Study group discussion: Fetal hemoglobin

What is the difference between fetal Hb (HbF) and adult Hb (HbA)? In term of the structures?

HbA has two beta chains and HbF has two gamma chains.

The gamma fraction allows fetal Hb to have higher affinity of it for oxygen which allows it to extract oxygen from maternal blood.

And inducing Hb F production is also used in the treatment of sickle cell anemia.

Hydroxyurea is the drug used for the same.

Hb F production starts from 8th week of intra uterine life.

Fetal Hb has more affinity towards oxygen than adult Hb, meaning the oxygen dissociation curve is shifted left compared to normal adult Hb.

Left doesn't leave the oxygen! (http://medicowesome.blogspot.ae/2013/05/oxygen-hemoglobin-dissociation-curve.html)

The primary structural differences between HbF and HbA are located in or near the 2,3-BPG binding site between the γ1-γ2 interface of HbF and the β1-β2 interface of HbA. The net effect of these structural differences is that 2,3-BPG binds less tightly to deoxyHbF by comparison to deoxyHbA. Thus, 2,3-BPG does not stabilize the deoxyHbF as effectively as it stabilizes deoxyHbA, thus accounting for the leftward shift of the O2 saturation curve of HbF compared to HbA when tested with the same concentration of 2,3-BPG.

Fetal hb has more affinity because of poor binding of 2,3-DPG by the gamma polypeptide chain so it can take larger volume of oxygen than adult hb at low oxygen pressure

A higher affinity for oxygen allows higher concentrations of oxygen into fetal circulation, however this also inhibits oxygen dissociation into fetal tissue where the oxygen is needed. To overcome this, other mechanisms are in place to ensure oxygen delivery to fetal tissue: Increased Crit – higher number of red blood cells per blood volume. This is a common reaction to reduced oxygen availability. Exacerbated Bohr effect – acidic pH has a greater effect on oxygen unloading in fetal tissues allowing better oxygen delivery. Acidic pH shifts the fetal oxygen-haemoglobin dissociation curve to the right, so that oxygen unloading can occur at higher oxygen partial pressures.

Adult haemoglobin starts to be produced in utero, at around the 13th week of gestation.

I think it's 30the week the switch over from fetal Hb to adult Hb.

Its by 6th month of life.. That's when majority of a child's RBC shifts to adult haemoglobin. It's important in case of thalasaemia.. Because that's when most symptoms start showing.

What I meant to say was - Initiation of production of HbA starts from 13th week gestation.

At first, there is gradual increase in concentration of HbA until it reaches 20-30% of total Hb.

And the switch is not completed until 6 months of age.

What my hemaologist taught was HbA production will be started from 30th week of gestation and by 6th month of life only HbA is produced.

And the main function of HbF is delivering oxygen in hypoxic condition like immediately after birth.

But don't we need HbF to take oxygen from the maternal blood in the first place?

Because the partial pressures in the placenta aren't enough to allow the transfer from what I've studied.
Everything takes part in delivering oxygen depending upon tissue tension of O2. Before 7th week, there are embryonic Hb like portland, gower, etc.

Embryonic erythropiesis takes place from yolk sac.

From 7th week to 30th week liver.

After 30th week, long bones start erythropoesis.

Gene for both HbA and HbF are present since birth but Its all epigenetics that make these genes to produce one kind in one period and other type in other period.

Oh I didn't know the Hb concept in such depth.

My sir told these details. Epigenetics is given in Robbins 5th chapter.

That's all!
Be sure to let us know if there are any errors or corrections.
-IkaN

Study group experience #1

It was SO very exciting to meet new people from all over the world. I got to speak to my followers directly which I don't get to do very often with the one sided blogging.

We had people from different countries and I was internal fan girl screaming throughout the process. (Still am!)

As promised to not leave you out, this is what we discussed in the group:

Fetal hemoglobin
Epigenetics
Deep vein thrombosis

We were talking about how everyone is from different age groups and grades, some younger than others. One of the group members said, "No one is small in the face of a big dream." I found it to be very motivational. Elegantly put!

We had one negative experience, a member was sending dating messages to a girl and she left the group :(
To future group joiners, make sure you report if such a thing happens to you so that we can ban the user.

The first group is full. The plan is to not add more than 50 people in one group. (It'll prevent too many anonymous users and it won't be too annoying!) The 50 spots which are empty can be used up by friends of trusted group members on request.

The new comers will be added in the second group and everyone will get a spot. Maybe in the future we'll segregate people on time zones but for now you'll be randomly allocated.

Thank you for the wonderful experience, awesome medicos!

Looking forward to more <3

-IkaN

Medicowesome study group on Whatsapp

Some of my friends discuss questions and concepts on Whatsapp. So for a long time, I've been wanting to do this. Make a huge all time accessible study group where we can learn!

This is the first trial attempt, of course. It may not work. It might work brilliantly.

If it doesn't work out, we dissolve the group and pretend it never happened T_T

If it does, we'll be learning something new on a daily basis *_*

So who's in?

All you've got to do is message me your number. You can email me at medicowesome@gmail.com with "Whatsapp study group" in the subject.

IMPORTANT: Make sure you include your proper country code when you email me your number. (Otherwise your number won't be displayed in my Whatsapp list and I might miss you out!) 

DO NOT ignorantly leave your contact details publicly in the comments for everyone to see! *whispers* Keep it secret, keep it safe.

I'll message you in a week max.

I have a lot in mind but it varies with the response. Let's try this out first and see how it goes!

PS: I'll also try posting what we discuss on the group out here as well for those who don't have access / are uncomfortable with Whatsapp.

*hoping for the best*

-IkaN

Apoptosis: Proapoptotic and anti-apoptotic molecules mnemonic

Hello! We are going to have life and death talks today.

Just kidding. We'll be talking about apoptosis - remembering molecules that promote or inhibit apoptosis, as the title suggests.

Let's start!

"Bax kills cells with an axe."
BAX promotes apoptosis.

"Caspase converts cells into casper (the ghost)."
Caspases promotes apoptosis. (Conversion into ghosts, that is, death).

"Dying is bad."
BAD promotes apoptosis.

Getting baked is like dying.
BAK promotes apoptosis.

I think bcl 2 is saying, "be clever, live" reminding us to live longer.
bcl 2 inhibits apoptosis and thus, is anti-apoptotic.

That's all!
Life and death.
-IkaN

Oral hypoglycemic drugs and weight - Weight gain or weight loss mnemonic

Sulfonylureas, Insulin and Thiazolidinediones cause weight gain.
"SIT" is my memory aid for remembering this. (Sitting at home makes you fat.)

Biguanides like Metformin cause weight loss.
"Metformin forms you in,
makes you thin."
(I could be a poet! :P )

For Glucagon-like peptide-1 (GLP-1) receptor agonists, you need to remember that the drugs end with "-tide". Exenatide liraglutide, etc. Tide is an anagram for "diet" - so tides cause increased satiety and reduce diet :D

SGLT-2 and Weight loss: SGLT2 Surely Generates Less Tummy.

That's all!
-IkaN

Prolactin mnemonic

Hello.

Prolactin is pro-lactation hormone. It aids in breast development during pregnancy and milk secretion from the breast during nursing.

It's regulation is kind of complex which is why we'll be learning about it today. I'll also be sharing a few mnemonics that will help you remember these facts!

I have no idea about USMLE Step 1

I have noticed that some of my readers haven't spoken to anyone about USMLE step 1 exam and ask very basic questions about the preparation so I decided to write a separate post on it.

For those who have started preparing for the exam and have a general idea
- You'll find most of this post useless and redundant.
- I have marked asterisks (*) for important points you might wanna look at :)

Lastly, most of these are replies from conversations that I've had with real people so
- I haven't sequenced them in order.
- Ignore grammatical errors that I may have overlooked.
- Some of them have shout outs to Indian medical students (Simply because I know the Indian system better and it's hard to separate those points and write em again. Please don't mind that. I love you all equally, medics of the world!)

Okay, let's begin!

I just started. Which books do I get?
Kaplan notes and Goljan pathology.
* Don't buy First Aid initially since you'll be requiring a new edition in the last 3-6 months of your prep.

How do I start preparing?
You'll have to start with Kaplan videos. Supplement them with notes. Add extra points, stuff not mentioned in the videos to it. Hear Goljan audio while travelling, cleaning the house. Read the book and know it cold.

What is Goljan audio?
Recorded lectures of an absolutely amazing pathology professor, Edward Goljan.

What all is encompassed in Step one? Which subjects?
Anatomy, Biochemistry, Physiology, Pathology, Microbiology, Pharmacology and Behavioural science.

* It has a lot of clinical questions as well so it's hard for me to restrict the syllabus to basic sciences. For a hypothetical example, say, a question on burns was asked on my Step. In India, it is taught in Forensic Medicine and Toxicology and Surgery. So you get the idea? You require an over all comprehensive knowledge for Step 1.

Behavioural science?
It's Biostatistics from Preventive and Social Medicine (3rd year minor for Indian medical students) and Psychiatry from Medicine (3rd year major for Indian medical students).

If there are minor and major subjects, won't I score better if I give the exam after I am done with MBBS?
Yes, I think people who give the exam after they complete final year score better than those who give it in their basic science years simply because people from first year and second year lack clinical knowledge essential for Step 1.

I must say, my opinion is biased on my experience. I know of a senior who gave his exam before final year and scored a 265 on his Step 1 (So that's pretty awesome and you should go ahead, give the exam without doubt in your basic science years!)

Umm so why give Step 1  early?
- You're utilizing your time efficiently.
- You'll need the score to apply for electives in certain colleges.
- You get "done" with the exam and you can chill out.

When and how to register?
You'll need an ECFMG id to give the exam. That requires college stamp. You'll get the instructions online. If you can't figure it out, email me.

When do need to get the id? ASAP?
3-6 months before you feel like giving the exam, you make the id. It takes approx 1 month to make.
The thing with ECFMG id is that you need to pay a certain amount of money to make the id. That's why, I recommend you to make it when you're absolutely sure about giving the exam.

What is uWorld?
It's an online question bank. They are questions which are similar to those on Step 1 and essential to get an idea of what the exam is like.

When do I start with uWorld?
It is a resource you would like to use in the later months of your preparation because it is difficult (You can't do it without having any knowledge) and because it trains you for the real exam.

Are there other questions banks that I can do?
Many. Kaplan Q bank, USMLE Rx to name a few.
* Unlike uWorld, you can start with other question banks well before the exam because they are not very similar to the real exam, they scare the shit out of you with facts you don't know and motivate you to study.

What is NBME?
Mock exams created by examiners who write questions for the test. They predict your score.

I've heard you need to do research stuff in the field you are interested, is that right?
Yes. Research and electives are required for residency.

How do I become a part of some research?
That is later. In USA. Give your step exams first.
For Indian medical students - You can do research in India as well but it has no value. You'll get experience but that's about it. No credibility.
Procedure in very short: You'll need to contact the HOD of that department, get permission from ethics committee and contact a professor who would like to mentor you for research.

No advantage of research in Step 1?
Nope. They help you in residency match. Just get a good score for now and worry about the other details later.

(I'll keep updating the post with recent questions as and when I can.)

Related posts:

Preparing for the USMLE Step 1 exam

http://medicowesome.blogspot.ae/2015/01/preparing-for-usmle-step-1-exam.html

USMLE for Indian medical students 

http://medicowesome.blogspot.ae/2015/01/for-indian-medical-students.html

Giving the test you failed in while studying for the next exam

I'm a third year med student and today I just got my result for the annual exam and I flunked in biochem :'(
It's been like the end of the world to me today. I feel so hopeless and helpless.
I really have no idea how I'm gonna retake the exam while having the 3rd year classes side by side... I really really hope that I can do as what you did and be just awesome as you are in the future but right now I don't have a clue. Any suggestion about how to manage things side by side? - Asked on Tumblr

I'm sorry you have to go through this :(

It's not the end of the world even though you feel like it is. There is so much ahead of you.

Although I have never been through it, I had a friend who had failed and had to give the exam again in the next year.

This is what we did -

Regret and forget:
You can take a few days off to cry, feel bad about it. Regret, hate, feel guilty and blame whoever you want to. But be done with it. Once your few days of sadness are over, you have no right to complain, feel hopeless EVER. You're not allowed to feel like this again. It's very similar to what they show in movies - write on a piece of paper and burn it.

This is important because you can't feel bad for yourself while you're preparing, you can't have low energy or blame others in that phase. It's going to be very hard and you have to be strong.

Get your spirits up: Believe that you can do this. Half the battle will be in your head - the previous failure will haunt you and the anxiety will try to take over. Make sure your winning the battle in your head. YOU CAN DO IT.

Plan: Now, you have new syllabus to study and give the re-exam, right? How many months for the re-exam? How much time do you have to study for the new exam?

Tips: You wanna study the very important and parts you were weak again very throughly.

You can do it side by side, you'll need to discipline yourself to study one particular amount of time for the re-exam and one slot for the new syllabus. You can give less time for the new stuff and then study over time for it later. Passing this subject is your priority.

I love this part, telling the success story - My friend did it. She passed the exam the second time and did good in the next year subjects as well. If she can do it, you can do it too!

You will do great and you'll be much more awesome than me in the future. I believe it! :D
(The fact that you spoke about it and aren't giving up is evidence of the same.)

Just work really hard and keep fighting your way through it. All the very best!  Drop by and update us on your progress sometime later :)

Avoiding negative thoughts

Low self esteem is a challenge I'm also facing. I can ignore it while I'm studying or doing something but it's always in my thoughts during transportation times. - Tumblr

I know ignoring negative thoughts can be really hard, especially when your mind is free to wander while traveling. I listen to motivational tapes or audio lectures to keep me occupied when I wish to ignore these thoughts while transporting myself.

Long QT syndrome mnemonic

Hey guys!

We'll be talking about congenital long QT syndrome today!

Short story: Surviving Diabetes

Hi, readers.
I am Sakina aka “M”

Lead poisoning mnemonic

Hello everyone! 

We'll be learning about lead poisoning today! 

The mnemonic for lead poisoning is, "LEAD BATTERY"

L: Lead lines
E: Encephalopathy (Common in children)
A: Anemia (Pallor is earliest sign)
D: Drops (foot drop & wrist drop)

B: Basophilic stippling, Burtonian line (on gums)
A: AminoLevulinate (ALA) Dehydrase and Ferrochelatase (Heme Synthase) affected
T: Toys (Lead toys cause toxicity in children)
T: Tremor
E: Encephalitis
R: Renal Tubular Acidosis (Fanconi syndrome)
Y: Young children affected

That's all! 

-IkaN

Related post: Chelating agents mnemonic

Self doubt and low self esteem

"When med students ask you about whether they have what it takes to get through med school or if they deserve to be here - You tell them that they made it this far, they were already good enough to even get into a med school, they have the skills. But what if you never deserved to be at med school and got in because you paid money to get the admission and belong go a well off family? What if your scores were just average?

I always had dreams of being a doctor. I want to work hard and I want to help people. The thing about not deserving to study medicine, low self esteem and self doubt is getting me down so bad.

How do I deal with that? Please help me, looking forward to your honest reply." -Asked on Tumblr

Inability to concentrate before exams

"I have exams in less than 2 weeks and I'm unable to concentrate. Thought of sending you a message."

At times, our concentration does begin to taper right before exams. Maybe it's because exams are pressurizing and we don't want to learn while we are stressed.
Here's what you can do, with varying success -

Read out loud: It's just a way of making sure you are studying something. If your mind starts wandering, you'll won't understand what you are reading out and you'll alert yourself.

Write: Fill up pages with words that are important. It helps you stay on topic and concentrate. Whenever I am unable to concentrate, I make mini notes on what I will write in the exams. (I also write extra points that others are not likely to write in the exam, pretend my answer is going to be the best - Just to boost my spirit and make myself feel better!)

Pathophysiology of symptoms in anemia

Hello!

I'm answering some questions asked by readers on anemia. They asked -

Why does anemia cause insomnia?
Iron is vital to the brain’s dopamine system. Dopamine is a neurotransmitter that plays a role in neural networks including sleep activity. Hence, iron deficiency causes sleep disorders like insomnia.

Why does iron deficiency cause chest pain?
Reduced oxygen supply to the myocardium causes angina.

That's all!
-IkaN

Related post: Total iron dose infusion formula (Haldane and Ganzoni) mnemonic 

New year

Here's something written by a friend as motivation for new year.

Thanks for letting me publish this, Raman! -IkaN

So many years have passed and you kept making resolutions every year, same ones year after year just to keep them for few  weeks or may be months.

But this year, it's time to stop making resolutions and start making decisions; decisions firm enough to make this year the absolute best year. 

And while doing so, promise yourself not to fall back on your old ways, and affirm yourself every morning that these decisions ate the ones that are going to help you make new rituals in order to change your life in a positive way forever. And additionally, after a span of some 5 or 10 years you will be looking back at 2015 with a sense of satisfaction and gratitude.

USMLE for Indian medical students

What is the best time to start preparing?
As soon as you have the slightest gut feeling that you might wanna go to the US. It's better to start preparing early and then change your mind than to start late.
I started in March of my third year. Ideally, you should start in your early second year.
It's never "too late" to start. I have a friend who started in internship and nailed the exam within a few months. Preparation time varies.

Preparing for the USMLE Step 1 exam

"How do I prepare for the USMLE Step 1 exam?" -The most requested post ever!

The essentials - Kaplan videos & notes (for basics) + Goljan book & audio + uWorld + First Aid is the general way to go for most IMG students.

Kaplan videos and notes: They are a good start. If you are time restricted, you may want to skip stuff, fast forward through it.

Anxiety and depression before exams

"How do you manage stress before an exam? I study a lot, but I stress too much and I usually forget everything before the exam. I have anxiety and depression because of this." -Asked on Tumblr

Sounds like you need to believe in yourself a little more. You study a lot. There is no reason for you to worry so much! 

You should start your day with positive thoughts. Affirm this to yourself every morning, "Today is a great day to study and be productive." Clap your hands while you do this. It'll flip your mood right around! Before exams, "I have studied enough and I will do well."

Trust yourself, you've got this. You are a medical student. Getting into medical school ain't easy, but you did it.  You can do this too. 

We have different reasons for getting stressed out -

When you get tired of studying

"Sometimes I get the feeling that my brain can't take more information. Can this be? What can I do when I have this feeling?" -Asked on Tumblr

Yes, it can be! We often get exhausted and feel like we can't take any more information.

In my experience, taking breaks is the best solution for this. I read a research a while back (Don't remember where!) that your performance deteriorates after 45-60 mins of studying depending upon your capacity. If you take a 5-15 min break, however, you do much better.

You can exercise, eat, mediate, dance, listen to music or an inspirational tape if you want in this mini tape. Closing your eyes and lying doing for a while is very relaxing.
Do not use your phone. Your phone has text all over and reading does exhaust you.

I usually get really distracted if I take mini breaks after studying for an hour and don't return to books for another hour. If you have the same problem, you can study for 2-3 hours straight and then take a longer break like a shower, have a long lunch break or a walk around the park.

Change

I spent a lot of time thinking over the name and the logo of the blog, before I even started!

It had to be related to the medical field with a tinge of young enthusiasm. It is a student's blog after all! After a  lot of pondering and questioning, the eureka moment happened. Which word makes us awe in amazement? Awesome! Medicowesome!

If you have a good idea, do it. You don't need to be perfect.