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Mechanisms Of Hypercalcaemia In Malignancy

Milk is famous because it comes from animal breasts and is widely touted as a source of calcium.

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In the body, calcium is primarily stored in bones and teeth, because it’s good to have a regulated amount circulating in the blood. You know, to avoid things going wrong.

Hypercalcaemia means too much calcium in the blood.

What controls calcium?

Parathyroid hormone (PTH) is a substance released from the parathyroid glands, which are 4 tiny structures located behind the thyroid gland.

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Let’s analyse this, like language-obsessed…language obsessors. Real poetic, yes.

Para: beside.

Thyroid: thyroid.

Gland: a bunch of cells that collectively secretes things.

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Yet another medical acronym!

Why is PTH important?

Because PTH liberates calcium from bones into blood.

In political terms, PTH is the Joan Of Arc freeing the oppressed French calcium from the English occupation of bone.

But if there’s too much or too little PTH, the blood calcium level can be thrown off.

And yes, if your PTH is burnt at the stake, things will also not be good.

PTH 101

More PTH ==> more calcium release from bones ==> blood calcium level goes up.

Less PTH ==> less calcium release from bones ==> blood calcium level goes down.

Simplified mechanisms of hypercalcaemia in cancer

What are the ways in which blood calcium levels can be elevated? There are 2 main ones.

1. Too much PTH

Fake PTH

Most commonly, some cancers involve the release of PTH-related protein, a substance similar to PTH that isn’t PTH.

On investigation, endogenous PTH will be low, due to endocrine suppression. From blood tests, expect high PTH-related protein and low actual PTH; your body thinks there is enough PTH around, so it stops making as much. The fake PTH isn’t measurable according to normal PTH tests.

Real PTH

More uncommonly, a cancer can abnormally make its own PTH.

On investigation, endogenous PTH will be high, due to excessive production. Your parathyroids again stop making PTH because there’s too much already, but the extra PTH is measurable in blood because it’s actual PTH…even if it doesn’t come from the right place.

2. Too much calcium from other sources

Bones

If cancer spreads to bone, it can induce calcium release that way. The blood calcium level goes up.

Intestines

Cancer can make extra vitamin D, a substance that normally encourages intestinal calcium absorption.

If too much calcium is absorbed from the intestines, the blood calcium level rises.

Detailed mechanisms of hypercalcaemia in cancer

  1. PTH-related protein: most common cause of hypercalcaemia in non-metastatic solid tumours.
  2. Osteolytic lesions: caused by metastases to bone.
  3. Tumour-produced 1,25-dihydroxyvitamin D: most common cause of hypercalcaemia in Hodgkin lymphoma.
  4. Tumour-produced PTH: rare occurrence where the cancer makes its own PTH.

References

  1. UpToDate. (2016, August 22). Hypercalcemia of malignancy: Mechanisms. Retrieved 3 April 2017, from https://www.uptodate.com/contents/hypercalcemia-of-malignancy-mechanisms
  2. History.com. Joan of Arc relieves Orleans. Retrieved 3 April 2017, from http://www.history.com/this-day-in-history/joan-of-arc-relieves-orleans

Podcast 005: Palliative Care With Dr Katherine Allsopp

What do palliative care, Snape, Donald Trump, unicorn pillows and Croatian men have in common?

NOTHING.

Except they’re all in this podcast.

In this episode, Dr Katherine talks about her career in palliative care.

Palliative care is a branch of medicine that deals with making end-of-life patients as comfortable as possible, rather than seeking to cure.

What’s the appeal of this specialty? What does it involve? Is it all as sad as it sounds? Dr Katherine answers these questions and more.

You might still wonder: Why is palliative care so important?

Because after life, there’s the guarantee of death.

Sometimes that receives the Voldemort treatment, where people are afraid to talk about That Which Cannot Be Named.

Kicking the bucket. Passing away. Going to a better place. While there are countless euphemisms for the act of dying, there’s only one way of saying that someone is born. Given the reality that death is inevitable, this can be a disproportionate emphasis on life.

But the final moments are just as important as the beginning.

Podcast

About the guest speaker

Dr Katherine Allsopp is a supportive and palliative care staff specialist from Westmead Hospital. She works with such distinguished colleagues as Dr Philip Lee, Parramatta Citizen of the Year, and Dr Sally Greenaway, haematologist and palliative care physician.

Music credits

Opening and closing themes by Phil Poronnik.

Transudate Versus Exudate

Both are fluids that can occur in the body during inflammation or changes in liquid-solid (oncotic-hydrostatic) pressures.

Memory aids

Transudate is transparent, because it is clear and has a low protein content. It comes from a deranged balance of oncotic-hydrostatic pressures. As a generalisation, think systemic disease.

Exudate involves extruded proteins. It has a comparatively high protein content. As a generalisation, think local inflammation or malignancy.

Pleural effusions

A pleural effusion can involve transudate or exudate. Light’s Criteria is used to determine which is the case.

References

  1. Exeter Clinical Laboratory. Blood Sciences Test / Transudate or Exudate. Retrieved 19 March 2017, from http://www.exeterlaboratory.com/test/transudate-or-exudate/
  2. Life in the Fast Lane Medical Blog. Pleural Fluid Analysis. Retrieved 19 March 2017, from https://lifeinthefastlane.com/investigations/pleural-fluid-analysis/
  3. American Family Physician. (2006). Diagnostic Approach to Pleural Effusion in Adults. Retrieved 19 March 2017, from http://www.aafp.org/afp/2006/0401/p1211.html

Podcast 004: General Surgery With Dr Corinna Chiong

How To Win Friends & Influenza is now on iTunes!

Are you always the person who cuts birthday cakes?

Do you enjoy variety?

Are your hands steady?

Is your anatomy knowledge quite good?

Perhaps surgery is for you.

From a first-hand perspective, Dr Corinna gives an overview of the general surgery training and lifestyle. She gives excellent information. She dispels myths. She offers useful advice for medical students and junior doctors who are considering this career path.

Do you want to know things you can start doing now to set yourself apart?

Yes.

Yes, you do.

So turn your speakers up to 11* and listen to this podcast!

*Not to be taken as valid medical advice, even if your speakers do go up to 11.

Podcast

About the guest speaker

Dr Corinna Chiong is a Senior Resident Medical Officer on the path to general surgery. In her spare time, she’s an avid fan of Dragon Ball Z, a maker of delicious pies and a convincing proponent of microwaving vegetables to save time.

Music credits

Opening and closing themes by Phil Poronnik.

Ototoxicity Means “Ear Poisoning”

If your balance and hearing have been affected, you just might have been ototoxified.

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Depressing? No, let’s talk about upbeat things.

If you cook meth in your basement, that’s a fun cave.

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Alternatively, you might be caught and sent to prison, which is another fun cave.

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Speaking of drugs, here are major ones that can cause ototoxicity.

 

Ototoxicity = drug-induced damage to the ear

 

Furosemide (loop diuretic)

Und*

NSAIDs (non-steroidal anti-inflammatory drugs)

 

Cisplatin and carboplatin (chemotherapy agents)

Aminoglycosides, such as gentamicin (antibiotics)

Vancomycin (antibiotic)

Erythromycin (antibiotic)

 

*German for and.

 

Renal failure can be another hazard for ototoxicity, given its impact on clearance.

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References

  1. Lustig, L. R. (2017, January). Drug-Induced Ototoxicity. MSD Manual Professional Version. Retrieved from http://www.msdmanuals.com/en-au/professional/ear,-nose,-and-throat-disorders/inner-ear-disorders/drug-induced-ototoxicity
  2. myVMC. (2015, September 30). Ototoxicity. Retrieved from https://www.myvmc.com/diseases/ototoxicity/
  3. KidsHealth. Ototoxicity (Ear Poisoning). Retrieved from http://kidshealth.org/en/parents/ototoxicity.html

Natalie Rapportman

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There are reasons to have good patient rapport.

When you play charades and your team mate is writhing around on the floor making squawking noises* and you spontaneously yell out “shark!” before being met with the sounds of ecstatic relief…that’s based on rapport. You knew the answer because you had a connection with your friend who regrettably never attended acting school.

*When everyone’s miming is so bad that nothing makes sense, cheating is allowed and even encouraged.

People deserve respect, so treating them well is obviously a given. However, it can also help management; a patient who feels listened to is often one who listens to you in return.

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If yo’ having compliance issues, I feel bad for you, son. I got 99 problems but rapport ain’t one.

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That said, let’s assume for a second that treating patients like people has no value beyond being nice.

In all truth, you’d rather have the worst, most offensive doctor who’s the best in the world…

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…than the extremely likeable but utterly incompetent clinician.

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However, we don’t have that information in real life. There isn’t usually firm guidance about who the best clinician is, so what can we do? You know, aside from going to medical school with a large cohort and ferreting out the good and bad ones from that experience.

Interestingly, outward behaviour can serve as a proxy.

The doctor who takes the time and effort to be nice to patients? Well, they just might be the one who takes the time and effort to interpret the history more thoroughly.

Perhaps they’re the one to take the time and effort to perform a fuller examination.

Or maybe they’re the one to take the time and effort to order the right investigations.

Clinical competence is obviously a requirement, but there’s more you can do on top of that. How can patients who never attended medical school with you know if you’re prone to passing spectacularly or flunking dramatically? You can show them that through the way you treat them — with respect, attention and concern.

You might still be a horrible doctor, although let’s certainly hope not, but treating patients with respect is such a small switch that you can control with ease. If we treat competence and attitude as two separate things, it’s better to be a bad doctor with good bedside manner than just a really bad doctor.

At the very least, it’s nice to be nice to people.

Podcast 003: Infectious Diseases & Microbiology With Dr Elaine Cheong

Germs. Germs! GERMS! EVERYWHERE!

Why would anyone want to study them? Because they’re interesting and increasingly relevant globally.

In this episode, Dr Elaine talks about her distinguished career progression in the field of infectious diseases and microbiology. If this is a specialty you’re even slightly considering, this interview is for you!

Podcast

References

  1. Abbott, A. (2016, January 8). Scientists bust myth that our bodies have more bacteria than human cells. Nature. Retrieved from http://www.nature.com/

About the guest speaker

Dr Elaine Cheong is the Department Head of Microbiology at Concord Repatriation General Hospital, a major teaching hospital. She was once called in to handle a feline outbreak of carbapenem-resistant Salmonella.

Cats. Always the cats.

Music credits

Opening and closing themes by Lily Chen.

What If You Were An Accountant?

Have you ever thought about dropping out of medical school? Have you ever felt that it’s all just too hard?

Perhaps it’s the night before your big multiple-choice examination. You suddenly realise that guessing C isn’t as solid a strategy as you once thought it was.

No! Your world comes crashing down.

You then do the unthinkable; you idly dream about how easy life would be if you were in some other profession. Wouldn’t engineering or law be nice?

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“Oh! If I’d gone and worked in management consulting instead, I’d be rich by now!”

“I could have been a professional Morse code translator, but I chose to study medicine. I would have been so loaded if I’d done that instead of going through medical school for all these years.”

It’s not uncommon to hear people say things like this. The presumption is that life would have been just as successful, if not even more so, in some alternate leg of reality.

Unfortunately, the truth isn’t so simple.

Your unrequited love

Let’s talk about romance for a second.

The person you’re interested in, stalking or uncomfortably fantasising about performs some tiny action, like saying hello to you. What does that mean? WHAT DOES THAT MEAN?!

Nothing, really. But it becomes over-interpreted by a lot of people.

Even if you’ve been married for 40 years, you never fully know what another person is thinking. Despite that, many singletons will still resort to detective work, insisting on picking apart the complex signals that are supposedly being transmitted to them.

Example 1

Scenario: He or she texted you back with a playful emoticon.

Over-analytical interpretation: HE OR SHE IS JUST SO INTO YOU. HE OR SHE IS INTENTIONALLY USING PICTORIAL COMMUNICATION TO EXPRESS THIS DEEP CONNECTION.

Actual meaning: He or she texted you back with a playful emoticon.

Example 2

Scenario: He or she lightly brushed your hand.

Over-analytical interpretation: THERE IS NO WAY IT WAS AN ACCIDENT. HE OR SHE WAS SUBTLY DECLARING HIS OR HER UNDYING LOVE AND THIS MEANS HE OR SHE IS THE ONE. YOU SHOULD START PLANNING THE WEDDING NOW.

Actual meaning: He or she lightly brushed your hand.

The lesson

Event A having occurred means that Event A occurred. Anything else is additional inference at best or unfounded assumption at worst.

Medicine is your reality

In the same way, being a doctor does not automatically mean that you’re smart or that you could do any other job. Passing medical school means you were able to pass medical school. That’s a good achievement in itself, but it doesn’t explicitly prove anything more than that.

The difficult thing is that you can’t quite exist in two jobs at once; simultaneously being a doctor and a lawyer was what made the Crazy Cat Lazy start her cat collection.

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It began with one.

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And then it ended with many.

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Because the what if? situation didn’t occur, it’s hard for anyone to prove you wrong. Maybe you would have been a great computer programmer. Maybe you wouldn’t have been. Maybe you would have been successful enough to invent Facebook before Mark Zuckerberg did. Maybe you would have been terrible, gone bankrupt and lived in a dumpster for 20 years.

You cannot accurately say that you would have earned a vast amount of money in an industry you never actually tried. You just wouldn’t know, because thinking in terms of what if? is not productive or real.

It’s entirely possible that the set of skills you have is best suited to medicine. It’s entirely possible that your personality works in internal medicine but would have been utterly crushed in financial planning. Even if medicine seems to be working out for you, you might well have drowned in some other industry.

Because really, maybe this is where you fit. Maybe this is where your best contribution to society lies.

So remain grateful that you managed to find a place in this great industry. Stay happy for this fit and the fact that it has worked out. Or is working out. Or looks like it will work out.

Health economics considers the best use of scarce medical resources and you, an individual, are still a scarce medical resource. You are special and unique. You snowflake, you. There is only one of you in this world and it’s wonderful that you’ve crawled your way into the industry you fit into.

This is in fact a once-in-a-lifetime opportunity. This is the reality that came true. This is where you belong, not in a world of second-guessing.

In learning the great art of medicine, you have been given an amazing privilege. If not for society’s sake, make the most of it for your own sake.

References

  1. Sheats, J. (2016, June 17). Want to Get Rich and Live a Comfortable Life? You Should Seriously Consider Being a Doctor as Your Path! Interview with Peter Steinberg. Radical Personal Finance [Audio podcast]. Retrieved from http://itunes.apple.com/

Podcast 002: Study Tips With Steve Waring

Rising medical student, welcome to the start of your new life in health care!

An amazing adventure in helping people awaits you, but first you must pass that dreaded beast called medical school examinations.

With so much information waiting to be crushed into your exploding skull, figuring out which resources to use can be stressful. Do you go to lectures? Do you watch third-party videos? Do you form a study group or remain a hermit? And how can you possibly survive anatomy classes, especially if you didn’t do a medical science degree beforehand?

In this episode, Steve runs through some of the most popular medical school materials. Are you afraid of missing out on an important study resource because no one told you about it for your entire first year? Don’t worry. That’s an odd but valid fear.

Instead of suffering through trial and error, relax in this concise collection of the big options available to you. You don’t have to waste time searching for the best resources when many of them are presented to you here.

It’s ultimately up to you to choose the study methods that work best for you — but to do that, you first have to know what your options are!

Podcast

Resources mentioned

USMLE preparation and video lectures

  • First Aid
  • Pathoma
  • Doctors In Training

Flash cards

  • Anki
  • Brosencephalon

Anatomy

  • Essential Anatomy
  • Acland’s Video Atlas
  • Textbook atlases
    • Netter
    • Gray’s Anatomy For Students
    • Moore’s Clinically Oriented Anatomy

Podcasts and audio

  • Humerus Hacks
  • MedConversations
  • Goljan

OSCE videos

  • Geeky Medics

Other resources

Review notes

  • Toronto Notes

Video lectures

  • Dr Najeeb
  • Osmosis

Question banks

  • BMJ onExamination
  • Passmedicine

About the guest speaker

Steve Waring is a medical student from The University Of Sydney. He enjoys drinking coffee, eating bland vegetables and helping subsequent generations of medical students achieve their best.

Music credits

Opening and closing themes by Phil Poronnik.