”I don’t have big ideas. I sometimes have small ideas, which seem to work out.” – Matt Mullenweg
I previously detailed my WordPress setup, but over the last few weeks, I have given my site (another) overhaul worthy of an updated blog post.
New WordPress Theme
I recently switched to the X WordPress Theme. This theme comes with four different minimalist style layouts that help focus on blog readability over everything else, yet remain easily and highly customizable through the built-in WordPress customizer. I’ve played with a ton of different WordPress themes, and for a premium theme, this one is as easy as they come. If you want to make any very specific modifications, you may need to learn a little bit of CSS and/or PHP.
Strong Focus on Increasing Site Speed
The speed that your site loads is highly important for two reasons:
Improved experience for readers (better chance that readers will actually read your writing). According to KISSmetrics:
”47 percent of visitors expect a website to load in less than 2 seconds, and 40 percent of visitors will leave the website if the loading process takes more than 3 seconds.”
Unfortunately, many of the tips offered by Google are difficult to know exactly how to optimize. Besides having your site hosted on a fast server, the lowest hanging fruit are easily solved with a few WordPress plugins:
WP-Optimize. This plugin actually increased my PageSpeed score by 10–14 points, and works by removing any excess junk such as comment metadata in your WordPress pages.
Smush.It. This optimizes images in several lossless ways, such as stripping JPEG metadata and optimizing compression. The free version can “smush” image files under 1MB.
BJ Lazy Load. This plugin uses a jQuery script to improve site loading by delaying loading of any images files until just as the reader has scrolled down to that image.
VaultPress. Premium service from Automattic (the makers of WordPress) that offers real-time backup and has options for security protection. I switched to this service given the ease of restoring backups compared to WordPress Backup to Dropbox.
“It sounds plausible enough tonight, but wait until tomorrow. Wait for the common sense of the morning.” ― H.G. Wells
Humans don’t wake up ready to give 100%.
Our daily startup sequence has more similarities to older PCs that run best if restarted daily than modern devices that are always ready to go. Most of us benefit from going through some type of morning routine to get ourselves set for optimal output.
A well defined morning routine is important because it decreases the number of choices that you make in the beginning of your day, which reduces decision fatigue.
“Imagine you have 100 points for making decisions every 24 hours. The more decisions you rack up in one area, the fewer decisions you can effectively make elsewhere.
If you make a ton of unnecessary decisions: which email to check, what to do first in the morning, what breakfast to have, you are going to deplete your hit points, and that will lead to poor decision making later, because you’re going to run out of your 100 points.”
An effective morning routine should essentially be a mental do-confirm checklist with the goal of getting minimizing or eliminating unnecessary decisions as you get ready for the day.
My typical morning has five things that rarely deviate:
Water. The first thing I do is drink a large glass of water. As much as I wish I could start with coffee, water is what wakes me up in the morning.
High protein breakfast. For at least the last 10 years, I have eaten two eggs almost every morning, typically with some sausage or ham. Rare exceptions are when I’m traveling or eat at a restaurant. (I’d love to eat bacon every day, but don’t typically have time to do the full bacon method). Sometimes I’ll have a small handful of berries, depending on the season.
Coffee. Usually French press with freshly ground beans. Caffeine is a wonderful thing.
Walk the dog. Although I typically only have time for a 5-10 minute walk on work days, I always find it refreshing to get outside and move around. Bonus: it keeps the dog from plotting against me.
Shower. I always feel mentally fresher after a shower, and given a chronically busy schedule, I used to say, “a shower is worth 2 hours of sleep.” We now know that sleep is much too important to skimp on, but my patients probably prefer that I take a morning shower anyway.
Over time, I’ve essentially designed my work wardrobe in the style of Steve Jobs’ daily uniform, so that I could get dressed in the dark (which occasionally happens) and still match.
For my rheumatology colleagues that are not familiar, #NephJC is a thriving nephrology journal club on Twitter and NephJC.com. If you’re relatively new to Twitter and using hashtags, but would like to participate, the simplest way would be to follow the instructions on their site.
I’m excited to see what we’re able to learn from our nephrology colleagues, and hope us rheumatologists have much to share as well.
Background on establishment of the use of rituximab for ANCA-associated vasculitis
Until recently, the only standard therapy for treatment of ANCA-associated vasculitis had been induction with cyclophosphamide plus glucocorticoids. In 2010, the RAVE and RITUXVAS trials respectively established rituximab as non-inferior therapy for the induction of systemic and renal ANCA-associated vasculitis, with similar adverse events.
The RAVE trial compared rituximab to oral cyclophosphamide, and had a primary outcome of complete remission and tapering of glucocorticoids at 6 months, with results as follows:
Rituximab group: 63/99 patients (64%)
Cyclophosphamide group: 52/98 patients (53%)
Despite a trend toward improved outcomes in the rituximab group, the RAVE study was powered as a non-inferiority trial, and the differences between the groups were not statistically significant (p=0.09, 95% CI -3.2 to 24.3).
Cyclophosphamide/azathioprine: 39% at 12 months, 33% at 18 months.
Again, despite the numerical trend, this data was only able to support rituximab as non-inferior to cyclophosphamide. Additional analysis showed that in patients with relapsing disease, rituximab was superior at 6 months (p=0.01) and 12 months (p=0.009), but this effect did not extend out to 18 months (p=0.06).
The difficulty of frequent relapse in ANCA-associated vasculitis
Clearly, maintenance of remission for patients with ANCA-associated vasculitis remains a challenge and patients continue to relapse frequently despite current management strategies. Prior studies looking at remission rates with maintenance immunosuppression show significant relapse rates:
What is the role of rituximab in maintenance therapy for ANCA-associated vasculitis?
Until now, only retrospectivedata has suggested that rituximab might be useful as a maintenance strategy for ANCA-associated vasculitis. This question was addressed in our current journal club article:
This study recruited patients aged 18-75 with newly diagnosed ANCA-associated vasculitis who were in complete remission after treatment with glucocorticoids plus pulsed cyclophosphamide. Disease activity was measured using BVAS, a standard vasculitis activity measure. Patients who previously received rituximab were excluded.
Induction of remission in both groups was:
Prednisone starting at 1 mg/kg with gradual taper, with some patients initiated with pulse methylprednisolone 500-1000 mg for 1-3 days.
Pulse cyclophosphamide 0.6 g/m² on days 0, 14, and 28, followed by 0.7 g/m² every 3 weeks for 3-6 additional pulses until remission was attained.
After 4-6 months, patients were randomly assigned 1:1 to either:
Rituximab 500 mg on days 0 and 14, then at months 6, 12, and 18.
Azathioprine 2 mg/kg for 12 months, 1.5 mg/kg for 6 months, then 1 mg/kg for 4 months.
In both groups, prednisone was further tapered to approximately 5 mg/day for at least 18 months, after which prednisone could be further tapered at investigator discretion.
“The primary end point was the percentage of patients with major relapse (reappearance or worsening of disease with a BVAS >0 and involvement of at least one major organ, a life-threatening manifestation, or both) at month 28.”
Secondary end points: Rates of minor relapse, adverse events, mortality.
Under the hypothesis that rituximab would decrease major relapses by 25% at month 28, assuming 5% exclusion or dropout, to have 80% statistical power and a 2-sided alpha risk of 0.05, 118 patients had to be enrolled in the trial.
115 patients were enrolled (87 with GPA, 23 with MPA, and 5 with renal-limited ANCA-associated vasculitis). 58 received azathioprine and 57 received rituximab. Patient demographics were not significantly different in either group. 80% of patients had newly diagnosed disease, and 20% had relapsing disease.
Primary end point
At month 28, major relapse rates in each group were:
Azathioprine 17/58 patients (29%)
Rituximab 3/57 patients (5%)
Which was statistically significant, with hazard ratio for relapse, 6.61; 95% confidence interval, 1.56 to 27.96; P=0.002.
To put it another way, in the authors words, “hence, to avoid one major relapse, 4 patients (95% CI, 3 to 9) had to be treated with systematic rituximab infusions rather than with azathioprine.“
Secondary end points
Minor relapses were not statistically different between each group, with 9/58 (16%) in the azathioprine group and 6/57 in the rituximab group (11%) (p=0.43).
Rates of infection were similar in both groups, with 8/58 (14%) in the azathioprine group and 11/57 (19%) in the rituximab group.
There were two deaths in the azathioprine group, one with vasculitis involvement of the aortic valve who had a major relapse and received pulse steroids but died of E. coli bacteremia. The second patient had developed pancreatic cancer.
The authors concluded that “in the present study, rituximab was superior to azathioprine at maintaining remission of ANCA-associated vasculitis; this was especially true for granulomatosis with polyangiitis, which was the condition seen in most of the study population.”
“Our data also show that successive 500-mg infusions of rituximab, given every 6 months up to month 18 after remission, were not associated with more frequent severe adverse events than azathioprine.”
Interestingly, the authors note that the 6-month interval between rituximab infusions was chosen based on expected B-cell reconstitution and relapses after a median of 1 year.
They also state that a single 500 mg rituximab dose was chosen because patients were already in remission (i.e. B-cell deplete) and in hopes of decreasing risk of infection.
Unable to generalize to all patient types with ANCA-associated vasculitis since most had PR3-ANCA/GPA.
Leaving prednisone tapering up to discretion of investigators after 18-months (although authors note that only 2/20 relapsed patients had stopped prednisone).
Azathioprine maintenance until month 22, with a gradual taper (although 8 relapses occurred in the first 12 months at a dose of 2 mg/kg, and only 2 relapses occurred between months 12 and 22).
Another important point from the authors is that “several major relapses (7 of 17 in the azathioprine group and 2 of 3 in the rituximab group) occurred after treatment with the trial maintenance drugs was stopped.”
Having personally used rituximab in the clinical setting for both remission-induction and treatment of relapse for ANCA-associated vasculitis, and knowing that B-cells play a significant role in disease activity, I was not surprised that rituximab would be an effective therapy. This being said, I certainly did not expect a NNT of only 4 patients. I was also impressed were able to achieve these results using only single 500 mg doses of rituximab every 6 months, which may be important not only for potential decreased infectious risks, but may have financial implications as well.
One concerning observation in this study is that after stopping maintenance therapy in either group led to several major relapses. I have often wondered if we can ever safely stop all immunosuppressive therapy in these patients, and if so, how to identify which patients this can be safely achieved.
[Update 12/12/2014: Added slideshow version of the Storify below by @nephondemand. This gives additional background on management of ANCA-associated vasculitis and the trial covered in this journal club.]
Despite ways to manage many of these challenges, certain decisions in medicine are inherently going to remain extremely difficult.
Features of extremely difficult decisions in medicine:
An incorrect decision has a high risk of adverse consequences.
Limited information is available to make the decision.
Of these two features, we typically have no way to control the amount of risk involved in our decision. We might also feel that we have no control over having limited information, but this is incorrect.
We are actually able to manage information limitations in medicine.
The 40-70 Rule in Decision Making
Former U.S Secretary of State and General Colin Powell is known for the 40-70 rule in decision making, stating that a leader should make a decision when they have between 40% and 70% of the information available.
”If they make the decision with less than 40% of the information, they are shooting from the hip. But waiting for more than 70% of the information delays the decision unnecessarily.”
Applying this to medical decision making:
By the time you have gathered 40% of necessary information, a skilled clinician should have narrowed diagnostic and treatment possibilities enough to make an effective decision.
By waiting for more than 70% of information to become available, we may actually increase risk by delaying a decision.
The surprising part here is that by delaying our decision beyond a certain amount of information, we may end up with worse outcomes.
“A tribe is a group of people connected to one another, connected to a leader, and connected to an idea. For millions of years, human beings have been part of one tribe or another. A group needs only two things to be a tribe: a shared interest and a way to communicate.” ― Seth Godin
Despite the fact I was only able to attend the meeting for a relatively short time (Saturday evening until late Monday morning), I was able to be involved in a number of activities. I’ll have to come back for sightseeing in Boston another time.
The biggest thing I was involved in while in Boston was the ACR Social Media Bootcamp, with excellent sessions on Twitter and blogging for rheumatologists.
The next big thing was the #ACR14 Tweetup. This event is designed with the goal of helping myself and others meet more people face-to-face at a major medical conference, and was again a big success. As always, it was great to catch up with a number of friends from all over the globe.
During the conference, I had Tweeted out a link to one of my favorite articles:
I’m also including a link to “Episode 34 – Interview with Irish rheumatologist Ronan Kavanagh”, since it was such a fun episode to record and we had discussed a bit about the social media bootcamp (among many other things).
“When you first start off trying to solve a problem, the first solutions you come up with are very complex, and most people stop there. But if you keep going, and live with the problem and peel more layers of the onion off, you can often times arrive at some very elegant and simple solutions. Most people just don’t put in the time or energy to get there.” – Steve Jobs
The goal for this presentation is to try to remove the major barriers to entry into the world of blogging. Before moving onto the technical aspects of setting up a blog, I hope that the following observations also help break down a few other hurdles that might also be holding you back from starting.
There are a number of excellent blogging platforms currently available. As a general rule, the more control the platform gives you over the design of the blog, the more technical knowledge will be required. The 80/20 rule applies here again, such that only a small amount of technical understanding can have you running one of the most powerful blogging platfiorms: WordPress.
The simplicity of using WordPress is owed to the fact that it comes with both extremely well written documentation and has a large community of users, so you are usually able to find answers to most questions easily with Google.
If your hosting service doesn’t offer it, register a domain name using a company that offers WHOIS privacy. My suggestion for this service is Hover.
Going through the tutorial on learn.wordpress.com will teach you almost everything else you need to know.
Designing your site:
The best way to set up the design of your site is a relatively personal one. I think you should design a blog that you would enjoy reading. As you browse around the web, take note of which sites draw you in. Personally, my blog is inspired by the readability and simplicity of Medium.com and Instapaper.
In WordPress, the design or template of your blog is called a Theme. WordPress.org currently has over 2,700 free and premium themes in their directory, which can be installed with just a few clicks. Alternatively, a number of more advanced profession themes are available. This site is currently running Thesis 2 (of note, this specific theme does require you to be a bit more technically savvy, but the majority of them minimal additional technical knowledge).
These are the tools to add various functions to your blog. Often enough, whenever you think of something you want to add, a plugin already exists that you can install and have running with a few clicks. Details of the types and specific plugins I recommend are covered in my prior post: My WordPress Setup, Plugins and Writing Tools.
Driving traffic to your site:
Typically, the biggest driver of readers to your site is going to come from social media. On Twitter. adding a hashtag can be extremely helpful, and in the world of rheumatology, top suggestions would be to use a conference hashtag such as #ACR14 or the rheumatology education hashtag #RheumEdu.
The other way that people will find their way to your blog will be through search engines, which is referred to as organic search. Because of the algorithms that Google uses to index pages, it is worthwhile to think a little bit about Search Engine Optimization (SEO) so that readers can find you organically. On WordPress, there are a number of plugins that take care of most of this automatically. If you’re looking to really dig into some of the details you can read through Google’s Starter Guide.
The 80/20 of SEO for most bloggers simply requires that you:
Write good content.
Give your writing accurate titles.
Adding visual content to your site:
Humans are visual creatures, so adding images to your site and posts both draws people in, and will also improve social sharing.
If you’re not using one of your own photos, options for free images include public domain images (works that are free of known copyright around the world) or else images with certain Creative Commons licenses that usually allow works to be used with proper attribution. A nice resource for free images can be found here.
Last, I want to include a list of all of the current active rheumatology bloggers that I’m aware of at the time of #ACR14:
“There was a time when nails were high-tech. There was a time when people had to be told how to use a telephone. Technology is just a tool. People use tools to improve their lives.” — Tom Clancy
“One of the great challenges of our age, in which the tools of our productivity are also the tools of our leisure, is to figure out how to make more useful those moments of procrastination when we’re idling in front of our computer screens.” — Joshua Foer
I’m always drawn to everyday carry type posts and trying to figure out the optimal set of daily tools, which should have the following set of characteristics:
1. you use in your day to day life
2. a first tier level of preparedness for an unforeseen emergency
3. they need to be functional.
My current everyday carry gear (clockwise, from top left):
MacBook Air (13.3-inch, Mid 2013, 1.7GHz dual i7, 8GB memory, 512GB SSD). I bought the best MacBook Air available at the time refurbished from Apple, which was an amazing deal and would suggest to anyone. With the SSD, it is strikingly fast. The only thing keeping it from being the perfect machine is lack of Retina display, but everything else makes up for that.
iPad mini with Retina display. (64GB, Space Gray, WiFi only) with Blue Smart Case. I primarily use this for consuming longer form content using these four apps: Kindle App, Instapaper (saved articles from web), NewsBlur (RSS reader), or Documents by Readdle (for PDFs).
Kleen Kanteen (27 oz, stainless steel). These are great because they’re dishwasher safe. I have a few of them. Stay hydrated my friends.
3M Littmann Cardiology II S.E. Stethoscope. This is an older stethoscope that appears to have been replaced by the Cardiology III I have two stethoscopes: a Littmann Master Cardiology that I keep at the clinic I spend the majority of my time, and this one that I carry in my bag for when I’m seeing patients at the hospital or my weekly satellite clinic.
Small, cheap umbrella. I don’t believe in buying a big, expensive one.
Cocoon Grid-It. A great tool for organizing various cords and other things that end up wandering around your bag. I currently travel around with a 1 m Apple Lightning to USB cable, Apple EarPods, and a short micro-USB cable. There is also a pocket on the back that I keep a microfiber cloth.
IntoCircuit Power Castle 11,200 mAh USB Battery Pack. Carries enough power to recharge most of your devices multiple times. For comparison purposes, the iPhone 5S has a 1570 mAh battery, the iPhone 6 has 1810 mAh, the iPhone 6 Plus has 2915 mAh, and the iPad mini with Retina display has 6471 mAh.
“Tell me and I forget, teach me and I may remember, involve me and I learn.” ― Benjamin Franklin
The use of social media in medicine has experienced enormous growth in the past few years, and this short blog post can’t even start to scratch the surface.
A great overview of the importance of social media in the field of rheumatology was recently published earlier in 2014 by Dr. Francis Berenbaum (@Larhumato), rheumatologist from Paris, titled The social (media) side to rheumatology in Nature Reviews Rheumatology. This paper includes discussion of the use of social media in medical education (for providers and patients), how it has affected the doctor-patient relationship (in a great way), and its role in medical research.
Our hope is that we can lower the barriers of entry, decrease the learning curve, and enhance the experience of new users. But we’d also like to introduce experienced healthcare Twitter users to a fresh look, to new information, and to new people who share your passions.
With all of this in mind, I’m extremely excited to be part of the following social media events this year in Boston:
Social Media Bootcamp
The goal of the social media bootcamp is to introduce more individuals to the core tools in social media: Twitter and blogging. These sessions are the brainchild of Dr. Ronan Kavanagh (@RonanTKavanagh), and I’m happy to be involved moderating the Sunday session and speaking on the technical aspects of setting up a blog on Monday. Also speaking are Dr. Philip Gardiner (@PhilipGardiner) and Dr. Christopher Collins (@RheumPearls).
Sunday, Nov. 16, 9:00–10:00 a.m.: Twitter Basics—The thoughts, opinions and ideas of your rheumatology colleagues, in 140 characters or less, shared in real time for open discussion. Learn how to tweet and engage participants in live tweet forums during the conference!
Monday, Nov. 17, 9:00–10:00 a.m.: Blogging for Beginners—Learn the basics of setting up a blog and how to use it effectively to communicate with targeted audiences. Blogging can be a great resource for communicating timely and relevant content in easily digestible quantities. These will include two sessions.
When: Sunday November 16 from 4:30-6:00pm
Where: Room 150 of the Boston Convention Center
The yearly gathering of rheumatology Twitter friends from across the globe has gotten to be a bigger and better event each year. Take a look at my post on last years #ACR13 Tweetup and this post that includes links back to every prior rheumatology tweetup that I could find.
Just as last year, this event will again open to anyone who would like to attend. No need to RSVP (although I would appreciate it if you would leave a quick comment to this post if you plan on going, just to get a sense of how many people might attend).
If anyone has questions, feel free to ask me on Twitter (@psufka) or else in the comments below.
I look forward to catching up with everyone again this year.