Gender interactions on Twitter and medical education: how is nephrology doing?

Gender inequities negatively impact productivity and career advancement for women. Social media platforms like Twitter can be used to achieve greater parity and address underrepresentation by providing a medium for education, research and mentorship, however, it is unknown how it may contribute to gender inequity. Our aim was to examine gender interactions during a nephrology medical conference.

Nicotinamide Mononucleotide Prevents Free Fatty Acid-Induced Reduction in Glucose Tolerance by Decreasing Insulin Clearance.

The NAD-dependent deacetylase SIRT1 improves ß cell function. Accordingly, nicotinamide mononucleotide (NMN), the product of the rate-limiting step in NAD synthesis, prevents ß cell dysfunction and glucose intolerance in mice fed a high-fat diet. The current study was performed to assess the effects of NMN on ß cell dysfunction and glucose intolerance that are caused specifically by increased circulating free fatty acids (FFAs). NMN was intravenously infused, with or without oleate, in C57BL/6J mice over a 48-h-period to elevate intracellular NAD levels and consequently increase SIRT1 activity. Administration of NMN in the context of elevated plasma FFA levels considerably improved glucose tolerance. This was due not only to partial protection from FFA-induced ß cell dysfunction but also, unexpectedly, to a significant decrease in insulin clearance. However, in conditions of normal FFA levels, NMN impaired glucose tolerance due to decreased ß cell function. The presence of this dual action of NMN suggests caution in its proposed therapeutic use in humans.

Equal work for unequal pay: the gender reimbursement gap for healthcare providers in the United States.

INTRODUCTION: Gender disparities in income continue to exist, and many studies have quantified the gap between male and female workers. These studies paint an incomplete picture of gender income disparity because of their reliance on notoriously inaccurate or incomplete surveys. We quantified gender reimbursement disparity between female and male healthcare providers using objective, non-self-reported data and attempted to adjust the disparity against commonly held beliefs as to why it exists. METHODS: We analysed over three million publicly available Medicare reimbursement claims for calendar year 2012 and compared the reimbursements received by male and female healthcare providers in 13 medical specialties. We adjusted these reimbursement totals against how hard providers worked, how productive each provider was, and their level of experience. We calculated a reimbursement differential between male and female providers by primary medical specialty. RESULTS: The overall adjusted reimbursement differential against female providers was -US$18 677.23 (95% CI -US$19 301.94 to -US$18 052.53). All 13 specialties displayed a negative reimbursement differential against female providers. Only two specialties had reimbursement differentials that were not statistically significant. CONCLUSIONS: After adjustment for how hard a physician works, his/her years of experience and his/her productivity, female healthcare providers are still reimbursed less than male providers. Using objective, non-survey data will provide a more accurate understanding of this reimbursement inequity and perhaps lead the medical profession (as a whole) towards a solution that can reverse this decades-old injustice.

Wanted: pediatric nephrologists! - why trainees are not choosing pediatric nephrology.

A workforce crisis for many pediatric specialties, particularly nephrology, is due to growing retirement rates, attrition during training, and retention difficulties. To obtain specific information regarding pediatric nephrology trainee shortages, we administered two cross-sectional surveys to non-renal pediatric subspecialty fellows and pediatric nephrology program directors. We characterized the fellows' experiences with nephrology and the program directors' experiences with their fellows as well as their outcomes in the last 10 years. We analyzed responses from 531 non-renal fellows (14.4% response rate). Overall, 317 (60%) fellows rated nephrology as difficult, particularly women (65.4% vs. 49.5%, p < 0.001), with American women medical graduates rating nephrology as more difficult compared to all others (p = 0.001). More men than women (24% vs. 8%, p < 0.001) considered the monetary benefit as not adequate. Program directors (25; 64% response rate) represented 57% of all USA fellows in training, and 15 (60%) found it difficult to recruit qualified applicants. Of the 183 graduates in the past 10 years, 35 (19%) were reported as not in the USA pediatric nephrology workforce. These findings support our belief that a strong effort needs to be made by the academic community to teach nephrology in more interesting and understandable formats. While these are national samples, we were unable to contact non-nephrology fellows directly and program directors from larger programs were underrepresented. Difficulties in attracting/retaining trainees (particularly women) to nephrology must be addressed systematically, identifying incentives to practice in this field. Bold concerted efforts are required and we propose seven steps to achieve this goal.

Laboratory stewardship perceptions and testing patterns at a pediatric tertiary care center.

BACKGROUND: Despite stewardship efforts, laboratory testing overuse persists across medicine. OBJECTIVES: To understand laboratory stewardship perceptions and testing patterns at a tertiary care pediatric hospital so that we could identify potential improvement opportunities. METHODS: An electronic survey exploring laboratory stewardship was sent to all pediatric medicine resident and staff physicians. Laboratory testing data were also assessed for patterns of testing and overuse. RESULTS: The survey response rate was 54% (43/80). The results indicated good familiarity with stewardship but poor familiarity with testing specifics (eg, cost). A mobile reference application was the most preferred quality improvement intervention, and online modules were the least desired. Overuse was apparent, with as many as 53% of laboratory tests being repeated within 7 days and only half of repeated tests subsequently yielding abnormal results. CONCLUSIONS: Altogether, the data we collated demonstrated poor understanding of laboratory stewardship and substantial repeat testing with few abnormal results. These study findings suggest that laboratory stewardship is lacking at our center, and that multiple improvement opportunities exist.

Adolescents' Cannabis Knowledge and Risk Perception: A Systematic Review.

To systematically review evidence evaluating cannabis-related knowledge and perception of risk in children and adolescents. We systematically searched Medline, PsycINFO, and EMBASE using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. 133 studies from around the world (including ages 10-18 yrs) met inclusion criteria, with 70% meeting grade 2C quality. Increased knowledge and perception of risk of cannabis frequently correlated with lower levels of current use and intent to use. Studies examining correlations over time generally demonstrated increased adolescent cannabis use and decreased perception of risk. Included prevention-based interventions often enhanced knowledge and/or perception of risk in adolescents exposed to the intervention. Studies exploring outcomes relating to legislative changes for recreational marijuana use demonstrated considerable heterogeneity regarding knowledge and perception of risk whereas studies that focused on medicinal marijuana legislative changes overwhelmingly demonstrated a decrease in perception of risk post legalization. Increased knowledge and perception of risk of cannabis in adolescents often correlate with lower levels of current use and intention to use in the future. Further study and implementation of public health and clinically-oriented strategies that seek to increase knowledge among youth about the potential health harms of cannabis use should continue and be prioritized.

Overexpression of glutathione peroxidase 4 prevents ß-cell dysfunction induced by prolonged elevation of lipids in vivo.

We have shown that oxidative stress is a mechanism of free fatty acid (FFA)-induced ß-cell dysfunction. Unsaturated fatty acids in membranes, including plasma and mitochondrial membranes, are substrates for lipid peroxidation, and lipid peroxidation products are known to cause impaired insulin secretion. Therefore, we hypothesized that mice overexpressing glutathione peroxidase-4 (GPx4), an enzyme that specifically reduces lipid peroxides, are protected from fat-induced ß-cell dysfunction. GPx4-overexpressing mice and their wild-type littermate controls were infused intravenously with saline or oleate for 48 h, after which reactive oxygen species (ROS) were imaged, using dihydrodichlorofluorescein diacetate in isolated islets, and ß-cell function was assessed ex vivo in isolated islets and in vivo during hyperglycemic clamps. Forty-eight-hour FFA elevation in wild-type mice increased ROS and the lipid peroxidation product malondialdehyde and impaired ß-cell function ex vivo in isolated islets and in vivo, as assessed by decreased disposition index. Also, islets of wild-type mice exposed to oleate for 48 h had increased ROS and lipid peroxides and decreased ß-cell function. In contrast, GPx4-overexpressing mice showed no FFA-induced increase in ROS and lipid peroxidation and were protected from the FFA-induced impairment of ß-cell function assessed in vitro, ex vivo and in vivo. These results implicate lipid peroxidation in FFA-induced ß-cell dysfunction.

Why not nephrology? A survey of US internal medicine subspecialty fellows.

BACKGROUND: There is a decreased interest in nephrology such that the number of trainees likely will not meet the upcoming workforce demands posed by the projected number of patients with kidney disease. We conducted a survey of US internal medicine subspecialty fellows in fields other than nephrology to determine why they did not choose nephrology. METHODS: A web-based survey with multiple choice, yes/no, and open-ended questions was sent in summer 2011 to trainees reached through internal medicine subspecialty program directors. RESULTS: 714 fellows responded to the survey (11% response rate). All non-nephrology internal medicine subspecialties were represented, and 90% of respondents were from university-based programs. Of the respondents, 31% indicated that nephrology was the most difficult physiology course taught in medical school, and 26% had considered nephrology as a career choice. Nearly one-fourth of the respondents said they would have considered nephrology if the field had higher income or the subject were taught well during medical school and residency training. The top reasons for not choosing nephrology were the belief that patients with end-stage renal disease were too complicated, the lack of a mentor, and that there were insufficient procedures in nephrology. CONCLUSIONS: Most non-nephrology internal medicine subspecialty fellows never considered nephrology as a career choice. A significant proportion were dissuaded by factors such as the challenges of the patient population, lack of role models, lack of procedures, and perceived difficulty of the subject matter. Addressing these factors will require the concerted effort of nephrologists throughout the training community.

Atypical Immunoglobulin A Vasculitis in a Pediatric Patient With Ulcerative Colitis.

Rates of pediatric inflammatory bowel disease and biologic therapy use continue to rise. Consequently, specialists and generalists should recognize potential complications and side effects. We report the unique case of an adolescent with ulcerative colitis (UC) on vedolizumab presenting with severe abdominal pain, hematochezia, and subsequent purpura. After extensive investigation and a complex clinical course, diagnosis of atypical immunoglobulin A vasculitis was made. This is the first pediatric case of vasculitis in a patient with UC on vedolizumab and only the second reported case overall in UC. This case illustrates the emerging diagnostic challenge of distinguishing inflammatory bowel disease treatment complications from other common pediatric conditions.

Analysis of image-guided superficial radiation therapy (IGSRT) on the treatment of early-stage non-melanoma skin cancer (NMSC) in the outpatient dermatology setting.

BACKGROUND: Interest in image-guidance superficial radiation therapy (IGSRT) for the treatment of early-stage non-melanoma skin cancer (NMSC) has resurfaced given its low complication rates, superior cosmesis and local control and cure rates. In addition, it has been recommended by the American Academy of Dermatology (AAD) for early-stage NMSC in patients who are considered poor surgical candidates. METHODS: 1899 NMSC lesions were treated with energies ranging from 50 to 100 kilovoltage (kV), for a mean of 20.2 fractions, and treatment dose of 5364.4 centigray (cGy). Lesions were treated for a mean of 7.5 weeks and followed for 65.5 weeks. SAS studio was used to conduct Kaplan-Meier analysis to calculate local control rates and account for differences in follow-up intervals. A log-rank test was used to calculate statistical differences between histologies. RESULTS: Absolute lesion control was achieved in 99.7% of the patients after an average of 7.5 weeks of treatment, with a stable control rate of 99.6% when the follow-up duration was over 12 months. 95% of lesions with toxicity scoring received a Radiation Treatment Oncology Group Toxicity (RTOG) score of 1 or 2. CONCLUSION: IGSRT has a high safety profile, can achieve superior cosmesis and should be considered first-line for treating early-stage NMSC tumors as cure rates have been shown to be effective in all NMSC on early follow-up.

Basic pharmacology of topical imiquimod, 5-fluorouracil, and diclofenac for the dermatologic surgeon.

BACKGROUND: Ultraviolet radiation (UVR) contributes to the vast majority of nonmelanoma skin cancer (NMSC). As the incidence of NMSC continues to rise, topical therapies will be used with increasing frequency. Topical therapies may benefit high-risk surgical candidates as an alternative treatment modality and may improve overall cosmesis. The most commonly employed topical therapies are imiquimod, 5-fluorouracil (5-FU), and diclofenac. OBJECTIVE: To review the detailed mechanism of action and side-effect profiles of each topical therapy used to treat NMSC and to explore newly discovered actions. Uncommon adverse events are also presented. MATERIALS AND METHODS: An extensive literature search was performed to describe the pharmacologic actions of imiquimod, 5-FU, and diclofenac. CONCLUSION: A keen understanding of the pharmacologic concepts of these topical therapies may aid the dermatologic surgeon in making sound choices before, during, and after surgery.

Successful treatment of cosmetic mucosal tattoos via Q-switched laser.

BACKGROUND: Tattoo removal using Q-switched lasers is well established in the medical literature, but it is not clear how tattoos on mucosal membranes should be treated because of their infrequent presentation. OBJECTIVE: To report successful cosmetic tattoo removal using Q-switched laser irradiation on the oral mucosal surface. MATERIALS AND METHODS: Three men with cosmetic tattoos on the orolabial mucosa of the lower lip sought permanent removal. Each patient received treatments using a Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser to the desired endpoint. RESULTS: Treatment of the affected area with the Nd:YAG laser resulted in clearing of the pigment without scarring. CONCLUSION: Q-switched laser treatment is a safe and very effective means of removing cosmetic mucosal tattoos on the inner lip and should be considered the criterion standard treatment option.

Web-based nephropathology teaching modules and user satisfaction: the nephrology on-demand experience.

Nephropathology is an integral component of nephrology education. Online teaching sites provide valuable educational materials to learners, but learner satisfaction has not been measured. We developed a nephropathology website and measured learners' satisfaction. The Nephrology On-Demand Histopathology website (http://blog.ecu.edu/sites/nephrologyondemand/?page_id=4502) provided nephropathologic specimens with explanations. Users were asked to complete a Likert-based survey (1-strongly agree . . . 5-strongly disagree) regarding four key areas of content quality: accuracy, currency, objectivity, and usefulness. Learners of all training levels perceived the content quality favorably. The mean (±SD) for accuracy was 1.70 (0.89), currency 1.62 (0.90), objectivity 1.80 (1.01), and usefulness 1.72 (0.95). Nephrology On-Demand Histopathology is a well-received teaching tool to learners of all training levels. Educators may consider using it, as well as other online nephropathology sites, as adjunctive teaching tools.

Tweet me: conferencing in the era of COVID-19 and 280 characters.

The European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) Social Media (SoMe) Team provides Twitter coverage of the annual congress. During the coronavirus disease 2019 (COVID-19) pandemic, #ERAEDTA20 was the first major Nephrology congress to be delivered virtually. The effect of The SoMe Team and the consequences of the COVID-19 pandemic have not been explored previously. Tweets of the ERA-EDTA congresses 2016-20, using official hashtags, were evaluated. Metadata of each tweet were collected prospectively; original tweets, retweets and evidence-based tweets were identified. The gender of tweet author and location of Twitter activity were established. Network maps were created to ascertain the degree of polarization between the 2019 and 2020 Twitter activity, using Gephi 0.9.2. Between 2016 and 2019, the total number of tweets and the number of tweet authors increased, as did the proportion of female authors (20% versus 27%). In 2019, there were fewer multimedia and evidence-based tweets: 8% versus 20% in 2016. Globally, there were fewer Nephrology conferences in 2020 and the number of tweets per day reduced by 53% from 2019. In 2020, The ERA-EDTA congress saw an increase in authors of 9% and only an 8% reduction in tweets. It was easier to disseminate information in 2020, measured by increased correlation coefficient (0.14 versus 0.12 in 2019). A higher proportion of countries was represented (n = 55 versus n = 48 in 2019) and a higher proportion of tweets came from women. In conclusion, the introduction of SoMe Team was associated with increased usage of Twitter and ease of information dissemination. Compared with #nephtwitter activity as a whole in 2020, SoMe Team has mitigated some of the pandemic's deleterious effects in scientific dissemination, relevant to Nephrology.

Pharmacologic or genetic activation of SIRT1 attenuates the fat-induced decrease in beta-cell function in vivo.

BACKGROUND: There is evidence that sirtuin 1 (SIRT1), a key regulator of nutrient metabolism, increases ß-cell secretory function. Excess circulating fat, as seen in obesity, has been shown to decrease ß-cell function, an effect that may involve decreased SIRT1 activity. Consequently, SIRT1 activation may increase ß-cell function in conditions of elevated plasma-free fatty acid levels. Here we attempted to attenuate the lipid-induced decrease in ß-cell function in vivo using pharmacological and genetic models of SIRT1 activation. METHODS: Our pharmacologic model involved 48 h intravenous infusion of Wistar rats with either saline or oleate with or without the SIRT1 activator resveratrol. Additionally, we used ß-cell-specific SIRT1 overexpressing (BESTO) mice and wild-type littermates infused for 48 h intravenously with either saline or oleate. In both models, the infusion period was followed by assessment of ß-cell function using the hyperglycemic clamp method. RESULTS: Lipid infusion resulted in a significant decrease in ß-cell function as expected in both rats (p < 0.05) and mice (p < 0.001). Both models of SIRT1 activation, which did not alter ß-cell function in the absence of fat, resulted in partial protection from the fat-induced decrease in ß-cell function (NS vs. control). CONCLUSION: These results suggest that SIRT1 is a therapeutic target in decreased ß-cell function specifically induced by fat.

Acquired cystic kidney disease and renal tumor.

Immunosuppression is a well-known risk factor for malignancy. Renal transplant patients are at high risk for cancer in the native kidneys especially in the presence of acquired cystic disease. We report a case highlighting the importance of screening for renal malignancy in renal transplant patients.