Filling Income Tax via e-filling

Today I filled up my income tax form for the year 2014 and I've got my tax returned for >RM1000. It was my first experience to filing tax as a houseman who work under Kementerian Kesihatan Malaysia.

This is how I do it:

The Prerequiste:

1) E-Penyata Gaji. To register for e-penyata gaji, you need to to call up your hospital unit hasil and ask for your nombor gaji. Once you have your nombor gaji, you can register for your e-penyata gaji at http://www.anm.gov.my/. From this e-penyata gaji, you can see your monthly pay slip and your yearly pay slip. What is more important for your income tax return is your yearly pay slip (Penyata Pendapatan Tahunan).

2) No. Pin e-Filing. To get No. Pin e-Filing, you can register via eHasil website or you can visit the LHDN office for the No. Pin. What I did, I visited the LHDN office to get the No. Pin. There are many branches. The one I visited is at the PGRM building, Cheras. There, they gave me the No. Pin ( xxxx-xxxx-xxxx-xxxx) and No. Cukai Pendapatan (SGxxxxxxxxxxx). With these numbers, log in to their website at https://ez.hasil.gov.my/CI/ and choose "log-in kali pertama". Once you are done, you successfully got an account on eHasil.

Timing

The time frame to file your last year (2014) income tax is 1st March 2015 to 30 April 2015. It is the same for every year. Of course, this only apply for non business owner (worker on salary).

Filing your income tax

Log in to your eHasil account. click e-Borang > e-BE >2014. Enter your particulars, email, phone number, bank account number. In your jumlah pendapat section: fill up according to your Penyata Pendapatan Tahunan Bahagian C payslip. Not your annual total pay, because Bahagian E on your Penyata Pendapatan Tahunan is tax exempted.

Then, fill up all the details for Tax Reliefs, like KWSP, computer you brought, etc. What I fill up was medical books I brought at Kamal (Rm131), Laptop I brought (RM3000), and MRCP exam under Education section (RM5000), and KWSP. I guess we must keep all receipts ready for proof for tax reliefs.

Submit your income tax, and sign it digitally with your IC number and password. Once you sign it you are done filling your income tax! You can check your tax via e-filing>semakan pengesahan.

Cheers!

ERORR: MRCP  exam fees is not TAX exempted. DO NOT CLAIM AS TAX relief. Always check with HASIL/ qualified accountant.

 

My Top Medical App list (Android)

image from androidguys.com

Working in Malaysia government hospital as a junior doctor, the following is my 4 frequently use Medical App list:

1) My Blue Book. This app is serve as a useful quick reference for all the drug available in our Malaysia government hospital. I use this app almost everyday. I use it to check drug dosing; name of the drug brand name use in our government hospital; check if my specialist is require to sign for the drug prescription. The down side of this app is not all information is accurate.

2) Medscape. I use this app to check drug dosing, especially if I want to know the pharmacokinetics, duration and half life of the drug. I also use this to check pregnancy and lactation category of a particular drug. Another useful thing of this app is to check the Peak Expiratory Flow prediction when managing asthma patient.

3) Rapid GFR. It's a quick way to estimate the GFR and CKD status of my patient. This app use Cockcroft Gault Formular and MDRD formula. The only word of caution as this app assume there is no black race in Malaysia. And we did see a number of African patient in our hospital.

4) Renal dose. This is another useful app if we want to know the renal dose of each drug. It is simple and straight forward.

I use the following app, but not as frequently.

1) Cardiac Risk Calculator. I use this mainly for educating my patient on their risk status on developing cardiovascular disease. I like the fact that this app uses the Framingham equation.

2) NHS Antibiotic guidelines South of England.

3) SIGN guidelines. SIGN stands for Scottish Intercollegiate Guidelines Network

4) Warfarin HTK. Warfarin dosing and interaction


This is the following app I would love to use. The only barrier is the extra cash:

1) UpToDate. No doubt, UpToDate is the best source of medical information in the world. It is evidence based, straight forward, very detail and yet easy to read and understand. However this app is just too costly for an average doctor. Whooping USD400 per year!

2) Lexicomp.  I know most pharmacist in my hospital use this app. The information is reliable. It cost USD 570 for 3 years subscription.

Yeah, so that's the list. Please share if there is any good medical app I missed?

MRCP part 2

I recently passed my MRCP part 2 (Dec 2014). The following is the resources I use to prepare for this exam:

1) Oxford Handbook of Clinical Medicine. 

Please don't underestimate this small handbook book. I did, initially. Whatever is written in this book is the correct answer for the MRCP paper. It is as if the author of this book is also the author of the MRCP exam paper. I read this book in and out twice, and I must say most of my time is worth it. Forget thick book like Harrison or Davidson. This book is the bible for MRCP.

2) Rapid Review of Clinical Medicine for MRCP Part 2

Another must book to read. It is the "syllabus" of the Part 2 exam. Go though each page slowly and let it sink in as you read. If everything sticks, chances that you are ready for the exam.

3) Question banks. It's no-brainer, this is a must. The more question you practice, the better you are. I choose Pastest Qbank because most senior recommended me this. The other is Onexamination.com.

4) Facebook groups, Whatsaap group, Internet forum, etc. There are plenty of support groups, and all provide the much needed motivation and resources. I learnt plenty of radiological images, hematological slides, spotter for skin lesions, and fundus from these groups. The group I followed for my MRCP part 2:

https://www.facebook.com/groups/177315392301807/
https://www.facebook.com/groups/mrcpuk/
https://www.facebook.com/groups/528967743805371/
https://www.facebook.com/groups/285352564831987/
http://www.rxpgonline.com/forum11.htm


5) Time management and motivation. As a busy junior doctor, you need to manage your time well to prepare for this exam. I use evernote as checklist to make sure I cover most topic before the exam day. Evernote is also an excellent too for making notes everytime I studied a topic and I will share those notes to my friend via evernote. I certainly recommend this app.

One more thing,

6) During the exam, answer all question as fast as you can. The way of doing it is:

1) Read the answer option first,
2) Then, read the question .
3) Then read the case and identify what's the important point as quick as possible. Underline those important point.

Don't think so much or spend too much time on one question. If you don't know the answer, listen to your gut feeling and most likely those answers were right.

Most people fail MRCP part 2 simply because they don't have enough time to complete the paper. Each paper contain 90 questions and you have only 3 hours. Hence max 2 minutes for each question. So, yeah, keep looking at the clock as you answer your paper.

I wish you all the best. Cheers.

ps: You can read my "Part 1" post here.

If heaven doesn't exist, then what are Christians looking forward to?

http://upload.wikimedia.org/wikipedia/commons/thumb/2/2b/Dreamy_Twilight.jpg/320px-Dreamy_Twilight.jpg

This essay is in reply of my friend who post this on Facebook:
"If heaven doesn't exist, then what are Christians looking forward to?"

 This question reminds me Blaise Pascal's wager on existence of God with the following logic:

	God exists	God does not exist
Believe in God	Infinite gain in heaven	Insignificant loss
Disbelieve in God	Infinite loss in hell	Insignificant gain

  from Pensées


Hence, Pascal concluded that even if God does not exist, it is still worth it to believe in God because it only cost "insignificant loss" compared to the more costly losses should God really exist and yet if we don't believe.


However, while I do respect and admire Pascal's geniuses and contributions, I think Pascal misses the point. The incentive of being a Christian is neither heaven or hell.

Think about it:

Heaven no matter how wonderful the place is but after awhile anyone will get bored. A day or two in Universal Studio in Singapore would be fabulous. The unlimited ride, the amusement and entertainment, but I won't want to be stucked there for even 1 week! And frankly speaking, I don't have much liking of the aesthetic part of gold besides the fact that it is a rare commodity and hence it's rising price and value. And gold in heaven is no longer rare. So it is not about the place. It is about something else.

If not the place, then, what is it about?

"It is about Promise and Trust."

You see, the Bible says that we had and have sin (sin is a big concept which I will explain next time) and the consequence of sin is great and many. Of many consequences, there are 3 main ones:

1) One of the dread consequence of sin is that we become slave to Sin. Some of it may be subtle, and some of it may be evident like Alcoholism, Internet addiction, etc.  Romans 6:18 promise us that with Jesus's power: "You have been set free from sin and have become slaves to righteousness." He also promises in Psalm 119:11 that If we hidden God's word in our heart, that we might not sin against God. Those who had memorized the Bible can testify that Psalm 119:11 indeed is true and powerful. Because Psalm 119:11 and Romans 6:18 works, we have confident in the Bible and hence, we can trust in God and what God says must be true!

2) The other consequence of sin is that we are separated from God. Sin is so offensive to God that we are so separated from God. With all our needs and wants taken care off, with all pleasure and gain, at the end of the day, we felt that emptiness in us. We look for something "spiritual" to fill that gap. We, however failed miserable. Jesus had taken our guilt and offenses, and pay the penalty of sin with His blood, and because of that we became a righteous man (or a good man) as if we have not sin before! As the result, we become without sin and was adopted as sons of God and no longer separated from God!(Luke 19:10, 2 Cor. 5:21, 1 Peter 2:24, Rom. 8:3-4, Gal. 3:13) And as a result, we become so close to God that we live everyday as if God is beside us. That means, whatever bible text we read in the morning, we trust that He as if speaks directly to us. And we trust whatever God says.


3) The third consequence of sin is that this planet earth is breaking apart. Matthew 24, predicted the dooms day of this planet earth and every single detailed had and has come to pass. Sin has cause disaster, war, famine, global warming, political instability, corruption, disease, death... you name it! And God promises that He will end all this sorrow by preparing Heaven for us. He promise that during dooms day (which the Bible says, will happen any time soon), He will come back and destroy this Earth and make a perfect world again called Heaven. And He promise that it is going to be an awesome place to stay. 1 Corinthians 2:9 promises that:  "What no eye has seen, what no ear has heard, and what no human mind has conceived" -- the things God has prepared for those who love him

That means, Heaven is not like one chunk of Gold building like I can imagine. It must be something better than that. I dont know. But I trust God, that I am going to like it and won't get bored (no matter how I try to perceive Heaven) because God said so. It is trust and promise!

So coming back to the question...

If heaven doesn't exist, then what are Christians looking forward to?

If that statement is true in an absolute sense, I think the short answer is: We, Christian will be so utterly disappointed. Not because we wanted to go there so badly, but because we trusted in what God has promise us. Is like when your boyfriend promise that he will marry you but later change his mind and go for another girl. How would you feel? Cheated right?

However, we know that most of God promise had fulfill and come to pass. And our daily walk with Jesus on this planet Earth had evident that He can be trusted and His Word can be taken word for word. So, even though we can't see Heaven yet, we can be sure, it really exist. That is what the Bible call: HOPE!

"If there is no resurrection of the dead, then not even Christ has been raised. And if Christ has not been raised, our preaching is useless and so is your faith."

-- Paul the Apostle (1 Cor 15:13-14) 

Fact or Fiction? Debunking Exercise & Nutrition Myths for Preventing Heart Disease & Risk Factors by Mayo Clinic

Interesting video by Mayo Clinic Cardiologist which discussed the specific lifestyle behavior which can prevent heart disease:

1) Running vs Walking in reducing heart attack risk?
2) Low fat diet, very low fat diet vs. Mediterranean diet (only low saturated fat diet)?
3) Chocolate reducing heart attack risk?
4) Coconut oil good for your heart?

Teaching Sabbath Class for Beginners

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Disclaimer:

The Sabbath School is a program by the Seventh-Day Adventist Church. You may not understand the following unless you frequented the church service.

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The following essays are merely my thoughts, suggestions and a guide to new teachers who wish to teach Sabbath School Class. In fact there are many other better ways to teach the Sabbath School Class effectively.

Sabbath School Class is a place where learning happens. The teacher's role is to facilitate this learning process.

There are many ways and method to teach, however it is important to tailor your teaching style according to your class:

1)how motivated they are,
2)their familiarity with the scriptures,
3)do they learn their lesson,
4)how willing they participate in the discussion
5)are they in a learning mood or they are engrossed in giving their point of view

Two characteristics of a good Sabbath School teacher:
1) to ask good questions that stimulate thinking process
2) to able to derive those answers from the Bible

Preparation

1) It takes no brainer to know that a good teacher is familiar with the topic she teaches. That means she will read the lesson and the bible text related to it over and over again. She will take notes, search for more resource from the internet, books, etc.

2) Ask yourself what are the few learning points you want the class to learn? List may be 3 learning point. If there are more than 5 learning point, then you are not summarizing the lesson enough. Remember, you cannot teach or discuss more than 5 learning point. You simply don’t have the time during the 45 minutes Sabbath School class. In addition, too much point will not drive home any message and end up people didn’t learn any.

3) Once you got the learning point, the most crucial part is to make good questions on the lesson. A good question is where there is answer in the bible. Do not ask any question if there is no answer in the bible. It is nice to ask those questions but there is no place of such question in Sabbath school. It will just create confusion, encourage human opinion rather than the Word, and a waste of time discussing it. Remember, the goal of a good Sabbath School class is to learn the Bible.

There are 3 kinds of questions:

A) Ice breaking question. The purpose of this question is to make people talk, to break the silence, and to encourage discussion. It is used in the beginning of the class. This question must be very easy to be answer by everybody regardless of their spiritual maturity, education or age.

Eg. How is your week? What is the topic of this week lesson? If the topic is about love, ask: “How many of you have lost someone you really love?”

“How many of you being loved and cared for?”

 If your class members is enthusiastic, you can ask them to share the experience, if they are not enthusiastic or not close to each other, it might be wierd to ask people to share something so personal.

Don't ask questions which you know people will not answer.

Eg. Is God the center of your life? If you ask this question in the beginning of the class you are going to expect a silent class where people will stare each other or they will look at their shoes.

B) Bible study question. As mention earlier, ask a question which there is a direct answer in the bible. A good question must not be vague, and the answer must be straight forward. Don't ask vague question or questions which have vague answer.

Example of good question: Why did God ask the children of Israel to build a Sanctuary? answer Exodus 25:8 so God can dwell among them. It is a good question because both question and answer is straight forward and not vague.

Example of vague question are usually found in the Sabbath School lesson bottom page. These questions are good to ponder but not a good question for discussion.

Eg.

How does the sanctuary service help us to understand our utter dependence on God for forgiveness of our sins? What comfort does this truth bring you? At the same time, what important responsibilities follow?

This question is taken from Oct 29, 2013 Tuesday lesson. It is a good question to ponder but it is too vague.

C) The appeal questions. Ask this in the end of the lesson. Don’t ask an appeal question unless you think the class is ready.

4) Write all your question down with a specific answer. The answer is from the Bible directly! I normally list about 10 carefully selected questions which can cover the span of 45 minutes class.

One place to get good questions is from the powerpoint presentation Aunty Jacie sent weekly. The other way to construct good question is to have a bible text ready (the answer) and make question in such a way that the answer is found on the readily available bible text.

5) When you have the questions ready written down, then it is easy for you to teach the class.

6) Finally, always summarize at the end of the class. You can bring home the 1-3 learning points in that week.

7) Pray.

During the class

1) You must not tolerate anyone to put anyone down. It is tough, but we must try. Watch out for people who use Sabbath School as a platform to criticize an individual. If he/she attempt to criticize the whole class, then that’s fine. Individual problems are dealt individually.

2) Some of the "lines" that may be helpful to you:

A. When someone said a brilliant point, don’t say "Thank You", but say this:"I think Bro. John had just bring out an important point. He said... (summarised what he just said to re-enforce his point)"

B. When someone asked an out-of-topic question, "That is an interesting/ a good question, I wish we have the time to discuss that, but probably we can talk about/ answer your question after potluck... etc.."

C. When the discussion goes out of topic, "That is an interesting....(say same thing like before), however, what do you think of...(ask a questions pertinent to the lesson to continue the discussion)" That is why always have your questions written it down. It becomes very useful when your mind goes blank or when you got confused by the discussion

D. When someone ask a difficult questions you have no idea what is the answer. Look at the class and ask "Bro John ask.... (summarised his question) what do the class think the answer to his questions?" If the class is silent, and if you think Bro. John is just "testing" the class and you know he knows the answer, just ask directly "Bro John, so what is the answer" or if you know Bro John is genuine on want to know the answer, "That’s a good question, okay, it is our home work to find out the answer"

E. When someone disagree with the obvious Bible text truth/Spirit of Prophecy and keep pushing his or her point. Quote a bible verse and move on with another discussion. Don’t attempt to disprove him/her.

F. When a cute baby walks by pass your class and the whole class was distracted instead of listening to you. Don’t get offended. It happens all the time. Just smile, and pause and wait for the cute baby to walk pass and when everyone has your attention, continue with your lesson.

3) If you are scared and not confident. Pray and receive the confidence from God.

If you are still not confident, it is okay. Relax and be still and just do our part teaching prayerfully and wait upon the Lord.

If you are still afraid and stammer, read off the questions you had just prepared and written down. I cannot emphasis more on how important is it to write the questions and answer down.

4) The best way to get everyone involve in the class is to take turn read the bible verse after your questions. If you direct a question to specific person, you may embarrassed him/ her. Of course that depends according to the person.

Finally,

1) Get very familiar with the lesson. Read many times. Use variety of Sabbath School resources online.
2) Make good questions. Write down each question and answer down. Provide a bible verse for each question.
3) Write down the summary of the entire lesson. 1-3 learning points.
4) Pray and just do the job well!

Ad: Financial Guide for Doctors - Unit Trust

One thing they don't teach you in Medical School is how you plan your finance; investment, loans, mortgage, credit cards, stocks, savings, unit trust, insurance, property etc. We learn non of these and often we relied our parents advice.

Picture: http://www.chicagonow.com/own-your-legacy/files/2013/06/save-money1.jpg

Of these, one thing, I want to point out, as a junior doctor is now it is a right time to save your money every time we receive your monthly salary. According to your needs and expenses, always set aside a fixed amount from your monthly salary for saving.

If we save consistently, in a fixed amount, no matter how small, we can accumulate much at the end of the day.

The money accumulated may not make us rich, but it can act as a financial safety net. For example, you may need extra cash if someone you love may be hospitalized (God forbid), money to start up your first clinic, to start a mission or charity projects or to add to your retirement fund.

However, when you set aside your monthly saving and you put inside the bank, you must be aware of that your hard earn money will eventually depreciate. For example, our hard earn RINGGIT depreciate around 6% annually.

That means, if you put your money in a fixed deposit which gives around 3% annual interest, you end up losing around 3% yearly.

That is the next better option is to invest our monthly saving into a Unit Trust.

Okay, the disclaimer is that my mum is a certified unit trust agent. Should you want to invest, please call 016 2096338. Support support!

:)

How Unit Trust works is when you buy a fund, the fund manager (who is an expert with the stock market) will  pool your money together with the money from the thousands of people like you who buy the funds.

With that huge amount of money he will invest in various stocks in a way which according to his expertise, you trust that he/she will make a handsome profit out of it.

So you will earn whatever profit he/she make and the fund manager will cut a small fee from you.

It is however, not without risk. Should the fund manager loses money in his/her investment, you will lost your money too. However the risk is minimized because he/she invest in many many stocks. Some make money, some lose money. Hence, the overall, the profit will make up with the losses.

Hence, generally if you invest in a good fund, you may get a steady 10-15% annual profit. Some lousy funds, you may earn less.

Yes unlike buying stocks, unit trust may give slower return. But it is less risky, and you can concentrate in your work more instead of watching for stock price daily.

 So how your saving works:

You can use a compound interest calculator to calculate.

Say you put aside RM1000 monthly for saving and put in to a unit trust fund which gives average 10% interest return.

In 10 years you can save up RM 204,051.34

In 30 years ( when you retire), you manage to save RM 2,096,742.12!

So, ask yourself how much you can save in a month, calculate your saving using the compound interest calculator and decide.

Call up my mum 016 2096338 to discuss which fund is suitable for you. And start saving! For a start, invest in a low risk fund with a steady return.

Yes, it is a free advertisement for her! :)

Pathfinder SDA KL Church Intake 2014

Pathfinder Club KL English Church activity in 2013!
 
Contact the following should you wanna join for 2014 intake:
Sherlyn Sikin 
Petrik Andrews  
Ellen Andrews  
Lim Gek Choo

Different classes separated according to age groups: kindergarten, primary school, secondary school.

Admission opens now.

Applying Housemanship in Malaysia

Simply Google, you will end up many blogs which gives you instruction on how to apply for housemanship in Malaysia. For example: http://zmlee.wordpress.com/2013/08/29/fresh-graduates-how-to-apply-for-housemanship-in-malaysia/

Just make sure you stick to them religiously.

Unlike in Singapore which offers me Medical Officer post, to work in Malaysia, I must do 2 years of housemanship! :(

To sum up:
1) Apply provisional registration with MMC.

• Download form 4, print, and filled it up carefully: http://mmc.gov.my/v1/docs/form/1.Provisional%20-%20updated14052013.pdf
• Get all your documents certified, passport size photos, and bank draft of RM 20
• Submit your application with relevant documents personally at MMC office

• You may get your registration after 1 hour! These guys are efficient!

2) After that arrange an interview with Suruhanjaya Perkhidmatan Awam Malaysia. Call Puan Normah 03-88856313 to make an appointment for Interview.

3) Submit borang BMD at Kementerian Kesihatan Malaysia.

The interview at SPA:

I arrived early at 7:30am. Nombor giliran 3! By 8:00am the hall is crowded with future houseman. I estimate 200 plus.

There are 2 interviewer. One is the pegawai from SPA, the other a doctor from KKM.
Question asked by the pegawai from SPA:

Saya hanya ada dua soalan kepada kamu:

1) Apa kamu tahu tentang Kementerian Pembangunan Luar Bandar dan Wilayah

Answer: Saya tidak pasti. Saya tidak pernah dengar tentang kementerian ini

2) Okay, tidak apa, soalan kedua ialah, setiap 5 tahun, kita di Malaysia ada Rancangan Malaysia. Tahun ini, rancangan ke berapa?

Answer: Saya tidak pasti.

That's it! I know nothing!

Then the doctor from KKM asked: Give me 3 causes a 70 year old man comes to ER with seizure.

I gave her 3 reasons: Hypoglycemia, Breakthrough seizure if known seizure disorder, Meningitis. She stared at me silently, I gave 5 more reasons. There is still silent. I gave 5 more causes, this time explaining each more in detail. She still silent. Then I talk about the hypoglycemia episode, why I must rule out first, I will give IV dextrose even if I don't have the reading, bla bla bla, then I talk about deteriorating renal function, skipping meals, overdose, forgetfulness, living alone without caretaker, alcholic, stress like infection. Finally she seems satisfied and didn't asked more questions.

I got my surat tawaran on the same day itself. God has been good to me!

Calcium Metabolism Disorders

I have recently wrote this for meducation.net. Enjoy!

http://upload.wikimedia.org/wikipedia/commons/a/a3/Illu_thyroid_parathyroid.jpg

Calcium Metabolism Disorders

author: Chan En Ze, MBBS

date: 13 October 2013

What are the functions of calcium in our body?

Calcium has numerous functions in our body and can broadly divide into two:

1) The first role is calcium act as structural support in the form of bone. A bone is composed of 35% organic matrix (mostly proteins in the form of Collagen) and 65% inorganic calcium hydroxyapatite (hy·droxy·ap·a·tite). When you put a bone under a flame, the organic part will be all burnt up, and what remains is the inorganic calcium hydroxyapatite, which gives the white chalky texture. The Calcium Hydroxyapatite has the biochemical formula Ca5(PO4)3(OH) which shows that it composed of both calcium (Ca) and phosphate (PO4), thus regulation and metabolism of Calcium in our body is closely related to the regulation and metabolism of Phosphate. It is interesting to note that some orthopedic prosthetic implants are coated with Calcium Hydroxapatite to promote osseointegration.

2) The second role is it maintains normal cellular function: neuromuscular signalling,hormone release, cardiac contractility, and blood coagulation. That is why, the calcium concentration in our blood is maintained within a narrow range (2.2-2.7mmol/l) because any small disturbance of the concentration will greatly affect the muscle, nervous system, endocrine, heart and blood coagulation. The details of these mechanism is beyond the scope of this chapter.

How calcium regulation take place in our body?

The four main organs which tightly regulate calcium in our body are the intestine, bone, kidney and parathyroid glands. For simplicity sake, think of the intestine takes in all the calcium into our body, bone act as a huge store room for calcium, kidney as calcium disposer, and the parathyroid that secretes parathyroid hormone (PTH) maintains the blood calcium concentration.

There are 2 main hormones which tightly regulate calcium concentration:

1) The parathyroid hormone(PTH) secreted by parathyroid gland which regulate blood calcium concentration minute by minute. Increase of PTH will increase calcium concentration and vice versa. The only way to get calcium supply in this short amount of time is to get it from the bone and to immediately decrease kidney secretion of calcium ion. You can’t count on the intestine to wait for supply of calcium in the next meal! That is why after a total thyroidectomy done, a surgeon will measure the corrected serum calcium the following day after the surgery. If the parathyroid is affected, there will be a quick decrease in serum calcium concentration the following day. I say “corrected” because calcium is bounded to albumin in plasma, hence we need to take albumin concentration into account.

2) Unlike the PTH, the Vitamin D has a more long term role on calcium regulation. It has the major role on calcium absorption in the intestine and lesser role on the bone and kidney. With the help of Vitamin D, these absorbed calcium is then stored in the bone. Another way of thinking the Vitamin D is it act as “bone builder”, it increases calcium and phosphate absorption to the bone and decrease excretion of calcium and phosphate in the kidney. This is contrast to PTH which breakdown the bone by releasing calcium and phosphate into the blood, decrease calcium excretion in the kidney but increase phosphate excretion.

The Vitamin D is obtained from diet and synthesis in the skin by the action of sunlight. It is serially activated to 25-hydroxylation in the liver and 1-hydroxylation in the kidney. That is why decrease in sunlight exposure, liver and kidney failure will affect Vitamin D concentration.

In the “mind” of the hormones	Parathyroid hormone	Vitamin D
My Goals	My goal is to regulate serum calcium concentration minute by minute by increase serum calcium in a very short time.	My goal is to build strong bones and long term calcium regulation.
How I do it?	Breakdown bone, increase calcium and phosphate release into the blood. Increase decrease excretion of calcium in the kidney but increase phosphate excretion in the kidney	Activate the intestine to absorb dietary calcium. Build bone by increase calcium and phosphate absorption in the bones. It also need increase supply of both calcium and phosphate by decrease excretion of both ions in the kidney.

The other hormone is the Calcitonin (produced by the C-cell of the thyroid) act exactly opposite to the PTH, but has less physiologic importance.

What are the causes of too much calcium in our blood (hypercalcemia)?

The causes of hypercalcemia are increase calcium intake, increase calcium release from the bone, and other causes.

Increase calcium intake:

1) Excessive ingestion of OTC medicine Calcium Carbonate to treat dyspepsia. This is known as Milk-Alkali Syndrome. This is more markedly in pregnancy when there is increase absorption of calcium in the guts.

2) Total parenteral nutrition

3) Vitamin D intoxication

4) Excessive Vitamin D production in granulomatous disease like sarcoidosis, tuberculosis, and silicosis. In these lesions, there are excessive macrophages which produce Vitamin D, which in turn activate the gut to absorb calcium.

Increase calcium release from the bone:

1) One most important cause is hyperparathyroidism. Primary hyperparathyroidism is when there is single or multiple parathyroid adenomas or hyperplasia causing increase secretion of PTH inspite of already high calcium concentration in the blood. In normal condition when serum calcium is high, the feedback mechanism causes decrease secretion of PTH. However, in primary hyperparathyroidism, there is increase in serum calcium and normal or high, PTH level. There is also increase urinary calcium, decrease in serum phosphate due to its action on the kidney. Because of the action of PTH, there is increase bone resorption, activation of osteoblast and osteoclast which results in high alkaline phosphatase level, resorption cavities in the bones (known as osteatitis fibrosa cystica) and bone marrow fibrosis. Treatment for this condition is to surgically remove the parathyroid gland. In familial cases, hyperparathyroidism is associated with MEN type 1, a neoplastic lesion of pituitary, parathyroid, and pancreas.

2) Parathyroid carcinoma can results in increase PTH production and hence, hypercalcemia.

3) In renal failure, there is decrease production of activated Vitamin D which cause prolonged hypocalcemia state. This cause compensatory hypertrophy of the parathyroid gland. In this case, the PTH level is high, but the calcium level remains low or normal. This is known as the Secondary hyperparathyroidism. In long setting of this condition where there is parathyroid hyperplasia, eventually blood calcium level is raised. This condition is known as tertiary hyperparathyroidism.

4)  Lytic skeletal metastases in malignancies such breast cancer and myeloma

5) Many solid tumours like squamous cell carcinoma of lung secrete Parathyroid Hormone-related Protein (PTHrP) which behaves like PTH and causes hypercalcemia. This may be the first sign of malignancy and is consider a paraneoplastic syndrome.

6) Hyperthyroidism can cause hypercalcemia but the exact mechanism is not understood. Thyroid hormone is known to stimulate osteoclast differentiation and hence increase bone resorption causing hypercalcemia.

7) Like wise, prolonged immobilisation increase bone resorption causing hypercalcemia.

Other causes:

1) In the parathyroid gland, there are calcium sensor receptor (CaSR) which sense the calcium concentration level and in return the parathyroid gland will secrete the appropriate amount of PTH. Mutations that reduce the activity of this receptor can result in higher concentration of  calcium and PTH. THis condition is known as Familial hypocalciuric hypercalcaemia.

2) Lithium therapy also can affect the function of CaSR and causing hypercalcemia.

3) Endocrine disorder such as Addison’s disease, Pheochromocytoma, VIPoma

4) Medication such as thiazides, Vitamin A toxicity,, Theophylline toxicity.

What are the causes of too little calcium in our blood (hypocalcemia)?

The cause of hypocalcemia can be divided into two categories: hypocalcemia with low serum PTH level (hypoparathyroidism) and hypocalcemia with high serum PTH level (secondary hyperparathyroidism).

Low Parathyroid Hormone Levels. This is due to defective in the parathyroid gland itself. Failure of PTH production cause decrease serum calcium level. The causes are of low PTH hypocalcemia are the following:

1)Parathyroid destruction can be spontaneous due to autoimmune causes. Autoimmune hypoparathyroidism can be associated with autoimmune polyglandular syndrome type 1 (mucocutaneous candidiasis, adrenal, gonadal, thyroid failure)

2) Post radiation, post surgery like parathyroidectomy and thyroidectomy, infiltration by metastases or systemic disease; all these can cause low PTH

3) Hypomagnesemia can impaired synthesis and secretion of PTH. Hypomagnesemia is always associate with hypocalcemia and hypokalemia.

4) Previously, we mention CaSR. Mutation that reduce the activity of CaSR can cause hypercalcemia in case of familial hypocalciuric hypercalcaemia; in contrast, mutation that increase the activity of CaSR can cause hypocalcemia and this condition is called autosomal dominant hypocalcaemia with hypercalciuria.

5) Parathyroid agenesis like DiGeorge syndrome (mnemonic CATCH-22: cardiac anomaly, abnormal facies, thymic aplasia, cleft palate, hypoparathyroidism - Chromosome 22 abnormality)

High Parathyroid Hormone Levels. The parathyroid gland is fine, but there are other factor which cause hypocalcemia. Hence, to compensate, there is overactivity of parathyroid gland. The causes of high PTH hypocalcemia are the following:

1) Vitamin D deficiency can occurs in malabsorption, dietary deficiencies, lack of sunlight..Vitamin D resistance including receptor defects (vitamin D dependent rickets type ii) can cause hypocalcemia. In chronic renal failure, there is impaired production of activated vitamin D and hence causes hypocalcemia.

2) Also, in chronic renal failure, there is hyperphosphataemia. When phosphate level is high, it will precipitate ionising calcium and cause serum hypocalcemia. This is why hyperphosphataemia will cause ectopic deposition of calcium in tissues. The other causes of hyperphosphataemia besides chronic renal failure are acute rhabdomyolysis, tumour lysis syndrome, phosphate administration.

3) Deposition of calciums also can occurs in pancreatitis, hungry bone syndrome following parathyroidectomy.

4) Pseudo-hypoparathyroidism is when the parathyroid gland and secretion of PTH is normal but there is PTH resistance. Pseudo-hypoparathyroidism is due to G protein mutations with a characteristic of short stature, short metacarpals, and intellectual impairments.

4) Drugs can cause hypocalcemia by precipitate serum calcium are like EDTA. Some drugs like bisphosphonate inhibits bone resorption causes hypocalcemia. Phenytoin and ketoconazole can altered vitamin D metabolism which causes hypocalcemia.

What happen if there is too much Calcium in our blood?

We know that calcium is important in the signalling process in nervous system and neuro-muscular junction. Hence patients with hypercalcemia will experience, neuropsychiatric symptoms like depression, decrease concentration, personality changes, lethargy, confusion and muscle weakness. Calcium is also important in cardiac contractility, hence in hypercalcemia especially in acute hypercalcemia, there will be bradycardia, AV block, short QT interval. That is why administering calcium intravenously is done slowly and in diluted form (rules of 10: 10ml Calcium gluconate dilute 10ml of 10% Dextrose given in 10 minutes) and with monitor attached on the patient.  Hypercalcemia also can cause gastrointestinal symptoms like nausea, anorexia, constipation. It also can cause pancreatitis. Hypercalcemia can increase gastrin production and causes peptic ulcer disease. Hypercalcemia decreases renal concentration ability which cause nephrogenic diabetes insipidus where there is polyuria and polydipsia. Hypercalcemia which cause hypercalciuria also can cause renal stones (nephrolithiasis). Hypercalcemia due to long standing elevated PTH can cause bone pain. The easy way to remember all these symptoms of hypercalcemia is to remember this mnemonic: "stones, bones, abdominal groans and psychiatric moans"

The treatment for acute hypercalcemia is adequate hydration, intravenous disphosphonates and identify the underlying cause and treat appropriately.

What happen if there is too little Calcium in our blood?

Calcium ion is important signalling process in nervous system and neuro-muscular junction and in hypocalcemia, there will be neuromuscular disturbance like muscle spasm, tetany, seizure, confusions, neuropsychiatric and myelopathy. Signs in hypocalcemia including on tapping the facial nerve causes twitching of the facial muscle (Chvostek’s Sign) and sphygmomanometer-induce ischaemia causing carpopedal spasm (Trousseau’s sign). Hypocalcemia can affect cardiac contractility which cause prolonged QT syndrome. Chronic hypocalcemia can affects bones growth like rickets and osteomalacia. It also can impair dental growth. There will be dry skin, brittle nails, and hair loss. It also known to cause cataracts in chronic hypocalcemia.

Treatment for hypocalcemia including calcium replacement: intravenous calcium gluconate infusion if severe hypocalcemia or oral calcium supplements if less severe. Vitamin D supplement for Vitamin D deficiency, renal failure, and hypoparathyroidism. Thiazide diurectics and low salt diet can increase calcium level. Recombinant human 1-34PTH is available but the cost is prohibitive.

References:

1) Harvey R et al (2010) Biochemistry (Lippincott's Illustrated Reviews Series), Chapter 28 Vitamins

2) Khosla S (2008) Harrison's Principles of Internal Medicine, 17th Edition Vol 1 , Chapter 47 Hypercalcemia and Hypocalcemia

3) Kalra P (2009) Essential Revision Notes for MRCP Third Edition, Chapter 13.5 Disorders of bone, mineral metabolism and inorganic ions.