Star Fruit - No Good for Kidneys?

Star fruit is not safe for any patient with chronic kidney disease.

1. Star fruit is a popular fruit in tropical and subtropical countries and its consumption is high in Asia. Multiple case series have reported its nephro-and neurotoxicity in CKD patients as well as in people with normal renal function.

2. The amount of fruit ingested which causes toxicity is related poorly to severity of symptoms. In cases of moderate to severe intoxication, neuropsychiatric manifestations can occur and may progress rapidly to coma and refractory status epilepticus, resulting in death.

3. Star fruit nephrotoxicity is believed to be due to its high oxalate content which could cause acute obstructive tubular nephropathy. Prompt treatment with intensified hemodialysis and hemoperfusion, close monitoring and supportive care has been propsed as an effective therapeutic approach.

I have highlighted this previously in a letter to Clinical Medicine (RCP Journal), and it was cited in a review for kidney toxicity due to herbs and dietary supplements in Food and Chemical Toxicology journal.

Full text:
KG Lee. Star fruit intoxication with acute kidney injury. Clinical Medicine 2012; 12:494

Grit: In Medicine

I looked back and realized about my this article written in 2008 which was published in the UCSI School of Medicine newsletter. It is now 10 years after it and I feel that my view on housemanship has somewhat changed. It was partly written in another post on evaluation system on housemen.

Housemanship is undeniably a hardship period, but it is not really over after you completed it. You have a growing medicolegal responsibility when you advance further, along with many other sources of stress and requirements (e.g. finding time to prepare for exams during busy work, locuming for extra income to pay for exam fees, family commitment etc.), the hardship is in fact never-ending. You work extra-hard during HOship in order to be a competent MO, just as same when you work extra-hard during MOship to train to be a Specialist, and subsequently to a Subspecialist.

To be able to keep this journey going, I think the key element needed is grit. Modified from Angela Lee Duckworth's famous quote, I'd say that, "Grit is surviving journey of medicine like it's a marathon, not a sprint." It's true - you need the power of passion and perseverance at all levels, not just the HOship!

David Blaine is Back

This is David Blaine's performance which everyone has been talking about. I find it hard to describe what he did, the show is absolutely more than just "entertaining", but utterly shocking. I can't call this just "magical" because it is simply flawless and looks REAL. In The Tonight Show, he sewed his mouth shut (literally), and performed an impossible card transposition, and ended with a huge surprise (which you have to check it out).

From his first TV special Street Magic, to then many of the endurance stunts including Buried Alive, Frozen in Time, Vertigo, Above the Below, Drowned Alive etc, he has never failed to impress not only the audience but the magic society.

Duplicate SVC on Arteriovenous Fistulography

"Left SVC persistence, a rare but important congenital vascular anomaly with a reported incidence of 0.3% to 1.3% in the general population, results when a left superior cardinal vein fails to regress during gestation. Left SVC drains into the RA through the coronary sinus with no major hemodynamic effect and patient is usually asymptomatic...However, there are practical implications when the patient is subjected to endovascular interventions...in which the procedure may be made difficult by the anatomic variation and serious complications including arrhythmia and coronary sinus thrombosis have been reported."

Full text:
KG Lee, RY Tan, VA Chidambaram, SC Pang, CS Tan. Duplicate superior vena cava on arteriovenous fistulography. J Vasc Surg Venous Lymphat Disord 2017; 5:739.

Frank's Sign

 

"First described in 1973, Frank’s sign, also known as diagonal earlobe crease (DELC), was observed to be an aural sign of coronary artery disease (CAD). Since then, there has been much interest in examining this unique association. This may occur as a result of age- or disease-related weakening of dermal and elastic fibers in the ear lobes, making it a dermatological predictor of an underlying coronary vessel insufficiency. Over the years, more insights were gained from studies showing the association of DELC with significantly increased prevalence, extent and severity of CAD, independent of traditional CAD risk factors, with good sensitivity and positive predictive value. Recent studies have also demonstrated DELC’s independent association with increased carotid intima-media thickness as well as cardiovascular events (CVE) comprising not only coronary, but ischemic cerebrovascular and peripheral vascular diseases, suggesting that DELC may be a marker of generalized atherosclerotic disease. Wong et al. in a study of 558 consecutive patients (445 patients had CAD on coronary angiography), found that the presence of DELC is independently associated with 5-fold higher risk of CAD. Of note, there has been proposed classification of DELC based on the characteristics of length, depth, bilateralism and inclination of the crease. Although bilateralism has been shown to have good specificity for CVE association, the significance of the characteristics needs to be further studied."

Full text:
KG Lee. Frank's sign - A dermatological link to coronary artery disease? Med J Malaysia 2017; 72:195-6.

A Golden Buzzer Act that Will Make You Cry

Have you watched Marc Spelmann's brilliant act at Britain's Got Talent? A mentalism prediction of multiple outcomes performed in perfection, revealed with a deeply emotional story - it moved the whole audience and the Golden Buzzer was just well-deserved. "Utterly extraordinary (performance)", told by Amanda Holden, which I just couldn't agree more. Beautiful!

Nephrology Board Exam M'sia

I somehow feel that my Nephrology journey is filled with exams, one after another. After my MRCP and USMLE, I did my SCE Neph exam (UK) in 2012 in preparation to enter the Singapore Renal Fellowship (Senior Residency) program. During the 3-year training, there is annual US in-training exam (ABIM exam in Nephro), and additionally at second year an ACGME-I Graduation Exam, and finally at end of third year there was a Singapore JCST Board Exit Exam as completion of training and for Specialist Board Accreditation.

As now I have returned to home country for family, I was required to obtain the certificate of M'sian Nephro Board Exam, and I'm glad to share that I have successfully completed it.

Pursuing Nephrology has been my dream and passion. Having been exposed to different examination format (UK/ Singapore/ US/ M'sia), I would like to share on a series of Nephrology topics and hope these help if you're also preparing for any Nephro exams:

Nephrology Foundation

Nephrology Guidelines

Nephrology Updates 2017

Nephrology Resources

And many more to come!

A Dermatologist Magicienne

Angela Funovits - a highly impressive magicienne (female magician) that you'll ever see. I wrote about her many years ago that she was a Dean's list medical student and was professionally performing magic. She then completed her Dermatology Residency in Cleveland, Ohio where she served as a Chief Resident. This is her recent appearance on Penn & Teller Fool Us episode - a mentalism act elegantly performed. Looking at her extraordinary academic and magic portfolios, all I can say is she is truly inspiring and magical!