Oral and Perioral Manifestations of the Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome (AIDS)

Background

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 infectious even 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. Wolfe Publishing.

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

Top Tricks For Effective Studying

Pre-Med

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!

Genetic Disorders: Wilson’s Disease

Medicine and Health

Introduction

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

copper disorders. The Lancet Neurology, vol. 14(1): 103-113. https://doi.org/10.1016/S1474-4422(14)70190-5

Coffey, A. J., Durkie, M., Hague, S., McLay, K., Emmerson, J., Lo, C., Klaffke, S., Joyce, C. J.,

Dhawan, A., Hadzic, N., Mieli-Vergani, G., Kirk, R., Allen, E., Nicholl, D., Wong, S.,

Griffiths, W., Smithson, A., Griffin, N., Taha, A., Connolly, S., Gillett, G. T., Tanner, S.,

Bonham, J., Sharrack, B., Palotie, A., Rattray, M., Dalton, A. & Bandmann, O. (2013). A genetic study of

Wilson’s disease in the United Kingdom. Brain, vol. 136(5): 1476-1478. https://doi.org/10.1093/brain/awt035

European Association for the Study of the Liver. (2012). EASL clinical practice guidelines:

Wilson’s disease. Journal of Hepatology, vol. 56(3): 671-685. https://doi.org/10.1016/j.jhep.2011.11.007

Ferenci, P. (2005). Wilson’s disease. Clinical Gastroenterology and Hepatology, vol. 3 (8): 726-

733. https://doi.org/10.1016/S1542-3565(05)00484-2

Lorincz, M. T. (2010). Neurologic Wilson’s disease. New York Academy of Sciences, vol.1184(1):

173-187. https://doi.org/10.1111/j.1749-6632.2009.05109.x

Loudianos, G., Lepori, M. B., Mameli, E., Dessi, V. & Zappu, A. (2014). Wilson’s Disease. Prilozi

(Makedonska akademija na naukite i umetnostite. Oddelenie za medicinski

nauki), vol.35(1), 93–98.

Merle, U., Schaefer, M., Ferenci, P. & Stremmel, W. (2007). Clinical presentation, diagnosis and

long-term outcome of Wilson’s disease: A cohort study. Gut, vol. 56(1): 115-120.

https://doi.org/10.1136/gut.2005.087262

Rodriguez-Castro, K. I., Hevia-Urrutia, F. J. & Sturniolo, G. C. (2015). Wilson’s disease: A review

of what we have learned. World Journal of Hepatology, vol. 7(29): 2859-2870.

https://doi.org/10.4254/wjh.v7.i29.2859

Kyphoplasty

Medicine and Health

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/

Disparities in Health

Medicine and Health

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.

The Basics of an Anti-Inflammatory Diet

Medicine and Health

The Basics:

In an over simplified definition of inflammation, you could say it is your body’s way of fighting off something that could potentially harm it. Inflammation is actually necessary for you to have a healthful life. When you cut your finger or scrape your knee, your body turns on its acute inflammation response to heal the area. The same idea can be translated into your diet. Every meal you eat triggers inflammation in your gut. This isn’t necessarily a bad thing. When you eat a meal, although you are (hopefully) taking in lots of good nutrients, you are also consuming bacteria. Your body is responsible for taking in all of the good stuff you feed it, fighting off the bacteria and discarding the bad stuff. In a recent study, scientists have discovered that the efficiency of your immune system and metabolism is highly dependent on the ratio of nutrients and bacteria that you are eating. The less nutrients you consume, the harder it is for your body to fight off bad bacteria in your gut and you’re stuck in a constant state of inflammation.

Unfortunately, due to the nature of industrial agriculture today, we are seeing a steady decline in the nutritional value of the foods we eat. Our soil is poisoned with chemicals used to improve plant growth and kill certain organisms that harm it. The bad news is that these chemicals tend to remain in the soil for long periods of time, killing communities of organisms in the soil that are beneficial to us and the quality of the food we eat. The food we eat today, even the organic ones, are less nutritious than the food our parents and grandparents ate. You can imagine how hard it can be to consume the right ratio of nutrients to ensure our body is not in a constant state of alert.

This leads me to my next point: what effects does chronic inflammation have on our bodies? The human body is very smart. It learns to adjust and adapt for survival. When your body goes from an acute state of inflammation to a chronic one, it knows that it needs to make adjustments to keep going. These adjustments can lead to acute, as well as chronic, diseases.

Some Diseases Linked to Chronic Inflammation:

• Obesity
• Type 2 Diabetes
• Hypertension
• Rheumatoid Arthritis
• Crohn’s Disease
• Pancreatitis
• Some cancers
• Fatty liver
• Metabolic syndrome
• Heart disease

Some Symptoms of Chronic Inflammation:

• Fatigue
• Body aches
• Depression
• Anxiety
• Frequent infections
• Weight gain/loss
• Insomnia
• GI complications (diarrhea, acid reflux, constipation)

Although not all inflammation is related to diet, following a healthful anti-inflammatory diet is a great way to decrease symptoms associated with chronic inflammation. After all, your gut and your immune system are closely related. Your gut health is the captain leading the direction of your overall health. I recently purchased an amazing book which I will recommend in the books section of my blog this week. It has tasteful anti-inflammatory recipes and includes a lot of great information for beginners.

Now, let’s get to the point

Foods that Worsen Inflammation:

1. Processed and Red Meat

Ideally, you want to decrease your meat consumption. If you want to savor meat here and there, make sure you are buying organic, grass-fed meat. The quality of the meat you eat is very important. Skip out on the processed options. A good brand to look into is Nature’s Rancher.

2. Sugar

For decades we have been blaming fat for obesity. The real threat has always been sugar! We need good fats for our brain to function properly. Ditch sugar (even brown sugar) or any form of sugar substitute like Aspartame, Saccharin, Sucralose, and for the love of everything that is good in this world STAY AWAY FROM HIGH FRUCTOSE CORN SYRUP! Consider sweetening your coffee with honey.

3. Processed Foods

This one is the hardest. In reality, the options of foods you can eat is a lot greater than what you can’t eat. The issue is that every supermarket you walk into is selling primarily processed foods. You probably have been eating processed foods your entire life. A good way to know if what you’re buying is processed or not is to check the label. If the ingredients list is full of junk that you can’t even pronounce, drop it! Also, try to buy foods that aren’t pre-packaged and full of sodium, saturated fats and added sugars.

4. Refined Grains

This is the stuff we all hold so close to our hearts and have a hard time letting go of. Some examples of refined grains are white rice, flour, white bread, pasta, cookies, and cereal. These grains are modified from their natural form. They are literally stripped of all of their vitamins, fiber, and pretty much anything that is good for you. A delicious substitute for pasta is lentil pasta and for rice is quinoa.

5. Dairy

Cutting dairy out of my life has changed me in ways I can’t even begin to describe. Dairy is a huge food allergen and it’s no surprise that a lot of people are considering alternatives. There is a common misconception that drinking milk leads to having strong bones. A 1997 study that investigated the effects of milk on bone strength discovered that drinking milk actually has the opposite effect than what is considered popular belief today. In fact, the women in the study that drank 2 glasses of milk per day for 12 years, had a 50% higher chance of suffering from a bone fracture compared to the women who consumed 1 glass or less of milk per week. Don’t panic if you love milk, yogurt, cheese, and butter. There are various delicious vegan substitutes for dairy products. Some of my favorite alternatives include Violife cheese, Califia Farms butter and almond milk, and Forager yogurt.

6. Plant-Based Oils

Some oils to avoid include corn, sunflower and soy oils. These oils contain very high levels of pro-inflammatory omega-6s. Coconut oil is a good substitute but it is high in saturated fats, so you should consume it with moderation. The best substitute is olive oil.

Foods that Fight Inflammation:

1. Fruits and Vegetables

When buying fruits and vegetables, keep the Environmental Working Group’s (EWG) Dirty Dozen and Clean Fifteen guidelines in mind. Try to buy organic if you can. If you have to chose which produce to buy organic, follow the list. Specifically, berries, watermelon, apples, and pineapple have high levels of phytonutrients making them strong anti-inflammatory options. Try to consume fruits that have high-antioxidant vitamin C such as citrus fruits. Also, season your dishes with garlic and onions because they are beneficial to your immune system.

2. Whole Grains

Examples include quinoa, brown rice, popcorn, oatmeal, amaranth, millet, buckwheat and teff. These grains are rich in fiber, micronutrients, protein and antioxidants. Don’t be fooled, they are also flavorful!

3. Omega-3 Fatty Acids

Dorothy Calimeris, RDN calls these “All Star Anti-Inflammatoriy Agents” in her book The Complete Anti-Inflammatory Diet for Beginners. Foods that contain this type of unsaturated fat include salmon, sardines, walnuts, pine nuts, and seeds like hemp, chia & flax.

4. Pre/Probiotics

These kinds of foods are good for your digestive and immune health. Examples include pickles and sauerkraut. They are abundant in good gut bacteria. These are bacteria that your digestive system needs to properly function. Due to the overuse of antibiotics in our foods and healthcare system, many of us suffer from a gut microbial deficiency. These foods help in balancing the microbial communities in your gut. The good guys vs. bad guys ratio.

5. Herbs and Spices

Of course, I won’t leave you without telling you what to season your delicious meals with. Eating healthy doesn’t mean sacrifice flavor. Great spices and herbs to add to your kitchen are turmeric, ginger, saffron, thyme, rosemary, and basil. These options smell and taste great!

Wrapping Up:

I know this all seems like a lot to take in. It can be at first. Take it one day at a time and embrace the trial and error phase. Purchase anti-inflammatory recipe books or downloads similar apps. You will realize that the hassle of readjusting and retraining your brain is well worth the benefits you will experience. You will notice that your meals won’t drag you down. You will be satisfied for longer and feel energized after you eat. Food isn’t meant to make you tired. You are providing your body with nutrients that it craves to survive. If you feel sluggish or tired after a meal, it’s a good indication that you aren’t feeding your body what it needs. You may also experience weight loss, a decrease in anxiety levels and a boost in your health.

I challenge you to try an anti-inflammatory diet for one month and see how it changes your body and the way you feel!

My International Medical Volunteer Trip

Pre-Med

This is Alberto. He was my favorite resident. He loved to dance and sing
Picture is a husband who moved into the nursing home to be with his wife who has dementia
I painted the resident’s nails during down time. Linda loved her new pink nails
I helped cook, feed and clean the residents. Here’s a picture of me in the kitchen
This woman was 107 years old. She was the sweetest resident there and I loved spending time wit her
Me at La Paz Waterfalls interacting with butterflies

This week’s blog will be a little different than the usual. Instead of me taking the lead, I let you guys ask questions about my volunteer trip abroad. In December of 2019, I went on a 1 week medical mission trip to Costa Rica. I graduated that same month and that was my graduation gift to myself. It was one of the best experiences I’ve ever had and it made me realize how much I love volunteering and why I want to be in medicine. I could sit here and write 10 pages on my experience and why I think everyone should do an international volunteer trip at least once in their life. Instead, I’ll answer questions you guys have about my trip.

Here are answers to the top asked questions about my trip:

1. What organization did you use?

I volunteered with International Volunteer HQ. I researched different organizations for a couple of weeks, and decided that IVHQ was the one for me because it was affordable and I felt safe traveling with them. I joined their facebook group and asked questions to current and past volunteers about their experiences and how they liked it. Every person I asked said their trip was very safe, the organization was reliable and their experience was life changing. IVHQ also had the most destinations available in comparison to other organizations. Their projects aren’t all medical, this means that if you want to volunteer in a different area or let your talents shine, you can.

Aside from Medical and Health, some of their other projects include:

• Childcare
• Teaching
• Wildlife and Animal Care
• Construction and Renovation
• Environment and Conservation Arts and Music
• Sports
• NGO Support
• Refugee Support
• Women’s Empowerment
• Community Development
• Elderly Care
• Special Needs Care

They have volunteer opportunities in:

• Africa (Ghana, Kenya, Madagascar, Morocco, South Africa, Tanzania, Uganda, Victoria Falls, Zambia)
• Middle East (Jordan)
• Asia (Bali, Cambodia, China, India, Laos, Nepal, Philippines, Sri Lanka, Thailand, Vietnam)
• North America (Mexico, United States)
• Central America (Costa Rica, Guatemala)
• Caribbean (Belize, Jamaica, Puerto Rico)
• South America (Argentina, Brazil, Colombia, Ecuador, Peru)
• Europe (Belgium, Croatia, Greece, Italy, Portugal, Romania, Spain)
• Pacific (Australia, Fiji, New Zealand)

2. How much did it cost?

Every project and destination will have a different cost. The cost depends on where you go, what project you are doing, how long you will be staying and whether you will want to do other “touristy” activities before you leave. The Costa Rica medical trip I went on was only $445 for 1 week. The rest of the cost covered flights, a background check, transportation and other small fees like lunch and snacks. The program was very independent. We were volunteering through their local organization called Maximo Nivel and aside from being dropped off at our host family’s house, we had to get around on our own.This meant taking the bus to and from work and doing anything else while we were there. In total, I spent about $1,300 for everything. The most costly were the flights because I booked them last minute and couldn’t find any deals ($600 for round trip, ouch!). I didn’t have to pay for breakfast or dinner because my host mom cooked for me and of course, I stayed at her home for free. I only had to pay for lunch and transportation. Tourism was an option, but the cost of my trip would’ve increased and I would’ve had to extend the trip to accommodate the extra activities. Considering I was there to primarily volunteer, I didn’t worry too much about the extras. I wanted to volunteer and live like a Tica for a week. I rode the bus, ate Gallo Pinto, and practiced my Spanish. Depending on how much money you have to spare, you can add different excursions and activities to your trip to mix tourism and volunteering. It’s entirely up to you!

3. Were you allowed to do “hands-on patient” work?

Yes and no. I was required to submit proof that I was a pre-pa, pre-medical or pre-dental student. I also had to submit proof that I had some sort of experience in the medical field. Not every volunteer needs to do that though. Depending on how many science classes you’ve taken and your major, you don’t have to provide proof of Certification or health care experience. Since I was just starting my pre-requisites, I submitted proof that I was a Certified Expanded Functions Dental Assistant (CEFDA) and had 2 years of experience. I worked in a nursing home and was able to shadow the nurses, doctors, nurse practitioners and physical therapists. I was also able to feed the patients, transport them, help change their clothes and participate in fun activities. Aside from patient care, I helped with laundry and cleaning. My house-buddy was in nursing school at the time and she volunteered with me at the same nursing home. She was allowed to do a little more than I was, so it really depends on your experience and how much you know. Everyone was very supportive and trusting. They let you get as much hands-on as you want, you just had to take the initiative.

4. Were translators provided?

No! Translators were not provided and we had to get by on our own. This was intimidating at first but I am so thankful for it. I practiced my Spanish the entire week and came back home speaking Spanish 10x better than before I left. A lot of my friends there had google translate open and used it to communicate. I spoke the most Spanish out of our group, so most of the time, I was translating for them. Costa Ricans are very welcoming and had no problem trying to communicate with us. Don’t be shy if you don’t speak Spanish or the language spoken in the country you volunteer at. Embrace the experience and communicate through compassion. A smile is understood universally, so is a hug, a handshake, a pat on the back. Use hand gestures and body language to communicate. If you want to practice and learn the language, they did offer Spanish classes for students who were interested. The classes were divided into different levels and ranged from $125 to $390 a week depending on whether the class was private and the size of the group. So if you are intimated by the language barrier, that is always an option. A little costly, but, an option.

5. Did you volunteer the entire time or were there other activities?

I mostly volunteered, but there were options to do a lot of other activities. Some volunteers were planning on staying for weeks or months, so they traveled during the weekend to different tourist spots. I was only there for 1 week, so I wanted to spend 95% of my time volunteering. Various activities and excursions were offered through the organization and they were affordable. Some volunteers decided to explore on their own and utilized Uber or public transportation to site-see on their own. Unless you are with a group, I wouldn’t recommend that because it’s not as safe as having a guide. I volunteered the entire week and on my last day went to La Paz Waterfalls with friends I made on the trip. It was a lot of fun and since there was a big enough group, we were able to split the fare making the excursion fairly inexpensive. If you have more than a week to spare, you can chose different volunteering and tourism options. Some volunteers will work for 1 week and travel for the other or will travel on weekends and work the full 2 weeks. It all depends on how much money you want to spend and how much time you to have to spare.

6. Did you pay for everything alone?

Almost. I had $200 in donations from family and friends to help fund my trip. The rest was paid 100% by me. If you are concerned about how you will afford the trip, try fundraising. You can use Go Fund Me or sell baked goods to raise the money. I didn’t sell any goods to fund my trip because I didn’t have the time. I was working and finishing up my Bachelor’s, so I decided to bite the bullet and gift myself the opportunity. From my personal research, IVHQ seemed to be one of the most affordable organizations to travel with. There are also church and school organizations that participate in international volunteer trips. If you don’t have the money to spare for IVHQ, you can always seek opportunities at your University and church.

7. Did you feel safe throughout the trip?

Yes. Costa Rica is a very safe country. Did you know they don’t have a military? Since I was traveling alone, safety played a big role in me picking Costa Rica as my destination. Of course, I took extra precautions because there are bad people everywhere. I did not travel with any expensive jewelry, kept my phone put away, and didn’t go anywhere alone. Like I said, we traveled around the city by ourselves and utilized public transportation because it was cheaper than Uber. Not once did I feel unsafe. I always had a friend with me and maintained full awareness of my surroundings. Unfortunately, I can only speak for Costa Rica. Check out the IVHQ Facebook page and ask around. There are volunteers in that group from all over the world and they can give you more insight on the safety of their destination.

8. Did you learn anything important that you’d like to share?

Oh, absolutely! First, I learned that I am 100% meant to be in medicine. Costa Rica was beautiful and traveling was fun, but my favorite part was being in the nursing home and working with patients. I loved spending time with the residents, getting to know them, and being hands on. When the week was over, I didn’t want to come home. I wanted to stay and work more. It really showed me how much I love what I do and how much compassion good quality health care requires. It takes more than being clinically sound to be a good physician or any provider of care. It takes patience, compassion, understanding, and love for your neighbor. This is one of the reasons I think everyone should volunteer abroad in a health care setting. You will know right then and there if you are seeking medicine because you love it or not.

Advice to Pre-Med High School Seniors

Pre-Med

These last few weeks I have received so many messages from high school seniors who want to go into the healthcare field. Many of them asked for advice regarding what to major in, classes to take, and what to do to prepare. These messages prompted me to write this post to serve as a simple guide to these students. First thing’s first, don’t stress yourself out trying to plan out every single moment of your life for the next 4 years. I did that and it was ridiculous because at the end of the day, nothing happened the way I planned. Life gets in the way, classes get full, you have to pick up a job, and stuff happens. So plan and prepare yourself but also relax and enjoy the ride. College is fun and you learn a lot about yourself in those (very) short 4 years.

1. If you’re going to screw up your grades, do it freshman year

Of course, you shouldn’t fail any of your classes but if you are going to party a little too much or have a hard time getting accustomed to college life… do it sooner than later. Most people think that medical schools will only look at your GPA, but in reality, they look at your application holistically. That means grade trends matter. Sometimes, a student with a 3.4 GPA is more competitive than a student with a 3.6. WHY? Because the student with a 3.2 failed a few classes freshman year or so but then had all As sophomore, junior and senior year. If those As were in classes that were harder, required more effort and were pre-requisites or science based (such as organic chemistry or biochemistry), that student is competitive. The 3.5 student may have excelled in the beginning during their general education credits, but proceeded to not do as well in their upper level science courses during junior and senior year. These classes best represent what graduate school will be like, so that student is not as competitive as the 3.2 student. The 3.2 student made a few mistakes in the beginning or had a difficult time adjusting to college, but their upward trend conveys they are prepared for graduate school. The 3.5 student on the other hand, may not be as prepared for graduate school (or at least that’s what the admissions committee will think). UPWARD TREND MATTERS. Don’t get all As freshman and sophomore year and then slack off junior and senior year. This will hurt you more than if it was the other way around. Don’t plan to fail at all. Aim for all As and settle for Bs. That should be your mindset throughout all of college, but if it happens, don’t stress too much. Learn from your mistakes and do better the second time around. If you haven’t read my post about whether you should retake classes or not, I talk about it here.

2. If you can take science AP classes senior year, do it

These courses most likely won’t count as pre-requisites for medical school BUT, when you retake them in college, you will be a step ahead of everyone. This means you will have a better chance at getting an A and retaining the information you learn, which is the most important thing. Just keep in mind, AP classes may transfer into your college transcripts, but they aren’t accepted at many medical programs. Your best bet is joining a dual enrollment program in High School and taking actual college credit courses at a community college instead of AP. If that option isn’t available at your school, then at least get a head start in the race and take AP classes. If anything, the general education courses that aren’t pre-requisites will absolutely count and will mean you have one less class to take in college. OH, and did I mention it’s FREE? Free college people, DO IT!

3. Do not take more than 2 core science/lab classes at once

You know your study habits better than I do, but I’m here to remind you that core science classes are not a piece of cake and you want to allow yourself the fair chance of not only getting an A in the course but also retaining the material and making time for extracurricular activities. I worked full-time throughout undergrad, and for me personally, two lab classes was pushing it. First, at my University, science classes were hardly ever offered at night, so taking more than one just wasn’t feasible with my schedule. Second, I was taking 5-6 classes while working every day. This meant I had to be strategic with my time. I was able to get straight As for three years and I strongly believe it’s because I planned my schedule out very strategically to ensure I maximized my efforts.

Take core “hard” science classes in conjunction with easier “soft” science/health/medical classes or classes in whatever major you chose. For example, if you have to take Chemistry II + Lab, don’t take Microbiology + Lab, Anatomy + Lab and then another 2 classes all in the same semester. Those classes require a lot of effort, so biting off more than you can chew will hurt you in the long run. Unless you are a genius, you are risking failing, getting a C in the class or not truly learning the material as well as you should because you were trying to survive the semester. Take the chemistry II class with 3-4 other soft science classes like epidemiology, medical terminology, health policy and etc. Don’t get me wrong, if school is all you are doing, go for it. You probably will be okay, but in reality, you shouldn’t JUST be taking classes. You want to volunteer, gain PCE, join clubs, get leadership experience and get involved in extracurricular activities that will make your application stand out in 3-4 years.

Also, don’t get caught up in feeling like you MUST major in a science related field. The science degree will allow you to complete your required major classes and pre-requisites faster because they will overlap. Depending on the school you attend, classes aren’t always available or science majors get first choice when registering for science classes. This means that if you major in a non-science field, you may be in school for longer than expected because you will have to complete all of your general education credits, your major credits AND the pre-requisites required for medical school. If you chose this route, try to take the pre-requisite classes early on so you can apply your Junior/Senior year while you are completing your major requirements instead of the other way around.

Your major isn’t as important as your GPA, MCAT scores and the rest of your application. Schools want to see well-rounded students. You don’t have to be the cookie cutter “pre-med biology major” student. Make your college experience enjoyable by doing something you like and you will be more successful for it. If you are passionate about music, major in music! Open a club that plays music on weekends for nursing home residents. Start a band that plays at functions to raise money for a specific organization you want to support. Use your passion and skills to your advantage!

5. Try to find Patient care experience as soon as you can

Many students put off getting PCE because they think they have time and don’t have to worry about it. In reality, finding PCE can be hard if you don’t have experience or underwent a training program. Network early on and try to get a job as a scribe for a few years until you can find better hands on experience. Scribe America is a great company to get started with. They hire students with no experience, train them to be scribes and offer flexible schedules. If you have a hard time getting a PCE job, volunteer! Go to a local clinic or offer to be a support volunteer at a hospice. Many of these places want volunteers to come in and talk to patients or even help clinically. Volunteer experience is still experience and getting the right connections may help you land a job later on. It’s all about effective networking. This leads me to my next advice: build your network!

6. Build your network

The best way to build your network is to get involved. You want to be a well rounded applicant. This means that aside from good grades and exam scores, you want to have other great things to add to your application. You will need recommendation letters and good experience. The right network will allow you to become more competitive. Get involved in clubs that interest you. If you like fishing, join the fishing club. If your school doesn’t have a fishing club, START A FISHING CLUB! Spend time with friends, volunteering and doing things that interest you and make college less stressful. Work your way up and hopefully get a leadership position in one of the clubs you’re in. Join the pre-med club or the international volunteer association. Do a semester abroad if you can financially afford it or get a scholarship. Take in every moment of college and cherish it because it flies by and you will regret not doing it.

Getting Patient Care Experience with No Experience

Pre-Med

I was a dental assistant for 3 years before deciding to find a job as a medical assistant. When I made the decision to transition from pre-dental to pre-med, I knew that my dental assisting experience wasn’t going to be ideal. Oral health is extremely important and it plays a big role in a patient’s overall health, but it isn’t the only factor at play. I loved being a dental assistant and it was comfortable for me, but I knew I needed to find a job that would teach me more about the entire body and prepare me for medical school. I was afraid of starting over and being at the bottom again. When I first started working in the dental field, I worked front desk and would shadow the clinical team during down time. It took me a year to find a job where I was 100% in the back and helping the dentist. I didn’t go to a traditional dental assisting program so I had to learn to make temporaries, pack cord and everything else that is involved in chair-side assisting from scratch. I was lucky to find people that were willing to guide and teach me along the way, but the fear of not being as lucky a second time around paralyzed me.

I didn’t have the money or the time to take off from school and undergo a traditional training program. I did some research on different options I had and what was considered PCE vs. HCE. After a few hours of reading, I knew that the best route for me was to become a CNA or a medical assistant. CNA was faster and I would probably have easily found a job, BUT, the pay was $10 less than what I was used to making and my husband and I couldn’t take the financial hit. Medical assisting was going to require a little more time and dedication, but I had a better chance of working normal hours alongside a PA, NP or MD/DO and making a little more money. So, the big question arises:

“How in the world am I going to find a job doing something I have never done before and have no training in, in the midst of a pandemic?”

It was intimidating and required a lot of vulnerability. To say it took persistence and faith is an understatement. I want to share with you guys what I learned these last few months and what I believe helped me get my first medical assisting job with no prior experience or schooling.

Why Medical Assisting:

Better chance of having normal 8-5 M-F hours. Since I am still in school, working regular hours allows me to better plan my week and organize myself. I like to know what nights I’ll be studying what subject and how many hours I have to do it. I like a set schedule and preferably, weekends off to unwind and reboot.
Better pay. Medical assistants make more than CNAs. Since I didn’t want to undergo a traditional training program, my only options to gaining relevant PCE were becoming a MA or CNA.
Working alongside MD/DO, PA, NP. Since my end goal is to become a provider, I wanted to work with them as much as possible. Being a MA would allow me to work side by side with Physicians and get a better idea of what their day to day is like. As a CNA, I would have spent most of my hours working with nurses. That is still great experience and nurses have a lot to teach, but personally, I wanted to spend more time with physicians.

1. Find Volunteer Related Experience

Before trying to find a job, try to find volunteering experience that is health care related. Some hospitals will train you to volunteer in different units. Many hospitals are looking for students who have taken science related courses and have aspirations to become doctors or mid-level providers. Call clinics and hospitals in your area to offer your skills. I was lucky to find a volunteer position at Southwest Florida Free Pain Clinic. I went there twice a week and worked helping with administrative work and translating in the back with the provider. Not only did I get to experience first hand what it was like to work in a clinic and with vulnerable populations, I loved it! It has opened my eyes to how effective functional medicine is and how many people don’t have access to care in my community.

If you want to volunteer in a different country, consider International Volunteer Headquarters. They will allow pre-professional students and current medical students to partake in international medical mission trips. I saved up money and traveled to Costa Rica in December of 2019. I spent 1 week working in a nursing home alongside nurses and other providers. I was able to help feed, bathe, and care for patients in the nursing home as well as practice my Spanish skills. It was a great experience and I was able to add it to my resume to help me land my first medical assisting job.

2. If You Can, Get Certified

Although most providers and hospitals prefer medical assistants who underwent a traditional medical assisting program, some may consider you without one. The NHA allows you to become certified online without going through a traditional program. You do have to have some sort of related experience, but no schooling. If you qualify to take the exam, do it! They provide a study guide book that you can purchase and 6 online practice tests before you go in for the official exam. The exam is proctored through PSI and it’s 180 questions. The best thing about the NHA certification is that it doesn’t cost much. It’s about $200-$300 depending on if you purchase the study materials.

If you don’t think reading through a study guide is for you or if you don’t have the related experience to qualify to take the exam, you can do a fully online, self-paced course that prepares and qualifies you to sit for it. The U.S Career Institute offers a course that is fairly priced. Some classmates of mine underwent the program in just 2 weeks and passed their exam. This option is the best in my opinion. It’s fast and inexpensive. There are online courses that allow you to take the CNA exam as well. If you think being a CNA is a better fit for you, go for it! Both medical assisting and nurse assisting are great patient care experiences to have and will expose you to medicine.

3. Include Health Related Classes in Your Resume

Many students forget to include their courses in their resume. It may sound silly, but in many of my interviews, I was asked about those courses and how well I did in them. Taking Anatomy, Physiology, Genetics, Pharmacology, Pathophysiology, Microbiology or any other class that relates to medicine and health care will put you a step ahead. Employers and providers like to see that you are passionate about medicine and have the potential to learn fast. If they are going to take a chance on you, they want to know their time will be well spent. This is your time to shine, so don’t be shy. Include your classes, your extracurricular activities (like volunteering) and any research you have been or are involved in. In my interviews, I was asked about my volunteer trip, my GPA and even quizzed on medical terminology. Don’t be afraid to sell yourself. Be confident and show that you can and will learn fast and are willing to work hard to do so.

4. Be Willing to Take a Pay Cut

As a dental assistant, I made pretty good money. I was working full-time while in school making a lot more than my classmates were making. The dental field pays better than the medical field and I knew that I would be taking a pay cut in the transition. I accepted that fact and moved on. You’re going to have to make sacrifices throughout your pre-med journey. I’m sure you have already made many—missing family holidays to study or not spending time with friends to catch up on sleep. This was just another sacrifice I made for my future.

The good thing is, after you are trained and know what the heck you are doing, you have a great chance of getting a raise. Many employers will give you a raise based on performance, so work hard and learn as much as you can. Show initiative, ask questions, jump in to help, be compassionate, and be a team player. You may see that raise faster than you expected. Like they say “hard work pays off!”

5. Be Eager to Learn and Show Initiative

In all of my interviews, I made sure to emphasize my desire to work in the field and to learn as much as I could. I didn’t leave that interview until I knew that the person interviewing me knew, with 100% confidence, that I was smart, dedicated and ready to learn. I described my experiences in the dental field and how I didn’t undergo a traditional training program. Many employers are okay with teaching a new grad or pre-med student the ropes. Their fear is that you aren’t willing to put in the work it takes to really learn the job and excel. Unfortunately, there are a lot of pre-professional students that just want their experience hours and nothing else. They aren’t invested in learning or in the process. They have their eye on the prize and are disconnected with the present.

DON’T BE THAT STUDENT!

Show initiative! Describe your skills outside of health care that will enable you to become an asset to their practice. Explain what you will do to learn as much as you can and to exceed their expectations. Offer to come in and train on your days off or stay after hours to shadow an experienced MA, CNA or nurse. Don’t be lazy! Just because this isn’t your end goal, doesn’t mean you get to be sloppy at it. Be GREAT at everything you do. Whether you are working retail or as a PA. Your journey matters and who you are during it will define who you become at the end.

6. Believe in Yourself!

I know, very cheesy, but also very true! Don’t let your fears prevent you from following your dreams or getting the experience you need to become a physician. Experience matters. The quality of your experience is more important than the amount of hours you have accumulated. I was afraid to change jobs. I was comfortable being a dental assistant. I was good at it and I was getting paid great money. I had to make a sacrifice for my own benefit. I am in a position now that will teach me skills I can carry into medical school. I am working alongside doctors and mid-level providers who are willing to answer questions and help me develop my skills. It’s terrifying at first and requires quite a bit of vulnerability, but it’s worth it in the end. You will be better prepared for medical school and will have a bucket of knowledge to carry with you. It will make you a more competitive applicant and hopefully help you stand out in the midst of thousand of applications.

Take a chance on yourself and don’t let fear dictate your future!

Organic Stew Recipe

Medicine and Health

Okay, let’s be real: eating healthy is hard. It’s hard because we have spent most, if not all, of our lives eating crap. Western culture and the modern world we live in today has normalized a restless lifestyle. We feel bad when we stop to rest. We feel guilty if we are not being productive with our time. We must keep pushing, working, drinking caffeine and borrowing energy to keep-up.

With all of the pressures and responsibilities in the modern world (bills, mortgage, college, deadlines), cooking is not our priority. We grab a protein bar in the morning as we rush our the door for work, we skip lunch because we have a deadline to reach and we buy take-out dinner because cooking takes way too long. Not to mention the sheer thought of cleaning up after. Let’s face it: after a long day of running against the clock, we don’t want to cook.

What we don’t realize is that the take-out food we are buying and the lunch we are skipping is the reason we are tired, depressed, anxious and feel like complete crap half of the time. Food is meant to give your body energy to keep going. The protein bar you think is going to hold you off until lunch isn’t food. It’s processed junk and no matter how busy you are, if you don’t make time to fuel your body with the nutrients it needs, you will never feel better. It doesn’t matter how many deadlifts you do at the gym or how many yoga classes you go to…

Health starts with your diet!

I was just like most people in America. I skipped meals, ate processed junk and convinced myself I was healthy as long as I was going to gym. If you want to try and transition into a healthier lifestyle, try out this great stew recipe that I started out with when I decided to finally stop making excuses and take care of myself. Here’s the best part: it’s Crock Pot friendly. You just throw everything into your Crock-Pot and go about your day. Do your yoga, walk your dog and take a shower because dinner will be ready in no time.

I know eating healthy is intimating because first, you may not know a thing about what BPA, GMO or organic even means. It may feel like you don’t know where to start. Second, everyone talks about how expensive organic foods are. Don’t worry, this recipe is affordable and if you don’t have time to go to Whole Foods or the super market, you can purchase all of the ingredients above on Amazon. If you didn’t know, Amazon has partnered with Whole Foods, so everything you want to buy at Whole Foods is available online. Plus, you get a discount when you do go buy your groceries in store.

These seasonings are optional. You can mix it up if you’d like. These are seasonings my husband and I love to use. You don’t have to buy them at any fancy organic store. Get them wherever you’d like or use what you have at home. Like a true Latina woman, I don’t measure any of these seasonings. As my mother would say, we season with heart, so add the seasonings to taste. I personally use one whole onion and one whole garlic in my soup because I love how they taste. If you can, do purchase an organic onion and garlic. Organic vegetables contain more nutrients than regular ones. You are doing yourself a favor by spending the extra $0.20 on a clean and natural vegetable versus not.

How to prepare:

Dice the garlic and onion and cook it over medium heat on a regular stove. Cook until they brown. After, place them inside of the Crock Pot.
Drain the organic kidney beans, garbanzo beans, and pinto beans from the can and place them inside with the garlic and onion.
Add 2 full cartons of beef bone broth and 1 box of the red lentil penne pasta.
Add the organic frozen vegetables and cauliflower.
Add seasonings to taste.
- Salt & Pepper
- Paprika
- Ground Cumin
- Ground Coriander
Let the soup cook in the Crock Pot for as long as necessary. Usually, I leave mine on high for about 3 hours, and then reduce it to low. I like my pasta very soft as well as the vegetables, so you may cook your stew for less time than me.
When I think it’s done, I add in chopped parsley to taste. If you don’t want to add it to the entire soup batch, you can add it to the individual bowl when you are ready to eat or serve.

That’s it! Seriously, that is actually it.

If you have the seasonings already and only need to purchase the ingredients, you will spend about $25.00. If you need to buy onion and garlic, you may spend about $27.00-$28.00 depending on if you buy organic or not.

There it is. An easy, Crock Pot friendly, and affordable healthy recipe for you to kick-start your diet and lifestyle change. Let me know how it tastes once you try it. I’m super excited to see what you all think.