WILTIMS #206: Witches' warts for Halloween!

And so the lame-duck week has come to an end. When crazy tests are put on a Wednesday, I don't think anyone expects much to get done on Thursday and Friday. Very few people stuck around for lecture and the presentations were held to mostly introductory topics. We learned our first 3 of untold scores of virus categories today: papillomavirus, polyomavirus, and adenovirus.

HPV by electron microscopy

The only one of these you're likely to know is (human) papillomavirus, aka HPV. These viruses can cause warts (yes those warts too), a slimy infection of mucous membranes (yes those membranes too), and cervical cancer (there's only one cervix, but for the sake of completeness: yes that cervix too).

TIL: The way HPV can cause such diverse conditions is that each subtype of virus encodes a specific subset of genes from its tiny genome. Subtypes 16 and 18 cause cancer because they express genes for three oncoproteins. These use the same techniques as cancer to convince the infected cell to replicate unchecked. The virus doesn't actually care if the cell divides and/or becomes cancerous; it just needs the cell to replicate its own DNA so the virus can then use the cell's replicative machinery to reproduce itself.

WILTYIMS #205: Thank you, sir, may I have another?!

Yesterday was another marathon exam session (hence my silence earlier in the week (actually, my posts are almost always silent (wait! I found an exception!))). We had exams from 9 to 5 with an hour lunch spent cramming for the tests we hadn't yet taken. Livin' life to the fullest right here.

Anyways we did, in fact, have class today because reasonable recovery time is for losers, apparently. We started our final chunk of microbiology with lectures on fungi today to be followed by an introduction to viruses tomorrow (or mycology and virology, respectively). To be honest, I don't think my brain had fully reset yet before lecture today and I retained absolutely nothing from sitting in class. But for the sake of you, my determined reader, I dug back through the lecture slides^* and found a thing:

TIL: Ringworm is a complete misnomer. Unlike roundworms, pinworms, and hookworms, which are all horribly gross macroscopic worms that can live, grow and breed inside people^☨, ringworms are not actually worms. Ringworm is the colloquial term for a large group of cutaneous (skin) infections caused by fungi. Amusingly though, the colloquial term has its origin in the actual medical name for the disease.

The different types of ringworm are classified by the Latin word tinea, followed by the Latin term for the body part they infect. So athlete's foot, which is a type of ringworm is called tinea pedis, which literally means "foot worm" even though there is no worm involved.

* Dug all the way to slide number 3
☨ Seriously, wear shoes or larvae will puncture your bare feet, swim to your lungs, crawl out of your trachea, to be swallowed into your intestines and grow into worms that feed and grow while releasing eggs in your poo. Yay parasites!

WILTIMS #204: ✌♒ These aren't the symptoms you're looking for...

Today I spent far more time with my study group than in class and here is the result of 3½ hours of work:

Totally makes sense, right? Myeloid neoplasms still to come...

TIL: "B symptoms" are a weird term for symptoms used in lymphoma staging. They include intermittent fever, night sweats, and unintentional weight loss. If those are the 'B symptoms', what are the 'A symptoms'? you might reasonably ask. There aren't any! Or, more precisely, "A" indicates the lack of symptoms. So a stage IIA lymphoma is less severe than a stage IIB which presents with some or all of the symptoms listed above.

Say you want to check if a CT scanner malfunctioned during a scan or you're treating a nuclear power facility worker who was briefly exposed to a radioactive source. How could you tell if damage was done when outwardly these patients look and feel totally fine? Well, it turns out that the most sensitive cells to a massive full-body radiation exposure are leukocytes (T cells, B cells and natural killer cells of the immune system). So by doing a complete blood count (CBC) you can quickly see if these canaries in the proverbial coal mine have keeled over, indicating more serious systemic cell death to come.

WILTYIMS #203: Translocate THIS

T At some point IL and today IL more about: There are a whole slew of chromosomal translocations that cause leukemias and lymphomas. These dangerous mutations occur when one gene, usually involved with cell proliferation, is grafted into another locus that encodes for some highly expressed protein.

Think of it as though some cellular proteins are painstakingly made by hand while others are mass-produced on an assembly line. Then some cancerous businessman comes in and finds a way to slip the blueprints for the handmade protein into the assembly line. Suddenly the shoddily made copies of the rare protein flood the market using the machinery of a simpler (gene) product.

In real life the assembly line protein is some important part of the immune system, like a piece of the antibody molecule of which we need to be able to produce immense quantities to fight infections. Then a mutation swaps-in a normally highly regulated molecule that controls cell growth and division, like cyclin D. The growth protein is then made at levels reserved for antibodies causing cells to divide in the uncontrolled manner of cancer.

The image to the right (from Wikipedia, amazingly) is a nice graphic showing the locations of the chromosomal fragments that swap, as connected by the disease that the swap causes. Notice that a bunch of diseases are connected to chromosome 14; this is where the immunoglobulin heavy chain (IgH), a part of all antibodies, is normally encoded. A translocation between part of chromosome 8 and this region of chromosome 14, or put more succinctly t(8;14), causes Burkitt's lymphoma. t(11;14) causes mantle cell lymphoma and t(14;18) causes follicular lymphoma.

The t(9:22) translocation is particularly interesting. This is called the Philadelphia chromosome (after the city of its discovery) and it's associated with chronic myelogenous leukemia.  Here, the gene that's swapped in is not just expressed more but, due to some convenient splicing, actually made more potent. The gene product is a tyrosine kinase, an enzyme that phosphorylates other proteins, and because of this translocation it is constitutively turned on, having widespread and, it turns out, cancerous results.

WILTIMS #202: Shivers and smiles

Today was not a productive day. Well, it wasn't a productive day toward the goal of passing my upcoming exams, but I did do couple things. I started by giving a presentation on preventing lung cancer to a class of middle schoolers through our school's Cancer Education Awareness Program. It's always fun to scare some silence into a rambunctious class by pulling out my cancer souvenirs.

Then my team played our last flag football game of the season. It was 50-something degrees with 20+ mph winds and somewhere between drizzle and teeming rain. Ever since high school and rainy water polo games (yes, east coast people, we always played outdoors), I've thought rain makes any game more epic. But even though this was a playoff game, this just felt fun. The team we played was from our year and we all knew each other. Everyone was cold, drenched and just wanted to put in our hour on the field and go warm up at home.

But home is not where I went. Tonight was our weekly volunteer evening at the juvenile detention center. So I dug out a towel from the trunk of my car*, changed into drier clothes and headed over to the facility to spend some time with a very different set of kids than the ones I had taught this morning. Though I love giving my little cancer spiel for CEAP, playing games with the kids at the detention facility is probably more fun and possibly more rewarding for everyone involved.

TIL: (and I am literally looking this up right now so that I have something to show for the day, knowledgewise) Elephantiasis is caused by the parasite Wuchereria bancrofti. These roundworms are introduced into the bloodstream by a mosquito bite and then travel to lymph nodes to mature, mate and reproduce. After repeated cycles of reproduction, the dead remains of older generations of worms block the lymphatic drainage resulting in edema (swelling) of the lower extremities and scrotum (on persons with scrotums).

Also learned elephantiasis is called elephantiasis not elephantitis. Just now.

♒☆ The more you know! ♒☆

*This is one frood who always knows where his towel is.

WILTYIMS #201: FCM and a comic

Today was a full day of FCM (Fundamentals of Clinical Medicine, the "how to be a doctor" class). We had a brief lecture on how to talk to difficult patients, for instance patients who you suspect of prescription drug abuse or who decide to pursue a treatment plan other than the one you recommend. The latter is often called "patient non-compliance" which has become a sort of dirty word due to the obviously negative connotation. The doctor and patient need to be a team and come to a joint decision on the best course of action for that individual based both on medical science and the personal or cultural considerations of the patient.

The rest of the morning we practiced these skills in small groups with standardized patients. Though the actors' stories are theoretically "standardized," it was interesting hearing from different groups about how uniquely each actor played their part. Some were defiant but willing to budge, others were argumentative and some sounded downright hostile. Our Step II clinical board exams after 3rd year will have similarly difficult patients, but thankfully the vast majority of real world patients will be much more willing to work with us to navigate treatment decisions.

Finally, the afternoon was taken up by our first preceptor session of the year. During each of our first two years we are assigned a local doctor to shadow and learn from for an afternoon every 3-4 weeks. This year I am learning in Mount Vernon, a city in Westchester County just over the county line from the Bronx. Last year I did pediatrics, so it's nice to mix it up and see adults this year.

This first visit was once again frustrating because we have yet to learn much of pathology, but it was already so much better that last year when we were truly useless. I enjoyed talking with patients and riddling through the doctors questions for me about topics I haven't covered in enough detail yet. Hopefully by the end of the year I will feel more comfortable before actually starting our clinical education in July.

TIL: Hypertension (high blood pressure) can come in several forms. One categorization is of whether the increase in pressure is seen in systole (heart contraction) or diastole (heart filling). The former is usually seen in older patients (>50yo) due to atherosclerosis (hardening) of the aorta from the accumulation of plaques. Each time the heart pumps blood out the aorta pushes back and these plaques make it less accommodating, thereby putting pressure on the heart to pump harder. Hypertension caused by other chronic conditions usually increases the diastolic pressure and these conditions are often seen at an earlier age.

WILTIMS #200: Writings, reminiscence, and zombie amoebae

Bicentennial post! My blog now has as many med school posts as the US had years of existence in the seventies! That's a terrible comparison but I'm going to run with it. Both started at dubiously defined times (US: Declaration of Independence vs ratification of the Constitution; WILTIMS: move-in week rather than day 1 of classes), both didn't align with the larger time division (US: 200yrs in 1976; WILTIMS: #200 in October), and both very nearly didn't make it this far (US: Civil War; WILTIMS: neuro... ugh neuro). And yet, here we are!

Amusingly, today was the release date of our school's student journal the Quill & Scope in which my remarks from the Convocation of Thanks were reprinted. That was one of my most meaningful moments of the past 200 school days and it was all thanks to this blog. Writing every day, even if it's only short paragraphs filled with sesquipedalian (needlessly multisyllabic (apparently there is no word for this that isn't self-descriptive)) scientific words, is the only reason I was able to write that piece (though clearly I haven't learned to control my use of parentheses (or irony)).

A second throwback milestone for the day was learning in pharmacology about the chemotherapy that I was taking just over two years ago. It was very surreal watching classmates take notes on the symptoms that I knew - and still remember - all too well. Nausea is three-pronged: pre-treatment, acute, and delayed. Hair-loss sucks. We were told that low blood cell counts can leave you immunocompromised or anemic, but they didn't mention the psychologic distress of waiting for permission from the lab tech to get the treatment you hate.

I am still so glad I wrote about chemo as I was going through it because, as we broach these topics as student clinicians, I can integrate my experiences with my medical education and that of my friends. Also, I have a head start on the material!

TIL: Naegleria fowleri is a single celled parasite found in warm freshwater that will eat your brain! These creatures get into your head when the unsuspecting swimmer gets water way up his or her nose. The amoeba then burrows up through the very thin cribriform plate of the skull and starts munching on the brain. The amoebae don't want or need to live off of a human host, but when life gives you brains, make brain-ade? Unfortunately for us, infections are almost always fatal.

Alkylating chemotherapy agents are derived from the chemicals in mustard gas from WWI. Well, it does kill cells.