Horrible Hormones

I thoroughly enjoyed a lecture given by a senior lecturer at Newcastle University about common endocrine disorders and their biochemical causes. Of course I was already aware of how important hormones are to the body, but the way in which one tiny change can affect the body is truly extraordinary. 

The centre of this talk was obviously the pituitary gland and the way tumours associated with it affect the body. I learned that the pituitary gland is made of two sections with separate functions; the anterior and the posterior. A hormone produced in the anterior called prolactin is associated with the production of milk in mammals and also 'switches off' the menstrual cycle during this process to prevent further reproduction. Without considering this factor, the West decided to send bottled milk to Africa for children to be fed with rather than breast milk from mothers, which meant they no longer required milk which halted prolactin production and restarted the menstrual cycle. This effectively reversed mother nature's contraception and caused a population surge. This is a good example of when meddling with nature can have unexpected consequences, something which should always be considered in medicine. The posterior of the pituitary gland is associated with the production of ADH and oxytocin, but the main disorders discussed related to the anterior. 

The presentation of pituitary tumours seemed to be fairly generic at first, but could be anything from excess/deficiency in hormones to apoplexy in acute cases. They can also cause bitemporal hemianopia; a change in the field of vision due to pressure on the optic nerve or chiasm. Depending on where the gland is altered, there are varying physical effects. 

One disorder is acromegaly, which is an excess of growth hormones, caused by hypopituitarism. An example used by the lecturer was a man called Gary Tiplady who was 7ft3! Because these tumours are so slow growing, the tumours are often not noticed for years, by which time the patient often has many other problems related to pituitary adenomas. This includes Cushing's diseases, caused by an excess in secretion of ACTH and production of steroids by the adrenals glands and can result in conditions such as diabetes, osteoporosis and obesity if not recognised and treated. Another condition could be Addison's (which JFK had) which is often known as tuberculosis of the adrenal glands and presents as increased pigmentation and often also vitiligo, which contrasts massively on the skin. People may have an Addisonian crisis if they have a lack of steroids which is why people who take steroid medication will carry a card around with them stating this. 

We also looked at the thyroid as an area where problems often arise, thinking about both hypothyroidism and thyrotoxicosis. Hypothyroidism is often caused by an iron deficiency, but this cause is uncommon in the UK due to a good supply of iron in the diet. Thyrotoxicosis, however, is the opposite and can result in conditions such as Grave's disease, which is sometimes known as thyroid eye disease due to an antibody causing inflammation of the eye, meaning the patient often sees double. Grave's disease can also cause atrial fibrillation due to the overactive thyroid and this was exhibited in George Bush senior, when he collapsed on a golf course while in office as president as a symptom of his condition. This can be treated with inhibition of hormone synthesis orally or in extreme case with thyroid surgery. Alternatively, and more commonly in more current medicine, it can be treated with radioiodine, which is taken by the patient and ablates the thyroid. The patient is then given hormone replacement therapy to maintain the correct hormone balance usually controlled by the thyroid. 

In the most extreme cases, hormone deficiency can cause pituitary apoplexy, which can present as a subarachnoid haemorrhage, with symptoms such as a severe headache and visual loss. It is vital in these cases that the hormones are replaced as quickly as possible otherwise it is potentially fatal. 

Overall, the talk outlined to me that there are so many things that can go wrong with hormones in the body and it is so important that doctors are able to spot these disorders and treat them effectively. I was fascinated by the variety of conditions and the biochemistry that causes them. I continue to be amazed by the complexity of the human body, where there are so many opportunities for things to go wrong, yet the majority of us are lucky enough to be unaffected by these conditions. It seems almost unfair that most of us go through our lives completely blissfully unaware that these conditions exist and it's purely down to our genes and luck that we are not directly affected by them. It is in these situations where the vigilance and care of doctors, nurses and other medical professionals really come into their own and are able to provide life changing care and treatment. 

Work Experience

Last week I spent  4 days in my local hospital following several very busy doctors around! I was able to spend time in various departments of the hospital.

Surgery

I watched several operations both laparoscopically and open, all of which were extremely interesting. I particularly enjoyed a mini stomach bypass on an obese man. I was amazed by the innovative equipment the surgeons had access to and was fascinated by the intricate manoeuvres they could perform. The bypass was performed in about an hour, with no complications. More than the actual procedures, however, I was watching the interactions between the doctors and scrub nurses. It was interesting to see the team of people working together on the one operation and it really confirmed to me that being a doctor is definitely a job for a team player. I took opportunities to ask the doctors about their lives and their training and one thing that stuck in my mind was when a surgeon told me that if I wanted to make money and be praised then I shouldn't be a doctor, but went on to say that if I wanted to make a difference to people and have good job satisfaction then I was making the right decision. I think I am. I asked him what the worst part about being a doctor was, and he told me it was most definitely the family life (or lack of, for that matter). This is something I'm sure I cannot fully understand, given that I am only 17, and have lived away from my family since I was 14 at boarding school. However, I know it is fully possible to have a family life in the medical profession, it just may not be completely conventional, but that being said, I don't think I would enjoy a conventional life. I think I will enjoy the challenge, being constantly stretched. I also attended a lunchtime meeting with the consultants where they discussed all of the new cancer patients they would be dealing with and the direction they thought their treatment should go in. One of the consultants told me that the reason for this meeting was to get as many opinions as possible and ensure the patient was receiving the best care possible, yet another example of doctors acting in a team.
A&E
I absolutely loved my morning in A&E again! I followed a lovely nurse, who showed me everything there was to see! There were some difficult cases and of course dealing with sudden loss is a major issue in A&E. Something that stood out hugely in A&E was the importance of good nurses and good bedside manner. A lot of the people who came in were distressed and their relatives and loved ones were upset and worried, requiring friendly faces and chatty nurses to take their minds off the hard time they were going through. I enjoyed talking to the patients and laughing with them as they had bloods taken and obs done because I felt as though I was helping them slightly. I was really stretched in A&E where the consultant asked me what I wanted to gain from my morning in her department and I told her I wanted to gain insight, experience and an idea of what it's like to be an A&E doctor, but also to be challenged. She rose to that straight away and handed me a case of a man who had been referred to A&E by MIU for them to then refer him to the specific department he needed. She asked me how efficient I thought this was and if I could think of a better pathway to go through. Well… It was 9am on a Tuesday morning and I had definitely been thrown in in the deep end but I loved it. I told her I thought it was very inefficient given that A&E had nothing to do with this particular patient until they were given his file by MIU, which seemed an unnecessary link if only
Cardiology
The cardiology department was probably my most challenging stint (stent ;) haha) in my work experience because it required a good level of understanding about all of the areas of the heart and the blood vessels around it. Luckily, this was my favourite chapter of the biology course, so I looked more into it! Thank goodness! I watched the procedure performed with catheters to investigate a stenosis in a lady's coronary artery and discussed with the doctor the procedure to insert a stent to widen the artery to prevent an MI. The doctor then took me to an audit meeting about a new blood thinning drug. He explained that this drug was better than Warfarin because with Warfarin, the blood needs to be tested regularly whereas with this drug, testing is much less frequent. This is positive because it means the drug has less of an impact on the patients life.
Interventional Radiology
Nowadays, surgery itself is much less invasive because of the fantastic advances in technology, and this includes certain operations which now don't even need to be operated on as such. They can be performed with ultrasound or X-Ray assistance. I watched a procedure where a lady had a gall stone stuck in her bile duct which was causing blockages and infection, but the woman was old and the risk of removing the gall stone, along with the stress it would cause her to have to undergo surgery, was deemed to not be worth it. So instead, the doctor used ultrasound to direct him to her liver, gave her a local anaesthetic, and used a needle to go through her liver to find the stone. He used dye which could be seen on a screen to be filling her bile duct, and the stone was so obvious. He then used the needle to guide a wire, over which he could pass a tube, to act as a bypass around the stone. This would prevent it from causing anymore blockages and less infections. The procedure took no more than 20 minutes! The personal side of this was more difficult than most of the others I watched, because the lady had dementia, and was very upset, asking why we had done that to her. She was crying and would beg me to let her go home and make her stop, reaching her hands out to me. I must admit, I wasn't overly sure how to approach this situation, given that I knew she couldn't go home just yet and was in no position to help her. I found it so hard to see her in pain the way she was, both emotional and physical. However, I was so touched by the way the other professionals in the room dealt with her and reassured her and calmed her down. They were so kind, patient and compassionate with her, which is exactly the type of doctor I hope to be one day.
Neurology
The final department I visited was a ward in neurology where I saw a lumbar puncture! I noticed on the ward how attentive the nurses were to the needs of the patients but also, how much administration the doctors had to! There was a lot of paper work and less patient contact that I expected. The doctors spent  quite a lot of time looking at scans and discussing treatment plans as opposed to seeing patients. I still enjoyed this though, because I was able to see lots of scans. 

Bad Science, Ben Goldacre

In my opinion, this book can be described as nothing other than brilliantly eye opening. Ben Goldacre discusses serious issues faced by the public, including medical professionals with a fantastic sense of humour and flair. I seriously enjoyed reading his book.
I enjoyed his chapter about Gillian McKeith, but that was mostly due to his whit as opposed to the science based knowledge he wrote about, which was definitely not lacking in other areas of the book. To start with, he debunked techniques that are widely used in schools, called 'brain gym', which I myself have been subjected to and wasn't overly enamoured by. These techniques include things such as creating 'brain buttons' which can be used to stimulate your carotid arteries from outside your ribcage by simply rubbing your chest. Obviously impossible. He then goes on to discuss the fact that the cosmetics industry are using long words which the general public are unlikely to understand in order to sell more products on the basis that if people do not understand the sciencey words they are likely to think that the product will be beneficial to their health. For example, the use of the names of specific compounds that are ingredients in the cream, when in fact, if you look closely enough at the packaging, or any of the advertising for the product, there are no claims that those specific chemicals will actually make you look better. As the author states, the claim is made for the cream on the whole, because as we are all aware, moisturising the skin will make it look nicer, but that could be done using a cheap cream as opposed to the expensive one with the magic, fancy chemical. This is an interesting point, which basically encompasses the message Ben Goldacre is trying to get across for the rest of the book, and that is the fact that we are too quick to believe the things we are told, particularly when it comes to scientific fact.
A fantastic example of this is the famous case with the MMR vaccines being linked to autism. The case which was eventually disproven, but only after thousands of children didn't receive the safe vaccination they needed to protect them from extremely dangerous diseases. This book addresses the idea that we are so easily misled in a clever and humorous way that keeps the reader engaged in even the most potentially tedious areas of deeply confusing statistical methods.
One thing I'm really glad I've been able to take from this book was knowledge of the Cochrane Collaboration, an organisation who carry out reviews of clinical trials and review them systematically, which has provided us with a database of information about how well the trials were conducted and the results found over a collection of trials as opposed to just one.
Overall, I loved reading Bad Science and feel that it educated me on the pharmaceutical industry as well as opening my eyes to some of the money making scams and how the media mislead us on scientific topics every day. I would definitely recommend it.

How much of our brain do we actually need?

I attended a gifted and talented conference a few months ago where we were told about a man who had walked into a hospital with enlarged ventricles meaning that his actual brain tissue was reduced massively. I was so fascinated by this because I could not get my head around the fact that the brain can be so significantly damaged and for someone to be able to function with almost no real problems. I read further into this and found that this man had an IQ of 75, which is of course below average but by no means unusual, and definitely does not indicate the level of damage to his brain tissue which was seen. To me this shows just how much our brains can adapt to certain circumstances. This is especially impressive considering that the man had suffered from hydrocephalus as a child, which can often kill. The man must have had immensely increased intracranial pressure which, in his severe case should have caused some sort of mental disability. 

Another interesting case of brain injury (that I read about in Impulse) was the case of Phineus Gage, who had a metal rod driven through his brain, but managed to survive reasonably unchanged, given the circumstances. This is due to the fact that the rod penetrated his left frontal lobe, the area of the brain associated with recognising consequences and knowing the difference between right and wrong (among other things of course), which would explain why Gage's injury only resulted in a change in his voluntary behaviour. This was, of course, famously recognised by his peers, and the reason he was fired from his job as a foreman. 

I find it incredibly interesting that the brain is such a complex and vital organ, but can take serious damage without fatal consequences. When even the smallest thing goes wrong, for example in 'silent strokes', it can have significant effects, such as the onset of vascular dementia, but others can have a huge steel rod pushed through and remain mentally competent. It is definitely fair to say that the human body is a well oiled machine and something I often wonder if I will ever truly get my head around. 

Paediatric A&E

A&E has always been an area of medicine I have wanted to look into purely because it always seems so exciting and diverse. One of the reasons I love the idea of becoming a doctor is that I know I will never be bored and A&E has always appealed to me because of the need for quick and efficient problem solving and the ability to work under pressure. Some people might view this as scary or unpleasant but I love situations like that. So, when I was offered some time with a consultant in paediatric A&E at my local hospital, I jumped at the opportunity. I arrived and was sent straight to the staff room area which was full of doctors at computers typing away, with a big TV screen on the wall with names and DOBs and injuries on. I was introduced to a few doctors and told to just shadow anyone I liked. Great.

As soon as someone picked up a card to leave the room, I jumped up too and followed. A finger injury on a young boy following an incident with a folding chair… Oh dear! It was definitely difficult seeing the child so upset but it was nice to watch the way the doctor interacted with both the child and the parent. Reassurance, support and professionalism with the parent, and care, patience and compassion with the young child. 

After seeing the patient, I followed the doc to go and fill out a multitude of online forms to allow the boy to be discharged. That area of medicine is something which is definitely not well known among wannabe doctors, but it didn't bother me too much. I saw it as a pleasant break from patient contact to consolidate the things I'd seen and reset myself to go back to see more patients. 

I saw lots of chest infections but one which stands out was a young boy who was covered in a rash. I went into this consultation with a medical student who was doing a placement and after taking the history and conducting the physical examination, she suspected scarlet fever, but was unsure, and so didn't mention anything to anyone before relaying her findings to the consultant. By doing so, she avoided panic and ensured that no unnecessary concern was caused. The consultant then went to do her own exam and ruled this possibility out and diagnosed a chest infection. However, the medical student was still applauded for her efforts, despite her initial diagnosis being incorrect, because she was able to seek help and reassurance. This highlighted another, less obvious quality of a good doctor, and that is being able to check your work and recognise areas of weakness, asking for help where necessary, especially when the welfare of others is in question. 

Because I quickly got on really well with the medical student, she taught me how to take patient histories and taught me a method she had recently learnt called BINDS used when taking the histories of young children. B stands for birth, as in was the birth normal? Natural or Csection? I- Immunisations, are they up to date? N- nutrition, are they eating normally, enough, still have an appetite, drinking enough, less/more than usual? D- development, are they developing the way you would expect, do they act in similar ways to other children their age? S- social background, who do they live with? Do they live with any pets? 

Overall, I loved A&E experience :) 

Genetic Modification

This topic seemed to be a recurring theme in this month's New Scientists, and it got my attention. My first main interest was in a study being conducted by Oxitec, who were using GM mosquitos to fight the spread of dengue fever. The mosquitos were modified to die before reaching adulthood. A group of male GM mosquitos would be released into an affected area and then mate with normal (infected) females. Their offspring would die being reaching adulthood and the spread of the disease would be cut. Primary test in the Jacobina region of Brazil show that the number of eggs fell by up to 92% but there was no fall in the incidence of dengue fever. This, however, could be due to an extremely small sample size. The article states that a full epidemiological study must be conducted before results can be seriously considered. This concept is really topical in the world of medicine, with diseases like malaria causing so many deaths every year. If this study proves successful, could we be looking at seriously fighting malaria?
The second incidence of modification was in worms. Scientists had conducted a study involving the neurons of nematodes. They started by using electrical synapses to bridge a gap junction involved in recognition of salt concentration. They did this by injecting DNA onto the gonads of Caenorhabditis elegans which codes for a protein involved in establishing extra neural connections. They used mouse genes to avoid interaction with other neurons and found that the response to salt in the next generation of worms was massively depleted. The second investigation they conducted was in the smell of these worms. They added electrical synapses to neurons previously connected by a chemical link. This retraced the signals and eliminated the worms ability to recognise smells. This circuit for smell in the worms is comparable to circuits for eyesight in other organisms, which poses questions as to how else this technique could be used. One suggestion from the article was that it could be used to treat stroke victims. They could be given a pill to reconnect the damaged areas of their brain by creating neural bypasses to avoid damaged areas. Another important idea raised was that, by editing synaptic pathways, one could genetically modify an organism to possess a specifically grown brain circuit with a certain skill set. This could include organisms such as worms able to protect crops by identifying dangerous bacteria, which is definitely appropriate given the food crisis we are heading into. However, this made me wonder whether the genetic modification of organisms is ethical. Admittedly, in nematodes, it is less of a concern, particularly given their small CNS, but in larger organisms, it raises an issue for me. If we are able to insert skills be rewiring a brain in a certain way, why do we need to learn? What need to we have for education? When we are simply able to have an operation to allow us to have a certain skill set, why would anyone want to spent 4 years and a crazy amount of money to train in that skill? When society is levelled out in this way, it reduces the need for skilled individuals. I think this is a dangerous concept.
And I believe lots of the rest of the population agree with me that GM can be a little scary, perhaps just for different reasons. Another article was discussing GM crops, and it was heavily focused on the public opinion of this idea, which is generally fairly negative. They seem to be concerned about the ideas of 'tomatoes with scorpion genes in them,' and this concern seems to make them reluctant to consider the less shaky, more high tech ways of modification. They also appear to be unaware of how regularly genes are naturally swapped between species in the wild. This got me thinking why people have this view. Is it the fault of the scientific community? Or is it simply that they haven't bothered to do enough research into it themselves to see that there are alternatives that don't involve putting a salmon genes into strawberries? Either way, the scientific community is forced to concern itself with this public opinion, and I can't decide if this is right. I'm not sure that it seems right that professionals are forced to halt all progressions in their research if someone unqualified doesn't really like it much, particularly if the research is looking into solving a world issue, such as the food crisis. Granted, if the public are unhappy about GM crops, the research may be slightly useless because they won't buy the product, but can this concept be transferred to other areas? For example, stem cell research. To be answered.

Work Experience

Having already done some work experience in France and finding out how exciting it can be, it's fair to say when I was able to organise some more in England with an NHS doctor I was absolutely chuffed. I'd really struggled to find any work experience in the NHS because of my seriously busy schedule, particularly around exam season, but I finally managed to organise some with a doctor, called Sam, who had a clinic for looked after children. I spent a day with her in her clinic and was able to watch the complex interactions in a highly sensitive situation. This was unlike any other exposure I had had to medicine before and I enjoyed discussing the way these situations were handled with Sam, including how she handled the emotionally challenging cases she saw daily. Something that I found particularly difficult was the often detached and impersonal way the fosterers could talk about the children they were caring for. I found it difficult to see carers discussing 'problems' they were having with the children they were looking after while they were in the room. Often the carer would talk about the child in a very negative way, despite the fact that they were present at the time. I brought this up with Sam after one particularly difficult consultation, telling her how I found it sad that the young boy had to sit and listen to the carer basically complain about him. She explained to me that often the view of an outsider on these types of situations can be that they are harsh and upsetting but that through training and exposure, she reassured me that these things become easier and that finding it difficult was simply a sign of remaining compassionate, as opposed to be unsuited to a medical career.
Another part of this experience I found interesting was discussing ADHD, as it is diagnosed more often in looked after children than average. I learnt that this is because looked after children are often victims of trauma, which can cause similar symptoms meaning that they are misdiagnosed as having ADHD, when in fact they are simply responding to their hyper vigilance, as opposed to hyperactivity. When I got home, I looked into this more, and found an article which described that children who experienced trauma, such as violence, are much more sensitive to subtle changes in tone of voice, facial expression or body language due to a fight or flight mentality they have been forced to adopt. This explains why often at school, they can seem easily distracted by irrelevant concepts, such as sounds around them or the behaviour of other children. This can cause concentration on normal subjects to be hugely difficult for the children, and can be easily misdiagnosed as ADHD. The article (http://healthyliving.msn.com/diseases/adhd/diagnosis-adhd—or-is-it-trauma-1?pageart=2) states that often the drugs prescribed for ADHD can act as a stimulant, which of course would make the symptoms worse. This, to me, highlights how important it is to ensure the correct diagnosis is made, especially given that fostering, adoption and placement are all considered to be potentially traumatising.
Sam also allowed me to attend a genetics lecture organised by the department. Despite struggling to keep up with some of the more complex ideas, (especially those involving lots of acronyms that I had never heard of!) one thing I took out of the talk was an interest in Huntington's disease. This was brought up because it causes an ethical difficulty when screening looked after children whose grandparents have showed symptoms. If the parents do not wished to be screened or would rather not know if they have the mutation related with HD, it becomes difficult to screen the children, because of course if they are positive, it's obvious that one of the parents is also positive (because it is autosomal dominant mutation and does not skip generations). This is a problem because if a grandparent has symptoms or has been confirmed as having HD, there is a chance the child will also have it, and one could argue that the child deserves the right to be screened, particularly in cases where the gene is suspected to be from the father. This is due to greater instability in the paternal genes than maternal genes, meaning the mutation could be greater and therefore could lead to early onset Huntington's.