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Issue 10 - Intercalation, what's new this week and amiodarone-induced thyroid disease...

Evening all! Welcome to the tenth instalment of our weekly dose. We're kicking off this edition with
Issue 10 - Intercalation, what's new this week and amiodarone-induced thyroid disease...
By Pulsenotes • Issue #10 • View online
Evening all!
Welcome to the tenth instalment of our weekly dose. We’re kicking off this edition with some thoughts on intercalation following our recent live Q&A; Sam will let you know what’s new this week and Norton’s focussing on amiodarone-induced thyrotoxicosis in his medical corner!
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Intercalation
An Intercalated degree can be a fantastic experience.
An Intercalated degree can be a fantastic experience.
Intercalation involves taking time out of your regular medical degree to study a specific area of interest.
Many students will have the option to undertake an intercalated degree during their time at university. There are many options for intercalating, but most students will do either a BSc or a MSc. This can be undertaken at your ‘local’ institution or externally. In some medical programmes, this extra degree is mandatory or integrated into the standard 5-year course, whilst in others it is a competitive process based on academic record. Deciding on whether to 'intercalate’ and have a whole extra year at university can be a difficult decision for many students.
We recently ran a live Q&A session on intercalation. If you missed it, the recording is available on our website. We’ve also summarised the main positives and negatives below. Whilst reading these, just remember that everyone will have their own reasons for intercalating (or not). When deciding, make sure you think about what’s important to YOU!
Pros
  1. New experience. Intercalating is your opportunity to explore a new area of interest, often with a new group of people. Many students choose to intercalate in something outside of medicine. Many find this experience a breath of fresh air!
  2. Introduction to research. Completing an extra degree is often a wonderful opportunity to get involved in research and delve into the academic side of medicine. For those thinking about an academic career, this is a golden opportunity!
  3. CV building. Wouldn’t it be great if we didn’t have to constantly improve our CV! For those looking to bolster future applications, intercalation is a great way of getting points on the foundation programme application and beyond.
  4. New friends. Intercalating is a terrific way to meet new people from a range of different backgrounds. Take this opportunity to explore new extra-curricular activities, get involved in university life and meet like-minded people!
  5. New skills. Always been interested in rheumatology? Fascinated by immunology? Intercalation is a way to develop a new set of skills in a particular area of interest. It can show excellent commitment to specialty when applying for jobs at the later stages of training.
  6. Recharge. Lets face it, medicine is a long old slog. People may choose intercalation as a way of recharging the batteries and doing something different for a year.
Cons
  1. Financial. For many, completing an extra year at university comes with financial implications. There are bursaries available for intercalating, including the NHS bursary and university grants. However, funding depends on when you choose to intercalate and any previous degrees. Do your research before you apply!
  2. Timing. Intercalating means completing another year at university and can mean delaying key examinations and ultimately, graduation. For some people, getting through university and starting work is far more important.
  3. Missing friends. A year out means delaying training and dropping down a year. If you’re part of a university where only a small number intercalate, this can mean being detached from friends, graduating in a different cohort and missing events.
  4. Not a doss. A lot of students see interacting as a ‘doss’ year. However, trying to learn a whole subject in immerse detail in a single year can be tough. Usually there is a steep learning curve at the start. Just remember, coming back with a lower class degree, when you specifically took time out to work academically, can actually act as a negative on an application.
  5. Lose knowledge. At medical school you can get into a good rhythm with work and knowledge for exams. Some students worry the time away from medicine can lead to gaps appearing in their knowledge resulting in them having to 'relearn’ lots of topics.
  6. Empty knowledge. Many people change specialty and career choices all the way through their medical training. Sometimes you can end up doing a degree that has no relevance to your future ambitions. Whilst this can be positive, you have to think about the financial and time implications linked to this decision.
Final thoughts
One thing that usually comes up in the intercalation discussion is whether there is opportunity to complete extra degrees or courses in post-graduate training. For a lot of students, intercalating is not an option due to financial implications, academic record or personal considerations. For those students, don’t worry! There is enormous opportunity to undertake further degrees during post-graduate training, either as a part-time programme or during time-out between training posts. If you’re proactive in medicine, there is ALWAYS opportunity.
During our training, we all (myself, Norton and Sam) intercalated in biological sciences at the University of Exeter. We each had our own reasons, but what was really important to us was staying in the same area surrounded by our friends. To others, a particular course, location or financial implications are the overriding factors. Just remember, you need to make the right decision for YOU!
Got a question? Message me on twitter! @plasticsreg
Benjamin Smeeton @plasticsreg
What's new this week?
LIVE webinars - what we’ve got coming up…
We’re providing FREE LIVE WEBINARS over the summer.
This is what we’ve got lined up for the week ahead. Sadly, due to heavy on-call commitments, we can only host two LIVE lectures this week - but they’re going to be absolutely brilliant!
  1. Tuesday 7th July 10:00 BST - Pulsenotes LIVE: Necrotising Fasciitis. Plastics registrar Ben and Surgical doctor Sam are here to tackle the much-examined surgical emergency, Nec. Fasc.
  2. Friday 10th July 11:00 BST - Pulsenotes LIVE: Stroke. Norton’s back to continue his ever-popular neurology series. This time he’ll be covering the all-important topic of strokes.
Remember - recordings of all these LIVE events will be available for members that aren’t able to make it!
New stuff…
We’ve just uploaded recordings of the following LIVE events for you to watch at your leisure!
  • Live Q&A: Intercalation
  • Multiple sclerosis
Our notes library keeps growing (we’ve just hit 166 topics!) and this week we’ve added these:
And there are many new question sets too!
  • Schizophrenia
  • Depression
  • More ECGs!
  • Epilepsy
  • GCA
  • Testicular cancer
  • Status epilepticus
Norton's Corner
Amiodarone-induced thyrotoxicosis
Amiodarone is an excellent, and commonly used, antiarrhythmic drug. However, due to its high iodine content, it can wreak havoc on the thyroid gland. Amiodarone can cause both hypothyroidism and hyperthyroidism. Here, we’ll look at amiodarone-induced thyrotoxicosis (AIT).
There are two types of AIT - type 1 and type 2. The basic principle is that in type 1 there is increased synthesis of thyroid hormone (thyrotoxicosis with hyperthyroidism) and in type 2 there is destructive thyroiditis leading to excess release of thyroid hormone without increased synthesis (thyrotoxicosis without hyperthyroidism).
AIT - Type 1
In type 1 AIT, the excess iodine load from amiodarone acts as a substrate for increased thyroid hormone synthesis. This is usually seen in patients with preexisting multinodular goitre or latent Graves’ disease. Essentially, the thyroid gland is primed to increase synthesis. In AIT type 1, a radioactive uptake scan is usually normal, there are no signs of inflammation (e.g. IL-6 normal) and treatment is with anti-thyroid drugs.
AIT - Type 2
In type 2 AIT, amiodarone is directly toxic to the thyroid gland leading to a release of excess stored thyroid hormone. Importantly, there is no increased synthesis of thyroid hormone and it usually occurs in patients without pre-existing thyroid disease. Like most thyroiditis-related diseases, the initial release of thyroid hormone and thyrotoxic state is followed by a hypothyroid phase due to the thyroid gland essentially ‘running out’ of stored hormone. In AIT type 2, a radioactive uptake scan is decreased (due to no increased hormone synthesis), and there are signs of inflammation (e.g. IL-6 raised). These patients may be treated with prednisolone and need to be monitored for hypothyroidism.
In clinical practice, AIT can get quite complex. It can be difficult to distinguish between both types, sometimes ‘mixed’ cases occur with features of both, and what do we do about the amiodarone?! For these reasons, patients are managed by the endocrinologists and advice regarding the need to continue amiodarone is guided by the cardiologists.
Don’t get too worried about the detail, this is niche, interesting stuff (or at least I think so)! Just knowing there are two types is more than most!
Benjamin Norton (@medicalreg)
Final words
Remember to get in contact with any questions, suggestions, or topics that you wish to be covered!
Thanks for reading, remember to tell your friends, and see you next week!
Instant access to over 165 topics, 1.2K questions & 45 hrs of video lectures!
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