THE CELL issue 0002 THE WORLD FORGOTTON In the second issue of the cell, we explore everywhere from fetal medicine to oncology
What's Inside? 1-3 This issue's interview with Jasmin Gill and Maria Touma 4 Winnie the pooh and psychological health how the children's cartoon explores disorders 5-7 The treatment of Leukemia discussing the progress of treatment over time 8 how cancer forms a comic on the science behind tumour formation 9-11 In-utero cleft repair The developing medicine 13-14 The cost of cancer beyond disease 16-17 Art Showcase 19-22 Behind oncology a look into the field
Written by Simran Gill
Jasmin applied for a lot of work experiences by going to doctors she knew and shadowing personal contacts such as General Practitioners in Dubai. I was amazed to hear about all the stories Jasmin had about patients because she learned so much through those experiences. She said it is really important that you reflect actively on what you learn in work experience because interviews for medical schools usually want detailed responses on your work experience by knowing specific examples that relate to the values in Medicine.
Advice from Jasmin Gill, a Repton Graduate and Bio-Medical student in Newcastle University AND Maria Touma, a Repton Graduate and now a Medical student at St. Andrews University:
What was the greatest challenge you faced when applying for Medicine? According to Jasmin, gaining work experience was the hardest challenge for her as it was really hard to secure during the pandemic as every place rejected her admission. Therefore, she advises that you try to do work experience in advance as it can help you see if you like Medicine and looks great on your university application because it shows you are committed and caring. She also said that doing medical admissions tests such as the UCAT, before you need to start applying is really useful to gauge how hard it is and if you have chosen to do the UCAT make sure to practice a lot as you will be fine if you are able to pass many past papers!
Do you have any stories from work experience? And how did you get those opportunities?
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According to Maria, she was sure all students that applied to medicine agree that there was a lot to prepare in a short time and it can get quite stressful alongside schoolwork and deadlines piling up. She personally thought the preparation for her UCAT exam and the actual examination was the greatest challenge when applying for medical schools The timing of the exam at the end of September just before mocks was not ideal and required a lot of preparation beforehand during the summer. Trying to balance the necessary practice for the UCAT and revision for the mocks was quite difficult especially with Maria stressing about upcoming mocks and predicted grades!
Maria found attaining work experience in the middle of the COVID pandemic a great struggle but fortunately she was able to contact a family friend that had a paediatric clinic and shadowed him for 2 weeks over the summer. Every day they saw new patients ranging from newborn babies with worried first time parents to older teenagers and the doctor explained everything he did during the consultation. During the breaks between patients, he discussed the medical field and answered all the questions Maria had, really stressing the importance of observational skills specially in paediatrics One occasion stands out when looking back and it really highlighted how much knowledge and experience doctors need to have. A baby was supposed to get a regular booster shot but the doctor noticed a slightly irregular head shape and asked the mother to get the child imaged and later found out the child’s skull was fused together which is a problem with a developing brain that needed space to grow. This was corrected almost immediately as a result of his initial observation which Maria found to be incredible.
Jasmin is not training to be a doctor so she cannot say what Medicine is really like however, as she is in her last year of university, she knows that the Biomedicine workload is really demanding therefore, she believes medicine would possibly be even more demanding. One key point of advice she offered was that you need to be aware that a work life balance is difficult to achieve in medicine because it is not always possible to have a free social life depending on your job. General Practitioners may have more flexibility in their schedules compared to an A&E consultant for example and know that being a doctor is a job in high demand Furthermore, you should always have a back up plan in case the first time you apply does not work out.
In Jasmin’s opinion, all three topics each have a brief history which is important to research and it is very important to know current issues in the field if you would like to specialize in these fields For example: cancer research for oncology particularly the history of Henrietta Lacks (whose cells would not stop dividing but the ethical limitations of that research) or novel cell lines from Leukemia! You should also have an awareness of all sorts of health care professionals as you will work on a multidisciplinary team when you are a doctor
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Do you have any advice you would like to give to future medical students especially about the realities of medicine?
For this issue, we have focused on foetal medicine, oncology and psychological problems, do you have anything you would like to say about these topics and fields?
Maria wants to stress the importance of a supportive and understanding network that balances the demands of work while still enjoying your time experiencing all the new things and events happening around you. It can be difficult entering an environment where everyone has that same strive to achieve the best but again, finding those right people and working through it together really helps because she realised everyone is just as anxious as you. Maria also like to keep a little token during applications and now at university, whether it be a picture or a small object that reminds her of the reason she wanted to study medicine in the first place and put it somewhere in the back of her shelf so every time it gets a little overwhelming she can take it out and am reminded of her goals when she started, she found it helped focus and remotivate herself.
When I asked Jasmin to further elaborate on something particular for each of the topics we are studying, she really fulfilled what was asked of her. In fetal medicine, she talked about the controversy of abortion including the difficulty a doctor may have as they are not supposed to let personal beliefs influence their decisions however, they still have a right to reject a patient if they feel another doctor could provide better care. Furthermore, Jasmin even mentioned eugenics, forced sterilization and abortion laws for instance considering Margaret Sanger who developed birth control but used to focus testing on minority women
Maria believed that the topics for this issue sounded really interesting, especially foetal medicine now that she has been able to learn more about it. The advancements made just in recent years are incredible with procedures that identify diseases and abnormalities when a foetus is just a couple weeks old that showcases the rapid speed of innovations needed in medicine This is exemplified with the detection and treatment of mitochondrial genetic defects This only affects a very small proportion of foetuses but doctors have the ability to take a fertilised egg that contains the defective mitochondria and remove the parental nuclear material and place it in a donor egg with a removed nucleus that contains healthy mitochondria and allows a healthy foetus to grow which would have been a challenge a few years ago 3
I loved Jasmin’s response when questioned on Psychological Problems as she really understood how troublesome Stigma is in society particularly against autistic, depressed or anxious people As she has recently looked into Dementia in depth, I was really interested to learn from her Did you know that the word Dementia translates to ‘out of one’s mind’ from Latin? Dementia affects cognitive functioning such as your memory, conscious thoughts and reasoning skills Vascular dementia is caused by an issue in the blood supply to a certain area of the brain which can be caused from a stroke. Frontal temporal lobe dementia affects these areas of the brain and is underdiagnosed in Asia and Africa. Alzheimer’s is a form of dementia particularly caused by amyloid beta proteins which leaves plaques on the brain and Parkinson’s disease involves leally bodies if you would like to research that too as there is a lot to know about dementia!
Jasmin also talked about social care needed to treat mental health issues because in the past medical policies such as Bevan’s first policy for the NHS focused on physical health therefore, if you had a psychological issue, you were expected to just deal with it yourself However, now mental health is becoming, and the NHS is improving their support for this which is amazing!
Written by Simran Gill
5 Treatment by bone marrow transplant showed a remission rate of 15%.
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The patient died shortly after in 1827, yet the term leukemia was not coined until 1845 by Virchow. 3 During this period, leukemia was known as a fatal disease, and while treatments did focus on easing some of the symptoms of leukemia, no one had hope in curing it.
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Throughout the 1900’s, there have been developments in infection control, tissue typing, chemotherapy, transfusion and immunosuppression protocols; all of which contributes to the slow but steady increase in the survival rate of leukemia Due to the extreme and relentless nature of the disease, however, it must be acknowledged that despite these advancements, the impacts of leukemia are in many ways debilitating. Unlike other diseases, patients treated for cancer may experience “late effects” side effects that appear years after the leukemia has been treated. 7 While these effects are not always subsequent to leukemia, patients in which late effects do occur are affected psychologically, financially, and may find themselves thrown in an entire new way of living to accommodate these pressing health conditions
Leukemia, in short, is a cancer of the blood, yet the term encompasses cancers affecting the lymphatic system and bone marrow
The first case of leukemia was documented prior to the birth of the term “leukemia” itself: a patient presenting with swellings of the abdomen, spleen, and liver, and most notably “blood like gruel.”
A patient’s T cells are altered so that they kill cancer cells
A type of radiation treatment
More contemporary research, such as the works of Sidney Farber, report children given a folic acid inhibitor (aminopterin) showed improvement, stating that this treatment “provides real hope in this now hopeless disease ”
Myelodysplastic syndrome
Written by Reem Shami
A discussion on the developments in the practice of treating leukemia
Transfusion Blood is replaced in a patient who has lost or does not have what they need HLA type
Individual variations which differ between immune systems
Immunosuppression
Almost 3% of all cancer cases globally are some forms of leukemia around 300,000 cases diagnosed each year 1 Despite the first case of leukemia diagnosed over 100 years ago, treatment of the disease has been persistent in its notoriously high mortality rate.
Proliferate Cell division CAR T cell therapy
The weakening of the immune system sometimes done on purpose so that a patient does not reject treatment
A cancer of the blood in which a person does not have enough healthy blood cells
Early treatment of leukemia consisted of radiation, thorium X and (not uncommon for the time) arsenic Despite it’s reputation, arsenic has been found to have an effect on certain types of leukemia; research shows that 8 out of 11 patients achieved clinical remission when treated with arsenic.
Remission Cancer, with it’s signs and symptoms, decreases Thorium X
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Shifting now to the 21st century, change has both been minimal and substantial. Radiation is still being used, primarily to destroy leukemia cells but also to relieve discomfort caused by swelling Radiation is also given to patients preparing to undergo stem cell transplant. Chemotherapy, probably the most well known treatment, is actually the primary treatment for most leukemias A variation of this treatment, “targeted therapy” specifically attacks leukemia cells, reducing the damage done to non leukemia cells. 9
The treatment of cancer is quite harsh in itself, but what is often overlooked is that the acute side effects resultant from radiation or chemotherapy are not the only risks. Patients treated with radiation and chemotherapy are at risk of developing melanomas, myelodysplastic syndrome, cardiac and long term gastro intestinal problems too 8
6 T cell
In future, there is hope that stem cell therapy can be used as a common treatment for most leukemias. Stem cell transplants fall in two types: autologous and allogenic. Autologous is a transplant that involves the use of stem cells from the patient’s own body, whereas allogenic stem cells are taken from a donor who matches the patient’s specific blood profile. The physics of stem cells could potentially be manipulated to directly alter a specific component of blood, which would increase its effectiveness 1 0 The ability to proliferate is an important characteristic of stem cells, eventually perhaps this trait could be manipulated to maximize proliferation; of course, this would have to be within bounds, as leukemia is hardly a treatment for leukemia.
What also needs to change is the accessibility of treatment. In the US alone the monthly cost of lifesaving chemotherapy can reach up to $12,000.1 1 This is arguably counterintuitive, as the stress of affording healthcare may limit the extent to which the quality of life for the patient improves with treatment research has found a profound link between stress and tumor growth.1 2 Obviously, leukemia does not discriminate and affects the impoverished as much as it does those who can afford to treat it. So, as the treatment of leukemia continues to advance, society needs to ensure that profit does not hinder the of saving lives. Metastatic Melanoma Cells 1 https://www medscape com/answers/1201870 175991/what is the global prevalence of leukemias accessed 21 11 2021 2 (Gunz FW Leukemia in the past In: Henderson ES, Lister TA (eds) Leukemia WB Saunders Company: Philadelphia 1990 3 11 3 https://www leukaemia org au/blood cancer information/the blood cancer journey/not in active treatment/life after treatment/ 4 (Niu C, Yan H, Yu T, Sun HP, Liu JX, Li XS, Wu W, Zhang FQ, Chen Y, Zhou L, Li JM, Zeng XY, Yang RR, Yuan MM, Ren MY, Gu FY, Cao Q, Gu BW, Su XY, Chen GQ, Xiong SM, Zhang T, Waxman S, Wang ZY, Chen SJ Studies on treatment of acute promyelocytic leukemia with arsenic trioxide: remission induction, follow up, and molecular monitoring in 11 newly diagnosed and 47 relapsed acute promyelocytic leukemia patients Blood 1999 94: 3315 3324 5 Farber S, Diamond LK, Mercer RD, Sylvester RF Jr, Wolff JA Temporary remissions in acute leukemia in children produced by folic acid antagonist, 4 aminopteroyl glutamic acid (aminopterin) New Engl J Med 1948 238: 787 793 6. Thomas ED, Buckner CD, Banaji M, Clift RA, Fefer A, Flournoy N, Goodell BW, Hickman RO, Lerner KG, Neiman PE, Sale GE, Sanders JE, Singer J, Stevens M, Storb R, Weiden PL One hundred patients with acute leukemia treated by chemotherapy, total body irradiation, and allogeneic marrow transplantation Blood 1977 49: 511 5 7. https://www.leukaemia.org.au/blood cancer information/the blood cancer journey/not in active treatment/life after treatment/ accessed 27.11.2021 8 https://www leukaemia org au/blood cancer information/the blood cancer journey/not in active treatment/life after treatment/ accessed 27 11 2021 9 https://www cancercenter com/cancer types/leukemia/treatments accessed 21 11 2021 10 Gossen M, Freundlieb S, Bender G, Müller G, Hillen W, Bujard H Transcriptional activation by tetracyclines in mammalian cells Science 1995 268: 1766 1769 11 https://www asbestos com/featured stories/high cost of cancer treatment/#: :text=Depending%20on%20the%20drug%20and,beyond%20the%20average%20annual%20income Accessed 27 11 2021 12 Sklar, L S , & Anisman, H (1981) Stress and cancer Psychological Bulletin, 89(3), 369 406 https://doi org/10 1037/0033 2909 89 3 369 7
Written by Mariam Alogaily 8
Treatments &
In the past and indeed in today’s world, children with cleft lips or palettes would have to undergo repair surgeries within the first year after birth and then follow up surgeries to compensate for the complications that may occur, this is one of the reasons why an in utero approach appeals to many plastic surgeons having a scarless repair may prevent further deformities, such as dentoalveolar defects
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advancements 9
Written by Reem Shami
Despite the continuously advancing field of embryology, there is no clear cause as to how clefts actually form Yet there are obvious risk factors, such as smoking, which increase the likelihood of abnormal fetal development holistically. New research does indicate that there is a genetic link to the development of clefts, such as research by Dixon et al 2011 and Marazita 2012.
In Utero C l e f t R e p a i r S u r g e r y
From all known birth deformities, cleft lips and palettes are arguably the most common of them, with 175,200 children being born with them each year. 1 But what is a “cleft” to begin with? It is exactly as it sounds: an opening in the upper lip or roof of the mouth, they can extend all the way to the nose and may appear in any region of this area In short, they occur because the face does not fuse completely during early development a cleft can be seen on ultrasound as early as 13 weeks. 2
However, When it comes to cleft lips and palettes, only fetuses at a high risk of morbidity when it comes to post partum surgery are selected, as it is still a developing field 4
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doctors preforming in utero surgery for spina bifida, another example of abnormal embryonic development baby with microform cleft lip baby with complete cleft lip and gum known as "alveolus" What are clefts?
Traditionally, clefts are repaired after birth because there was no other way to treat it. However, there is a whole new area of medicine emerging fast in utero repair surgery (in other words, attempting to suture the face in the womb so after birth, there is no visible defect )
for
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free article] [PubMed] [Google Scholar] 4 Lorenz,
http://embryo asu edu/handle/10776/11469 7 Kersten, Jillian R , "Jeffrey Weinzweig's Experiments on In Utero Cleft Palate Repair in Goats (1999 2002)" Embryo Project Encyclopedia (2017 04 07) ISSN: 1940 5030 http://embryo asu edu/handle/10776/11469 8 Hallock GG In utero cleft lip repair in A/J mice Plast Reconstr Surg 1985 Jun;75(6):785 90 doi: 10 1097/00006534 198506000 00001 PMID: 4001196 8 https://www mayoclinic org/diseases conditions/cleft palate/symptoms causes/syc 20370985#: :text=Babies%20with%20cleft%20palate%20are,Speech%20difficulties Accessed 19 11 2021 In utero repair: 10
2021 2 https://www
T MD In Utero
accessed 19 11 2021 3 Dixon
While it may seem trivial, proper muscle function in this region is actually very consequential If muscles here do not work adequately, it can result in improper vocalization, and the inability to swallow 7 Research on mice has also found the same effect, no evidence of scar formation whatsoever. 8 While clefts are not fatal, they may be accompanied by a host of other problems A baby with a cleft may have a higher likelihood of developing glue ear, for example, 9 or even hearing loss. Furthermore, there may be issues with mother baby bonding after birth as a result Surgery post partum can fix most of these issues, but as the field of medicine develops, ways of improving current surgical practices are becoming more researched. Arguably, in utero cleft repair surgery may become mainstream 1 https://operationsmile ca/our cause/ accessed 11 mayoclinic org/diseases conditions/cleft palate/doctors departments/ddc 20370992 MJ, Marazita ML, Beaty TH, Murray JC Cleft lip and palate: understanding genetic and environmental influences Nat Rev Genet 2011;12(3):167 178 [PMC H Peter MD; Longaker, Michael T MD In Utero Surgery for Cleft Lip/Palate: Minimizing the “Ripple Effect” of Scarring, Journal of Craniofacial Surgery: July 2003 Michael Surgery Cleft Lip/Palate: Minimizing the “Ripple Effect” of Scarring, Journal of Craniofacial Utero Cleft Palate Repair in Goats (1999 2002)" Embryo Project Encyclopedia (2017 04 07) ISSN: 1940 5030
Surgery: July 2003 Volume 14 Issue 4 p 504 511 6 Kersten, Jillian R , "Jeffrey Weinzweig's Experiments on In
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There is a window of time during gestation in which Dr. Jeffrey Weinzweig believes fetal tissue can be operated on without risk of even minor scarring. During this window, the fetus can be operated upon; Weinzweig took the open fetal surgery approach when conducting his research approach, completely exposing the fetus goats head, and preforming the operation. He found that post partum there was not even microscopic scarring, and bar a slight indentation to where the cleft would have been, there was no indication the cleft existed at all Moreover, the goats with repaired clefts could feed without problem, and the muscles in the palette were in completely normal function
Volume 14 Issue 4 p 504 511 5 Lorenz, H Peter MD; Longaker,
m o d e l s o f e m b r y o s a t G e o r gA u g u s tU n i v e r s i t ä t G ö t t i n g e n 3
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The cost of cancer
With over 200 forms of cancer, there is not a box standard payment plan for cancer patients Multiple factors influence the degree of the costs for each person and include some of the following:
Treatment Setting: Depending on whether care is delivered in a hospital, clinic or physician’s office, patients may have to pay a different fee. Sometimes, the patient may get the choice on where to receive treatment but other times there may only be one suitable place.
Coverage: For patients with insurance, the kind of health insurance the patient has is one of the most important factors in determining the ultimate costs Whereas if a patient has no insurance they are responsible for all of the costs
Written by Jamila Mohamudbucus
Cancer, in all its twisted shapes and forms, is among the largest killers of the human species. It places not just a physical and mental strain on one’s body and mind but a huge financial burden that makes it just that much harder to beat the disease. Sometimes, costs keep people from completing cancer treatment. In 2018, cancer patients in the U S had to pay $5.6 billion for cancer treatments out of their own incomes
Treatment Plans: This encompasses the type of treatment as well as thequantity of it The stage at which the cancer is detected in the body as well as the type of it heavily effects this portion of the costs as well as it may dictate the amount of chemotherapy a person may have to endure.
Insurance Status/Type of Insurance
There are traditionally three primary approaches to treating cancer surgery, radiation and pharmacological therapy and patients may require a combination of these or just one for their treatment. The costs of these three methods vary depending on the type and extent of the treatment:
Location: Expenses differ depending on where the patient lives and the availability of their given treatment. In the USA, the average monthly cost of chemo drugs can range from $1,000 to $12,000.
Most patients who receive radiation treatments do so at a hospital or cancer treatment facility.
Radiation: Radiation therapy uses waves or high energy particles to destroy or damage cancer cells
Surgery: Surgery can be used to remove tumours, diagnose cancer and/or to find out how far a cancer has spread Many people who have cancer have surgery at least once as part of their treatment
The indirect costs when tackling cancer also add to a person’s expenses. These may not be as obvious but by their nature, they are hard to calculate and track The accumulation of the following further add to the financial toxicity of cancer:
Radiation treatment requires complex equipment and a team of health care providers Treatment protocols vary, but some cancer patients receive radiation daily or several times a week for many weeks, which contributes to relatively high patient costs
Lost wages or income: Some cancer patients must stop working temporarily or permanently, or reduce their work schedules
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In conclusion, cancer costs cannot be predetermined and do change vastly from person to person The nature of cancer is that it is impossible to calculate what treatment and the extra costs that come alongside it will be which makes it hard for cancer patients to pay the high costs.
Caregiving costs: Children may need looking after and at home help may be necessary in some cases
Many people are forced to skip treatment due to their financial difficulties highlighting the inaccessibility of good health care for people. Does wanting to live warrant having to pay such a great cost? It is imperative to mention also that costs fluctuate to each person and disadvantage some groups more than other The disparity in costs are seen here:
Pharmacological Therapy: Medication is a very common part of cancer treatment. This can include chemotherapy, targeted therapy, immunotherapy, hormone therapy and supportive care like pain or anti nausea medication. Some of these drugs can be taken as pills obtained at a pharmacy and some are administered in a doctor’s office, clinic or hospital.
Transportation: If a suitable place to receive treatment is not nearby, patients may be forced to travel long distances on a regular basis
Art by Louis de Decker 16
Art by Louis de Decker 17
There are three specific specialities in oncology which are medical, clinical and surgical. A medical oncologist uses medication for instance immunotherapy which involves biological medication and drugs to overcome the cancer by boosting the body’s immune response. This can involve vaccines, monoclonal antibodies (proteins that specifically target cancer cells and are made using genetic modification) and T cell transfer therapy which is a type of white blood cell developed from stem cells taken from bone marrow that can be grown in large batches to strongly attack the tumour However, some patients may not respond to medication therefore, other approaches need to be made.
To be an oncologist, there are a lot of responsibilities that need to be upheld They diagnose cancer in their patients and talk to them and their families about how their cancer can be treated. They must provide counselling for the patients and their families before trying their treatments and after since, they are likely to use various types of therapy depending on the severity of the cancer and what the oncologist specialises in. Oncologists work long hours and are expected to be on call with a schedule that is always changing They work in consulting rooms, theatres and special units therefore, they are always in direct contact to their patients when overseeing their treatment
Written by Simran Gill
Behind Oncology
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There are also surgical oncologists who specialise in removing the cancerous tissue from the body They preform surgical operations on patients but also diagnose cancers with different biopsies. A biopsy refers to the removal of a small sample of tissue from the tumour to examine under a microscope. They can use an image guided biopsy for instance by using Ultrasounds or Magnetic Resonance Imagery (MRI) scans to track treatment and the size of the tumour. As well as fine needle aspiration biopsy to collect the small sample or even a liquid biopsy where a small blood sample is taken to identify the cancer. Whilst, many other medical fields include branches, oncology does not have any sub specialties. Instead, oncologists have ‘site specialties’ that increase their expertise and knowledge to a particular type of cancer such as breast cancer. Additionally, some oncologists specialise in a particular area of cancer care such as geriatric oncologists who specialise in working with patients above the age of 65 due to additional challenges faced and paediatric oncologists who work with children or teens! Lastly, there is also palliative care in oncology which focuses on improving the patient’s quality of life by making them more comfortable instead of curing the illness itself because the cancer is too severe or terminal.
A clinical oncologist creates treatments that involve a mixture of chemotherapy and radiation in radiotherapy
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Chemotherapy is often heard by the general public because this treatment has overcome many different types of cancers such as leukaemia (mutation in bone marrow stem cells where too many white blood cells are made) and Hodgkin disease (cancer in the lymphocytes of the white blood cell that help fight against infection) Chemo is the use of cytotoxic drugs that kill tumours and is a very versatile tool because mutated cells usually do not recover from the effects of chemotherapy whereas, healthy cells in the body which are also damaged by chemo can regenerate better Radiation therapy for example by using high range x rays may also be used in combination with surgery and chemotherapy to destroy smaller tumours and reduce the size of the cancer however, chemotherapy with radiation still may not be the best treatment for everyone.
Qualifications: In the UK, you must have: a five year medical degree completed the two year NHS UK foundation Programme at least two years of speciality training knowledge about research in related areas to oncology
“When you have exhausted all possibilities, remember this: You haven’t” Thomas Edison Cancer can affect everyone, and it does in our daily lives You may know someone who had cancer or has cancer and is still fighting today for their lives. When you meet someone who has cancer ensure there is no stigma instead encourage and support them through their difficult times. Currently there are more than 200 types of cancer. If you were an oncologist, you would be able to improve the lives of patients with Cancer and help them during the difficult moments of their treatment You could help contribute to Cancer research so one day, humanity would be able to find a cure for cancer and you could help families and patients deal with their struggle and in some cases, their loss You would be able to make a difference so start now, by raising awareness and even donating to Cancer research programmes!
“When you come to the end of your rope, tie a knot and hang on” Franklin D. Roosevelt
Skills: able to make difficult decisions stay calm focus under pressure communicate lead and manage a team
“Nothing is impossible, the word itself says, ‘I’m possible!’” Audrey Hepburn
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