Mesothelioma is a cancer that arise from the pleura surroudning the lungs.  Increased incidence among people with heavy exposure to asbestos.  Long latent period of 25-45 years for the development of asbestos related mesothelioma.  Estimated 7-10% lifetime risk for people with heavy exposure of asbestos.  If they smoke, there is greater chance of dying from lung carcinoma rather than mesothelioma.  Evidence of exposure includes asbestos bodies and asbestos plaques.

Macroscopic Description of Mesothelioma

Diffuse lesion that spreads in the pleura space, ensheathing and invading local tissue that is usually associated with a pleural effusion.

Microscopy of Mesothelioma

Mixture of two cell types, one of which may predominate.  Mesothelial cells can differentiate into either epithelioid cuboidal, columnar or flattened cells forming tubular or papillary structures resembling adenocarcinoma (epitheliod type).  Particular immunohistochemistry staining needed to differentiate from metastatic disease.

Electron Microscopy of Mesothelioma

Presence of long tonofilaments but absent microvillous rootlets and lamellar bodies.  The mesenchymal type of mesothelioma appears like a spindle cell sarcoma (sarcomatoid type).  The mixed type of mesothelioma contains both epithelioid and sarcomatoid patterns.

Clinical Symptoms of Mesothelioma

Chest pain, dysponoea and recurrent pleural effusions.  Lung is invaded directly and there is often metastatic spread to the hilar lymph nodes, liver.

Prognosis of Mesothelioma

50% die within 12 months of diagnosis, few survive beyond 2 years.  Aggressive surgical, chemotherapy, and radiotherapy may improve the poor prognosis.  Mesothelioma in the peritoneal cavity associated with heavy asbestos exposure may occur.  Other sites you can have mesiothelioma: pericardium, tunica vaginalis, and genital tract.

• 0 Comments

The Mayo Foundation and Mayo Clinic is the world’s largest group practice, and the medical school is an important part of it.  The clinics, run as outpatients, are in 3 locations: Rochester (Minnesota), Jacksonville (Florida), and Scottsdale (Arizona).  4 hospitals (St. Mary’s Rochester, Rochester Methodist, St. Luke’s, Jacksonville and May Clinic Hospital, Scottsdale) are linked for tuition and the referral of patients.  All off very high-tech subspecialities.  There are also rural health centers.  There are great research opportunities with Mayo, and because teh small class size, one-to-one teaching is common.

How to contact Mayo Medical School to set up your medicine electives:

Mayo Medical School

200 First Street

SW Rochester, MN

55905

Telephone Number: +1 507 284 3671

Fax Number: +1 507 284 2634

• 0 Comments

The medical school (part of the oldest Catholic- and Jesuit-sponsored university in the USA) works with the University Hospital, 389 beds, and 9 federal and community hospitals.  The Medical Center, the largest in the capital, has a concentrated care center providing emergency, outpatient, surgery, X-ray, and transplant facilitites.  The Lombardi Cancer Research Center is near and there are good sports and dining facilities.

How to contact Georgetown University to set up your medical clarking elective:

Georgetown University School of Medicine

3900 Reservoir Road

NW Washington, DC

20007

Telephone Number: +1 202 687 1154

• 0 Comments

Causes of infectious colitis:

(a) Campylobacter spp. Most common diagnosed cause of bacterial diarrhoea. Backpacker’s diarrhoea; contaminated food/water. Summer months. ~1wk duration. Very young children, and young adults. Prodrome of fever, headache, myalgia and abdominal cramps. Faecal WBCs and RBCs.

(b) Salmonella spp. Cafeteria/restaurant outbreaks, family gatherings. contaminated food/water (eggs/poultry). Summer months. Very young and very old. Prodrome of fever, headache, myalgia and abdominal cramps. Faecal WBCs (and RBCs, but not so much).

(c) Shigella spp. person to person spread; within families, day care. Sudden onset fever, headache, myalgia, abdominal pain. Faecal WBCs and RBCs

(d) Y. enterocolitica person to person and contaminated food/water. Fever, RLQ abdominal pain. Mimics appendicitis. Faecal WBCs and RBCs.

(e) V. parahaemolyticus raw/undercooked seafood. Sudden onset fever, headache and abdominal pain. Faecal WBCs and RBCs.

(f) EHEC 0157:H7 contaminated food/water, meat, outbreaks in institutions, day care. Fever, abdominal cramps, very bloody stools. Can be complicated by HUS and TTP. Faecal WBCs and RBCs.

(g) E.histolytica contaminated food/water, travel in developing countries. Sudden onset fever, abdominal cramps, bloody diarrhoea (amoebic dysentery). Faecal WBCs and RBCs.

(h) C. difficile after treatment with Abx (especially clindamycin) and antimotility agents, and especially in hospital setting. Fever, abdominal pain, bloody stools. Faecal WBCs and RBCs. Toxin destroys colonic mucosa.

Investigations:

• Haemoccult and faecal cell count
• C. difficile toxin
• E. coli 0157:H7 toxin
• Stool bacterial culture
• Stool microscopy for ova and parasites

• 0 Comments

3 major life-threatening possibilities:

*AMI*

*PE*

*Aortic dissection*

• 0 Comments

Differential Diagnoses:

(a) Life-threatening

· Ruptured ectopic pregnancy à women of childbearing age; risk factors include PIF, STDs, intrauterine contraceptive device. Sharp, severe localised pain rarely on midline. May be shocked if there is haemorrhage. b-HCG and transvaginal US.

· Ruptured/leaking AAA –> risk factors include CAD, hypertension, DM, smoking. Epigastric pain radiating to back/groin. May be shocked. Plain abdo X-Ray and Spiral CT.

· Mesenteric ischaemia –> risk factors include IHD, DM, hypertension. 70% mortality. Colicky pain. CT/MRI/angiography.

· Bowel obstruction –> History of previous abdominal surgery. Vomiting, colicky pain, distention and constipation (initially diarrhoea). Increased bowel sounds. Plain abdo X-Ray.

· Perforated bowel –> History of peptic ulcer disease/diverticulosis. Acute onset epigastric pain (peptic ulcer) common; may localise due to walling off, or spread. Localised/generalised peritonitis. Decreased bowel sounds, fever and tachycardia. Plain abdo X-Ray shows free gas below diaphragm.

· Pancreatitis –> serum amylase/lipase, US and CT.

(b) Common

· Peptic Ulcer –> all age groups; assoc/w H. pylori, NSAIDs, Aspirin, smoking and alcohol. Epigastric pain 1-3 hours after food that’s relieved by food/antacids. Pain can awake patient at night. If perforation, presentation will be more severe. Give PPI, then gastroscopy and blood test for H. pylori.

· Acute appendicitis –> most common young adulthood. Umbilical pain that migrates to RIF over hours. If perforation, peritonitis and more severe systemically. Assoc/w low-grade fever and anorexia. WCC.

· Choledocholithiasis/cholecystitis/ascending cholangitis –> most common 30-50. RUQ pain that radiates to R. subscapular area. May be associated with fever and peritonitis (cholecystitis/cholangitis), jaundice and nausea and vomiting (all). WCC, amylase and US.

· Renal colic –> most common 30-40. Loin to groin pain, very severe. Assoc/w nausea and vomiting. Urinalysis (haematuria) and IV pyelography.

· Diverticulitis –> more common with age. LIF pain associated with fever, nausea and vomiting and change in bowel habit. Plain abdo XRay and barium enema.

· Acute gastroenteritis –> may be seen in multiple family members. Non-specific abdominal pain that follows nausea and vomiting, and assoc/w watery diarrhoea and fever. This is the last diagnosis after process of elimination.

· Important extra-abdominal causes:

• • DKA
  • MI
  • Pneumonia
  • PE
  • Sickle cell crisis

• 0 Comments

Syncope questions

The final common pathway for all causes of syncope is dysfunction of both cerebellar hemispheres or brainstem. It is a transient LOC. The life-threatening causes of syncope are primarily cardiovascular in origin.

The causes of syncope can be categorised into:

• Syncope due to hypoperfusion
  • Focal hypoperfusion of CNS
    • Cerebrovascular disease
    • Subarachnoid haemorrhage
  • Systemic hypoperfusion
    • Aortic stenosis
    • AMI
    • Tachycardia
    • VF
    • 2^nd or 3^rd degree heart block
    • Aortic dissection
    • Neurocardiogenic (vasovagal)
    • Miscellaneous reflex
• Syncope not due to hypoperfusion
  • Hypoglycaemia
  • Hypoxia
  • Seizure
  • Drug-induced
  • CO poisoning

Life-threatening causes of syncope:

• Hypovolaemia/haemorrhage
• AMI
• Arrhythmias
• Aortic stenosis (severe)
• Hypoglycaemia
• PE
• Subarachnoid haemorrhage
• Stroke

Questions to ask:

(a) What actually happened in the syncopal event (character of event)? Key elements include (i) setting (e.g. postprandial), (ii) rate of onset, (iii) standing, sitting or supine at time of onset, (iv) duration and (v) rate of recovery. Sudden onset while sitting/supine and more than a few seconds duration à think serious (cardiac) cause.

(b) What happened before the event? –> preceded by exertion (outflow obstruction), emotional stress, urination, defecation (reflex syncope), aura (seizure)

(c) Associated symptoms? –> chest pain or breathlessness (AMI/PE), gray/black vision (neurocardiogenic), incontinence of urine/stool (seizure)

(d) Past medical history?

· Cardiovascular disease? Arrhythmias? Valve problems?

· Diabetic? (at risk of hypoglycaemia)

· Recent surgery?

· Recent bleeding? Vomiting? Diarrhoea?

(e) Medications? –> beta-blockers, CCBs, ACE-Is, insulin and oral hypoglycaemics, diuretics, Digoxin

(f) Recreational drug use?

(g) Occupation? (CO poisoning)

Questions to ask all the time:

· Smoker?

· Appetite?

· Weight loss?

· Any recent changes to medications?

· Allergies?

· Diabetic?

Some causes and their clinical features:

• Arrhythmia –> abrupt onset and rapid recovery
• Outflow obstruction –> related to exertion; rapid recovery
• AMI –> recovery often incomplete
• PE –> dyspnoea and recovery often incomplete
• Aortic dissection –> recovery often incomplete
• Subarachnoid haemorrhage –> focal neurologic findings

Most important investigations = ECG, postural BP, then Ix according to D.Dx.

• 0 Comments

Man it’s been a long time since I posted anything interesting here on The Rejected.  It’s probably because my life is not that interesting at the moment.  From waking up early every morning, going to school, hanging out at the hospital, going to the gym, studying, and listening to other people’s drama, there’s not much going on.

I managed to pass all my OSCE’s from my last clinical rotation block so I was really excited about that.  The rotation that I was on was boring as hell and I’m pretty sure I will not be pursuing a career in that particular field of medicine.  I’m hoping general surgery will be better.

My first day on general surgery was pretty uneventful.  I got to go into theatre to see a laparoscopic cholesystectomy.  That was pretty cool.  Surgery does bring the anatomy to life.  Note to self: review anatomy.  However, the highlight of my night was being bitched at by an angry 60 year old nurse who clearly was annoyed that there were students invading her nurse’s station.  If I wasn’t such a nice guy, oh who am I kidding, I gave her a dirty look while talking about her to a colleage as we walked away.  There is no need to be a bitch at work.  I realise that your job is shitty, but being angry all the time is certainly not good for your health.  I don’t know maybe it’s just me, but I find that the younger nurses are much more helpful and inviting.  It was interesting to see that when the doctor came around the 60 year old nurse changed into a completely different person… needless to say all her sphincters clenched up nice and tight.

I think I’m going to enjoy general surgery.  It will give me a chance to practice my cannulation technique - which is pretty shotty at the moment.  The patients themselves are pretty nice even when you miss the vein or go in too far.  Note to self: review anatomy.  The only time when they’re reluctant to talk to you is when they’re in a lot of pain or feeling noxious.  When a patient says, “Get the F*** out of here!” or project their vomit at you, it’s a pretty good indication for you to be running in the opposite direction.

Medical School Gossip Update

The ugly people in my class are either married or engaged.  How the hell did this happen?  I come back from the summer and people are hooking up and getting married.  I can’t even think about marriage at the point.  I think my first wife will come at 35 and then probably a divorce shortly after that? I don’t know.  It’s something to aim for I guess.  Although seeing these people get married gives me hope that there is somebody out there for everybody.

• 3 Comments

Well that was the shortest summer vacation I have ever had… yes it’s still summer in Australia and I’ve already been in school for a couple of weeks.  Welcome to my hell… errr Third Year Medicine.  To kick things off we had a party at our place.  Surprisingly I was not drunk at all.  I think I’ve gotten to the point where drinking excessively and then making a fool of myself and having my pictures being plastered all over Facebook is all but a distant memory… plus I can be an ass without alcohol.  Here is a picture of the cooler we used for the party… well in Australia we call it an Esky… Because of the confidentiality clause placed on this blog, I’m not obligated to post pictures with my ugly face in it.  Sorry. … or maybe that’s a good thing.  We turned our bathtub into a cooler…

Third Year is going to be awesome…

• 0 Comments

I’m sure most of you who are on student loans in Canada have figured out by now that the current bank lending rate on professional lines of credit is now at a low 3.0% which is the current Canadian prime rate.  This is great if you have to borrow a lot of money to finance your education.  Every little bit helps.  Not everybody is lucky enough to have mommy or daddy come to the rescue.  Even though we’re paying a lot of money to study medicine I think it will be worth every penny… well it better be or I’m going to have to ask for my money back.

• 1 Comment