a flow chart) for better understanding of the topic being discussed. Sketchnotes are about hearing and capturing meaningful ideas and not how well you draw.  This book gives a way to take notes differently from what one might have traditionally done.  A picture can tell you more than a detail description of a nephron sub-segment. In one study in Plastic Surgery, a picture told more than words.  
Sketchnote will allow you to think out loud and clear your misconceptions. 

Some examples of discussions and mentions of use of such tactics in medicine are linked below.
33charts view on this topic.
Sketchnote version of the recent Med 2.0 2012 conference in boston
Pediatric Surgery

CRRT Update

A nice review in NEJM current issue Dec 2012, there is a clinical perspective review on CRRT use in AKI.
Dr. Tolwani reviews the implications of CRRT and the current state of practice. From the indications to the different clinical trials, the review nicely summarizes last few years of research and practice.
Two great tables to take home: Table 1 discusses the different modalitis( CVVH, CVVHD and CVVHDF) and compares it via solute transport, replacement fluid and flow rates. It is a nice summary table for many trainees to review.  Important to emphasize the true indications for use of CRRT and then which one of the above to choose. The access is an important component discussed as choice of vein should be in order of IJ>femoral>subclavian. In addition, anticoagulation is important as many times, heparin cannot be used in such cases and citrate based CRRT might be needed. Data on that are slowly emerging. Finally, dosing of drugs and antibiotics is important consideration in CRRT.

NEWphrologist in the making!

The Jan 2013 issue of ACKD has a focus on the role of the nephrologist in the intensive care units( medical, surgical, neurosurgical, cardiac). Vast topics from sepsis, care of a ventilated patient, critically ill ESRD patient are discussed in the entire issue. Interestingly, a new name is given to the role of the nephrologist in the intensive care unit- newphrologist. Definitely a growing field in nephrology and at some centers - a separate service. Not sure if the name justifies the function of the intensivist nephrologist.

Nevertheless, check out the entire issue on ACKD.

Blogging in nephrology: Local versus National conferences

Desai et al show in a study that scientific blogs can be a great tool in sharing and viewing scientific local meetings. Most of the recent literature and live blogging that has been done has been of national meetings. Most non academic practitioners want to hear about the happenings are national meetings. In Nephrology, many online blogging sites have done this in the last 4 years.  The data presented here in this manuscript suggests that while the number of viewers were less in local meeting blog posts, the minutes spent and time spent were equally comparable to national blog posts. The authors suggest that this would be a great way to share and use local conference material. Bogoch et al looked at blogging site of intern morning report and had subjective rating scales but knowledge content was not looked at. 

Overall,this manuscript is a step in the right direction and allows for openness of presentation of data in national and local conferences via blogging. Both conferences can be equally useful to the learner.  

Interestingly, publishing in formats as such( F1000 research journal) when peer review is also open and allows for free commenting before completely being accepted for publishing allows for more information to be discussed and an open dialogue. More and more journals should be moving to such platforms of publishing( at least partly). There might be red tape and other factors preventing this. The Plos Journals are a great example of the futuristic journal platform. Cost, and potential bias based reviews might be reasons why this might be not as attractive to many journal editors. 

CLINICAL CASE 66: Answers and Summary

ESRD PATIENT ON HEMODIALYSIS PRESENTS WITH HYPERGLYCEMIA OF 800. HOW WILL YOU TREAT?

Severe hyperglycemia in oliguric or anuric ESRD patients is not associated with features of a glucose-related osmotic diuresis as is seen in other patients but is more likely to be associated with hyponatremia, hyperkalemia, and acute intravascular volume expansion and instead of giving fluids and insulin, one must resort to good insulin therapy and prompt dialysis. A prior post discusses this in more detail. Hence the most appropriate answer is Insulin and dialysis.

microRNAs and renal disease?- more data

Epigenetics refers to a heritable change genetic code that is mediated by a mechanism specifically not due to alterations in the primary nucleotide sequence.  These epigenetic changes can lead to medical condition changes. Recent studies have shown that epigenetic modifications orchestrate the epithelial-mesenchymal transition and eventually fibrosis of the renal tissue.

MicroRNAs (miRNAs) are short non-coding RNAs regulating gene expression at the post-transcriptional level by blocking translation or promoting cleavage of their target mRNAs. Increasing evidence shows that miRNAs play central roles in gene transcription, signal transduction and pathogenesis of human diseases. Epigenetic changes might be resulting via the miRNAs.

MicroRNAs( miRNAs) have been the focus of many renal disease spectrums from glomerular diseases to transplant rejection. A recent study in Experimental and Molecular Pathology is one of the first to examine the role of miRNAs in HIVAN. The investigators showed that 11 miRNA were downregulated in HIVAN when compared to controlled mice. Further examination showed that miR-200 and miR-33 were the two that had effects on the podocytes specifically. 

This begs a question of looking at miRNA in many renal diseases. Another study recently published looked at urinary miR-21, miR-29 and miR-93 as novel biomarkers of fibrosis in patients with IgA nephropathy. Lupus Nephritis had miR-638, miR-198 and miR-146a compared to controls. 

Interestingly. miR-155 and miR-126 are elevated in ESRD patients as potential markers of inflammation. miRNAs have been studied in diabetic nephropathy as well. 

The list can go on and on... And we are sure to see more role of miRNA in clinical use perhaps in near renal future. Still unclear is how these numbers will be very helpful. Repeat studies to confirm that certain miRNA are markers for lupus flare versus diabetic nephropathy are needed. They might assist in a decision to biopsy or not to biopsy? Or are they mere markers of prognosis. More global decision has to be made on how to use these tests in future use:- markers, or targets for potential treatments....

ASN: Geriatric Nephrology Videos

ASN launched a new five-part video series, "Improving Dialysis Rounds for Geriatric Patients," produced by the ASN Geriatric Nephrology Advisory Group and made possible with support from the Association of Specialty Professors. The publicly available, free video series, accessible online and, covers important aspects of care of aging patients, including assessment, treatment decisions for patients with advanced kidney disease, care of elderly patients receiving chronic dialysis, recognition of physical and mental decline, the importance of quality of life, and of shared decision-making between patients, caregivers, and providers.

Have a look at this great educational resource.