The Medical Decoder Winter 2017 by The Medical Decoder

IN THIS ISSUE Science & Technology 4

Coffee: Energy Drink, Miracle Drug? Eugenie Bang Northwestern University '20

Managing Editor

The Medical Experience

Creative Director

A Novel Approach to Education William Grubbe Northwestern University '17

Health Care & Policy 10

Speak and Be Heard: Language in Medicine Nathan Shlobin Northwestern University '20

Human Interest 12

Caring for the Healers Michael Rallo Rutgers University '17

Korri Hershenhouse Nathan Moxon

Immunotherapy: The Latest Buzzword in Oncology Michael Albert Northwestern University '20

Editors-in-Chief

Prevalence of Mental Illness on Campus Monica Juarez Northwestern University '20

Medicine in the Performing Arts Christina Liu

Tips for Staying Healthy: Don't Neglect Your Exercise! Aditya Tanjore

Concussions: Impacts Beyond the Initial Blow Gina Johnson

Northwestern University '19

Northwestern University '20

2 â&#x20AC;˘ The Medical Decoder â&#x20AC;˘ Winter 2017

Eric Kim

James Guo

Business

Matthew Lam Evan Sitar

Writing Staff

Michael Albert Eugenie Bang William Grubbe Gina Johnson Monica Juarez Christina Liu Michael Rallo Nathan Shlobin Aditya Tanjore

Editing Staff

Eugenie Bang Troy Biermann Karol Bisaga Angie Chen Brandon Cho

LETTER FROM THE EDITORS

Dear readers,

Welcome to the eighth edition of The Medical Decoder!

Editing Staff (cont.) Ester Choi Esther Chung Selina Deiparine Regina Fricton Tyler Frye Maxime Godart Shannon He Uma Jacobs Monica Juarez Viswajit Kandula Pooja Kanthawar Sherry Li Brooke Mahoney Srijit Paul Charlie Schwartz Rachel Seng Parth Shah Nathan Shlobin Aditya Tanjore Emilie Touma James Walker Victoria Wu

Design Team

Mariam Ardehali Angie Chen Esther Chung Tyler Frye Matthew Lam Victoria Wu

As students rising into a healthcare climate wrought with uncertainty regarding future policy, this edition is most relevant as we strive to further understand and take control of our health and healthcare options. The ever-evolving challenge in providing effective, inclusive medical care to all patients is seen in Nathan Shlobin’s article “Speak and Be Heard: Language Barriers in Medicine” where he highlights the pressing need for change in the current communication structure utilized in the medical system. In one of our largest editions yet, we bring into focus a student group that works tirelessly to bring young students a comprehensive health education, filling in the gaps left by the standard school curriculum in William Grubbe’s “A Novel Approach to Education” In this article, Grubbe discusses the importance of providing guidance to young students in taking control of their health through teaching healthy decisions and healthy lifestyles. Furthermore, we shed light on current news regarding the concept and key rising pharmaceutical stars behind immunotherapy in Michael Albert’s “Immunotherapy: The Latest Buzzword in Oncology,” as the term has become increasingly prominent in the field of medicine. Additional featured articles include spotlights on PTSD, the true consequences of concussions, the realities behind a cup of coffee, and performing arts medicine. We would like to thank our readers for supporting the growth and improvement of this publication. Just like the topics we write about, this student run publication is always evolving, and we hope this edition serves our goal to further enlighten readers about health, medicine, and everything in between. We are pleased to present the eighth edition of The Medical Decoder. Enjoy!

Sincerely, Nathan Moxon and Korri Hershenhouse Editors-in-Chief medicaldecoder@gmail.com Letter from the Editors • Volume 8 • 3

Coffee: Energy Drink, Miracle Drug? By Eugenie Bang

f America runs on Dunkin’, it is probably because of the college students buying coffee to survive their morning lectures from either an insane night of studying or partyingor in extreme cases, both. The National Coffee Association’s National Coffee Drinking Trends 2011 survey reveals that forty percent of the 18- to 24-year-olds reported that they drink coffee on a daily basis, an increase from the thirty-one percent in 2010. The drink has become a routine for many - some to the point of addiction. Although coffee does have negative effects, students should not feel guilty about grabbing that cup of Joein the morning because moderate caffeine consumption has the potential to benefit them in the long run. Before viewing the positive and negative aspects of coffee, the biology of sleep and how we try to overcome it must be understood. Adenosine is a compound found in our DNA that plays a major role by promoting sleep and decreasing arousal.¹ In our brain, the amount of adenosine binding to its receptors rises as humans go about their daily activities. As the amount of binding increases, neuronal

activity decreases, eventually resulting in sleep. However, an adenosine antagonist like caffeine blocks adenosine from attaching to its receptors (A1 and A2A) by binding itself to these receptors first,.1 The result is the prevention of adenosine from working properly; it can no longer bind to its receptors to promote drowsiness. A study reported that there is a significant increase in the density of adenosine receptors after frequent consumption of coffee, which means that more caffeine will be needed to block the increasing number of adenosine binding sites.² This explains how people build a tolerance for caffeine, causing them to drink three or four cups of coffee a day just to feel the

4 • The Medical Decoder • Winter 2017

same effect, often leading to addiction. Besides addiction, coffee has other negative side effects. One study showed how mice that consume caffeine develop short-term anxiety and noted that patients suffering from panic attacks or mental disorders are especially sensitive to small doses of caffeine.¹ Longterm consumption of caffeine leads to less effective adenosine receptors, leading to many sleep disorders such as insomnia.¹ Digestion problems can also arise from coffee, as it increases the production of stomach acid, especially if coffee is consumed first thing in the morning.¹ If a

high level of hydrochloric acid is produced because of coffee, then the body won’t be able to produce hydrochloric acid when it really needs it later on in the day. Furthermore, caffeine can result in heartburn as it relaxes the pressure on the lower esophageal sphincter, resulting in its inability to prevent the acidic stomach content from traveling back up the esophagus.³ Besides these unhealthy effects caffeine has on our body, moderate coffee consumption surprisingly has many health benefits, many of which are related to cognition. The enhancement in cognition is due to the ability of caffeine to block A1 adenosine receptors. These are located in the hippocampus and the cortex, which are the areas

sleepiness in areas controlling cognition. This results in memory enhancement. The Three City Study, an intensive study in Boston, Chicago, and San Antonio showed that among those over the age of sixty-five, more than three cups of coffee a day slow the decline of verbal cognitive functioning and visuospatial memory.⁴ In a broader sense, coffee might even lower the risk of cognitive diseases such as Alzheimer’s disease. In a longitudinal study conducted by the Canadian Study of Health and Aging, risk of Alzheimer’s disease decreased by 31% in subjects over the age of sixty-five.⁴ One of the hypotheses that explains this phenomenon is the decreased risk of diabetes from consumption of caffeine. This is because diabetes has been linked to the occurrence of dementia.⁴ Coffee contains an abundance of magnesium, which is known to increase insulin sensitivity and the ability to effectively lower blood glucose levels- all of which in the brain that help treat diabetes.⁴ control functions Caffeine has also been such as memory.¹ discovered to aid in areas By blocking adenosine from other than cognition. Low doses attaching to receptors in the of caffeine have been found to hippocampus, caffeine suppresses increase locomotor behavior in

those with Parkinson’s disease, which stems from the blockade of A2A receptors in the brain.⁵ Caffeine was especially efficient for Parkinson’s patients in planting their heels on the ground while walking, which helps them walk more efficiently.⁵ Although caffeine promotes anxiety and stomach indigestion in those who consume an excessive amount, studies show that moderate amounts of coffee could help reduce the likelihood of some diseases such as dementia and Parkinson’s disease. Anything in excess always leads to problems, but the future of coffee seems bright as more research is being done , revealing more possible benefits as time progresses. The newly discovered advantages of coffee have the potential to rehabilitate lives and not just to save a college student from an all-nighter.

For references, please see Page 23

Science & Technology • Volume 8 • 5

Immunotherapy:

The Latest Buzzword in Oncology By Michael Albert

ou would not have to look too hard to hear the word “immunotherapy,” which seems to be the latest buzzword in the field of oncology. At the most basic level, immunotherapy harnesses the body’s own powerful disease fighting mechanisms, and puts them to work against cancers and other applications. The word “immunotherapy” is really an umbrella term for any treatment that bolsters or stimulates the body’s own immune system.

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The field truly grew out of one seemingly routine observation by a surgeon in the 1890s by the name of William Coley.1 Coley noticed that cancer patients eventually attaining remission often had accompanying fevers during their battle. This phenomenon suggested that patients who responded most successfully to their cancer treatment were receiving some sort of unknown aid, presumably from their own bodies. The principle behind this observation has been the subject of recent breakthroughs and success stories surrounding the cancer research community as the efficacy of toxic chemotherapy drugs seems to have plateaued. Pharmaceutical giants like Roche, Amgen, and Novartis have announced billions of dollars in funding and development of the next wave of chemotherapies, some of which are just starting to hit the market now.² Dr. Monica Guzman of Weill Cornell Medical College told The Medical Decoder: “I believe the scientific community is excited because retraining the immune system to detect tumor cells may long term benefit as the improved immune cells will not only be able to eradicate tumors, but be able to keep them away.” As Dr. Guzman alluded, these new therapies are capable of preventing relapse in certain situations, which would effectively overcome one of the greatest hurdles facing cancer research today. The sentiment behind this quote is reflected by

the entire research community as the first of the newest wave of immunotherapy drugs that aim to turn the cancer community upside down. Making waves recently is a drug called pembrolizumab, also marketed as Keytruda. This potentially revolutionary drug has shown immense potential in eradicating melanoma cells, as well as other cells across many different lineages and types of cancer.

he scientific community is excited because... improved immune cells will not only be able to eradicate tumors, but be able to keep them away.

-Dr. Monica Guzman, Weill Cornell Medical College

While therapies like Keytruda are beginning to gain traction and display reliable results, they are very much in the pipeline and still have much to prove. Keytruda and its counterparts exist primarily as proof of principle, but the underlying research opens up a vast network of cell receptors that can be targeted and exploited at the benefit of the cancer patients.⁵ For instance, recent Phase 3 clinical trials have proven Keytruda’s ability to be more effective and less debilitating than chemotherapy in lung cancer. Immunotherapy has the potential not only to influence remission rates, but also dramatically decrease side effects. Since the drugs have little cytotoxicity-a drug’s tendency of being harmful to cells-patients taking such drugs can reject many of the traditional side effects that come with chemotherapy.⁶ Additionally, whereas many conventional chemotherapy drugs are only effective until remission, the mechanisms behind many inhibitors allow for their use beyond remission, which would drastically reduce the relapse rate.⁷ As immunotherapy established itself as a staple in modern cancer therapy, more and more people will hear about immunotherapy and its promise.

Keytruda is just one example of the new, highly-funded immunotherapy drugs hitting the market right now.³ First approved for melanoma in 2014, Keytruda has now racked up approvals for lung cancer as well as several head and neck cancers.⁴ The mechanism behind Keytruda, along with many other immunotherapy drugs, is an antibody that binds to a programmed cell death receptor on the surface of the cell, effectively breaking down the malignant cell’s ability to resist treatment. For references, please see Page 23

Science & Technology • Volume 8 • 7

A Novel Approach to Education Why Peer Health Exchange is Revolutionizing the Classroom Environment for Health Education by William Grubbe

n 2017, the Chicago Public School (CPS) system is expected to operate $300 million below their original budget.¹ This is not the first budget deficit that the CPS system has operated under, and is not likely to be the last. With rising costs of education and decreases in funding, schools often cut arts, health, and extracurricular programs first. These cuts have the potential to not only limit the students’ exposure to topics outside of the core curriculum of most schools, but could also lead to a lack of health education for an estimated 400,000 students.¹ Furthermore, this curriculum is less likely to be consistent in pacing and content with what is expected to be taught in high schools across the nation. In 1999, Peer Health Exchange (PHE) was founded by six Yale University students with the goal of delivering a comprehensive health education to high

school students who would not receive one otherwise. Now, it has grown into a nationwide organization, operating in New York, Boston, Chicago, Northern and Southern California, and Washington, D.C., reaching 17,000 teenagers in 150 high schools across the United States, and has chapters at 25 universities.² Their mission has remained constant: “Empower young people with the knowledge, skills, and resources to

8 • The Medical Decoder • Winter 2017

make healthy decisions.” The novel design behind the PHE model for education relies on the use of college-aged students as teachers and role models, rather than a standard informative curriculum. This creates a collaborative environment where high school students are taught how to make healthy and informed life decisions, access resources that may be applicable to their health such as birth control methods, communicate with others, and reflect on the positive and negative consequences of their actions. While this does not completely encompass what is perceived to be a comprehensive health education, the curriculum targets issues that many conventional health classes tend to shy away from without inundating the lessons with unnecessary anatomy and physiology. For example, during my sophomore year of high school, we were taught

facts and statistics in our health class and were told to memorize the parts of the male and female genitalia. The topic of “mental health” was never mentioned, nor was the idea of heteronormativity challenged. PHE excels in educating its volunteers (and, by proxy, its students) about the existence of parts of society that they may not encounter in their day-to-day life to raise awareness for the privilege of an education that caters to them, especially on a campus like Northwestern. While health education may not be of paramount importance to high schools amongst other pre-collegiate concerns, it is one of the few classes offering students information that they are able to apply to different areas and disciplines of their life. Not only does a comprehensive health education such as the one in the PHE curriculum teach skills that result in a healthier lifestyle to its students, the mindset of focusing on your health and on the welfare of others permeates society at its most basic levels. By centering the education on concepts such as decision making and consequences, PHE teaches students to be conscientious about their actions and encourages them to put thought into their day-to-day routine: the words they speak, the way they communicate, the reactions to stress and success. Health is changing in this country, and health education must change with it. People are less

“ ealth is changing in this country, and health education must change with it.” afraid to talk about sex; birth control is becoming less and less taboo; sexual and mental health are topics prevalent in everything from political debates to music and art; drug laws are changing. The American population is a fluid, but unsettled, mosaic, and the ideas that society imparts in children will determine the direction in which the country moves. When I joined this organization, I was a sophomore without a clear idea of what I wanted to make of my college career. While not fumbling for purpose, I was unsure of how my skillset would translate into a successful and fruitful career post-graduation, and my only experience in any field up to that point had been as a high school science tutor and working in a warehouse moving boxes for my uncle during the summers. Having served on the executive board of the organization for two years, and as I embark on my third year as an active volunteer, PHE has taught me more about nation’s education system than any news article,

class, or conversation ever has. Education will be, and always has been, a cornerstone of great societies. A well-balanced education teaches people to challenge ideas, push themselves to failure, embark on journeys that cannot even be fathomed – but most importantly, it can teach people to critically analyze their decisions and choices. In our current age of greater awareness for mental health and the implications of actions on the psyches of other people, words have become an exorbitantly powerful tool that constantly shape the minds of those around us. PHE’s model of education should not be a back-up plan when CPS cannot fund a health department; it should be the pioneer that leads the United States into a health education system that directly mimics the amazing potential that every citizen holds.

For references, please see Page 23

The Medical Experience • Volume 8 • 9

Speak and Be Heard:

Language in

Medicine by Nathan Shlobin

ight percent of and utilize preventative health and longer hospital stays.³ the United States services.² As a result, they may This combination of factors population exhibits have poor health and avoid perpetuates a vicious cycle limited English proficiency. seeking medical care when of events in which medical In the past thirteen years, the they become ill, resulting in professionals are unable number of Americans with more serious complications to effectively treat many limited understanding of English from their illnesses and more patients who desperately need has increased substantialtreatment. ly, from almost 14 million A patient who speaks to 25.1 million, primarily poor English is at a greater Patients with limited reflecting an increase risk of experiencing a in immigration.¹ These medical error than a patient English proficiency are people with weak English who speaks English fluently. less likely to have a regularly experience diffiTo take one example, a culties communicating with 9-year-old Vietnamese girl primary care physician others, from simple misunwhose parents could not and access preventative speak English passed away derstandings to larger disagreements. from an adverse reaction to health services. In medicine, where the gastroesophageal reflux every detail may be disease medication Reglan. critical, this impaired She and her 16-year-old communication can have frequent hospitalization. Once brother, who both spoke English detrimental consequences. patients are finally admitted, poorly, served as interpreters Patients with limited English their severely hindered pa- during the office visit.⁴ Unforproficiency are less likely to tient-provider interactions pose tunately, this sort of situation is have a primary care physician greater risk of misdiagnosis all too common.

10 • The Medical Decoder • Winter 2017

interpreter services. These options include, but are not limited to, in-person interpretation, hospital-wide video conferencing, and interpretation via phone calls. More variants exist and are implemented throughout the country. The availability of trained interpreter services assists healthcare professionals in providing care. A Massachusetts health maintenance or-

medical errors when trained interpreters were employed, as opposed to untrained interpreters.⁷ Flores’ study also concluded that using untrained interpreters was just as harmful as providing care without an interpreter.⁷ Utilizing qualified interpreters improves patient care while employing untrained interpreters produces the very errors interpretive services seek to avert. However, a variety of factors prevent the widespread use of fully-trained translators. There is often a lack of access to fully-trained interpreters. Patients frequently elect to use family members as interpreters due to the high cost of hiring a trained interpreter. Medical professionals sometimes rely on their own, often inadequate, language skills in an effort to save time. Ultimately, each of these attempts fails to eliminate the language barrier. The United States’s healthcare system has advanced as medical professionals and patients alike have become more cognizant of the language barrier and its potentially deleterious effects. Still, avoidable problems persist. To err is human, but human fallibility can be minimized with widespread and affordable trained interpreter services.

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However, it is not only a patient’s limited English proficiency, but also the language level of the provider that can cause medical errors. The rates of English proficiency for immigrants who work in healthcare in the United States ranges from 91 percent for doctors to 55 percent for nursing, psychiatric, and home health aides.⁵ While most immigrant healthcare professionals are proficient in English, many still are not. This may lead to communication difficulties with patients and consequently ineffective treatment. Language barriers on both sides of the patient-provider interactions complicate care, most notably when the patient and the provider do not share the same primary language. For example, an endocrinologist whose primary language was Mandarin and spoke English as a secondary language failed to communicate effectively with a Thai woman whose primary language was Thai and secondary language was English. The woman then proceeded to develop a cancerous obstruction of her lymph nodes.⁴ Even though they both spoke some English, the language gap between them was too large to transcend and resulted in the fatal delayed diagnosis. In response to language barriers, many hospitals have begun to provide a variety of

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ganization began to employ five full-time in-person and over-the-phone Spanish and Portuguese interpreters and discovered that the delivery of health care increased for both preventative care and primary care.⁶ Similarly, a study conducted by Glenn Flores, the distinguished chair of health policy research at the Medica Research Institute, determined there were ten percent fewer For references, please see Page 24

Health Care & Policy • Volume 8 • 11

Caring for the Healers By Michael Rallo

xposure to trauma is an integral part of the human experience. Through the years, such reactions to traumatic events have been termed “soldiers’ nostalgia,” “irritable heart,” “shell shock,” “battle fatigue,” “post-Vietnam syndrome,” and “gross stress reaction.” Many different names for symptoms – sleep disturbances, flashbacks, anxiety, and fear – are now recognized as one psychological condition: posttraumatic stress disorder (PTSD).¹ Healthcare providers can quickly name the populations most at risk for developing PTSD: members of the armed forces, victims of violence, and those afflicted by overwhelming disaster. However, the general population often fails to realize that we, the healthcare community, also bear the stress and trauma that can manifest itself in PTSD. People encounter stress every day. While most can often overcome stressors such as a difficult exam or challenging day at work, some incidentswitnessing patients’ deaths, coworkers committing suicidecannot be handled alone.

Burnout and PTSD in healthcare workers are becoming a greater problem. Future healthcare workers must learn to recognize the signs of these conditions themselves and take steps toward alleviating them. They can only promote the health of their patients by maintaining their own. Physiologists have long been interested in understanding how the body responds to and copes with stressors. Homeostasis describes the tendency of biological systems to maintain a stable equilibrium. Biological and psychological stressors disrupt this equilibrium and initiate a cascade of physiological mechanisms to restore it, a reaction known as the stress response. Dr. Hans Selye, an Austrian-Canadian endocrinologist, pioneered the first work in establishing the stress response.² He found that organisms undergo three distinct stages in response to

12 • The Medical Decoder • Winter

“noxious stimuli,” which he termed general adaptation syndrome. The first stage, known as the alarm reaction, is the body’s immediate reaction to a stressor in which it prepares itself for physical activity. We often term this “fight or flight.” During this period, the sympathetic nervous system is activated, leading to increased blood pressure and heart rate, dilated pupils, sweating, etc. Stress hormones such as adrenaline, cortisol, and

norepinephrine are maintained at high levels to continue these effects for the duration of the stress. This reaction mechanism is quite beneficial; it primes our circulatory system, large muscle groups, and brain for a period of extreme exertion such as evading or confronting a stressor. The second stage is resistance; the body’s adaptation to the continued stress and its efforts to reduce the impact of the stressor. Hormone levels decrease, but are still elevated, maintaining the body in a constant state of threat.² Finally, if the stressor is not removed, the third stage, exhaustion, ensues. Hormones like cortisol, while essential to the stress

response, have damaging side effects, which can deplete the immune system. The body is no longer capable of sustaining the stress and will develop a pathological state.³ Conditions such as heart attacks, strokes, and immunodeficiencies are all associated with chronic stress. It is essential to understand this stress response because future healthcare providers will continue to experience it throughout our lives. The average man or woman must take action to relieve stress and burdens so that they can lead healthy, balanced lives. Sudden traumatic events, such as those experienced in combat or by victims of violence, trigger the stress response described above. In most cases, the reaction subsides naturally once the stressor is removed. Sometimes an individual may experience problems that last long after the situation is over, and they may be diagnosed with PTSD. PTSD is defined as “a disorder that develops in some people who have experienced a shocking, scary, or dangerous event” and is characterized by symptoms such as flashbacks, avoidance of feelings associated with the trauma,

feeling “on edge”, and intense changes in mood.³ To be diagnosed with PTSD, one must meet the criteria set forth by the American Psychological Association in the Diagnosis and Statistical Manual of Mental Disorders (DSM). Current criteria include re-experiencing, avoidance, negative cognitions and mood, and heightened arousal. The impact of these symptoms on one’s work and relationships is also considered in the diagnosis.⁴ It is estimated that 7-8 out of every 100 people will be diagnosed with PTSD at some point in their lives.³ Studies done on nurses, paramedics, hospital emergency personnel, and physicians have revealed a higher prevalence of PTSD in these populations; in one study, nurses were shown to have a 35% prevalence of nightmares related to their job. The recurrence of such nightmares and other PTSDrelated symptoms were often associated with end-of-life care and traumatic events.5,6,7 Major strides have been taken in identifying the underlying neurophysiological causes of PTSD. The era in which PTSD was viewed as a “weakness” with no physical cause is coming to an end. A variety of physiological factors are altered in patients with PTSD including endocrine hormones, neurochemicals, and brain circuitry or “wiring.”⁸

Human Interest • Volume 8 • 13

Interestingly, altered hormone cortisol levels are shown in individuals diagnosed with PTSD. However, the direction of the alteration (increased or decreased) remains inconsistent across several studies.⁹ Many researchers believe that an “imbalance” in brain chemicals (i.e. neurotransmitters) is the cause of several psychological disorders. While it is hard to describe what an “imbalance” in the brain looks like, altered levels of catecholamines (e.g. dopamine and norepinephrine) and serotonin have been found in patients suffering from PTSD.⁸ When altered, these neurotransmitters, which are responsible for normal communication between neurons in the brain, may negatively impact behavior, mood, and emotions. Finally, heightened activation of the amygdala, a brain structure that processes the emotions associated with memories, especially fear, has been found upon presentation of stressful stimuli to PTSD patients.¹⁰ While this is just a brief overview of the physical correlates, it demonstrates the strides that have been taken to understand PTSD. Further research will bring us closer to identifying therapeutic targets for treating victims. The most difficult question comes now: how do we take care of those who have built their lives on caring for others?

Healthcare workers and combat veterans – two populations at high risk for PTSD – pride themselves on their strength and ability. The stigma that PTSD is a fault or a weakness makes it difficult for these individuals to admit that they need help. For this reason, both military and civilian organizations have established campaigns to eliminate the stigma of PTSD and encourage victims to seek help. For example, the Cleveland Clinic has implemented a “Code Lavender” program through which its staff can call a “Code Lavender” to receive mental rehabilitation during difficult shifts in which they have lost one or more patients or witnessed devastating trauma. The program inspires a sense of community and supports the emotional needs of physicians and nurses.¹¹ Similarly, “The Code Green Campaign” was initiated in 2014 to raise awareness of the high rates of PTSD and suicide in first responders and to reduce the stigma of getting help.¹² Through television programs and social media campaigns, such as “Humans of New York,” PTSD has worked its way into the public eye. Aside from raising awareness, research through the Department of Veterans Affairs is working to understand, treat, and possibly prevent PTSD. This

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research has demonstrated the efficacy of prompt mental health care, prolonged exposure therapy, and deep brain stimulation in treating PTSD.¹³ No individual should ever feel ashamed of admitting that they have PTSD. In fact, the earlier one seeks help, the easier it will be to get treatment and recover. Stress and trauma are two elements experienced by nearly every person in every walk of life. Fortunately, our bodies are well prepared to deal with these physical ailments or psychological stressors. Some stressors are so prolonged that they overwhelm the body’s capabilities, and lead to sickness or fatigue. These bodily symptoms emphasize the importance of recognizing and handling the stress of everyday life. Other stressors, such as intense psychological trauma, induce severe reactions and result in long-term conditions such as PTSD. In these cases, it is essential for an individual to seek early therapy and work towards overcoming the trauma. Future healthcare providers will be subjected to a stressful work environment plagued with illness, death, and trauma. When events may become too difficult to handle alone, programs and strategies that acknowledge the risks for stress conditions will serve as crucial support mechanisms for providers. For references, please see Page 23

The Prevalence of Mental Illness on Campus By Monica Juarez

In a time wrought with transitions, impending adulthood, and new types of pressures around every turn, college can become quite stressful. With the societal stigma surrounding mental illness, the effects of several risk factors can lead to mental problems. Though there have been efforts to open a discussion, the stigma makes it difficult to truly understand its prevalence in our society. Per the National Institute of Mental Health, in 2014, 20.1% of the U.S. population ages 18-29 were diagnosed with a mental illness.² In regards to college campuses, in 2000, about 16.4% of students reported having severe psychological issues.³ If we fast-forward to 2010, this number shoots up to about 44% of students on college campuses with psychological problems.³ And when we look at college campuses today, 50% of students have a psychiatric disorder.³ Of these psychological problems, depression, suicide ideation, and anxiety disorder are the most common.⁴ In addition, there is a startling rise in numbers for eating disorders, substance abuse, and self-injury.³ Suicide ideation is not only a common mental illness found on college campuses, but also the

second leading cause of death for students. One study investigated several risk factors to predict the onset of STB (suicidal thoughts and behavior).¹ These risk factors included the but are not limited to: transition from adolescence to adulthood, physical or emotional abuse, new academic challenges, social pressures, dating violence, betrayal experiences, and stressful experiences (e.g. life-threatening illness, death of a loved one). The results revealed that dating violence before the age of 17 and betrayal experiences were the most strongly associated with the onset of STB.¹ In addition, for the onset of STB, one-year incidence in students were 3.7-3.9% for suicidal ideation, 0.9-2.2% for suicidal plans, and 0.2% for suicide attempts.¹ The study signifies that several factors can be used as an opportunity to detect the risk for suicide, specifically for students in their college years. With the stigma surrounding mental illness, it’s easy for others to play off the warning signs or risk factors as nothing. However, this study demonstrates the close relationship at play between trauma, stress, and STB. For references, please see Page 24

Percentage of College Students Reporting a Significant Psychological Issue

2000

2010

2016 0

Human Interest • Volume 8 • 15

Medicine in the Performing Arts By Christina Liu

16 â&#x20AC;˘ The Medical Decoder â&#x20AC;˘ Winter 2017

erforming Arts Medicine considering factors beyond is a relatively new and the injury itself to discover the developing field of med- root cause and prevent further icine that caters to the needs of injury. This enhanced docperforming artists, addressing tor-patient relationship is esthe variety of medical conditions pecially important considering that result from their profession. the increasing depersonalizaThese include chronic injuries as tion in medicine. well as psychological ones such Dr. Brandfonbrener exas performance anxiety and high plained, “If someone comes in stress levels.¹ It is therefore un- with a sprained wrist, I don’t surprising that there should be just look at the wrist; I study specialized medical care for this the whole patient. A musicommunity of musicians, dancers, cian’s medical condition fresingers, and actors. quently stems from multiple Northwestern faculty member sources, including techDr. Alice Brandfonbrener was a pioneer in the field of performing arts medicine. She established the Medical “A MUSICIAN’S MEDICAL Program for PerformCONDITION FREQUENTLY STEMS ing Artists here at FROM MULTIPLE SOURCES, Northwestern in INCLUDING TECHNIQUE, PHYSICAL 1985.² The proCONDITIONING, THE REPERTOIRE, gram later moved THE INSTRUMENT—EVEN THEIR to the RehabiliEMOTIONAL STATE.” tation Institute of Chicago, where physicians continue to develop treatment programs and educate artists about injury nique, physical prevention. conditioning, the repertoire, the Additionally, there are similar instrument—even their emoprograms developing all around tional state.”⁴ Treatment often the world. In the U.K., the British involves physical and occupationAssociation for Performing Arts al therapy and psychological serMedicine (BAPAM) actually offers vices, and also addresses other free clinical assessments.³ In their musculoskeletal injuries as well 2015 annual review, the BAPAM as vocal cord dysfunction.³ reported that 71% of registrants Performing artists are subject sought help with musculoskeletal to immense physical strain. Dancproblems, but psychosocial treating takes an obvious toll on the ment has also become increas- body, and it is very easy for singingly prominent, as performing ers to hurt their voices. Instruartists are usually afflicted with ments are usually asymmetrical, multiple health problems.³ requiring a physically awkward Performing arts doctors take posture to play them.⁵ This bea holistic approach to treatment, comes problematic particularly

because musicians practice such long hours. According to Dr. Brandfonbrener, “In general, music attracts people who are somewhat obsessive by nature, and that’s appropriate in that it requires tremendous discipline to be good. But some musicians overdo this to try to perfect a technique. Pianists are the worst abusers. They will lock themselves in a practice room six to eight hours a day and then wonder why they hurt.”² Performing Arts Medicine is important not only due to these chronic injuries, but also because it raises awareness about the health problems of performing artists.⁴ These problems are largely unrecognized as needing specialized treatment and need to be addressed, not downplayed, so that treatment can become more readily available. Universities are beginning to develop formal training in performing arts medicine, as well. The British Association for Performing Arts Medicine, in partnership with University College London, founded a Master of Science (MSc) program in Performing Arts Medicine in 2011.⁶ Additionally, there are post-graduate programs in the U.S. at George Mason University and Shenandoah University, among others.⁷ Raising awareness for performing arts medicine will help performing artists get the help they need and legitimize their health problems.

For references, please see Page 24

Human Interest • Volume 8 • 17

Tips for Staying Healthy: Don’t Neglect Your Exercise! By Aditya Tanjore We all know how important healthy stress management is to success as a student, whether you are a first-quarter freshman or a seasoned senior. During the college years wrought with intensive studying, an unfortunately immobile activity, it helps to exercise regularly to improve mental functioning. The Medical Decoder Team has put together a list of activities you can engage in to stay in shape both physically and mentally:

1. Moderate-intensity cardio: Studies have

found that a mere 90 minutes spent walking reduces neural activity in the subgenual prefrontal cortex of the brain, this region responsible for behavioral withdrawal in association with rumination,¹ or the focus on symptoms and consequences of distress, rather than the solution. A suggestion: take the stairs. Taking the stairs over the elevator when possible is an easy way to add cardio to your daily routine.

2. Keep a Positive Attitude: Exercise is supposed to help you! Studies have shown that certain multijoint exercises, which put stress on two more joints and muscles, such as bench press, leg press and squats produce large amounts of endorphins after working out. The release of these endorphins works in relieving the mind of tension, reducing pain, and to generally improve your mood.³ Focus more on the cognitive effects of exercise rather than the physical strain you put on your body to increase the likelihood of reaping the cognitive benefits of exercise.

3. Carve out time: Plan your day with exercise in mind. When students don’t plan around their much-needed exercise, they often skip exercising entirely. If the only available chunk of time you have is late at night, as is often the case for

18 • The Medical Decoder • Winter 2017

college students, don’t let that deter you. Contrary to popular belief, the time of day in which one exercises has little to no negative effect on bodily functions such as sleep: recent studies have shown that late-night exercise does not reduce the quality of sleep.⁴ Students at Northwestern have even attributed cardiovascular exercise to more restful sleep at night. “If I work out with enough time before I go to bed, I definitely feel more ready for bed and well rested in the mornings.” says Medill freshman Maggie Harden. While the reasons for this positive effect are unclear, researchers at Northwestern’s Feinberg School of Medicine have attributed this to cardiovascular exercise inciting a decrease in arousal that is commonly associated with sleeplessness.²

4. Stretch Dynamically: Stretching facilitates

the flow of blood and oxygen throughout the body and the brain.⁵ Oxygen, which is carried by hemoglobin in red blood cells, is needed by neurons to perform their function, therefore, efficient flow of blood to the brain is of the utmost importance for peak brain performance. Static stretches on the calves and quadriceps have been found to actually restrict blood flow instead of facilitating it.⁶ Other stretches, such as dynamic stretches, involve stretching muscles in and out in a repeated fashion, and are especially important in facilitating blood flow. Performing dynamic stretches such as lunges, high knees, and jumping jacks for 8-12 minutes can increase blood and oxygen flow and improve concentration without tiring you out.

For references, please see Page 24

CONCUSSIONS IMPACTS BEYOND THE INITIAL BLOW By Gina Johnson

oncussion-“an injury to the brain that is caused by something hitting the head very hard.” Though Merriam-Webster defines a concussion in simplistic terms, the consequences of such an injury can be much more severe than the description suggests. Typical symptoms include, but are not limited to, headache, dizziness, nausea, difficulty concentrating, fatigue, and sensitivity to light or noise.1 While most of these symptoms are widely recognized in the modern day due to improved research and increased media coverage, affected individuals tend to have significant differences in severity and type of symptoms.² People who have suffered from a concussion may experience lingering symptoms lasting anywhere from a few days to beyond a year. These symptoms are classified under the title of “post-concussion syndrome.”³ Persistent postconcussion symptoms such as chronic headaches or dizziness can severely restrict a person’s ability to participate in school, athletics, and other activities such as using electronic devices or listening to music. Furthermore, extended recovery

time can have a profound impact on the emotional, social, and academic aspects of the affected person’s life. Concussions and their effects are primarily associated within the context of athletics. However, the consequences of sustaining such an injury affect many aspects of a person’s life beyond athletics. A qualitative study conducted in 2015 by South Dakota State University examined the health-related quality of life in adolescents who had suffered from a concussion more than one year prior. The study reported that sportsrelated concussions not only impacted physical functions but also emotional well-being, school attendance, and interpersonal relationships.⁴ Participants in the study consistently voiced feelings of frustration and a substantial decline in academic and social functioning. Oftentimes, concussion symptoms force patients to suspend participation in sports teams, social events, and other extracurriculars which can have a profound negative psychological impact on their well-being. In a different study of concussed patients ages 8-18, over 50% of the respondents indicated that the loss of former extracurricular activities was the worst aspect about having a concussion.⁵ In many cases, a decline in

academic performance is noted as a major negative consequence of a concussion. A 2015 pediatric study on concussed students determined that most symptomatic patients and their parents reported a more adverse impact on school performance than did recovered peers and their parents. Within the group of symptomatic patients, 59% of students and 64% of parents reported significant academic concerns. Among the patients experiencing symptoms, 90% reported having trouble in one or more classes, and 55% reported spending increased time on homework. Cognitive issues involving memory and learning create a variety of problems for students. Of the symptomatic students, 70% said that chronic headaches were interfering with their learning and 61% experienced difficulty paying attention.6 The schools themselves, with bright lights and busy hallways, can exacerbate these symptoms as well. Difficulties arise when school officials are unable to recognize the issues these students face, since most people who have suffered from a concussion appear normal from the outside.⁷ My own experience has supported the evidence that the impact of concussions is not limited to just cognitive

Human Interest • Volume 8 • 19

functions. In the spring of my sophomore year of high school, I was involved in a bicycle crash during a triathlon. Though I was diagnosed with a mild concussion, I was plagued with lingering symptoms including headaches, dizziness, and an inability to concentrate for over a year. I was forced to quit sports teams, piano lessons, volunteering groups, and other extracurricular activities. Diminished contact with my teammates eroded some of my most valued friendships, and my inability to participate in activities I loved for an extended amount of time was extremely discouraging. However, the most profound hardships I faced were in the classroom. While my school was very accommodating to my needs, I had difficulty completing the school days with my symptoms. Constant headaches forced me to lay down in the nurse’s office up to three times per day. When it was time for homework, my brain was so exhausted that I was unable to focus for more than twenty minutes at a time. Instead of reading books, I had to listen to audiobooks, or, if those were unavailable, my parents had to read to me. Tests were too long for me to concentrate, so I had to arrange time with my teachers to come to school early and take a portion of the test before class. These struggles continued well into my junior year. Ignoring the advice of my doctors who advised me to drop all my AP coursework, I continued to push myself. Though my doctor’s note said I had “no due dates” for homework, I knew that if I fell

behind, my grades would suffer. I was under constant stress to keep up with the rigor of my classes, especially with college applications looming in front of me. Ultimately, I was able to make a full recovery, but not without overcoming significant obstacles along the way. My story illustrates just one example of the extensive academic challenges faced by those who have suffered from concussions. The inconsistencies in symptoms and lingering effects of concussions are the primary reason for the lack of concrete, effective treatment. Unlike a broken bone, a concussion is not the type of injury for which a medical professional can definitively prescribe how much rest time is needed for healing. Variation in recovery times compared to others who have suffered from concussions can be extremely disheartening

20 • The Medical Decoder • Winter 2017

to patients. In order to ensure that those who suffer from concussions are still able to succeed both academically and socially with their injuries, support systems must be implemented to facilitate healthy recovery. Schools should be proactive in securing academic accommodations for students who have suffered from concussions. Additionally, they should provide concussion education programs to prepare teachers and peers to respond appropriately and positively when a person voices concern or exasperation regarding his or her head injury. As awareness spreads, people will hopefully begin to recognize and understand the multi-faceted struggles of concussed patients. For references, please see Page 25

Coffee: Energy Drink, Miracle Drug?

REFERENCES

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Immunotherapy: The Latest Buzzword in Oncology

1. Grady, D., & Pollack, A. (2016, July 30). What is Immunotherapy? The Basics on These Cancer Treatments. Retrieved November 30, 2016, from http://www.nytimes.com/2016/07/31/health/what-is-immunotherapy-cancer-treatment.html?_r=0 2. Keytruda Approval History. (n.d.). Retrieved November 30, 2016, from https://www.drugs.com/history/keytruda.html 3. Kiesler, E., & Begley, M. (2016, May 10). The Future of Cancer Research: Five Reasons for Optimism. Retrieved November 30, 2016, from https://www.mskcc.org/blog/future-five-reasons-optimism 4. Merck’s Keytruda succeeds in key bladder cancer trial. (2016, October 21). Retrieved November 30, 2016, from http://www. reuters.com/article/us-merck-co-study-idUSKCN12L1BX 5. Parish, C. R. (n.d.). Cancer immunotherapy: The past, the present and the future. Retrieved November 30, 2016, from http://www. nature.com/icb/journal/v81/n2/full/icb200316a.html 6. Pietrangelo, A. (2016, October 12). The Value and Cost of Immunotherapy Cancer Treatments. Retrieved November 30, 2016, from http://www.healthline.com/health-news/value-and-cost-of-immunotherapy#3 7. Roland, D. (2016, October 20). Roche Sales Lifted by Cancer Drugs. Retrieved November 30, 2016, from http://www.wsj.com/ articles/roche-sales-lifted-by-cancer-drugs-1476940985

A Novel Approach to Education

1. Chicago Public Schools Fiscal Year 2017 Budget. (2016, November 30). Retrieved from http://cps.edu/FY17Budget/Pages/ FY17Budget.aspx 2. Peer Health Exchange - About Us. (n.d.). Retrieved November 30, 2016, from http://www.peerhealthexchange.org/about-us/

Caring for the Healers

1. Everly, G.S., and J.M. Lating. “Chapter 2: The Anatomy and Physiology of the Human Stress Response.” A Clinical Guide to the Treatment of the Human Stress Response. 3rd ed. New York: Springer, 2013. 17-51. Print. 2. Charmandari, Evangelia, Constantine Tsigos, and George Chrousos. “Endocrinology of the Stress Response.” Annual Review of Physiology 67 (n.d.): 259-84. Web. 3. “Post- Traumatic Stress Disorder.” Mental Health Information. National Institute of Mental Health, 1 Feb. 2016. Web. 4. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, D.C.: American Psychiatric Association, 2013. Print. 5. Mealer, Meredith, Ellen L. Burnham, Colleen J. Goode, Barbara Rothbaum, and Marc Moss. “The Prevalence and Impact of Post Traumatic Stress Disorder and Burnout Syndrome in Nurses.” Depression and Anxiety 26.12 (2009): 1118-126. Web. 6. Iranmanesh, Sedigheh. “Post-traumatic Stress Disorder among Paramedic and Hospital Emergency Personnel in South-east Iran.” World J Emerg Med World Journal of Emergency Medicine 4.1 (2013): 26. Web. 7. Laposa, J.M., and L.E. Alden. “Posttraumatic Stress Disorder in the Emergency Room: Exploration of a Cognitive Model.” Behaviour Research and Therapy 41.1 (2003): 49-65. Web. 8. Sherin, Jonathan E., and Charles B. Nemeroff. “Post-traumatic Stress Disorder: The Neurobiological Impact of Psychological Trauma.” Dialogues in Clinical Neuroscience 13.3 (2011): 263-78. Web. 9. Delaney, Eileen. “The Relationship between Traumatic Stress, PTSD and Cortisol.” Naval Center for Combat & Operational Stress Control (n.d.): n. pag. Web. 10. Shin, L. M. “Amygdala, Medial Prefrontal Cortex, and Hippocampal Function in PTSD.” Annals of the New York Academy of Sciences 1071.1 (2006): 67-79. Web. 11. “The Amazing Way This Hospital Is Fighting Physician Burnout.” The Huffington Post, 2 Dec. 2013. Web. 12. “The Code Green Campaign.” The Code Green Campaign, n.d. Web. 13. “VA Research on Posttraumatic Stress Disorder (PTSD).” Office of Research and Development. U.S. Department of Veteran Affairs, n.d. Web. 20 Oct. 2016.

The Prevalence of Mental Illness on Campus

1. Mortier P, Demyttenaere K, Auerbach R P, Cuijpers P, Green J G, Kiekens G, Kessler R C, Nock M K, Zaslovsky A M, Bruffaerts R. First Onset of Suicidal Thoughts and Behaviors in College. Journal of Affective Disorders, October 2016; 291-299.

References • Volume 8 • 21

REFERENCES

2. Hedden, S. L., Kennet, J., Lipari, R., Medley, G., & Tice, P. (2015). Behavioral Health Trends in the United States. Retrieved November 30, 2016, from https://www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-ami-among-us-adults.shtml 3. The State of Mental Health on College Campuses: A Growing Crisis. (2011). Retrieved November 30, 2016, from http://www.apa. org/about/gr/education/news/2011/college-campuses.aspx 4. Raghavan, R. (2014). Improving the Identification of Mental Health Need on College Campuses. Journal of Adolescent Health, 55(5), 598-599. doi:10.1016/j.jadohealth.2014.08.007

Speak and Be Heard: Language in Medicine

1. Zong, J., & Batalova, J. (2015, July 8). The Limited English Proficient Population in the United ... Retrieved October 23, 2016, from http://www.migrationpolicy.org/article/limited-english-proficient-population-united-states/ 2. Flores, G. (2006). Language barriers to health care in the United States. New England Journal of Medicine, 355(3), 229-231. 3. Chen, M.D., P. W. (2009, April 23). When the Patient Gets Lost in Translation. Retrieved October 23, 2016, from http://www. nytimes.com/2009/04/23/health/23chen.html 4. Quan, JD MPH, K., & Lynch, MPH, J. (2010). The High Costs of Language Barriers in Medical Malpractice. Retrieved October 23, 2016, from http://www.pacificinterpreters.com/docs/resources/high-costs-of-language-barriers-in-malpractice_nhelp.pdf 5. McCabe, K. (2012, June 27). Foreign-Born Health Care Workers in the United States ... Retrieved October 23, 2016, from http:// www.migrationpolicy.org/article/foreign-born-health-care-workers-united-states/ 6. Jacobs, E. A., Shepard, D. S., Suaya, J. A., & Stone, E.-L. (2004). Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services.American Journal of Public Health, 94(5), 866–869. 7. Hoffman, A. (2015, September 28). Millions of Americans Are Getting Lost in Translation ... Retrieved October 23, 2016, from http://www.smithsonianmag.com/innovation/millions-americans-are-getting-lost-translation-during-hospital-visits-180956760/

Medicine in the Performing Arts

1. Routen, Barbara. (2015, February 18). Conference to focus on performing arts medicine. Retrieved October 12, 2016, from http:// www.tbo.com/brandon/conference-to-focus-on-performing-arts-medicine-20150218/ 2. Kates, Joan Giangrasse. (2014, June 12). Dr. Alice Brandfonbrener, 1931-2014. Retrieved October 12, 2016, from http://articles. chicagotribune.com/2014-06-12/news/ct-alice-brandfonbrener-obituary-met-20140612_1_chicago-theatre-performing-artistswinnetka 3. British Association for Performing Arts Medicine. (2015, June). Annual Review 2015. Retrieved October 12, 2016, from http:// bapam.org.uk/news/wp-content/uploads/2016/07/BAPAM-Annual-Review-2015.pdf 4. Local Legends. Alice Brandfonbrener, M.D. Biography. Retrieved October 12, 2016 from https://www.nlm.nih.gov/locallegends/ Biographies/Brandfonbrener_Alice.html 5. Healthy Performers. Performing Arts Medicine. Retrieved on October 12, 2016, from http://www.healthyperformers.com/ performing-arts-medicine/ 6. University College London. Performing Arts Medicine Msc. Retrieved on October 22, 2016 from https://www.ucl.ac.uk/surgery/ courses/msc-performing-arts-medicine 7. Shenandoah University. Performing Arts Medicine Certificate. Retrieved on October 22, 2016 from https://www.su.edu/athletictraining/athletic-training-programs/performing-arts-medicine-certificate/

Tips for Staying Healthy: Don’t Neglect Your Exercise!

1. Bratman, G. N., Hamilton, J. P., Hahn, K. S., Daily, G. C., & Gross, J. J. (2015, May 29). Nature experience reduces rumination and subgenual prefrontal cortex activation. Proceedings of the National Academy of Sciences, 112(28), 8567-8572. doi:10.1073/ pnas.1510459112 2. Baron, K. G., Reid, K. J., & Zee, P. C. (2013). Exercise to Improve Sleep in Insomnia: Exploration of the Bidirectional Effects. Journal of Clinical Sleep Medicine. doi:10.5664/jcsm.2930 3. Ross, J. (2004) The Mood Cure: The 4-step Program to Take Charge of Your Emotions-Today. New York, New York: Penguin. 4. Myllymäki, T., Kyröläinen, H., Savolainen, K., Hokka, L., Jakonen, R., Juuti, T., . . . Rusko, H. (2011). Effects of vigorous late-night exercise on sleep quality and cardiac autonomic activity. Journal of Sleep Research, 20(1pt2), 146-153. doi:10.1111/j.13652869.2010.00874.x 5,6. Mccully, K. K. (2009). The Influence of Passive Stretch on Muscle Oxygen Saturation. Advances in Experimental Medicine and Biology Oxygen Transport to Tissue XXXI, 317-322. doi:10.1007/978-1-4419-1241-1_45

22 • The Medical Decoder • Winter 2017

REFERENCES

Concussions: Impacts Beyond the Initial Blow

1. ”Concussion: MedlinePlus.” Concussion: MedlinePlus. US National Library of Medicine, 8 Feb. 2016. Web. 23 Oct. 2016. 2. ”Injury Prevention and Control: Traumatic Brain Injury and Concussion.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 22 Jan. 2016. Web. 23 Oct. 2016. 3. Staff, By Mayo Clinic. “Post-concussion Syndrome.” - Mayo Clinic. Mayo Foundation for Medical Education and Research, 19 Aug. 2014. Web. 23 Oct. 2016. 4. Iadevaia, C. “Qualitative Examination of Adolescent Health-Related Quality of Life at 1 Year Postconcussion.” National Center for Biotechnology Information. U.S. National Library of Medicine, Nov. 2015. Web. 23 Oct. 2016. 5. Stein, CJ. “Young Athletes’ Concerns About Sport-Related Concussion: The Patient’s Perspective.” National Center for Biotechnology Information. U.S. National Library of Medicine, Sept. 2016. Web. 23 Oct. 2016. 6. Ransom, Danielle M. “Academic Effects of Concussion in Children and Adolescents.” Pediatrics 135.6 (2015): n. pag. American Academy of Pediatrics, 11 May 2015. Web. 23 Oct. 2016. 7. Halstead, ME. “Returning to Learning following a Concussion.” National Center for Biotechnology Information. U.S. National Library of Medicine, Nov. 2013. Web. 23 Oct. 2016.

References • Volume 8 • 23

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