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Issue 4 - Pulsenotes ROUNDS, how to get into surgery, what's new this week & more...

Hello all, Welcome to the fourth edition of our weekly dose. This week, Abhi (our newest member of th
Issue 4 - Pulsenotes ROUNDS, how to get into surgery, what's new this week & more...
By Pulsenotes • Issue #4 • View online
Hello all,
Welcome to the fourth edition of our weekly dose. This week, Abhi (our newest member of the team and all-round Ortho-boff) will be tackling how to get into surgery, Sam will be covering what’s new this week and Norton’s got another House-esque. medical knowledge-bomb!
Since I’m not really saying much in this week’s newsletter, I’m just going to reiterate how great our brand-new ROUNDS series is / will be (depending on when you read this!). ROUNDS is an exclusive LIVE webinar series for our members in which we guide you through the most common clinical presentations from the perspective of a newly-qualified doc / PA. Yes, yet another reason to become an unlimited member

NEW - LIVE Q&A and ROUNDS
NEW - LIVE Q&A and ROUNDS
Getting into surgery…
Surgery is an extremely rewarding career which marries logical decision making with practical skills. It allows you to make a holistic difference to a patient’s condition. 
There will be some amongst you that have wanted to do neurosurgery from Day 1 of medical school and others who remain unsure regarding their sub-speciality interest. The key message here is do not panic - time is on your side
If you are interested in having a career in surgery, it is imperative that you get adequate early exposure to its pros and cons. As ever, your approach should be guided by what interests you rather than something that may sound impressive. 
Crucially, do not let any stereotypes put you off pursuing something you are genuinely interested in. Now more than ever there is a concerted effort to ensure that training opportunities are more accessible. Less than full time training pathways exist to allow greater flexibility to attain better work-life balance.
Gain exposure
The entry into a surgical training programme is competitive. It requires prolonged drive through medical school and beyond (foundation/core training). Therefore, if you are picking a speciality without the proper due diligence, you may find yourself losing interest. 
Engagement with your university’s surgical society affords you some valuable contacts in the surgical sphere (through local mentoring schemes) and the opportunity to attend career days. You should make an effort to speak with surgeons (of all levels!) to get a true appreciation of what the training path entails. 
During your time on surgical placements, you should keep an open mind. Think - What is it about the case that interests you? Are you enthralled by the microsurgical elements of plastic surgery or do you prefer the challenges of managing severe trauma in orthopaedics? Are you interested in becoming an academic with an active role in surgical research?
Be proactive
It is never too early to make a start on your surgical portfolio.  This folder (or e-folder) demonstrates your interest, commitment and your journey through training. It is always evaluated in interviews when applying for training posts and should be laid out logically. Further guidance by the Royal College of Surgeons (RCS) can be found here.
You can start your surgical logbook now! elogbook is a free service used by UK surgeons to keep track of their operations. Been to an interesting operation on placement? Observed or assisted? Add it to your elogbook, over time you will build a body of evidence that demonstrates your interest in surgery.
In last weeks LIVE Q&A, we discussed the benefits of finding a suitable mentor and getting involved with research /audits. This does not need to be specialty specific in the early stages but undertaking such work demonstrates keenness. It also shows a clear understanding that time spent in theatre performing surgery is only a part of a surgeon’s commitments.
Plan ahead
After graduating and foundation jobs, you will either enter core surgical training then specialty recruitment or commence a run through surgical post. More information can be found here.
Person specifications for each specialty are freely available via the Health Education England (HEE) website. This gives you a clear idea of the essential and desirable criteria for each speciality. Do not get overawed by this, their purpose is to signpost you regarding the future. With early planning, you will have plenty of time to build a competitive portfolio.
Final thoughts
Surgery provides you with a great career - interesting operations, the ability to improve a patient’s quality of life and the opportunity to answer previously unanswered questions through clinical research.
It can be emotionally and physically challenging at times but there is nothing quite like it.
Got a question? Message me on twitter!
Abhinav Singh (@orthosingh)
What's new this week?
Pulsenotes LIVE
Records were broken! Over 1,300 of you wonderful people tuned into Norton’s lecture on AKI. Hopefully you all enjoyed more than an hour of renal goodness! Missed it? don’t worry, the recording is available to watch NOW on our website!
LIVE Q&A
We also launched our Q&A series - in the first episode we discussed getting involved in research and audit. As always the recording is available to watch NOW on our website. This Saturday we return to discuss “How to study in Medicine”.
Got a question or topic you’d like covered? Join the Pulsenotes COMMUNITY on Facebook and let us know!
LIVE Q&A: How to study - Saturday 23rd May 20:00 BST.
LIVE Q&A: How to study - Saturday 23rd May 20:00 BST.
Events - what we’ve got coming up…
  1. Saturday 23rd May 20:00 - LIVE Q&A: How to study. This week we’ll be discussing how to study. Ben, Norton, Sam and Abhi will be discussing how we studied at medical school and tips and tricks we learn’t along the way. Got anything you want us to cover? Let us know by posting to our Community FB group.
  2. Wednesday 27th May 14:00 - Pulsenotes LIVE: Principles of reconstructive surgery. Another Pulsenotes-SMILE co-lab, continues with Ben talking through the principles of reconstructive surgery (cue plastics keen-beans…).
  3. Thursday 28th May 14:00 - Pulsenotes LIVE: Chronic kidney disease. Our free lecture series (in association with SMILE) continues with Norton’s take on CKD - not one to be missed!
Wait, no ROUNDS! - sadly no, we’ve slightly overstretched ourselves this week. But ROUNDS will return on Thursday 4th June with Abdominal Pain.
NB - Remember that all events will be LIVE-streamed to the Pulsenotes website, plus recordings will be available for members that aren’t able to make it!
But where are the event links!?
New topics…
As always, we have been hard at work. This month saw the long-awaited launch of our Psychiatry and ECG series. Both have three brand new set of notes - and will continue to grow in the coming weeks!
Want to know more about ECGs? Check out our new notes!
Want to know more about ECGs? Check out our new notes!
Norton's Corner
Pharmacology exam classics
Pharmacology can be a really tough topic. SO many drugs, SO many interactions, SO many doses… It does get easier, I promise! 
When it comes to exams, there are a few pharmacology classics you need to imprint in your memory. I’ll discuss one I see commonly in the world of gastroenterology - azathioprine and TPMT
Inflammatory bowel disease is a big part of the gastroenterology workload. Patients often need to start immunosuppressant medications to suppress their immune systems. One of the first line choices is azathioprine, which is a thiopurine. However, before prescribing azathioprine we ALWAYS check the enzyme thiopurine methyltransferase (TPMT). 
Azathioprine is a purine synthesis inhibitor. This means it prevents the formation of DNA and RNA. It is metabolised in the liver to its active metabolite 6-mercaptopurine (6-MP). 6-MP may be converted into different metabolites by three enzymes: Xanthine oxidase, TPMT and hypoxanthine-guanine phosphoribosyltransferase (HGPRT).
Metabolism of Azathioprine
Metabolism of Azathioprine
Patients with low or absent levels of TPMT due to genetic variations, are at risk of myelosuppresion (i.e. reduced bone marrow activity that can lead to pancytopaenia). This is because Xanthine oxidase and TPMT are important in the inactivation of 6-MP to less toxic molecules. Without TPMT function, 6-MP accumulates and more is converted into toxic metabolites by HGPRT. 
In addition, inhibitors of xanthine oxidase can increase the risk of myelosuppression due to less inactivation of 6-MP. Allopurinol is a common xanthine oxidase inhibitor that is widely used in the treatment of gout. So make sure you take a good medication history!
Key point!
If we’re going to use azathioprine we must check the TPMT level. If we don’t, we may get a nasty surprise on the full blood count a few weeks later!
Want something covered next week? - send me a tweet @medicalreg
Final words
Remember to get in contact with any questions, suggestions, or topics that you wish to be covered!
Thanks for reading, see you next week!
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