Friday 29 April 2011

Phase I Revision Week (Part 4)

Dear Year 1 Medic Students,

I will help you with revision for the Lipid Metabolism input in Endocrine Block. I will first present the relevant Objectives, then some MCQs and finally an essay with a proposed model answer. They may not reflect what can come out in Professional I exam though but at least you know HOW TO go about studying the topic PROPERLY and to your advantage. Use them only as REVISION GUIDES. Good Luck for your exams.

Prof Faridah

                         Ojectives
MCQ - Answer True (T) or False (F) for each response:
Essay
Proposed Model Answer

Copyright 2011. Prof Faridah

Wednesday 27 April 2011

Phase I Revision Week (Part 3)


Revision Session: Wednesday, 27 April 2011, 9.30am-10.30am, Prof Faridah

QUESTIONS FROM STUDENTS

  1. What is important in Cardiovascular System Block? Since Doctor Adibah is not here, will her question still come out? [Please ask Physiology]
  2. Will the following come out? (i) Regulation of gene expression. (ii) Application of molecular biology in medicine. [Either one]
  3. Can Prof summarize these? (i) Fat metabolism. (ii) Regulation of fat metabolism. (iii) Lipoprotein metabolism. (iv) Cholesterol metabolism. [Type each title in Google and revise from the Internet pages]
  4. Prof, are these coming out? (i) Transamination and oxidative deamination of amino acids. (ii) Catabolism of amino acids. [Yes, but a bit different though. You must know the 3 categories of amino acids - i. purely glucogenic, ii. purely ketogenic, and iii. mixed, i.e., both glucogenic & ketogenic, and where they participate in metabolism. They are important for normal nutrition and for parenteral nutrition.]
  5. How about questions from Cell and Tissue, and Musculoskeletal Blocks? [Cell Tissue - please revise the basic general structure of all molecules learned so far, ~50 structures? Musculoskeletal - energy supply for exercising muscles.]
  6. Prof, is Urea cycle coming out? [Yes, I think]
  7. How about Bioethics Block? [Please ask Community/Family Medicine & Medical Education]
  8. How about Vitamin A (CNS Block) and Vitamin D (Musculoskeletal System Block)? [CNS Block - Visual cycle and structures of vitamin A. M/S Block - Vitamin D synthesis and modifications in the various organs.]
  9. In Endocrine Block, 4 lectures that doc conducted, which should we really concentrate? [Either endo- or exogenous lipoprotein pathway or HDL metabolism - reverse cholesterol transport.]
  10. What should we concentrate on biochem for OSPE? [Urine dipstick - either diabetes or fasting/starvation]
TQ

Prof Faridah

Biology, Creation and Evolution


The connection between biology on the one part and that of creation and evolution, on the other, is very intriguing. 

Indeed Allah has created and made everything work in the minutest detail, and yet when we realise that the whole of our earth is but a very tiny part of our solar system, and in turn the solar system is a very minuscule part of our galaxy, which in turn is just an inconsequential blip in the whole universe.... And there may be an infinite number of Universes, both tangible and intangible. And that the advent of humans on this earth is in a time frame which is but a teeny weeny fraction of the life of our planet so far. Then, we cannot fail to realize that Allah's greatness is truly unfathomable. 

There is the same complexity and vastness in our own bodies comparable to that of the Universe. Just take the mitochondria for instance. They are the tiny organelles inside cells that generate almost all our energy in the form of a chemical named ATP (adenosine triphosphate) On average there are 300-400 mitochondria in every cell, giving a total of ten million billion in each human body. Through their host cells the mitochondria shape the whole fabric of life, from energy, sex, and fertility, to cell suicide, ageing, and death. Mitochondria generate energy by pumping protons across a membrane (chemiosmosis) and this process is found in all forms of life, including the most primitive bacteria. 

Energy and life go hand in hand. When we breathe the oxygen in our breath is being transported to virtually every one of the 15 trillion cells in each of our bodies. It is used to burn glucose in cellular respiration. We are prodigious energy producing machines. Gram per gram, a person, even when sitting down comfortably, converts 10,000 times more energy than the sun every second. 

When mitochondria burn up food using oxygen, sparks (free radicals) escape to damage adjacent structures, attacking the genes in our cells almost every second. Much of the damage is put right without much ado, but occasional attacks cause irreversible mutations, and these build up over a lifetime. When cells in the body become worn out or damaged, the more seriously compromised cells die, and the steady wastage underpins both ageing and degenerative disease. One of the most important functions of mitochondria is programmed cell death (apoptosis), in which individual cells commit suicide for the greater good of the body as a whole. This function is important and cancer results when individual cells declare independence and cast of the shackles of responsibility to the organism as a whole. 

The cellular death sentence is given by the mitochondria, which integrate signals coming from different sources and “decides” to activate the cell’s silent machinery of death. Swift and smooth, almost unnoticed , some 10 billion cells die by apostosis each day in the human body. The death apparatus consists of a number of protein chemicals that are released from the mitochondria into the cell, which in turn activate enzymes which dismember the cell from within, and package its contents for reuse later by other cells. Nothing goes to waste. 

Apoptosis or programmed cell death occurs even in embryos. Most strikingly. whole populations of neurons disappear in successive waves from the embryological brain. In some regions of the brain , more than 80% of the neurons formed during the early phases of development disappear before birth. Cell death allows the brain to be sculptured and “wired” with great precision, enabling the formation of neuronal networks. The sculpting of our body is achieved by subtraction rather than addition; the formation of fingers and toes , for instance is by orderly cell death between the digits. 

Mitochondria also appear to act in the interest of the species rather than just the individuals that host them. Like all cells, it is in the interest of mitochondria to proliferate. They gain nothing by killing the host cell as they cannot survive without it. There is a limit as to how much the mitochondria can proliferate within a cell before it leads to overcrowding. So the only way they can do so is when the host cell divides. They divide and multiply in tandem with the host cell. A host cell may not be able to divide if it is damaged especially if the DNA of the cell nucleus is impaired. The mitochondria are then trapped – unable to get out and multiply. They can get out only if the host cell fused with another and recombined its DNA with that of a partner. The fused cell gains a new lease of life and the mitochondria a new playground. Sexual fusion of cells tend to mask damaged DNA, as the damaged gene is likely to be paired with an undamaged copy of the same gene. The obvious value of sexual fusion is the fast dissemination of variation and beneficial adaptations, throughout a population, thus benefiting the species.

Mitochondria have many mysterious properties and can even form into branching networks, communicating among themselves. They were once thought to be free living bacteria which adapted to life inside larger cells and now control our lives in so many surprising ways.

Mashallah, this is just one aspect of one of the signs of Allah's greatness.

Dr M Tahir

Tuesday 26 April 2011

Phase I Revision Week (Part 2)

EXAM TERMS

SEQ = Short Essay Question (10 min)
MCQ = Multiple-Choice Question (5 responses; answer each response True or False)
OSPE = Objective-Skills Practical Exam


Revision Session: Tuesday, 26 April 2011, 12pm-1pm, Prof Faridah

QUESTIONS FROM STUDENTS
  1. Will question come out on purine & pyrimidine synthesis as well as DNA regulation?
  2. Is purine & pyrimidine synthesis important?
  3. In GIT Block, what question will be likely to be asked?
  4. Should we concentrate on GIT amino acids?
  5. Which pathway do we need to remember? All the enzymes need to be included?
  6. Regarding enzymes, what should we focus on?
  7. Will gluconeogenesis, glycogen, and ketogenesis come out in SEQ?
  8. Is triacylglycerol (triglyceride) synthesis pathway important?
  9. Last year there was a question about endogenous pathway. Is there a possibility that it comes this year?
  10. Do endogenous & exogenous pathways of lipoprotein metabolism have high potential to be asked in SEQ?
  11. In Respiratory Block and Renal Block, what type of Biochemistry questions should we focus on?
  12. For Endocrine Block, which pathway should we focus on? Which of the pathway will most probably come out in SEQ?
  13. Dalam Block Pharmacology, topik apa yang kami kena fokus untuk exam ini?
  14. Do we need to focus on free radical & oxidant regulation & metabolism?
  15. What is your blog? http://medicinenewbie.blogspot.com/
 TQ ;)

-------

Dear Year 1 Medic students,

Thank you for asking questions about your Professional 1 exam (2 May 2011). I will just reorganise your questions into outlines which may be of help for you to revise for your exam. Remember, not all that we discuss here will necessarily come out in Professional 1.

SEQ GUIDE

Generally, you wish to know for all the blocks with Biochemistry inputs, which of the many pathways will most probably come out in SEQ, and whether you will need to remember all the associated enzymes of each pathway. The 5 blocks that have Biochemistry inputs are GI, Respiratory, Renal, Endocrine and Pharmacology. I have given some guides for each of the 5 blocks.

HOW TO STUDY BIOCHEMICAL PATHWAYS

You must know when, why & where each pathway occurs. Which organ? In the cytosol, mitochondrial matrix or other? For each pathway, must know the precursor(s), the first substrate(s), the end product(s), the rate-limiting enzyme  and how the rate-limiting enzyme is regulated. How the entire pathway is regulated. How each pathway is connected to the next pathway. What substance(s) regulate each pathway?

You can try work on these pathways:
  1. Glycolysis (breakdown of glucose; aerobic oxidation of glucose; anaerobic oxidation of glucose)
  2. Gluconeogenesis (making glucose from non glucose substances)
  3. Glycogenesis (synthesis of glycogen)
  4. Glycogenolysis (breakdown of glycogen)
  5. TCA cycle (Krebs cycle, citric acid cycle; reducing equivalents - NADH & FADH2 reactions, substrate-level phosphorylation)
  6. Electron Transport Chain (structure of the components, where NADH & FADH2 enters the ETC, how ATP is formed, Chemiosmotic theory).
RE-ORGANISED QUESTIONS FROM STUDENTS
  1. GI Block: (i) Amino acid metabolism. (ii) Regulation of Enzymes - enzyme inhibition curves/plots. (iii) Gluconeogenesis. (iv) Glycogen metabolism. (v) Ketogenesis. (vi) Triacylglycerol (triglyceride) synthesis. (vi) Endogenous pathway of lipoprotein metabolism (2010, 2011?). (vii) Exogenous pathway of lipoprotein metabolism. (viii) Reverse cholesterol transport.
  2. Respiratory Block - (i) Acid-base - Respiratory acidosis/alkalosis [no other topics]
  3. Renal Block - (i) Acid-base - Metabolic acidosis/alkalosis. (ii) Metabolic role of kidneys
  4. Endocrine Block -  Please refer to the SGD questions on Diabetes mellitus (DM) or Diabetic ketoacidosis (DKA). Integration of metabolism includes knowing all the pathways and under what conditions each occurs. (i) If Normal: Glycolysis + TCA + ETC. (ii) If Exercising:  + Gluconeogenesis + Glycogen metabolism. (iii) If fasting/starvation, + Fat mobilization + Ketogenesis
  5. Pharmacology Block: (i) Free radicals & oxidant regulation & metabolism - link this up to mutation over time (in the long run) and how diseases occur as a result of low antioxidant levesl. (ii) Purine & pyrimidine synthesis and how they are important in DNA structure. (iii) DNA regulation
REMINDERS
  1. A reminder to all students, if you think you will pass, then you will pass Professional I, insyaAllah, and vice versa otherwise. It is important that you think positive at this stage. Do not be intimidated if you have done your revision. Many have passed Professional I before you and you can too, insyaAllah.
  2. Another reminder is please seek your parents' forgiveness before you take Professional I exam. They have looked after you for 19-20 years and now you are on a long path to your largely unknown future. Request your parents to make doa for you and that you will take the exam with much ease and also pass. Doa by your parents will never be rejected by Allah, insyaAllah. Always remember that.
  3. DO NOT USE PENCIL FOR ANSWERING ON EXAM!! PLEASE REMEMBER!! 
  4. PLEASE DO NOT USE RED PEN!!!
  5. PLEASE DRAW A DIAGRAM WHERE REQUIRED AND THEN LABEL YOUR DIAGRAM. PUT A TITLE AND UNDERLINE IT.
  6. YOU CAN USE COMMON ABBREVIATIONS - NADH, FADH2, ETC, ATP, ADP
  7. TRY TO ANSWER ALL SEQ.
Thank you.

Prof Faridah

DON'T FORGET TO READ THE COMMENTS (below) FOR THIS POST.

Monday 25 April 2011

Asma al Husna Workshop

Workshop: The Ancient Science of Healing: The Power of 99 (Asma Al Husna)

Izzat Hakimi invites you ·
Time
06 May · 09:00 - 16:00

Location
Auditorium Nucklear USM Kubang Kerian

Created by:

More info
Hanya Melalui latihan 6 jam anda mampu memanfaatkan tenaga Asma Al Husna untuk berbagai keperluan anda. Terbuka kepada Muslimin dan Muslimah. Pendaftaran: Boleh dihubungi di Pejabat Timbalan Dekan Industri dan Jaringan PPSP, sambungan 6997 atau hubungi 0179373357

Phase I Revision Week

Kursus Doktor Perubatan Fasa I
Sidang Akademik 2010/2011


DEPARTMENTS
  1. Chemical Pathology - FAR
  2. Anatomy - AH, AIK, MASA
  3. Physiology - CBA, RZ, BSA

LECTURERS
  1. FAR = Prof Faridah Abdul Rashid (09-767 6484)
  2. AH = Dr Asma' Hj Hassan (6070)
  3. AIK = Dr Aaijaz Ahmed Khan (6080)
  4. MASA = Dr Mohd Asnizam Asari (6069)
  5. CBA = Dr Che Badariah Abd Aziz (6161)
  6. RZ = Dr Rahimah Zakariah (6156)
  7. BSA = Dr Ang Boon Suen (6157)

TOPICS
  1. Cranial nerves (MASA)
  2. Renal clearance (CBA)
  3. Sensory and motor systems (CBA)
  4. Respiratory physiology I (RZ)
  5. Respiratory physiology II (BSA)
  6. Joints of the lower limb (AH)
  7. Blood supply of the brain (AIK)
  8. Embryology I (MASA)
  9. Embryology II (AH)
  10. Fat metabolism & its regulation (FAR)
  11. Cholesterol & lipoprotein metabolism (FAR)

From:
Dr Mohd Suhaimi  bin Ab Wahab
Phase I Chairman
20 April 2011

2011 USM Medic Graduation Night Theme: "Ocean Melody"

Rus Lida25 April 06:27
Subject: for brothers and sisters year 5
Assalammualaikum dan Salam sejahtera.. Alhamdulillah, selesai sudah Peperiksaan Akhir tahun 5. Sekarang cuma masa untuk berdoa dan berserah sepenuhnya kepada pencipta. Moga segala usaha kakak2 dan abg2 selama ini akan dibalas dengan satu kenangan terindah pada hari Khamis nanti.

Buat pengetahuan, Exco tiket Malam graduasi akan membuka kaunter jualan tiket pada hari keputusan diumumkan di luar dewan kuliah…kami ingin memberi peluang kepada semua kakak2 dan abang2 untuk meraikan kejayaan kalian bersama kedua ibubapa dan keluarga tersayang. Kejayaan kalian memberi seribu makna kegembiraan buat mereka ..insyaALLAH.

Justeru, bagi sesiapa yg ingin mendapatkan tiket, bolehlah ke kaunter kami selepas keputusan diumumkan…atau menghubungi wakil kami:

Firdaus: 0194528280
Ruslida Saad: 0139716761
Tema Malam graduasi: Ocean Melody

Kami mengharapkan doa dari semua, agar persiapan kearah meraikan kalian berjalan dengan lancar. InsyaALLAH, kami cuba melakukan yg terbaik bg memuaskan hati semua pihak.

Sekian,wassalam

USM MedSSoc

Wednesday 20 April 2011

Vegan lifestyle ‘ups risk of heart attack, stroke’

People who follow a vegan lifestyle — strict vegetarians who try to eat no meat or animal products of any kind — may increase their risk of developing blood clots and atherosclerosis or “hardening of the arteries,” which are conditions that can lead to heart attacks and stroke, according to a new study.

Researchers come to the conclusion after a review of dozens of articles published on the biochemistry of vegetarianism during the past 30 years.

In the review, researcher Duo Li notes that meat eaters are known for having a significantly higher combination of cardiovascular risk factors than vegetarians.

Lower-risk vegans, however, may not be immune. Their diets tend to be lacking several key nutrients — including iron, zinc, vitamin B12, and omega-3 fatty acids, Li said.

While a balanced vegetarian diet can provide enough protein, this isn't always the case when it comes to fat and fatty acids. As a result, vegans tend to have elevated blood levels of homocysteine and decreased levels of HDL, the “good” form of cholesterol. Both are risk factors for heart disease.

It concludes that there is a strong scientific basis for vegetarians and vegans to increase their dietary omega-3 fatty acids and vitamin B12 to help contend with those risks. Good sources of omega-3s include salmon and other oily fish, walnuts and certain other nuts.

Good sources of vitamin B12 include seafood, eggs, and fortified milk. Dietary supplements also can supply these nutrients.

The finding appeared in ACS' bi-weekly Journal of Agricultural and Food Chemistry.

Source: BioScholar Latest Research News, 7 April 2011

FYI, I will write on chemical extraction when I have time. It is a big problem when extracting active compounds using hexane. One is danger of explosion especially when large amounts are kept on site. - Prof Faridah

Thursday 14 April 2011

Interview Skills

SPECIAL EDITION

Written by Prof Faridah Abdul Rashid, School of Medical Sciences, USM.

Most prospecting students don't know that they can be fully and better prepared for interviews. There are many things to look out for and students must take note you cannot pass an interview if you don't do the right thing. I'll just pen a few things to start students in the right direction so students can be their best when attempting an interview.

COMPONENTS
1. Background, preparedness & SWOT
2. Subject matter and the wider knowledge (wider than wide or the ripple theory)
3. Study by examples
4. Language and Communication Skills


1. Background, Preparedness & SWOT
You must have some bkgr knowledge in whatever you want to try. In Medicine, you must read and read the right stuff. There are many online materials - database, journals, e-books etc. Read as much as you can on Medicine. Medicine is a vast field today and there is no end to learning about Medicine. Find an area you like and read up as much as you can. The more you read, the more you will discover gaps in knowledge and so on. Read up and fill in. As you progress, so will your knowledge base - it will expand and you will have build your own knowledge base of Medicine. Most students fail to do this and therefore cannot even discuss in interviews what are subjects/areas they particularly like in Medicine. When you think you know almost everything there is to know, then try to do a SWOT analysis on your newly acquired knowledge. 

SWOT stands for S=Strength, W=Weakness, O=Opportunities and T=Threats. Study your knowledge base. Ask yourself, what are your strengths, weaknesses, opportunities and threats wrt a particular knowledge, discipline, disease, treatment etc. Do SWOT and re-assess when you think you know everything.

Reading up and listening to the news are good avenues to gain knowledge. Listen to six consecutive months of foreign news and you will see the breath and depth of areas covered in world news. All things that happen in this world will inevitably have a bearing on Medicine and human lives. Find and pick up a few relevant areas from world news and work on them as a form of leisure and also homework in your spare time. Make mind maps or bubble maps and link each bubble to another. Link all the bubbles  and read up to see how they link - this creates new knowledge. Then try and make short notes and add illustrations. Then post what you know in blogs or Facebook so other people can read and respond and give you comments. Use those comments and work on them and further increase your knowledge. Learning never ends; it is lifelong. Whatever learning you start today will become a lifelong learning activity. So begin today and keep going.


2. Subject matter and the wider knowledge (wider than wide or the ripple theory)
There are many disciplines in Medicine today and you will not have time to study them all before your life ends. Choose carefully what particular areas you like and take them up actively by reading up. There are different disciplines at different levels.


BASIC
I've written just very simple introduction for each discipline below so you can see and feel the difference and know what to read further. These disciplines are regarded as "pre-clinical". It doesn't mean that they aren't important to Medicine, quite contrary, they are the basis of Medicine! These subjects are usually emphasized in first-year Medicine. Students will need a strong foundation is these subjects before they are allowed to sit for the first Professional 1 Exam at the end of the first year.

Anatomy
Anatomy is the study of human body structure and how every structure functions (works) in us. A good knowledge of anatomy is desirous as that is what Medicine is about. Anatomy tells you what the bones are in the body, how there are arranged, what muscles hold them together and what they do. Of course, there must be good supply of blood to the muscles and bones and the nerves control the movements in us. Haven't you seen people who can't move and remain in wheelchairs? Why? What's wrong with them? Didn't it make you think that something is wrong with their anatomy?

Biochemistry
Biochemistry is a combination of two words - bio which means life and chemistry. Biochemistry is the study of what happens inside us when we eat, fast (puasa) and exercise. We use chemical reactions and enzyme to help us understand the changes that occur in us. These are specific chemical reactions and specific enzymes which must function. Let's say you eat nasi bungkus for breakfast. What happens next? Of course our body is covered with a skin and it is not transparent, so we can't see what's going on inside us. But we have a lot of knowledge as to waht happens. The food that you eat forms a mulch with saliva (air liur) and it goes down your esophagus into the stomach. More acid is added and specific enzymes are added and the food is broken down somewhat. That food is now called chyle and exits the stomach into the next portion of the intestine. More chemical reactions take place. In fact, thousands of reactions occur at any one time in our body. Some of the complex chemical compounds are broken into smaller ones and some are absorbed (others get excreted). Some foodstuff you eat give you a lot of energy while some just give you a little energy. When you fast, you run out of energy. When you eat too much you become fat. How one gets fat can be explained by chemical reactions. So this is what biochemistry is about. 

Physiology
Physiology is almost similar to Biochemistry but somewhat different. Physiology is a very detailed study of all things that occur in our body. In Physiology, you will learn how the heart beats and what causes it to beat. You will also learn how human sight works at the cellular level. It also teaches you how breathing occurs, how our bodies make urine, how hormones are made in us and how they affect us, how blot clots and what causes bleeding to occur. Physiology is the most interesting subject in first-year Medicine.

Hematology
Hematology is the study of blood and things inside the blood. It is an interesting discipline indeed. Students must have heard about Blood Groups? Haven't you heard of Blood Groups? Don't you know your own blood group? Well, there A, B, AB and O blood groups. Unfortunately, there is no D blood group but it would be interesting if students said (in interviews) that they do indeed have D blood group! LOL. Then of course, it is interesting to know if an A father married a B mother, whether the children would A, B AB or none of these. Imagine, an O child born to such parents! Interesting, isn't it?

Endocrinology
Endocrinology is the study of hormones and what they do inside our body. There are many types of hormones inside us. Can you imagine that our body makes hormones? Where? Where do you think hormones are made inside us? What do hormones do inside us? How do hormones affect us? If I told you that long ago in Europe, the ancient scientists were after a small pea-shaped/sized organ located under the large body of brain (matter), what is that pea-shaped body? You can take a sneak preview of the structure of the brain and all its appendages (if any) elsewhere and tell me the answer. I'll give you yet another clue. This pea-shaped organ is the centre of intelligence - you damage it, you remain dumb the rest of your life. I'll give you a third clue. The ancient scientists even ate this pea-sized body from dead people, thinking that they may become intelligent. from its highly prized contents. Big question - did they really become intelligent? Another big question - what did the pea-sized body contain? I'll leave you with those clues and you can come and tell me the answers at the interview if we meet. That in a nutshell, is what Endocrinology is about! Very interesting!

Nutrition
Nutrition is the study of the different foods which we like to eat/gobble, their nutritional contents and what we can get out of them, supposedly energy. What is energy? Energy for a car comes from petrol/gasoline/gas or LPG. Energy from the sun feels hot and burns the skin. Energy from a house fire can burn you to death! Energy from a campfire burns your marshmallows crispy. Energy from the microwave oven heats up food and bruns it dry too. But what really is energy? Can you touch energy? Can you feel energy? Is energy a "thingy"? Is energy tangible? Is energy something you can capture inside a bottle? What is energy? Well, in Medicine, energy is energy! Wait, I didn't explain that. If you're sick in bed and try to get up, do you have energy to get up and go to toilet? If you haven't eaten for let's say one full week because of the tsunami and food supplies didn't get to you, would you be alive on the 8th day? Hmmm....well, it really depends on how much energy you have stored inside you. If I asked you where do you store energy in your body, what is your answer? If I gave you a clue, that there is something soft and yellow inside you that is your energy store, what is the yellow mass? Any answers yet? I'll give you more clues. If I told you, if you weigh 67 kg (like me now), your energy store is approximately 30% of that weight. What then is this energy thingy? If you don't believe me, then next time you go to the market, see the yellow masses in between the red muscles of any beef. What is that yellow mass? Yes, that is your energy store. It is the same in man and animals, we all depend on this yellow mass for stored energy. To obtain the energy, something needs to happen and that is biochemistry. The rest is history,

Medical Ethics & Social Behaviour
Medical Ethics is both an old and new discipline. It existed since the time of the ancient Greeks but has remained till today in more sophisticated forms that it is very subtle and students tend to overlook its importance. There are times in medical practice when a doctor must decide to act or not, to be doing this or that, to inform or otherwise. Decision-making is not so straight forward (not crooked either) but a doctor must know and decide what to do next. It is the medical ethics that come into play and doctors must be guided not to go beyond what they know or standard operating procedure (SOP).  Doctors may not have much in terms of anti-social behaviour  but patients can come in any size and shape and more often than not can surprise even the most experienced doctor, and even leave unpleasant impressions on doctors. So this area is important as  more and more patients are knowledgeable nowadays and even a slight negligence or error may just land a doctor in court.

Community Studies
Students may think that Medicine is limited to learning in the lecture hall and hospital only. Far from it. There are trips that take them out into the community, including old folks homes, orphanages, temples, community halls, Orang Asli villages, far away villages in the interior, etc. These trips are meant to familiarise the students that their future work is varied and never confined to the clinics, wards and operation theatres. There's more to life than that.


INTERMEDIATE
Higher-level disciplines are Microbiology & Parasitology, Immunology,  Genetics and Pharmacology. They are also regarded as pre-clinical disciplines but they are usually taught in second and third year. 

Microbiology & Parasitology
Micro itself gives away what the discipline is about. Micro cannot be big! Micro means really small stuff that even the eyes can't see. Well, if the eyes can't see, what can? Yes, micro refers to the use of the microscope to study some  really small stuff. What stuff are so small that you really need the microscope to even see them? Well, that depends. You see, microscope are of many types but you can group them into a few types based on their capabilities. That's interesting! Let's see....a simple microscope may let you see a hair lice clearly and you can see what's sticking to its surfaces. You can even see the eggs of the various worms in our tummies. Most interesting is to observe the different bacteria under the microscope. You can even see that bacteria we often eat from our own faeces! LOL. Parasitology is the study of parasites - things that live on you, suck your blood, drain all your nutrients, and leave you nothing. Worms are a good example. Humans are another!

Immunology
This is a relatively new field. A lot is now known about this discipline. We all get sick off and on. Why? Any special reason why some people don't even get sick when everyone around them are dead sick? Hmmm.....must be their body defense system, I think. What's that? Goodness! You mean to say there's something else living inside us? No, not that! Bukan hantu lah! LOL. What I'm saying is there are molecules inside us called antibodies that kill off bacteria when they invade our body. What other things invade our body? Viruses. What important viruses do you know? Have you heard on people who have HIV/AIDS? What's that? What is HIV? What is AIDS? Which is better of the two? Both are not wanted! When the virus invades, it reduces your immunity and your body is no longer strong to kill off all the viruses. What happens next? You get AIDS! What's that? Essentially, as the days go by, you can see your grave clearer! That is what is means. It also means that you just bought a one-way ticket and that is to your own grave, in total misery!

Genetics
Genetics is quite interesting. I'll give you some examples to think about. If your father has black hair and your mum has white hair, will you have black & white hair? Of course not! If your brother has brown eyes and your mother has green eyes, does that mean you must have green eyes? Well, depends. If a child looks Malay to you, does it mean the parents are Malay? Not necessarily. If everyone in your family is 6 feet tall, does it mean that your grandparents were also 6 feet tall? No. Both your parents are short but you are tall. Does it mean that you are adopted? Can blind parents have children with normal sight? Who do some people have more hair on their bodies than others? Have you seen anyone covered full-body with black fur? What is the cause of that condition? Have you seen the tallest man? How tall is he? Have you seen the shortest man? How short is he? Have you ever seen the sweetest girl on earth? Who is she? What determines the features of a person? Have you ever heard of the word 'genes'? What do you understand by that? Can genes be inherited? Can genes be transferred from one person to another? Can genes be stored for long periods?

Pharmacology
Pharmacology is the study of drugs and how they work inside us. There are many classes of drugs and their modes of action are studied individually and in combination. Some drugs are safe but most drugs are dangerous and must be carefully studied. Some drugs interact with each other and must be avoided taking them together. Clearance of drugs from the body can be compromised if taken in excess (toxicology). New drugs are made when needed. They must be tested systematically by established procedures. Some drugs do not any adverse effects in the short term and take quite some time to manifest. Have you seen people without limbs or digits? What caused these malformations? Have you heard of a drug called thalidomide? It was prescribed for pregnant women in the early 1960s to overcome morning sickness (muntah-muntah). No long-term studies of thalidomide were known then when the drug was prescribed for pregnant women  Only when babies started having birth defects and that was traced to thalidomide was it recalled but the damage was already done. Chemicals in foodstuff have a lot to do with birth defects. So this discipline is very important to us.


ADVANCED
Advanced topics and clinical disciplines will include 4th and 5th year subjects such as Pediatrics, Obstetric & Gynaecology (O&G), Accident & Emergency (A&E), Surgery, Neuroscience, Radiology, Orthopedic, Ophthalmology, Anaesthesiology, Medicine (Cardiology, Internal Medicine, Respiratory Medicine), Pathology, etc. Teaching at this level will involve patients and are conducted in the lecture halls, wards (for bedside teaching and ward rounds), clinics, operation theatres and different hospitals. Sometimes simulation models/patients are used. Students spend a lot of their time at the hospital(s).

Neonatology & Pediatrics
Neonatology is the study of newborns (less than 7 days old) (bayi baru lahir hingga usia seminggu). Pediatrics is the study of babies/infants (more than 7 days old) and children up to age 12. Pediatrics is important for the study of newborns, infants and children. These age categories are easy prey for horrible diseases, some of which can leave children permanently disabled. A lot of corrective actions including heart surgery and cleft lip surgery (pembedahan sumbing bibir) can be done at this stage while children are still young. Cochlear implant may have to wait till children are older.

O&G
If pediatrics studies babies & children then O&G studies mothers. When combined, the two becomes a package known as Maternal and Child Health (MCH), quite a significant field globally. While Pediatrics and O&G are limited to the facilities at the hospital, MCH is performed as fieldwork, usually in a specific community.

A&E
A&E is a very important department in Medicine. You must have watched Emergency Room (ER) the movie. Well, the actual A&E is more hectic and congested and there is no time to even create drama as seen on TV. It is worth spending some time at any A&E at any hospital and observe the actually workings of that dept. What do you think go on at A&E? Why do ambulances rush the injured to A&E? What can the A&E do for injured patients? Have you heard the term resuscitation? Do you know what it means?

Surgery
Surgery is a discipline that deals with cutting and adding implants and body parts. If Mona Fendi had cut the human body into 18 pieces/chunks, where do you think she learned this? She didn't go to medical school., you know. But I would like to think this savagery comes from ilmu hitam. You can feel and count the joints in your own body and that will give you approx. 18 places where you can chop the body. Beheading is not part of modern surgery! Modern surgery is of course more civilised than just chopping off body parts and feeding those severed parts to the dogs. Surgery today is quite advanced and you can even stitch together hands and digits from other people. Well, if you had 10 friends and each donated an index finger, then you can have 10 index fingers! Of course it will be hard to eat nasi with 10 index fingers! Surgery has many specialised branches including Head & Neck Surgery, Reconstructive Surgery, Maxillofacial Surgery and many more. Head & Neck Surgery deals with surgery involving the head down to the neck. Reconstructive Surgery is cosmetic surgery and deals with giving better looks to gory or funny body parts. Let's say you need bigger breasts for some odd reason then you go and see a plastic surgeon/a recon surgeon. Maxillofacial Surgery is giving you better dentition and facial features as when you had an accident and lost your entire teeth and pretty face. So these maxifacie docs engineer a new face for you! But don't blame them if they make you look like Mickey!

Neuroscience
Neuroscience deals with the brain mostly. The study models are human heads! Yes, you get a human head and you slice every layer and study it. Then you also do scans and study all the scans. Then you also get to put the slices together digitally and see what went wrong. Today, neuroscience has advanced so much that you just need to go through an MRI and within a few hours, doctors can tell you what is bothering your head. All imaging will need to work closely with Radiology. Neurosurgery is surgery of the brain as needed in the removal of a brain tumor. Although brain surgery is much feared by the public, it is quite safe today. Most patients survive a brain surgery but with slightly decreased capabilities. I have a lovely friend who survived brain tumour surgery who went back to work and is perfectly ok but of course is on drugs, just in case there maybe secondaries. I once had an uncle who went in for brain tumour surgery and died! Most patients who have had stroke do come out of brain surgery with slurred speech but better that than no speech. Outcomes are highly variable but brain surgeons always want to try their best and hope for the best for all their patients.

Radiology
Radiology advanced as our knowledge on atoms and nuclear physics expanded. Radiology is more like keeping records of body parts like you would keep a stamp album. You should like collecting stamps if you want to venture into Radiology. There are many modes to obtain images of our body parts. In addition to the plain old x-ray, now there is ultrasound, MRI (magnetic resonance imaging), CT-scan, PET, etc. It should be noted that imaging machines are very expensive, each machine is more expensive than 10 Mercedes Benz put together! Another great advancement in Radiology is the archival of digital images on servers which can then be accessed by radiologists and doctors alike for interactive learning and reporting. If you like mathematics, physics, imaging, computers etc, then this is the most rewarding field for you to try. Of course, like everything in life, should you find this field not to your liking, you can always switch!

Orthopedics
Orthopedics is an ancient art since man first lost his leg and needed a replacement. If you go to the orthopedic ward where most patients have just had leg surgery, there's nobody walking about! How great! Yes, the orthopedic ward is the cleanest and boasts having the best-behaved patients since they all can't get up and therefore have to remain in bed. That was my impression when I visited that ward in HUSM. Well, there's a problem though, since patients can't get up, if you happened to visit, then you have to do the walking for them! Yes, and that includes replacing the empty water bottles. If you walk around the ward, you will be able to see the different types orthopedic cases - debridement (kokok buang isi buruk) and leg amputations (potong buang kaki) are common sights in the ward. There are also those who are waiting for further leg amputation - they come with a bamboo shaft to hold the already amputated leg, and often the patient is very sad. Of course all rotten legs and foot stink!

Ophthalmology
Ophthalmology is the study of eyes and eyesight. If you are reading this text, then probably you also have some ophthalmic problem because I made this text small so can appreciate what it means to have zero sight (buta). Be thankful that you can see. There are millions of kids who are born blind, becoming blind and some just have lifelong poor eyesight. I have been wearing glasses since age 12 and straight lines always looked crooked. I cannot tell if I have typed single, double or triple 'l' letter and I cannot use graphic paper to draw graphs. That is how bad sight can be for some. For others, especially boys, they can't even tell the traffic light colours! Their world is shades of grey and they can even wear purple and orange and they feel perfectly happy with such colour combinations! The retina is the most prized layer of the eye but in some people (like me) the retina peels off and folds over and that can severely affect sight. There is retinal surgery now but even the thought of eye surgery turns me off! Very nauseating! Nak muntah dibuatnya! Another problem sometimes seen in young children is eye tumor. In this eye condition, one or both eyes are abnormal and can take on gory shapes. It feels very sad just looking at their pretty faces.

Anaesthesiology
Anaesthesiology had a funny beginning in Medicine. It didn't start with chloroform but maternal delivery. When mothers delivered their babies, most mothers screamed their heads off! Imagine if all our mothers screamed in labour room! Goodness, even the walls can fall apart with all that screaming. Many chemicals were tried to calm mothers for delivery. Among the chemical tried were nitrous oxide and much later, chloroform. Nitrous oxide is also known as laughing gas. Well, you can imagine mothers laughing and suddenly find out they have delivered! I too tried this gas and delivered a baby boy! It was wonderful to be gassed with nitrous oxide which dulls the brains but is both addictive! Anaesthesia for modern surgery is a different chemistry altogether. Gas mixtures and carefully gauged and delivered for a specified time and a reverse gas mixture administered for recovery. A funny thing can happen but doesn't happen too frequently is patients can become suddenly conscious during surgery! Of course re-gassing is best! Strict surgical fasting of about 12 hours or overnight fasting is most desirous for surgery that requires general anaesthesia (whole body gas and you go to sleep). It means your stomach must be empty when you undergo surgery or else the gas initiates vomiting and that can be very messy because you can aspirate your own vomitus, that enters your lungs and you cough indefinitely, and most probably, you die coughing, which is sad. There is also a minor anaesthesia which pregnant mothers prefer - epidural anaesthesia where the lower body is numbed and they feel no pain but of course they can feel things moving inside them, only the pain is not there.

Medicine
Medicine is an umbrella term and under this term are several disciplines including Cardiology, Endocrinology, Respiratory Medicine, Gastroenterology, Oncology, etc.

Cardiology
Cardiology deals with the heart and the blood supply of the heart and its surrounding structures. There are many reasons why we developed Cardiology in Malaysia. The first is to look at children's problems, especially hole-in-the-heart and blue babies. The second is for those who needed a heart replacement. The third is to clean and service the heart and its blood vessels, make sure all its highways are free from congestion. You will see different age groups having different heart problems. Cardiology is a dredge and tin mine, and many doctors who are cardiologists are rich. Well, if you like digging sick hearts, heart patients don't mind paying you, the sky is the limit. Of course you must return them a washed heart or else it's see you in court. Cardiology is interesting because like Radiology, there is a lot of heart imaging to do and interpretive reporting is challenging. Let me ask you this, what is the difference in the heart images of the dead and the live person? Remember, a dead heart with no heart beat doesn't mean a person is dead!

Endocrinology
Endocrinology is a big field that has attracted a lot of public interest. The two most studied fields are diabetes and obesity. Most endocrinologists today are diabetic specialists. Very few I know are obesity specialists for adult patients. If doctors are dealing with childhood obesity, then they would be in Pediatrics. Obesity means gross fatness or simply too fat. If you can't visualise that, then what is XXXXL? XS is extra small. M is medium. L is large. XL is extra large. XXL is doubly extra large (that's me) and that would be around 67 kg for ladies my age (52 years). My BMI is 29kg/m2. XXXL is triply extra large and BMI would be more than 30kg/m2. Well, if you had an accident and all of a sudden your weight increased from 50kg to 180kg, that's gross obesity and nothing can be done to reduce the obesity - the body goes into auto mode 'get fat fast'. The reverse mode works for super thin scraggy girls and ladies. You will notice that when you try to become thin, your voice becomes hoarse and you start growing fine body hair all over. Of course when you are thin and hairy, you will look worse than cat woman! Forget Batman and Robin, they prefer nice sexy energetic women who can vault 12 feet high!

Respiratory Medicine
Respiratory Medicine deals with your lungs and how you breathe when your lungs are compromised (tak boleh nak guna paru-paru yang dah rosak teruk; punoh habis). If you are an avid news listener like me, you will notice that we have more respiratory problems now than ever before. Why? We have a lot to feel guilty about. All the pollution we have created, all the earthquakes and broken lungs that have resulted, all the airborne diseases that have occurred (SARS, H1N1, RSV, etc etc etc), have landed us with so many patients who cannot breathe normally without assistance (unassisted vs assisted breathing). Long ago in the History of Medicine, we had iron lungs. Yes, you may giggle cos I taught some of you that in first year. Now the iron lungs have been revolutionised and they look like a bedside table! You wouldn't know that a patient is on assisted breathing if I didn't inform you. But modern medicine essentially means that.

Gastroenterology
All the endoscopy probing to see what you look like inside falls under Gastroenterology. There are many ways to probe and see what you look like inside. I'll give you a clue. It is very dark inside our body. How then do doctors view what is inside us? Ok, there's a light probe that doctors can use. How do they use a light probe? How big is the light probe? How is the probe inserted? Let's say the doctor sees something weird inside you and thinks he needs to get a sample of the weird stuff he saw (a biopsy), how does he do a biopsy? Biopsy samples are studied by the pathologists. You must have heard about the pancreas? What is dangerous/safe about pancreatic surgery?

Oncology
Oncology refers to the study & research of cancer - their causes, treatment and management. A lot of cancers affect humans and many humans are killed by certain cancers. Major cancers in women are breast cancer and that affecting the reproductive organs (cervical cancer, uterine cancer and ovarian cancer). Other cancers that kill men as well as women are brain tumours. Many cancer drugs are available today. Chemotherapy can be done at most hospitals today.

Pathology
Pathology deals with tissues excised either as biopsy samples or diseased body parts (gross specimens). Biopsy samples are sometimes displayed to the public at medical exhibitions. The usual body parts you see in display jars are gross specimen excised from live or dead bodies. Before you die, you can sign a consent form for your body parts to be used for various purposes including organ transplant and exhibition. Most people don't consider this as a good option. Some like to donate their entire body for full body exhibit which I think is great! In Pathology, you get to slice various body parts and observed them under the microscope. It will certainly teach you how organised our body is and of course you must be thankful to our Creator. We don't have a haphazard body. But it can become haphazard if you don't take care of your body and live like most people do. When you closely examine the diseased body parts, you will also discover how the patients lived.


3. Study by examples
There are many examples we can find on the Internet. There many health/medical cases which we can pick up and study. Type the condition in Google and search. There are so many examples that you can spend all weekend to read them and you cannot possibly cover all cases in one sitting. Take one or two examples and work through in your spare time. The Internet is a great tool. Use it to find interesting cases and make useful notes so you can refer to them later.


4. Language and Communication Skills
This is the most important component of any interview.If you ever aspire to be a doctor, make sure you can speak well first. If you can't speak well, then you have a lot of homework to do before you can be called fit for interview to be a medical student. Since our medical school doesn't provide any English training courses or crash course in Conversational English, you have to seek other places which may offer such courses. Try the British Council English courses and private courses. It is worth taking time to learn English rather than ignore it altogether and yet want to be a medical student studying Medicine in English and later work as a doctor where everyone speaks English. Spend time to learn it and be good at it. To really make it good, you got to practise using it daily and at every opportunity. When your spoken English is quite well-polished, there is no limit to what you can do with that. The sky is the limit. So get on with it, go learn English somewhere. Where? Try listening to foreign English news for six straight months - US English news and election reports are the best that I have used. Also listen to US non formal English and slang as that will give you some leeway to play around with English words and know the context to use them. It will give you a good feel and confidence in using some slang in order to fit in into daily talk when you are out among the public. These steps are very effective in trying to attempt fluency and diction both at once. You can also try record what you read and appraise that and improve. Repeat improving your pronunciation. Remember to speak like an American. California English is the best and easiest to learn. You will never regret it. Come back the best English-speaking person wherever you are. The feeling of achievement is greater than you can ever imagine. Believe me, give it a try and let me know if it works. Come back and write here if you will.


This article is prepared based on this workshop:

5th Workshop on Medical Student Selection for Pusat Pengajian Sains Perubatan (PPSP)
14 April 2011
8.10am - 1.00pm
Bilik Tutorial A, PPSP
USM Kampus Kesihatan
16150 Kubang Kerian, Kelantan

as part of
Faculty Development Programme 2011
Dept of Medical Education
School of Medical Sciences
Universiti Sains Malaysia

Tuesday 12 April 2011

S.P.I.C.E.S. Model

The School of Medical Sciences, Universiti Sains Malaysia has designed its medical curriculum based on the S.P.I.C.E.S. model shown below. The program is in line with the concept of student-centred learning (SCL) where students' learning time (SLT) is highly prized as it promotes the best form of learning under diverse conditions. Of course, all these work well in a conducive environment where students can blend many learning modes as in blended learning. ICT and e-learning now form the core of today's learning. 

The following is taken from the objective book of the Medical School:

KURIKULUM PERUBATAN, UNIVERSITI SAINS MALAYSIA

Program Ijazah Doktor Perubatan mengambil masa selama lima tahun.  Kurikulumnya adalah bercorak integrasi dan berasaskan kepada penyelesaian masalah (problem-solving) dan berorientasikan komuniti (community-oriented).  Program ini dibahagikan kepada tiga fasa:

           Fasa I                   -              Tahun Pertama
         Fasa II                  -              Tahun Kedua dan Ketiga
         Fasa III                 -              Tahun Keempat dan Kelima

Ketiga-tiga fasa dipadukan secara konsep berpilin (spiral concept) untuk mempastikan satu hubungkait  yang erat antara satu fasa dengan fasa yang seterusnya.  Pembelajaran dan kegiatan pada Fasa I, yang merupakan aras pertama pilin, akan didalami dan dimantapkan lagi pada Fasa II dan seterusnya pada Fasa III.   Konsep pilin membolehkan Pusat Pengajian Sains Perubatan (PPSP) melaksanakan falsafah integrasi mendatar (horizontal integration) dan menegak (vertical integration).  Kurikulum inovatif ini telah dirancangkan berdasarkan kepada kajian mendalam terhadap masalah yang wujud di pusat pengajian perubatan lain di dunia  serta  perkembangan dalam  bidang  Pendidikan Perubatan (Medical Education).

Strategi asas pendidikan yang diamalkan di PPSP ini boleh diringkaskan kepada “SPICES”.  Kurikulum model SPICES” dalam konteks ini bermaksud:

The following is modified from the objective book of the Medical School:


S - Student Oriented (berorientasi pelajar)

P - Problem-Based (berasaskan masalah)

I - Integrated & ICT-based (berintegrasi & menggunakan ICT)

C - Community-oriented (berorientasi komuniti/masyarakat)

E - Electives & e-Learning (elektif & e-pembelajaran)

S - Systematic & Self-learning (pembelajaran kendiri dan bersistem)
Spices spice up student-centred learning (SCL)

S.P.I.C.E.S. model:
S - student-oriented, P – problem-based, I – integrated & ICT-based, C – community-based, E - electives & e-learning, and S – systematic & self-learning. 

New student intake 2011/2012

Welcome new students who will be attending our Medical School interview on Saturday, 23 April 2011 and Sunday, 24 April 2011. You must be excited getting invited to come for the interview. Come prepared and with an open heart, full of enthusiasm, and not half-hearted or uninterested There is nothing better than attending this interview which looks at your personality, aptitude, preferences and maturity. Well, it takes a human to be a doctor and non-humans should not treat humans. You don't want Dr Spock from some spaceship to treat you when you are sick, do you? Same here. That's the purpose of the interview, to remove Dr Spock and only select genuine doctors-to-be who have a kind heart, not the money-making type though it is known that doctors earn a medical degree to become rich anyway. We'll argue it out at the interview. Be prepared to be "fired". Good Luck to all new students.

Dr Spock

Friday 8 April 2011

Origin of WHHL rabbits

Professor Yoshio Watanabe
Dr Yoshio Watanabe (1926-2008) was 82 when he died. He was a former professor at the Institute for Experimental Animals, School of Medicine, Kobe University, Japan. He discovered a male Japanese white rabbit in 1973 that showed hyperlipidemia despite feeding on a normal standard diet (Exp Anim 1977; 26: 35-42 (Japanese); Bull Azabu Vet Coll 1977; 2: 99-124 (Japanese); Atherosclerosis 1980; 36: 261-268). He confirmed the hyperlipidemia of this rabbit was inherited recessively from its parents.

WHHL rabbit
Dr Watanabe established this rabbit mutant strain in 1980 and named it WHHL (Watanabe heritable hyperlipidemic) rabbit ( Atherosclerosis 1980; 36: 261-268). After establishment of this WHHL rabbit strain, Dr Watanabe began to distribute the WHHL rabbits to many researchers worldwide.

Source: http://www.med.kobe-u.ac.jp/iea/wol.html

Thursday 7 April 2011

How to increase HDL

How to increase HDL # and HDL cholesterol levels

Sources of HDL
HDL are the smallest and most heterogeneous of the plasma lipoproteins. They can be formed in three ways:
(i) from intravascular lipolysis of triglyceride-rich lipoproteins (chylomicron & VLDL)
(ii) from intestinal mucosal cells
(iii) by the liver.

Lipolysis
When large triglyceride-rich lipoproteins undergo lipolysis at the capillary endothelium, the excess surface lipids of these particles are sloughed off as nascent discoidal HDL which are rich in phospholipids and contain little apolipoprotein. They also contain a surface enzyme called lecthin:cholesterol acyltransferase (LCAT). These discoidal structures can absorb free excess cholesterol off surfaces of rbcs and epithelial cells of the intima.

Intestines
The intestinal mucosa also secretes nascent HDL into lymph and they travel via the lymphatics, out through the jugular vein, into the general circulation. They then mature in the peripheral circulation by cholesterol uptake and subsequent LCAT action (these reactions are concerted).

States of cholesterol
Cholesterol exists in the body in two states, the active form is free cholesterol (FC) and the non active or storage form is the esterified form, cholesteryl esters (CE).

LCAT activity in blood
LCAT is present on the HDL surfaces. LCAT serves to catalyse the conversion of FC to CE.

Fates of cholesterol in HDL
FC and CE have different water preferences or polarity. FC is more polar than CE, which means FC is more likely to remain at the HDL surface while CE has to go somewhere. Where should CE go? CE will most likely enter the HDL core. This means as soon as FC is converted to CE by LCAT, the CE formed rapidly goes inside HDL. What is the result of CE entering into HDL core?

Outcome of LCAT activity: Impact on HDL size
From basic chemistry, we know CE is a larger molecule compared to FC. So when CE enters the HDL core, it will cause the HDL to swell or increase in size, ie HDL become larger particles. Is there a limit to how big HDL can get? Yes, definitely. Science is about exact numbers. So there is a limit to how big HDL can be.

Fates of HDL
What happens when HDL are as big as they can be? There are two possibilities that can happen - 1) big HDL (known as HDL2) can deliver their contents to the liver, and 2) they can transfer their contents to large atherogenic lipoproteins (chylomicron, VLDL, IDL) via an exchange mechanism (CE is exchanged for triglycerides, TG). This second route (CE exchange for TG) is part of the reverse cholesterol transport.

Liver
The liver secretes small spherical HDL and is the major producer of such HDL during fasting.

HDL cholesterol levels in blood
Other than normal HDL, why do we see cases of low HDL? Cases of high HDL? What can possibly lead to low HDL? What can possibly cause HDL to be elevated in blood?

HDL metabolism wrt size distribution
From research we understand that the lipoprotein particles are constantly in a dynamic state. This means their numbers and forms constantly change with time. The collection of HDL particles at time A may differ from HDL particles at time B in the same individual. How can this be? These lipoprotein particles are constantly being shaped and re-shaped  by enzymes which are part of HDL metabolism. There are also other factors such as nicotine, and hormones that affect HDL numbers and size distribution. What this means then is if I take a blood sample from two people of the same age and BMI but of opposite sex, I will not get the same HDL profile for both of them. Each HDL profile will be different not only because of gender but also hormones and other factors.

Causes of low HDL cholesterol in blood
Factors known to reduce HDL levels are being sedantary, ie not moving much and not using the skeletal muscles.

Causes of high HDL cholesterol in blood
Factors known to increase HDL levels are intense physical activity and non smoking Different scientists have different interpretations of physical activity levels. Asking two people of the same physical strength to do the same set of exercises may give different levels of HDL in the long run, let's say in three months. Quit smoking instantly raises HDL levels in blood.

HDL matrices and rubrics
What are the likely possibilities when we combine and permutate HDL # and HDL size?
What statements (hypotheses) can we draw from such manipulations?

# of HDL in blood reflects the synthetic activities of lypolysis, intestines and liver.
Small HDL (known as HDL3) are not favoured and regarded as less healthier.
Larger HDL (known as HDL2) are favoured and regarded as healthier.
The ratio of HDL2/HDL3 should be higher in healthier individuals
The ratio of HDL3/HD2 should be lower in healthier individuals.
It is safer to have more HDL2 than HDL3.
It is less safe to have more HDL3 than HDL2.

# of HDL will reflect HDL cholesterol levels in blood.
High # of small HDL may give normal or low HDL levels in blood.
High # of large HDL may give normal or high HDL levels in blood.
Low # of small HDL will necessarily give low HDL levels in blood.
Low # of large HDL will give normal or low HDL levels in blood.

HDL cholesterol lab test (analysis)
We sometimes forget that HDL is a double-step lab test, which means it is subject to more errors than a straight forward one-step test. HDL cholesterol is determined in the supernatant fluid after all other lipoproteins have been removed by chemical precipitation. Chemical precipitation is a tricky step to do in the routine lab. Sometimes it works alright, other times it is a total failure! Even the best lab technologist will introduce an error in the chemical precipitation step before the supernatant is harvested for chemical analysis to determine (HDL) cholesterol content.

After the chemical precipitation, the supernatant is analysed just as for cholesterol test. A cholesterol test is easy to do but an error can easily slip in at analysis time. We have to remember HDL cholesterol is a tiny value. One small error can easily give a false value.

Conclusion
In conclusion, if a HDL cholesterol value is LOW, I would suspect a technical or lab error first. If a repeat still shows a LOW HDL cholesterol value, then exercise is the way to go. HDL levels in blood are sensitive to physical activity and nicotine. Increase physical activity will increase HDL levels in blood. Since HDL are increased with intense physical activity (with much skeletal muscle involvement), I would say an intense physical training may be needed to raise HDL levels in some individuals who have a hard time raising their HDL levels.

Whether we fast or not, HDL are always produced by the body. Intravascular lipolysis and intestinal mucosa when combined produce quite a substantial amount of HDL and these sources are a bit more significant in the postprandial state (fed state). Otherwise the liver is a source of HDL.