Archive for the '[Medicine&Pharma]' category

A Bit of Sweetness for #KetoLife

Aug 28 2017 Published by under General Health

I think you can pick out July 17...

Like a number of my Twitter buddies, I have been following a version of the ketogenic diet since July 17. Pediatricians often hear about this as a treatment for seizures in children; however, eliminating high-glycemic index carbohydrates from the diet makes the fat practically melt off some people. You can read more about the basics here. One of the challenges of the plan is to find foods that replace your favorite high-carb munchies with something healthier. Over the weekend, a bunch of us got to talking about this on Twitter. I mentioned this creation of mine and promised to blog it.

I purchased a couple of #ketolife cookbooks to start. This gave me ideas for how to achieve flavors and textures associated with forbidden carbs. Love breaded pork chops cooked with Shake-n-Bake? A mixture of almond flour and ground up pork rinds will give you the same texture! Barbeque pork rinds provide a similar flavor! (BTW, the cookbook used this mixture to crispy coat orange chicken).

Sweet things can also be a challenge. One of the cookbooks I bought included Triple Layer Fat Bombs. The layers included a mixed nut-butter bottom, a cream cheese middle, and a chocolate topping. They were frozen, and the nut-butters never really firmed up for me, while the topping layer got rock hard. After playing around with the perfectly textured middle bit, I came up with a chocolate cheesecake dessert.

The most important tool for this dish is a silicone mini-muffin tin. MIne is by Wilton and available at Bed, Bath, and Beyond. You will never get the finished product out of a traditional tin.

Frozen Chocolate Cheese Treats


6 oz cream cheese, divided

6 Tablespoons erythritol, divided

3+ Tablespoons heavy cream, divided

1 teaspoon unsweetened cocoa

  1. Divide cream cheese equally between two small bowls.
  2. Add 3 Tablespoons of erythritol to each bowl.
  3. Add 1 Tablespoon of heavy cream to one bowl and mix well. If sweetener does not dissolve easily, add a bit more cream and continue mixing.
  4. Add 2 Tablespoons of heavy cream and the cocoa to the other bowl and mix well. A bit of additional cream may be necessary for the mixture to be smooth.
  5. Divide the white mixture among the twelve mini-muffin cups. This mixture is thick; after dividing it, scoot the pan back and forth on the counter so the contents level out (see photo).
  6. Top the cups off with the chocolate mixture. Don't forget to lick the bowl.
  7. Freeze overnight.
  8. To serve, pop out of the muffin cup and let it warm up for a few minutes.

Nutritional Information

Serving Size: 1 Treat  *  Calories:  38  *  Fat (g):  4  *  Carbohydrates (g):  0.3  *  Protein (g):  0.5

I have entered these into the Lose It! database for tracking purposes. I hope you enjoy them as much as I do.

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Another Info Sheet to Comment On: Nephrotic Syndrome

Jul 21 2017 Published by under [Medicine&Pharma]

Thanks to everyone who read and commented on my new improved biopsy handout. I have now tried to simplify my nephrotic syndrome sheet.

Once again, you can use the original sheet as the "exhaustive" lay handout with the complete information.

Original NS

New Nephrotic Syndrome

Thanks in advance for your comments!

One response so far

Your Feedback Works

Jul 06 2017 Published by under [Medicine&Pharma]

I have integrated comments from here and elsewhere into a yet more improved information handout on kidney biopsy.

This should be viewed as a supplement to the detailed discussion with me or another nephrologist, not an exhaustive discussion of the procedure.

Go to it, WhizBangers!

Newer Biopsy Handout

2 responses so far

Compare and Contrast

Jul 03 2017 Published by under [Medicine&Pharma]

I am trying to make my patient and parent handouts more user-friendly. I’m moving from text-dense to less wordy pieces, and I could use some beta testing from the WhizBanger Crew.

Wordy Original Handout

New Improved Handout

Please leave your views in the comments. Does the shorter less wordy handout capture the key points from the original piece? What questions do you have after reading the shorter one?

Thanks in advance for your help.


5 responses so far

Actual Conversation with Hospital Billing

Jun 01 2017 Published by under Medical Paperwork

The other day I got a bill for some of my husband's medical expenses. I went to my banking site to pay, and it was the same odd amount I had paid two weeks before. Figuring it was a duplicate bill, I called the billing office. According to their records, my payment had not been received.

My bank account had proof of payment posted on my account, so I asked about the process to get this fixed. The billing person explained that I had to send a clear image of the front and back of the cancelled check.

I had a PDF including that, along with all the routing information and dates of the electronic transactions. Damn, good digital information can be fun!

Now for the punchline; I could email this, but only within the body of the email. NO ATTACHMENTS.

Yes, the medical center was losing it's stuff* over ransomware about this time and requiring all emails with attachments be quarantined. Apparently the billing department had been told to trust no PDFs from their clientele.

I ended up printing a PDF and faxing it. In May 2017.

Collection agencies have not called yet.

*I'm trying to keep it PG here...

4 responses so far

Another Aspect of Pediatric Disease

May 02 2017 Published by under [Medicine&Pharma]

Jimmy Kimmel gave an emotional monologue this week about his newborn son’s congenital heart disease and the implications it has for his life with a preexisting condition. His pleas for coverage of all children with repairable conditions are important; as he says:

If your baby is going to die, and it doesn’t have to, it shouldn’t matter how much money you make.

Now stories of babies will get the crowd going, and most of the poor will be covered by Medicaid, at least for their initial care. It’s actually more difficult for those with some money and some coverage.

Insurers often require the use of provider networks. There may only be a single hospital in your state that provides the sort of pediatric specialty care we are discussing here. Are they in your network? If not, new parents could face thousands of dollars out-of-pocket, even with “good” insurance.

I understand insurers trying to limit their  expenses through limited contracts. For well child care and a number of other conditions, there may be enough providers distributed about to make networks a good solution. For pediatric specialty care, that often is not the case.

I would like to see network requirements and penalties not be enforced when there is no appropriate provider in network. Perhaps we can get that added to those basic health coverage requirements.

Oh wait, never mind. This is one more thing to eliminate.

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#ExpBio - Cannaboids and the Injured Kidney

Apr 26 2017 Published by under [Biology&Environment], [Medicine&Pharma], ExpBio 2017

Cannabinoid receptors exist in many tissues, not just those fun neurological areas we all think about. The kidney contains type 2 receptors (CB2), and experimental data suggests they might play a role in acute kidney injury. With unilateral ischemia-reperfusion injury (IRI) CB2 receptors are dramatically upregulated after 72 hours, returning to baseline after 168 hours (7 days).

Could activating these receptors help the kidney heal itself?

Pressly et al used a novel CB2 agonist (SMM-295) in bilateral IRI, administering it just after ischemia and every 24 hours after. Kidney function and structure were examined 24 and 48 hours after injury.

Animals treated with SMM-295 did not have elevated creatinines after IRI. NGAL, a marker of tubular damage, also remained lower with treatment. Tissue analysis showed decreased staining for PCNA and TUNEL, demonstrating reduced apoptosis. Tubular damage and casts were reduced by 50% with CB2 agonist treatment.

Acute kidney injury is a major problem in hospitalized patients, especially those undergoing cardiac surgery requiring cardiopulmonary bypass. Any agent that shows this much promise deserves further study, even if it won't give you the munchies!

Click author name above for full abstract.

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#ExpBio - The Problem with Spinach

Apr 26 2017 Published by under [Biology&Environment], [Medicine&Pharma], ExpBio 2017

Spinach and other dark, leafy greens can bomb the human body with oxalate, a major causative factor for kidney stones. Stones also predict chronic kidney disease, making them more than an inconvenient pain.

Spinach smoothie

Mitchell et al, Urologists from the University of Alabama-Birmingham, have found that patients with recurrent oxalate kidney stones show impaired monocyte mitochondrial dysfunction in response to stress in vitro. The present study examined this phenomenon in healthy subjects 21 to 31 years of age with no prior history of stones. Blood for monocyte isolation and oxalate levels was drawn before and 5 hours after an oxalate load delivered as a spinach smoothie.

Blood for monocyte isolation and oxalate levels was drawn before and 5 hours after an oxalate load delivered as a spinach smoothie.

As expected, blood and urine oxalate increased after the spinach smoothie. Overall, mitochondrial function decreased after oxalate loading, with ~60% of participants showing responses similar to the stone-forming population. The remaining participants had preserved monocyte mitochondrial function.

So oxalate may impair monocyte function in people. Could the 60% with abnormal responses represent future stone-formers? Are these the ones more predisposed to chronic kidney disease after stones? Only time will tell.

In the meantime, I plan to avoid green smoothies on principle. And disgust...lots of disgust.

For abstract, click link on author names above.

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#ExpBio - Counterintuitive Results from Framingham

Apr 25 2017 Published by under [Biology&Environment], [Medicine&Pharma], ExpBio 2017

Framingham is the small city that researchers will not leave alone. We are now into the Framingham Offspring Study, examining relationships between some dietary factors and blood pressure control. The study population included 2632 individuals 30-64 years of age who were not on blood pressure medication at the start of the 16 years of follow-up. In the first 5 years of the study, all kept a 6-day diet diary which was used to estimate daily intake of sodium, potassium, magnesium, and calcium. All analysis corrected for age, gender, smoking, activity level and the other usual suspects.

Results were similar for systolic and diastolic blood pressures, so I will just show systolic here:

Systolic blood pressure according to sodium intake among individuals not taking blood pressure lowering medication. Results were adjusted for sex, age, education, height, weight, physical activity, cigarettes per day and alcohol intake.
Credit: Lynn L. Moore, Boston University School of Medicine

How can that be? We have advised healthy individuals to lower salt intake forever to avoid hypertension, yet these folks make that look like exactly the wrong advice. Could there be a confounding diet variable? Let's throw potassium into the mix:

Systolic blood pressure according to the combined intakes of sodium and potassium among individuals not taking blood pressure lowering medication. Results were adjusted for sex, age, education, height, weight, physical activity, cigarettes per day and alcohol intake.
Credit: Lynn L. Moore, Boston University School of Medicine

So low sodium, with or without high potassium intake, produced higher blood pressures than higher sodium plus high potassium intake. Similar results were found for intake of calcium and magnesium, other ions in the diet that seem to ameliorate hypertension.

There are some caveats here, like with every research study. First, even though this is a large, longitudinal study, these are people who are second or third generation research subjects. Being in cardiovascular research likely makes them more health conscious, so their level of sodium intake may not reflect the general US population. Also, these are healthy, non-hypertensive people. Findings might be quite different in people with high blood pressure or salt-sensitivity. They also have no biomarkers of intake; all diet data is from a 6-day diet diary in the initial years of the study. How eating patterns may have changed over time is just not known. Citizens of Framingham get the same health news as the rest of us; did many start green juicing or go paleo?

This study does bring into question reducing sodium intake for the general population. Those of us with hypertension probably need it, but it may not be important for the majority of people. Intake of other minerals may be far more important for general health (check this post out for more on the interrelationships between Na and K transporters in the kidney).

The bottom line? We should all eat a varied diet, avoiding junk food and focusing on fruits, veggies, and dairy with lean protein sources. That DASH-type diet has been shown to reduce weight and blood pressure.

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#ExpBio - It's a Nose, It's a Tongue, It's a Kidney!

Apr 25 2017 Published by under [Biology&Environment], [Medicine&Pharma], ExpBio 2017

For several years I have blogged about the kidney "smelling" stuff. Shepard and Pluznick have now updated their work on kidney olfactory receptor 1393 and it's role in diabetic nephropathy. In mice with this receptor knocked-out, Sglt1 is reduced in the proximal tubular lumen, This results in glycosuria with improvement in glucose tolerance.


They then took these mice and fed them a high fat diet. Even with the development of obesity, the knock-out mice maintained better glucose tolerance and did not develop an elevated glomerular filtration rate as wild-type counterparts did. Insulin tolerance was similar between the groups. Mice lacking the olfactory receptor also accumulated less fat in the liver than their wild-type brethren, even though body weights were similar.

There's still more to learn from these animals, but this is exciting work for sure!

This year, we also learned that kidneys can taste! Sweet receptors have been found in the pancreas and other areas of the gut beyond the tongue. They can regulate function of these organs in response to sugars and artificial sweeteners. Kassem, Ares, and Ortiz now show that sweet receptors T1R2/T1R3 are present in the kidney! They localize to the thick ascending limb and increase the presence of NKCC2 on the surface in response to fructose feeding. Gumarin, an antagonist of the receptor, blocks this response to fructose. The knock-out mouse for this sweet receptor shows diminished levels of NKCC2 in the tubular surface; these mice also have increased urine output with decreased osmolality, consistent with diminished efficiency of loop function.

The study only addressed effects of fructose, but given interactions of artificial sweeteners in the gut, there will be a lot more exciting information coming up, I'm sure.

The kidney: it tastes, it smells, it pees. Makes you think twice about eating that asparagus, huh?

Abstracts linked to author names above.

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