WILTIMS #357: Factoid overload!

Today was a didactic day up at our school, so I am lacking in stimulating clinical stories. But I have oodles of facts! To keep you company through the onslaught of knowledge, to the right is my classmate Caitlin successfully delivering a fake baby from a fake pelvis in our school's simulation center. Enjoy!

TIL: Pulmonary hypertension is one of the only absolute contraindications to pregnancy. There are many things that increase the risk of danger to the fetus and/or pregnant woman, but if the mother is willing to take those risks, then we are generally willing to help her through the process. But pulmonary hypertension, where the blood vessels of the lungs start down a feedback loop of constriction and loss of flow, is all but certain to kill the mother of she tries to bring the fetus to term.

35 years old is the age that we consider "advanced maternal age" because it is the year that research has shown that the risk of chromosomal abnormalities like Down's syndrome start to equal the risks from the tests like amniocentesis that we can use to test for chromosomal abnormalities.

Unlike women who develop gestational diabetes partway through their pregnancy, women who already had diabetes before being pregnant have a risk of their baby having birth defects as well as the normal complications from uncontrolled diabetes late in development. Somewhat intuitively, this is because the high blood sugar must be present during the developmentally crucial first trimester to actually cause birth defects and gestational diabetes usually begins long after that.

VDAC and TOLAC stand for vaginal delivery after cesarean and trial of labor after cesarean respectively.

The chance of uterine rupture is prohibitively high at 7-10% during VDAC if the prior cesarean was done via a vertical incision, but only 0.7% if the incision was horizontal. This accounts for part of why few VDACs where traditionally attempted - because vertical incisions used to be the norm. But the far less damaging horizontal incision has been the standard for a while now, and research has shown that VDACs can actually be quite safe in these patients.

When the first movements of the baby are felt by the mother it's called "the quickening." This may seem like a weird term for that phenomenon, but actually that usage is far older than our current meaning of the word quicken. Instead of meaning "to go faster," to quicken" meant "to come alive." Thus "the quickening" was the time when you could tell that the baby was alive in utero.

One of the tests that can be done toward the end of a pregnancy to check fetal health is called a non-stress test. This test looks at the fetal heart rate which, rather counterintuitively, we don't want to be stable. Unstable in certain ways would be bad too, but the ideal situation is for the fetal heart rate to spike upward by ~15 beats per minute for 15 seconds every minute or so. If the heartbeat is too calm or it drops downward, that is a bad sign.

WILTIMS #285-7: Bingo!

WILTIMS makes its triumphant return for the 2nd year homestretch! Only three more weeks until finals and then our 6-week dedicated study period for the Step 1 board exam. Yipee!

MondayIL: HbA1c is a great marker for long term hyperglycemia, but is unreliable in patients with changes in red blood cell formation or destruction, as in anemias. Hemoglobin A1c (HbA1c) is an irreversibly modified molecule of hemoglobin that essentially has been floating around in sugary blood so long that it gets chains of glucose stuck to it. This hemoglobin can only be recycled once the red blood cells themselves are recycled every 120 days. If you are anemic, you lost some red blood cells before their 120 days were up, which will skew the HbA1c level.

Hyperpigmentation can be caused by high adrenocorticotropic hormone (ACTH) levels associated with primary adrenal insufficiency. The ACTH molecule comes from pro-opiomelanocortin (POMC), the same precursor as beta endorphin and melanocyte stimulating hormone (MSH). The latter does exactly what its name says, it stimulates the cells that produce pigment in the skin.

TuesdayIL: Diabetes is a particularly annoying chronic disease because it doesn't force you to deal with it. Other conditions, like asthma, hepatitis C and arthritis, all have debilitating symptoms that spike when a patient either doesn't seek treatment or does something that exacerbates the condition. Diabetes just slowly, quietly progresses - making the patient a little more thirsty and need to pee a little more each day for years. Even at more advanced  stages, diabetes just makes you swell and get numb - not exactly ER-worthy symptoms. Thus the undiagnosed stay undiagnosed, and the sick get sicker.

Insulin lispro is an insulin analog made by reversing a lysine-proline amino acid pair in the protein. Hence, lys-pro → lispro.

Neutral Protamine Hagedorn (NPH) is an intermediate-acting insulin analog named for the guy who first figured out how to complex protamine (originally found as, I kid you not, trout sperm basic protein) with zinc and insulin. The aforementioned guy, Hans Christian Hagedorn, also founded the company that would become Novo Nordisk, a major pharma company that specialized in diabetes treatments. 

TIL: Facies is a word. This is one of those words that I just assumed was a typo for "faces," but alas, I was wrong. Facies means a facial appearance that is associated with a disease. So, pretty much just faces...

Old men who are wheelchair bound and double-diapered can become feminized due to the heat of the diapered area interfering with the testes' production of testosterone. Easy fix: less diaper!

Job's syndrome, aka hyperimmunoglobulin E syndrome, is named for the biblical story of Job, because terrible things keep happening to patients with this disease. Common symptoms (and/or punishments from on high) include repeated infections, puss-filled skin lesions, easily broken bones and tooth deformities.

This last fact I learned at a Rare Disease Bingo Night! It was actually lots of fun. We made our own bingo cards from a list of many dozens of rare diseases. One of our deans/professors/radiologists led us through diagnostic studies and descriptions, quizzing us to earn our Xs.

WILTIMS #179: Don't Panic

Today, I sensed a disturbance in the force - like a handful of data points cried out and went tragically uncollected. 10 days ago, I transitioned the research project I worked on over the summer so that the two residents I worked with would take over our biweekly data collection while I was in school. But I had a feeling, a spidey-sense even, that the admittedly very busy residents would forget to collect and restock the data cards we have scattered all over the hospital. Apparently I was the last person to collect anything.I think we need a new plan... 

The fun activity for today was our pharmacology problem solving section. For these we break up into small groups and try to figure out which mystery drugs match the vitals signs recorded under various conditions. You work on the puzzle with your team and hope that your team comes to the same conclusions as the other teams. After, you have to justify your answer in front of the class (while being pimped by the professor, regardless of the correctness or completeness of your answer). "Yes, that is what that drug would do under all reasonable conditions, but what about this unreasonable condition?"

Thank the Flying Spaghetti Monster It's Friday! See y'all next week.

TIL: Freaking out during a heart attack will kill you (faster). Activating your sympathetic system increases the workload on your already ischemic heart muscle, which can cause the muscle to fail more rapidly and be more prone to dangerous arrhythmias. Not sure what you should try to feel other than panic during a heart attack though... a macabre curiosity? A stoic determination to make it to phone/hospital?

Folliculitis = inflamed hair follicles
Furuncle = infected hair follicles (aka a boil)
Carbuncle = a cluster of interconnected furuncles (typically caused by a combination of staph infection and diabetes mellitus)

Hashimoto's thyroiditis causes hyperthyroidism then hypothyroidism. This autoimmune reaction causes inflammation of the thyroid, causing it to release more hormones than normal, then as the self-destructive attack continues, the thyroid is damaged to the point of hypothyroidism.

WILTIMS #110: A tasty, tasty lie

Sometimes the body is stupid. The α-cells of the islets of Langerhans of the pancreas produce glucagon, the hormonal opposite of insulin. Whereas insulin decreases blood sugar levels, glucagon increases it. Ideally, you'd like the cells that make each of these hormones to be able to sense the amount of sugar in the blood, to see if they are needed. The β-cells, which make insulin, can detect blood sugar through GLUT2 glucose transporters. The α-cells, however, use an insulin sensitive glucose transporter, GLUT4, that requires insulin to function.

So, imagine you have type I diabetes. Sorry. Your β-cells don't produce enough insulin, so your blood sugar is always high. The lack of insulin turns off the GLUT4 transporters, convincing the α-cells that you are hypoglycemic when you are in fact quite the opposite. The α-cells release loads of glucagon to fix the imagined problem, stimulating the liver and other tissues to release even more sugar into the blood, making all of your problems worse. As I have said before, 'intelligent design' my ass.

TIL: One protein that promotes fatty acid transport is called, seemingly unimaginatively, fatty acid transporter. But this is conveniently abbreviated as FAT.

The actual cause of death for starvation is typically respiratory failure. In the body's desperate search for energy, it turns from burning the last stores of sugar and fat to breaking down protein, which is mostly found in skeletal muscle. When the diaphragm, the muscle responsible for the bulk of our breathing, is degraded to the point that it can't sufficiently do its job, the person dies.