Screenshot taken from Notion (Notion Labs, Inc., 2025) for educational use.
Students often juggle assignments, notes, exams, projects, research, and extracurricular commitments—and sometimes the entire circus collapses in a heap of sticky notes and half-finished reminders. Notion EDU brings order to the chaos by offering a single digital workspace where students and teachers can create notes, databases, calendars, study dashboards, project boards, course outlines, and more. It’s flexible, customizable, and surprisingly fun to use once you get the hang of it.
How the Tool Works (Cost, Features, Learning Curve) Notion combines documents, task lists, databases, and calendars into one space. A single page can include text, images, embedded Figma files, videos, checklists, and linked databases. For example, a “Design Wiki” might house style guides, prototypes, research notes, and stakeholder feedback side by side, with everything tagged and searchable. Users can build custom workflows for projects, from idea to final deliverable, and connect related pages with backlinks. Notion EDU is free for students and teachers with an academic email, while paid plans exist for larger teams and enterprises that need advanced permissions and security. The learning curve feels moderate at first because it’s so flexible, but most users become comfortable after experimenting with a few templates and learning how to use basic building blocks (pages, databases, and views).
Educational Benefits (student group, content, objective) Although the “Notion for design” page speaks directly to professional design teams, the exact same features translate beautifully to education. In a design course, for example, students could maintain a shared workspace that includes a design system, project boards, sprint plans, and critique notes, all stored in Notion. In more traditional academic settings—such as undergraduate or graduate programs—students can create dashboards to track assignments, exams, readings, and research projects. Group projects become easier when everyone can see the same task list, attach files, link prototypes or articles, and keep all discussions in context. For instructors, Notion can serve as a living course hub containing the syllabus, weekly modules, readings, and assignment instructions. This supports objectives like improving organization, increasing transparency for group work, and strengthening collaboration across disciplines.
Potential Problems and How to Overcome Them There are a few challenges to consider when using Notion in education. First, new users can feel overwhelmed by its flexibility; there is no single “correct” way to set up a workspace, which can lead to confusion or overcomplicated pages. This can be minimized by providing students with simple starter templates (for example, a basic course dashboard and a group project board) and gradually adding complexity only as needed. Second, since Notion is a cloud-based platform, reliable internet access is important for full functionality, though offline support has improved over time. Finally, collaboration can get messy if teams do not agree on naming conventions or page structure. Instructors can address this by modeling a clear, consistent layout and setting expectations about where different types of content should live within the workspace.
Screenshot taken from Full Code (Minerva Medical Simulation, 2025) for educational use.
Clinical reasoning isn’t built in a day—it’s crafted through repeated exposure to patient cases, uncertainty, and decision-making under pressure. Full Code provides this practice in a safe, immersive environment that feels like a virtual ER rotation. This simulation platform guides learners through patient encounters where they must assess, diagnose, treat, and manage cases across a wide range of clinical scenarios. It’s one of the most comprehensive medical simulation apps available and a favorite among students preparing for OSCEs, shelf exams, and real-world clinical rotations.
How the Tool Works (Cost, Features, Learning Curve) Full Code functions like a virtual hospital: users choose cases, conduct histories and physicals, order labs and imaging, administer medications, and perform procedures. Each decision affects patient stability, which makes the simulation rewarding—and humbling. The app provides immediate feedback, scoring, and teaching pearls. It offers over 150+ cases spanning emergency medicine, internal medicine, pediatrics, OB/GYN, trauma, and more. The app is free to download, but premium subscriptions unlock the full case library (around $15/month or discounted yearly plans). The learning curve is low; the interface is intuitive, and cases guide users step-by-step.
Screenshot taken from Full Code (Minerva Medical Simulation, 2025) for educational use.
Educational Benefits, Problems & How to Overcome Them Full Code is extremely useful for medical, PA, nursing, and paramedic students, or anyone needing additional practice with clinical reasoning. Students can practice rapid decision-making, differential diagnosis formation, and evidence-based management. It’s especially valuable for early learners who want clinical exposure before rotations. One challenge is that some students may become overly reliant on gaming the system (e.g., ordering everything). To overcome this, instructors can set guidelines such as focusing on cost-effective workups or pausing after each step to explain decision reasoning. Internet connection issues can also arise, but downloaded cases help.
Screenshot from Complete Anatomy (3D4Medical, 2025). Used under educational-use allowance.
Understanding human anatomy has always required more than memorization—it requires spatial reasoning, visualization, and the ability to mentally rotate structures from multiple angles. Complete Anatomy takes this to the next level by offering a fully interactive, 3D anatomical atlas with unprecedented detail. Whether you’re a medical student studying the brachial plexus at 2 a.m. or a professor demonstrating surgical landmarks, this tool makes anatomy learning more intuitive, engaging, and precise.
How the Tool Works (Cost, Features, Learning Curve) Complete Anatomy allows users to explore over 17,000 anatomical structures in full 3D. You can rotate, isolate, fade, dissect layers, view animations, study bone landmarks, and explore physiological processes. The platform includes quizzes, pre-made courses, and digital dissections. Students can customize models, labeling, and annotations, while instructors can create interactive lessons. Costs vary: there is a free trial, but full access typically requires a subscription—around $39.99/year for students and $99.99/year for educators, with institutional licensing available. The learning curve is mild; within one session, most users understand navigation, but mastering all features takes a bit of exploration.
Screenshot from Complete Anatomy (3D4Medical, 2025). Used under educational-use allowance.
Educational Benefits, Problems & How to Overcome Them Complete Anatomy is ideal for medical, nursing, PA, PT/OT, and health-science students. It is especially powerful for students who prefer visual or hands-on learning. Complex topics like pelvic floor anatomy, cranial nerves, or musculoskeletal attachments become much clearer with 3D manipulation. Educators can use custom screens, lecture mode, or prebuilt short videos for classroom integration. Challenges include device compatibility (older tablets may lag) and subscription cost. These can be managed by using campus-wide licensing, downloading models for offline use, and encouraging collaborative study sessions in tech-equipped spaces.
Medical school humbles you. No matter how brilliant you were before, how effortlessly you aced exams, or how much praise you collected along the way—medical school has a way of shaking that foundation.
For many of us, school was always our strong suit. We were the top of our class, the go-to person for notes, the ones who barely had to study to get an A. And then, suddenly, we step into medical school, and everything changes.
The sheer volume of information feels insurmountable. The study methods that worked before suddenly fail. And worst of all? Those A’s we once took for granted? Now, they’re B’s… or even C’s. And that’s where the existential crisis begins.
The Identity Crisis: “Am I Even Good Enough?”
For years, academic success might have been the core of your identity. Being “the smart one” wasn’t just something you did—it was who you were. But when your usual strategies stop working, and you find yourself struggling just to keep up, it can feel like a personal failure.
Thoughts creep in:
“Maybe I don’t belong here.”
“What if I’m not as smart as I thought?”
“Did I just get lucky before?”
Imposter syndrome thrives in these moments. You look around, convinced that everyone else has it figured out while you’re drowning in lectures and Anki cards. But here’s the truth—everyone is struggling, even if they don’t show it.
Why Performance-Based Self-Worth is Dangerous
One of the biggest mindset traps medical students fall into is attaching self-worth to performance rather than effort and growth. We tie our confidence, happiness, and sense of identity to grades, test scores, and class rankings.
But here’s the reality: – Getting a B or C in medical school does NOT mean you’re a failure. – Struggling does NOT mean you’re not cut out to be a doctor. – Your ability to learn, grow, and adapt matters more than your GPA.
The irony? The students who focus on effort, consistency, and resilience—not perfection—end up doing better in the long run.
How to Shift Your Mindset & Survive the Transition
So, how do you get through this? Here’s what helped me (and many others) make peace with the struggle:
1. Focus on Progress, Not Perfection
Medical school isn’t about being the best—it’s about becoming better every day. Measure success in small wins: mastering a topic, improving study habits, or simply showing up and trying.
2. Redefine What It Means to Be “Smart”
Smart isn’t about getting A’s anymore. Smart is about problem-solving, adapting, and persisting even when things are tough. In medicine, the best doctors aren’t necessarily the ones who got straight A’s—they’re the ones who learned how to think, problem-solve, and keep going.
3. Detach Self-Worth from Scores
Grades are just numbers—they don’t define your potential or your future as a physician. What matters is that you show up, do the work, and keep pushing forward.
4. Talk About It
You’re not alone. Find people who understand—friends, upperclassmen, mentors. The more we talk about these struggles, the more we normalize them.
5. Play the Long Game
Your goal isn’t to be the best student—it’s to become the best doctor you can be. And that means focusing on learning, not just performance.
Final Thoughts: You Belong Here
The transition from excelling to struggling is painful, but it’s also part of the journey. You are NOT alone in this, and you are more than your grades. Growth happens in discomfort, and every challenge you overcome is shaping you into the doctor you’re meant to be.
So if you’re in the thick of it, questioning yourself—take a deep breath. You’re doing better than you think. And no matter what your grades say, you belong here.
If there’s one thing I can say about my first year of medical school, it’s this: it was a rollercoaster of emotions, growth, and lessons I never saw coming. From the outside, it might look like just a lot of studying, but the reality is so much deeper. Med school isn’t just about learning how to care for others—it’s also about learning how to care for yourself.
Here are some of the biggest lessons I learned during this wild, humbling, and rewarding first year:
1. Comparison is the thief of joy
Starting medical school, I quickly realized how easy it was to compare myself to my classmates. Everyone seemed so smart, so confident, so put together. Meanwhile, I was just trying to survive my first anatomy lab without fainting.
What I’ve learned is that comparison doesn’t serve you. Everyone’s journey is different, and your success isn’t defined by how you measure up to others. It’s about how much you grow, how hard you work, and how kind you are to yourself along the way.
2. Imposter syndrome is real (but it doesn’t define you)
There were so many days I wondered, Did the admissions committee make a mistake? I’d feel like I didn’t belong, like I wasn’t smart enough to be here.
But here’s the thing: if you’re in med school, you’ve earned your spot. You worked hard to get here, and you deserve to be here just as much as anyone else. I’ve started reminding myself that it’s okay to feel uncertain or overwhelmed—that’s part of growing. The key is to focus on progress, not perfection.
3. Balance is a myth (but self-care is non-negotiable)
Trying to balance school, relationships, hobbies, and downtime sometimes felt impossible. Spoiler alert: it is. There will be weeks when school takes over, and that’s okay.
What I’ve learned, though, is that self-care isn’t optional. Whether it’s walking my dogs, calling my family, or binge-watching a show guilt-free, I’ve learned to carve out time to recharge. Even 30 minutes can make a huge difference.
4. Celebrate the small wins
Med school is full of milestones—passing your first exam, finishing a tough lab, or even just making it through a long day of lectures. I’ve learned to celebrate those moments because they add up and remind me why I started this journey in the first place.
5. It’s okay to ask for help
This was a hard one for me. I’ve always prided myself on being independent, but med school taught me that asking for help doesn’t mean you’re weak—it means you’re human. Whether it’s reaching out to a professor, seeking mental health support, or leaning on your friends, it’s okay to say, I can’t do this alone.
Acquired Immunodeficiency Syndrome (AIDS) is a disease caused by retroviruses—the Human Immunodeficiency Virus (HIV). It’s mainly characterized by extreme immunosuppression associated with opportunistic infections, malignancies, wasting, and central nervous system (CNS) degeneration. “The Human Immunodeficiency Virus directly infects lymphocytes and, in particular, depresses the number of T-helper (CD4+) cells and reverses the ratio of helper to suppressor (CD8) lymphocytes” (Cawson, Binnie & Eveson, 1988). There are approximately 36.9 million people currently living with HIV/AIDS. Two forms of the virus have been identified: HIV type 1 (HIV-1) and HIV type 2 (HIV-2). HIV-1 is responsible for most of the infections worldwide and HIV-2 is endemic to many countries primarily in West Africa.The morbidity rates of AIDS-related deaths have been on the decline since the 1990’s, largely in part to the continual improvement of drug therapies and education. In fact, it is now considered a chronic illness.
Route of Transmission
There are various possible routes for transmission including sexual transmission, transmission via needles or from mother to fetus/child. HIV can reside in semen and vaginal fluids, and these fluids can transmit the virus onto mucous membranes of another person. Needles, syringes, and other drug injection paraphernalia are common because they increase the risk for blood-to-blood contacts. Blood donations are now screened for the virus, so blood transfusion recipients are no longer at risk. For children infected with HIV, the mode of transmission is most often directly from the mother to the infant. The virus can be transmitted during pregnancy, birth or while breastfeeding. HIV, however, is not spread via saliva or casual contact.
It’s important to consider that a patient infected with HIV is infectiouseven in the absence of symptoms. Seroconversion is the term used when an infected person’s blood converts from being negative for HIV antibodies to being positive. Seroconversion usually occurs within 1 to 3 months after exposure but can take up to 6 months. The time between infection and seroconversion is called the window period. Consequently, blood collection centers must screen potential donors to identify those with high risk behaviors who are potentially within this particular window period.
The Phases of HIV Progression
There are three distinct phases in the progression of HIV which occur over a 5-14 year period; the primary infection phase, the chronic asymptomatic (latent) phase and the overt phase. The primary phase is an acute illness stage similar to acute mononucleosis. This phase includes signs and symptoms such as fever, fatigue, headache, pharyngitis, night sweats, oral or genital ulcers and gastrointestinal problems. The latent phase is characterized by a period in which there are few signs or symptoms of the illness. Some patients may present with swollen or sore lymph nodes in two or more locations, not including the groin. The length of the latent phase is averaged at ~10 years. Patients who have entered the overt phase develop AIDS and the risk for opportunistic infections increase significantly.
Manifestations and Features of HIV/AIDS
Other manifestations include, but are not limited to rapidly progressive periodontitis, Addisonian pigmentation, angular cheilitis, herpes simplex or zoster, parotitis, myobacterial ulcers, facial palsy, trigeminal neuropathy and major aphthae.
Treatment
Candidosis: The Centers for Disease Control and Prevention has published guidelines for treatment of oropharyngeal candidosis (OPC) in patient with HIV (December 2004). Their guidelines are divided by age group; adults and adolescents vs. children and infants.
Recommended treatment of OPC in adults and adolescents:
Fluconazole 100 mg PO QD for 7-14 days
Itaconazole oral solution 200 mg PO QD for 7-14 days
Clotrimazole troches 10 mg PO 5x/d for 7-14 days
Nystatin suspension 4-6 mL QID or 1-2 flavored pastilles PO 4-5x/d for 7-14 days
Itraconazole oral solution 200 mg (or more) PO QD
Amphotericin B deoxycholate 0.3 mg/kg IV QD
Recommended treatment of OPC in children and infants:
Fluconazole 3-6 mg/kg body weight (max 400 mg/dose) PO for 7-14 days
Itraconazole cyclodextrin oral solution 2.5 mg/kg body weight (max 200-400 mg/d) for 7-14 days)
Clotrimazole troches 10 mg PO QID for 14 days
Nystatin suspension 4-6 mL PO QID or 1-2 flavored pastilles PO 4-5x/day for 7-14 days
Itraconazole cyclodextrin oral solution 2.5 mg/kg body weight PO BID (max 200-400 mg/day) for 7-14 days
Amphotericin B oral suspension 1 mL (100 mg/mL) PO QID for 14 days or less
Hairy Leukoplakia: There are both local and systemic treatment options for Oral Hairy Leukoplakia (OHL). Local treatments often include the use of topical podophyllum resin (POD) and/or surgery. POD is made from different plants such as American mandrake and Indian apple. POD must be used with caution to limit toxicity. Large amounts of POD may result in serious system adverse effects and fatalities (Baccaglini et al., 2007). Topical treatment is ideal for small, contained lesions and is impractical for very large lesions. Systemic antiviral treatments may include antivirals such as desciclovir, valacyclovir and acyclovir but recent studies show that they are not as effective as local treatments with topical drug application and/or surgical removal of the lesion.
Osteomyelitis of the Jaw: Osteomyelitis is most commonly affects the mandible compared to the maxilla. Treatment is dependent on various factors such as which stage in the Cierny-Mader Classification system it’s in, which pathogen is involved and what other comorbidities the patient may have. Treatment may involve sequestrectomy (removal of dead bone that is separated from the rest of the jaw), hyperbaric oxygen therapy, resection and reconstruction of the jaw, drainage of the infection, specific antibiotic prescription based on pathogen cultured, and debridement of the area.
Ulcerative Gingivitis: Treatment for ulcerative gingivitis includes debridement, antiseptic mouth rinse such as chlorhexidine or hydrogen peroxide, improved hygiene and antibiotics. Treatment should be divided into 4 stages:
Stage 1: Stop the disease process and control patient discomfort and pain
Stage 2: Treat the preexisting chronic gingivitis through professional prophylaxis and/or scaling and root planning
Stage 3: Corrective treatment of disease sequelae with procedures such as gingivoplasty and/or gigivectomy
Stage 4: Maintenance through compliance with oral hygiene practices and controlling predisposing factors
References
Baccaglini et al. (2007). Management of oral lesions in HIV-positive patients. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontology, v.103, S50.e1-S50.e23. https://doi.org/10.1016/j.tripleo.2006.11.002
Campbell-Yesufu, O. T., & Gandhi, R. T. (2011). Update on human immunodeficiency virus (HIV)-2 infection. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 52(6), 780–787. https://doi.org/10.1093/cid/ciq248
Cawson, R., Bonnie, W. & Eveson, J. (1994). Color atlas of oral disease: Clinical and pathological correlations. WolfePublishing.
Hanley M., Hendriksen,S. & Cooper, J. (2020). Hyperbaric treatment of chronic refractory osteomyelitis. Treasure Island (FL): StatPearls Publishing. PMID: 28613536
Malek,R., Gharibi, A., Khlil, N. & Kissa, J. (2017). Necrotizing ulcerative gingivitis. Contemporary Clinical Dentistry, 8(3), 496-500. https://doi.org/10.4103/ccd.ccd_1181_16
Successfully finishing undergrad on a pre-med track requires strategizing. When I first started taking science classes, I felt like medicine wasn’t for me. I had zero background in science and I was working a full-time job. I felt like I’d never catch up to my classmates, or better yet, pass the classes I was taking. That was when I earned my first C freshman year. I was taking Human Biology at a local college in my hometown and thought my horrendous high school study habits were sufficient to get me through college level classes. I was rudely awakened to the fact that my method of studying was no where near what was required for a successful run at a college level class.
The process of perfecting my study habit and finding a flow that worked best for me was a slow a strenuous one. I’d say it took the entirety of my freshman year, and maybe even some of sophomore year, for me to start to really get the hang of it and not feel like I was in a constant state of TRYING NOT TO DROWN!
First, before I get into the tips, I want to introduce you to my 5 phases of studying. I’ve realized over the years that I study best and learn best when I follow specific steps and study in a certain order. I divided the process into 5 phases and I go through each in the same order every time. I try to not skip phases unless I’m falling really behind or feel like the material is easy enough to where I can jump straight into practice. All of these phases are after lecture and after I have skimmed through the material either before or after class (depending on my availability). The phases are as follows:
Recall Phase: The first step in studying the material I am learning. This involves me using active learning practices such as brainstorming what I remember from lecture, drawings pictures, writing out ideas, creating a song/poem or creating a poster board. The best thing to do is review information from class after a break in between, not immediately after lecture. This may seem difficult at first because you realize there are gaps in what you can recall, but that’s OK! It means you need to retrieve information from memory which is what we want to master anyways.
Action phase: This is where what I’m learning is put into practice. I do as many practice problems, exams, quizzes and tests that I can get my hand on. In this phase, I am not yet testing myself. I am using my notes and videos to guide me through the problems. I mark down questions I am getting wrong and do them until I understand my error and corrected it.
Testing phase:This is where I do exactly what I was doing in the action phase, but I use no help at all. I do everything by myself and grade my own practice as if I had taken an exam. This phase is extremely important because you may be do extremely well in practice when you have an aid and realize you are still getting stuck when you have to critically think through problems on your own.
Review phase: The review phase includes going over any final topic or material that you are still struggling with. If you are struggling after the testing phase, seek help from your professor or a classmate that understands the material better than you. Don’t be afraid to use outside resources for your own benefit. They are there for a reason!!!
Elaborating phase: This phase isn’t always possible, but it’s my favorite because it really helps me solidify what I know and makes me feel like I’m a smart cookie. I try to teach the material to either someone else or myself. This literally means talking out loud and, FROM MEMORY, going over everything I know from the topic and explaining it as if I was teaching it to someone who never heard of it before.
One of my favorite resources for learning better studying techniques is the learning scientists blog. On their website, you can find more resources on what they consider to be the best six strategies for effective learning. I personally practice at least 4 of them during my studying sesh on any given day.
1. Ditch the flashcards
Don’t get me wrong, flashcards can work wonders when you are trying to simply memorize information short-term. As you all very well know, if you are trying to pursue a graduate career past your undergradhate degree, a lot of the information you are learning (especially core science or science related courses) will come back to haunt you. You will either have to know it for the MCAT or for the first year of medical, dental, pharmacology and vet school. Don’t underestimate the future need for the information you are learning. Merely getting an A in the class should not be your main priority. You want to really learn and understand the material. Instead of flashcards, consider incorporating active learning into your studying. Refer back to my initial phase of studying description to get an idea of what active learning may look like.
2. Space out your studying
The worst thing you can do to yourself is try to cram an entire week of material into one day of studying. It doesn’t work! 7 hours of studying on a Saturday is not the same as 1 hour of studying 7 days a week. The latter results in you not retaining the information and is exhausting. Work out a healthy balance between your work, personal and school schedule and ensure you give yourself personal time for hobbies and relaxing. Space out your work over several days or blocks throughout your day so that it adds up to your goal time. For example, wake up an hour earlier and spend 45 minutes in the morning reviewing for course A. Then, at lunch from work, review what you did in the morning. After work, don’t do anything related to course A. Focus on a different course and swap the schedule the next day so that course A is your evening focus.
3. Make connections
Memorizing words, formulas or basic ideas can be fairly easy, but what is required for you to really learn and understand the material so that you never forget it again? How do you master a subject? My favorite technique for mastery involves making meaningful connections between what I am learning and something that is engraved in my brain. I read a book once about the mastery of memorization (click here to buy it on amazon) and I learned a thing or two about how to make things stick. One trick I found interesting in the book was making absurd connections to what you are trying to learn. So, when I say “meaningful” I mean something out of proportion, unreal or exaggerated. For example, mnemonics work best when they are funny or even slightly inappropriate. Mnemonics are not very useful unless you can memorize the phrase, right?
4. Condense information
I am a big visual learner and I believe most people are too. For me, fitting all of the information that was being taught (even if it was 70+ slides on a powerpoint) into ONE sole typed out sheet of paper helped me visually see the information in my head during exams. Sometimes, I have to make my letters really small, but I color coordinate the information and add tables or small figures to help. Adding figures is most effective when you are drawing them yourself and personalize them to what your understanding of the material looks like. I add the most important information from the entire powerpoint or chapter and study only this one sheet of paper. This helps the information not seem so daunting and you don’t have to flip through pages and pages of scribbled notes or useless information. You don’t feel as overwhelmed and when exam time comes, you are able to visualize what was written on that page to use either process of elimination or recall to answer the question. DO NOT READ THROUGH NOTES OR READ THROUGH THE POWERPOINT FOR REVIEW. I promise you, this is a waste of your time! The information will go in one eye and out any other hole you have except stay in your brain like it’s supposed to. Like I said, active studying is the most effective form of studying there is.
Here’s an example of a poster I made for organic chemistry to help me understand functional groups better:
5. Get a planner. Yes, like middle school
Remember when you were in middle school and you would get personalized planners for the school year? Your teachers would have you write down your homework for the day or assignments that were due in your planner so that you wouldn’t forget? I know it sounds childish but there is nothing better than being organized. Even if your brain is moving at 100 mph all of the time, you can still learn to slow down buy using a calendar. There is no task too small for planning. I like to plan out my entire week on Sunday evenings. I sit down at my desk at home and I write down everything that is due that week on a sheet of paper. Then, I write down things I want to accomplish that week that are not associated with school such as gym time, personal time, mediation, grocery shopping, errands… literally ANYTHING else.
I divide my tasks into blocks on my schedule and don’t ever schedule over 2 hours of studying in one sitting. We think we get more accomplished based on the time we spend doing it, but that’s not necessarily true. I decided that my max time was 2 hours but every person’s stop time may be different. A good way to know when it’s time to stop is when you no longer feel focused on the material and are just reading through or trying to rush through the information to finish the task or assignment. The extra time you spend doing that is ineffective and wasteful. You could be spending that time doing something for yourself like going for a run or playing with your dog. Take breaks and make time for healthy habits in your life. You will never be a good doctor if you are not in good health. Personalize your calendar to best fit your sleep schedule, life and goals. Being organized is important in every aspect of life. Remember: the only way to not get behind is to stay ahead!
Wilson’s disease (WD) is an uncommon autosomal recessive inherited disorder that is characterized by a copper imbalance in the body. Although copper is essential for the survival of living organisms, an excessive cellular copper load can lead to functional failure or death of the cell. WD impedes the normal biliary excretion of copper leading to itsaccumulation in various organs (Merle et al. 2007). Copper-transporting P-type ATPase (ATP7B) in hepatocytes transport copper from intracellular chaperone proteins to their designated secretory pathway. ATP7B is encoded by the WD gene, MIM 277900, hence its mutation results in a WD diagnosis (Ferenci, 2005). The accumulation of copper in organs such as the liver and brain results in the development of hepatic diseases such as liver cirrhosis and neuropsychological degeneration. The estimated frequency of WD is about 17 per million which translates to a carrier frequency of 1 in 122 (Lorincz, 2010).
Disease Inheritance
A study was conducted in the United Kingdom (2013) in an attempt to identify the rate of mutations in the WD gene ATP7B. 181 individuals with a confirmed WD diagnosis underwent genetic testing to determine the potential of non-ATP7B gene mutation causing the disease. According to the study, 116 different ATP7B mutations were identified and the overall chance of a mutation in a gene other than ATP7B causing a WD phenotype is very low due to the detection frequency of the specific mutation being 98% (Coffey et al, 2013). The study supplied strong confirmation for monogenic inheritance of WD, where traits for the disease are determined by single gene or allele expression and highlighted the need to consider rare genetic occurrences in clinical practice such as the presence of three mutations of the ATP7B gene or uniparental disomy.
Clinical Manifestations:
Patients with WD most commonly present with hepatic and neuropsychiatric symptoms. Considering clinical manifestations peak at around seventeen years of age, children often present asymptomatically. This means that accurate diagnosis is more difficult in children than in adults. Signs and symptoms of WD can be categorized into four categories: hepatic, neurologic, psychiatric and other. Hepatic symptoms include, but are not limited to, liver cirrhosis, active hepatitis with fibrosis andabnormal results on a liver function test. Neurologic and psychiatric symptoms include, but are not limited to, tremor, ataxia, dystonia, dysarthria epilepsy, cognitive impairment, dysphagia, mood and/or personality disorders, choreoathetosis, hallucinations and delusions (Loudianos et al, 2014). The most common symptoms relating to the eyes include Kayser-Fleischer ring and Sunflower cataracts, relating to fertility include infertility and amenorrhea, relating to the kidneys include tubular dysfunction, relating to the heart include cardiomyopathy and arrhythmias and relating to other organs include gallstones and endocrine disturbances (Loudianos et al, 2014).
Kayser-Fleischer rings are considered the hallmark of WD and are present in 95% of patients that present with neurological manifestations (Rodriguez-Castro et al, 2015). Dysarthria is present in relatively 85-97% of individuals with Wilson’s disease and is characterized as weakness, paralysis or damage to/in the muscles used for speech (Lorincz, 2010). WD tremors are also common and may be difficult to differentiate from essential tremors which can involve the arms, legs and head. Considering essential tremors often involve voice and symmetry, differentiating them from WD tremors can be easier when looking for asymmetric tremors in the extremities and voice tremors (Lorincz, 2010). Face of the panda is commonly found in midbrain MRI images of patients with WD which is due to a loss of intensity in the center of the midbrain. Liver disease is not as easily linked to WD as neurological manifestations. Manifestations of WD in the liver range from isolated biochemical abnormalities with no accompanying symptoms to cirrhosis of the liver. According to the European Association for the Study of the Liver (2012), Hepatic manifestations have an earlier onset than other types of symptoms and can precede neurological symptoms by as much as 10 years.
Diagnosis:
There are many ways in which a WD diagnosis can be made. Providers look for common manifestations—such as the ones presented above—and may perform diagnostic tests. Common diagnostic tests include serum ceruloplasmin, serum-free copper, 24-hour urinary copper, hepatic copper and slit lamp examination of Kayser-Fleischer rings (Bandmann et al, 2015).Ceruloplasmin carries copper in the blood and its levels are below the normal range in patients with active or neurological WD. The combination of liver disease and a decrease in ceruloplasmin levels in the blood may cause serum-free copper levels to rise. For this reason, the concentration of serum-free copper may be used as a diagnostic tool for WD (Bandmann et al, 2015). Urinalysis is perhaps the easiest of all tests to perform and it analyzes the quantity of copper excreted in a 24-hour period. Elevated levels, especially in patients without cholestatic liver disease, is an indication of WD.
Unfortunately, due to the potential for false positives, the diagnostic tests used for a WD diagnosis are not reliable in isolation. For example, low ceruloplasmin levels may indicate a WD diagnosis but may also present as a consequence of an alternate condition such as malabsorption (Lorincz, 2010). For these reasons, one test alone is unable to provide sufficient evidence to confidently diagnose WD. As a result, most providers use an amalgam of tests, signs and symptoms in the diagnostic workup process and consider the possibility of false positives. A less common, yet more accurate, type of diagnostic test is genetic testing. In the past, direct genetic testing for ATP7B was restricted due to the low detection of mutation and extended processing time (Bandmann et al, 2015). The advancement of technology has allowed for the reduction of both the turnaround time and the cost of genetic investigations making it highly likely for this type of testing to play a more critical role in the confirmation of a WD diagnosis in the future.
Disease Treatment and Management:
Early treatment (prior to symptom manifestations) can prevent liver and neurological deterioration as well as increase the life expectancy of an individual suffering from WD (Rodriguez-Castro et al, 2015). If treatment compliance is adequate, the prognosis of a WD diagnosis is highly favorable compared to the natural course of the disease which is characterized by an implacable deterioration of both neurological organs and the liver. Therefore, the main goals of treatment are to prevent the onset of symptoms and clinical deterioration. In severe cases, such as with acute-chronic liver failure or end-stage liver disease, treatment can be lifesaving and often involves a liver transplant.
Asymptomatic patients are treated with zinc salts and chelators at a lower dosage than symptomatic patients. Chelators such as penicillamine, trientine or tetrathiomolybdate remove excess copper in the body and zinc salts prevent the absorption of copper in the intestines (Rodriguez-Castro et al, 2015). Due to the rare nature of WD, current pharmacological studies and clinical trials have not been performed on drugs used to treat the disease. As a result, most of the current drugs available to treat WD have not been adequately tested for their effectiveness and potential adverse effects, and they lack registered clinical trials, research projects or networks.
A multitude of drugs are available and used to treat WD. As mentioned, D-penicillamine, trientine, tetrathiomolybdate and dimercaprol are common chelators used to rid the body of excess copper, and zinc salts block intestinal absorption of copper. D-penicillamine and trientine both promote the excretion of copper through urine and their absorption is maximized when administered one to three hours prior to meals (Ferenci, 2005). Tetrathiomolybdate is a decoppering agent that prevents the absorption of copper in the GI tract (similar to zinc) and makes copper in circulation unavailable for uptake. Zinc increases metallothionein action in the gastrointestinal tract. Metallothionein is more sensitive to copper than it is to zinc; as a result, zinc increases the binding of copper to metallothionein and prevents its entrance into circulation (Ferenci, 2005).
The most important factor in determining the prognosis of a WD diagnosis is the time frame for onset of symptom manifestation. Patients with hepatic symptoms have earlier onset of symptoms and a faster diagnosis compared to patients that present with neuropsychiatric symptoms (Merle et al, 2007). In diagnosing asymptomatic or younger patients, family screening has shown evidence of being highly effective in early diagnosis—roughly 4 years sooner and a good long-term outcome. In addition to the onset of symptom manifestation, positive prognosis is dependent on patient access and compliance to treatment (Merle et al, 2007).
References
Bandmann, O., Weiss, K. H. & Kaler, S. G. (2015). Wilson’s disease and other neurological
As I’ve mentioned before, I am currently working as a medical assistant in pain management. It’s now been almost a month that I started my new job and I love it! I get to work alongside the best pain management doctors in my area and have learned so much in a short amount of time. Last week, I had the privilege of shadowing several Epidural Steroid procedures as well as a Kyphoplasty procedure. It was the coolest thing I’ve seen since tori removal back in my oral surgery days. If you don’t know what a Kyphoplasty is, keep reading because this post is all about it!
What’s a Kyphoplasty?
A Kyphoplasty is a procedure performed to correct vertebral compression fractures (VCF) through the use of polymethylmethacrylate (PMMA) aka bone cement. The leading cause of VCFs is osteoporosis (Cooper et al, 1992), but falling or high risk activities like lifting heavy weights could also lead to a fracture. Due to the nature of the fracture, VCFs can be very painful; the vertebral body collapses causing the patient to lose height in their spine. During the procedure, a hollow needle is inserted into the body of the vertebra through the pedicle. An inflatable balloon is then placed inside, inflated to restore the vertebral height and to create a working channel for the cement to flow into. The entire procedure is guided through a fluoroscope and contrast medium.
Why a Kyphoplasty?
Other treatment options for patients with painful VCFs include non-surgical management (NSM) and a Vertebroplasty procedure. A Vertebroplasty is very similar to a Kyphoplasty. The primary difference is that a balloon is not used to create a working space for the cement to flow into and the cement used tends to have a lower viscosity. Both of these factors increase the most pertinent risk associated with the procedure: bone cement extravasating into the epidural space. Without a working space, the physician doesn’t have as much control of where the cement is flowing into. Also, bone cement viscosity is identified as a decisive guideline influencing leakage in a Vertebroplasty, so using a cement with a higher viscosity reduces the risk of extravasation (Giannitsios et al, 2005). In fact, the incidence of leakage during a Vertebroplasty ranges between 2-67% compared to 0-13.5% for a Kyphoplasty (Denaro et al, 2009). Other risks to consider include heart attack, cardiac arrest and stroke. In addition to surgical procedures, there are also NSM options for patients with VCFs. These include bed rest, pain relief medication and back bracing. Compared to patients who undergo a Kyphoplasty procedure, patients following a NSM treatment plan for VCFs experience less pain relief and improvement (Meirhaeghe, 2013). For these reasons, if a non-surgical treatment is insufficient, a Kyphoplasty is often the preferred treatment option for VCFs.
What are the main indications for the procedure?
Patients with Osteoporosis
Patients experiencing intense pain adjacent to the level of the fracture
Patients diagnosed with a fracture by an MRI, CT or X-Ray
Patients who failed non-surgical management for at least 4 weeks
Patients with lesion causing benign and metastatic tumors
Which patients are not candidates for the procedure?
Patients who did not fail non-surgical management for at least 4 weeks
Patients with asymptomatic vertebral compression fractures
Patients with allergies to materials used in the procedure such as PMMA or barium contrast
Patients with bleeding disorders that are unmanageable
How is the procedure performed?
The patient is placed on the table, face down with a gown open to the back. The patient’s skin where the needle will be inserted is prepped with an antiseptic solution. Most patients are sedated for comfort and since the procedure is minimally invasive, local anesthetic is primarily used.
The provider starts by inserting a bone access needle into the area affected to determine the trajectory of the working cannula. Once it’s confirmed through the fluoroscope that the access needle is at the correct location (on pedicle of vertebra), a bone drill is used to create a pathway through the pedicle into the vertebral body.
Once the pathway is created, a curved-tip osteotome is inserted into the vertebral body and manually curved/directed towards the fracture.
The balloon is inserted through the hollow needle and inflated to compact the soft porous bone inside of the vertebral body. Doing this not only restores the natural height of the vertebra but also creates a working channel for the cement to flow into. This decreases the chances of the cement flowing to places it shouldn’t flow into and gives the doctor more control of the cement’s trajectory. A contrast is used to visualize the inflation of the balloon and its location through the fluoroscope.
Finally, the balloon can be removed and cement is injected into the working channel under pressure using a special cement filler cannula. The pressure and quantity of cement being injected is strictly controlled to prevent leakage. The needle is removed slowly and carefully, ensuring the cement is not following the needle forming a “tail.” This is done by waiting for the cement to slightly harden and monitoring its progress through the fluoroscope.
The needle is removed and the incision is closed with either steri-strips or skin glue. Once the remaining cement on the table hardens, the patient is ready to be moved to the recovery room.
Pictures from the procedure I shadowed:
Works Cited
Giannitsios, D., Ferguson, S., Heini, P., Baroud, G. & Steffen, T. (2005). “High cement viscosity reduces leakage risk in vertebroplasty”. European Cells & Mat 10, Poster No. 314.http://www.ors.org/Transactions/5thCombinedMeeting/0314.pdf
McCall, T., Cole, C., Dailey, A. (2008). “Vertebroplasty and kyphoplasty: A comparative review of efficacy and adverse events.” Current Reviews in Musculoskeletal Medicine, Vol. 1: 17-23, doi: 10.1007/s12178-007-9013-0. https://link.springer.com/article/10.1007/s12178-007-9013-0
Meirhaeghe, J., Leonard, B., Steven, B., Jonas, R. & John, T. (2013). A randomized trial of balloon kyphoplasty and nonsurgical management for treating acute vertebral compression fractures. Spine, Vol. 38(12): 971-983, doi: 10.1097/BRS.0b013e31828e8e22. https://pubmed.ncbi.nlm.nih.gov/23446769/
Denaro, V., Longo, U., Nicola, M. & Denaro, L. (2009). Vertebroplasty and kyphoplasty. Clinical Cases in Mineral And Bone Metabolism: The Official Journal of the Italian Society of Osteoporosis, Mineral Metabolism, and Skeletal Diseases, Vol. 6(2): 125-130. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2781232/
The United States is known for having one of the most expensive and worst health care systems in the world.17.2% of our GDP is directed to health expenditures, compared to only 9.7% in the U.K, 10.9% in Japan, and 11.3% in Germany. Not only do we spend outrageously more than any other country, we don’t have a better system to show for it. Our death rate per 100,000 children aged 1-19 is 259 compared to 170 in the U.K, 147 in Japan and 166 in Germany. Even though we are one of the richest countries in the world, our people have one of the shortest life expectancies of any industrialized nation. Why in the world do we still have millions of Americans that don’t have access to basic preventative services and why do we pay so much?
The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health related societies to ladders. In this relationship, the rungs of the ladder are equivalent to the resources available for individuals in that “step” to live a healthy, secure, and prosperous life. This means that the individuals at the top of the ladder are the ones who possess college degrees, respected careers, and are financially prosperous. The individuals at the bottom of the ladder are not as privileged. They aren’t as educated, have lower income or unstable employment, and aren’t financially comfortable. Socioeconomic status contributes to disparities in health in that an individual’s place on the ladder directly affects how healthy they are or will be in their lifetime. For example, the risk of dying prematurely is 3 times greater for low socioeconomic individuals who fall on the lower rungs of the social ladder. When considering people in the middle, they are still 2 times as likely to die prematurely than the individuals at the top of the ladder. In addition to life expectancy, individuals at the bottom of the ladder are more likely to suffer from hypertension, obesity, diabetes, heart disease, HIV/AIDS, mental illness, and experience newborn health complications such as low birth weight, premature birth and birth defects.
The power that social status has over health and the quality of life we live is colossal and pervasive.
Individual Behavior vs. Genetics
There is a reason providers review family history with patients: genetics plays a role in the health of an individual, but behavior also largely contributes to health status. This doesn’t necessarily mean that the responsibility of health falls on the individual at 100%. The lower they are on the social ladder, the harder it is for them to practice healthy behaviors. An individual’s environment has the ability to expand or constrain the options and habits that improve health and prevent chronic diseases. For example, lower socioeconomic communities have fewer (or sometimes lack) fresh produce supermarkets, recreational facilities, libraries, and safety but have more liquor stores, fast food restaurants, and drug trafficking. to accompany this environment, stress levels are high in individuals who live in such communities. Stress directly impacts physical health, but also leads to individuals partaking in destructive behaviors such as smoking, abusing alcohol and consuming high levels of sugar and fat.
Social Determinants of Health by the Henry J Kaiser Family Foundation
Clearly, the relationship between behavior and the ladder isn’t as easy as scaling will-power. The issue with our medical model today is that many physicians look at patients and their diseases through only the biomedical model of health. Social and psychological factors are rarely accounted for. Appointment slots are 15-minutes for most practices and providers who feel compelled to do more simply don’t have the time. We can’t look at an obese patient and think “they have no moral fortitude and are lazy!” Alternately, we need to consider the patient’s position on the ladder to better understand their behaviors and properly formulate a treatment plan. Individuals on the bottom rungs of the ladder face environmental and social conditions that induce unhealthy behaviors. They are exposed heavier cigarette and alcohol marketing, they live with chronic high levels of stress, don’t have the same access to healthy food options due to location and price and have fewer educational and job opportunities. Motivational interviewing is new technique recommended for providers to help their patients practice healthier behaviors, but that discussion will have to be for another day.
Minorities and Health
The inequalities in health status shared among minorities in the United States is shocking. Not only are minorities more likely to be at the bottom of the social ladder, they have a much higher risk of developing various diseases compared to non-minorities in the same position on the ladder. Racial health disparities are due (mostly) to an unjust distribution of socioeconomic resources and not genetics. Minorities are more likely to live at or below 200% of the Federal Poverty Line, be less educated, and live in low socioeconomic communities. These are a few of many social factors that determine the health of an individual. Instead of being considered separate entities, they are a reflection of one another. Low education leads to low paying jobs. Low paying jobs leads to living in low-income communities. Low-income communities lack social resources (recreational facilities, libraries, fresh produce supermarkets) and have high crime rates. This environment influences health damaging behaviors like smoking, drinking alcohol, and abusing recreational drugs. Although Medicaid is available to low-income individuals, people who have a job and make more than the limit, don’t qualify for Medicaid but also can’t afford private insurance. This lands them in the insurance gap position, with little to no access to preventative services. This means they seek health care services when they are very ill or in life threatening situations.
In 2016, 40% of people living in the United States were people of color. By 2050, that number is projected to increase to over half of the population. Given that people of color make a disproportionate share of the low-income and the uninsured relative to their size in the population, addressing health care disparities is extremely important. Disparities not only affect the groups directly suffering, but also hinders improvement in the quality of care and health for the broader population and leads to unnecessary costs.
Why Address Inequality in Health and How to Do It
Not only are we improving individual health, we are decreasing health care expenditures because healthy people require less medical services. Pinpointing the underlying determinants of disease and successfully addressing it is the first step in reducing health care expenditures. The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health identified two policies that are required to reduce premature death and eliminate the increase in disparities as you move down the social ladder:
Policies that affect the length of the ladder and the distance between it’s rungs.
Policies that buffer the damaging conditions of living below the top rungs.
Changing the Ladder
To alter the length of the social ladder in the United States, we need to advocate for policies that improve access to quality education and impact income distribution. There is no reason for a qualified student to not attend college in the United States of America because of financial barriers. Also, public education should be of high and equivalent quality throughout all K-12 levels. In terms of income and wealth distribution, we need policies that increase saving incentives in family households and offer opportunities for job training and community colleges to lower socioeconomic individuals.
Limiting Consequences
To ameliorate the risks linked to an individual’s socioeconomic status, we need policies that improve the environment and limit bad behaviors. Such policies should reduce violence and crime, increase affordable housing, improve access to drug and alcohol abuse programs as well as smoking cessation programs, increase taxes on cigarettes, fast food and alcohol, make school lunches more nutritional, and support green markets and fresh produce grocery stores. These are some examples of many policies that would improve the quality of life that individuals on the bottom of the ladder live.
What You Can Do to Help
You don’t have to start a non-profit or get into politics. Although those are great things to do, you can help in many other ways. Here are five things you can do right now, regardless of your financial situation, to help bring health care access to people in your community.
Become a mentor to a minority student at your local high school. Help them find their passion and motivate them to pursue a higher education. Educate them on requirements to get into college and how to finance the costs.
Create a book drive to provide a mini public library to a neighborhood in your area that doesn’t have one. Books can be donated to the local school or could be handed out to students at an event.
Volunteer your skills. If you are a nutritionist or maybe a personal trainer, consider offering free services on the weekend to people in your community who need it most. Educate them on how to make better food choices and teach them exercises they can do at home.
Donate to smoking cessation or alcohol abuse programs in your community.
Help a neighbor plant a garden. Motivate your peers to eat healthier and make better health choices.
Remember: a little goes a long way. Just because you don’t see the results of your efforts immediately, doesn’t mean you aren’t making a difference! Keep pushing towards a better future for our generation and the next.
Works Cited
Orgera, K., Artiga, S. (2018). Disparities in Health and Health Care: Five Key Questions and Answers. 2020 Kaiser Family Foundation.
Adler, N., Stewart, J. (2010). Reaching for a Healthier Life: Facts on Socioeconomic Status and Health in the U.S. The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health.
Fiscella, K., Williams, D. (2004). Health Disparities Based on Socioeconomic Inequities: Implications for Urban Health Care. Academic Medicine, Vol 79, No. 12.
Pampel, F., Krueger, P., Denny, J. (2010). Socioeconomic Disparities in Health Behaviors. National Institute of Health Annual Review Social, 36: 349-370, doi: 10.1146.
Cohen, S., Janicki-Deverts, D., Chen, E., Matthews, K. (2010). Childhood Socioeconomic Status and Adult Health. Annals of the New York Academy of Sciences: The Biology of Disadvantage, doi: 10.1111.
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