Now we'll shift our gears and talk about the overall things that the clinicians and to some extent the radiologists are also supposed to be aware of. These will be what is the presentation of tumors and what are the causes of tumors, what are the predisposing factors of tumors, how we approach tumors, how we treat them and what are the outcomes of the treatment and what we are supposed to look at it. So these are the things that overall, as such it is an idiomatic thing, but these are the things that are associated with increased risk of brain tumors that will be exposure to wine and fluoride, eepstein bar wires and these are the syndromes like NF1, tuberous sclerosis and just think I don't even know how to pronounce it and Tucker syndrome and they bought basal cell carcinoma syndrome. So these are the syndromes that will predispose those patients will have a higher incidence of tumors. They have these genetic changes you would think of all the white matter changes to be less or likely high hematomas and more likely to be predisposing higher incidence of tumors and that. So how did they present the mainly the presentation what typical I have seen of the patients they generally come in with the chronic headache, visual changes or seizure the first presentation of seizure they come to the emergency room and then we find out that there's underlying brain disease on MR it turns out to be brain tumor. But the presentation will be to a great extent dependent on where the tumor is located. So if it is in the frontal lobe they will kind of present with the frontal lobe syndrome. If it is close to the Sylvian Fisher it will present with speech changes if it is in the occipital lobe it will present visual changes if it is in the parietal region frontal parietal adjacent the motor cortex he'll have sensory or motor abnormalities. So these depend if it is in the brainstem it will present with brainstem symptoms posterior for certain to be presenting sooner than later the supertentorial tends to present with seizures infratentorial does not tend to present with seizure. So those are the things depending on what kind of tumor how aggressive it is and what is the location of it and by the time it is presenting what is the size of it and how much of mass affected it is causing those are the things that decided its presentation. But by far we talked about the location having those typical symptoms and presentation they present with headache nausea vomiting and vision speech hearing changes or seizures. These are the most common presentations that the tumor will present with. Next what do we do with these how do we diagnose them so the basic thing for W.H. classification would be the histology of the electron or light microscopy that would be the first step of classifying that and after that for the nomenclature. The second step would be to do immunohistochemistry cytogenic and genetic analysis and name that as the second part of the tumor name. So we talked about putting in the IDH mutant or not mutant we talked about TRT we talked about real status we talked about P53 status we talked about MGMT status we talked about co-deletion. So those are the nomenclatures that you will add to it that will you'll get by genetic and genetic analysis and immunohistochemistry. So these are the tests that you will be doing in the brain tissue. So what are the factors that affect the overall prognosis of the tumor. Most important thing is where is the tumor located and what is its aggressiveness. So if the tumor is situated in a very, very important or eloquently or say brainstem. It is almost that the patient cannot be treated because of that either the treatment will be more harmful than the cure the patient will die or have a major motor deficit or some major function deficit. So it is it is very poor prognosis. The other thing is the grade of the tumor the grade one is very good in response the grade four is very poor response. Then we talked about all the chromosomal markers the IDH mutant is a good response the co-deleted is a good response the P53 increased expression is a good response. The TRT is a poor response ATRX is a good response. So we talked about those the genetic markers they will be decided. Then after that what how much of tumor is left after surgery if you could do surgery if it was an eloquent area and we could only do debulking the tumor is still there it will immediately recur so that will be a poor prognosis. So all these things these are characteristics of the brain tumor that decide. But on top of that if the patient has a very good tumor say in the frontal lobe or low grade WHO one IDH mutant co-deleted oligodendroglioma in the frontal lobe but the patient's health is miserable. He has immuno compromised status he has asthma he has diabetes he has cardiac disease he has all possible illness he has intestinal resection he had Crohn's disease ulcerative colitis and whatever the patients overall general health is poor. It is almost as if he has got a death sentence you cannot treat in that patient. You cannot give him chemotherapy you cannot give him radiation therapy you cannot do he cannot undergo surgery his physical status. So this this is one important thing that we tend to overlook that all of the things may be favorable as far as the tumor is concerned but as general health is poor then then the outcomes may be poor. Next we move on to the staging system for thank God by love of God we don't have a staging system in brain tumors otherwise that would be another thing that we would have to know. So by far there is no clear staging system it is just the WHO staging system and most of the time in my 15 years of practice I have only seen one tumor like a GBM going out of the brain and going into the bone which was a very very unusual tumor. Otherwise by far they're localized into the CNS system. The most they can do is tumors like medial blastomas and epinepumas corot pexus papillary carcinomas they can do is metastatize it on the neural axis but they tend to stay within the CNS. So that is by far the classification of the staging that is all we have to cover we really don't have to do a general body pex scan or look for metastasis here and there from brain tumors. Then what are the factors that we take into account to treat tumors again it is we talked about that the histology one through four classification that is the thing that is deciding how the outcome is how the treatment will be based the second is genotype of the cell. So the main WHO classification the first histology the second is being the genetic code of that tumor. Those are the two main things that decide how the treatment will be based how the outcomes will be how we will treat it after surgery and treatment how the tumor will respond. And the other things that decide is where the tumor is located in the brain how much close it is to eloquent area and how much of the cancer is left after surgery. So those are the things that also matter how the outcome was treatment. So what do we use for treatment one is surgery second is radiation therapy that can be focal radiation therapy like radio surgery or IMRT or it can be a total brain radiation if the tumor is spread over a very large area. Then we have chemotherapy then we have immunomodulation immunotherapy targeted therapy those are the things that we use. So we will just briefly go through that surgery again as any surgery anywhere you see something abnormal you take it out if you cannot take it out stick it somewhere close by. That is the principle that has been for surgery whether it is abdominal chest or brain surgery that is the same concept. The only thing in the brain tumor you have to be careful of is you have to make sure that you are not affecting the eloquent areas of the brain. Important areas important white matter tracks these are not affected and you do few tests of that to make sure that these parts are not affected and I will just go through briefly by the end of this lecture for that. The other things that we talk about is the chemotherapy. So there are different chemotherapy agents there are kindness inhibitors which stop cancer cells from reproducing and decreases their blood supply.  So the evastin being the one that is most common but this is associated with a false sense of safety. But this is one of the most commonly used drugs also at the same time. Then you have alkylating agents which adds methyl groups and stops the DNA from replicating and cells from replicating. Then you can have temzolamide which is DNA replication inhibitor and then you can use combination of that which the most common being PCV or procarbazine hydrochloride lomastin. These are bunch of alkylating agents basically adding methyl groups and preventing DNA replication and therefore preventing the tumor genesis of that or decreasing the growth of the tumor. So these in combinations are separately but by far the names that you will hear most would be evastin, temzolamide, lomastin and procarbazine. These are the names that you will most frequently hear from the oncologist and the way they act is we talked about this alkylating agent acts methyl groups. So this depends on the MGMT, the promoter gene hypermethylated or unmethylated whether the DNA will be able to respond. So again, do these don't matter? By and large when we look at the images of the radiology they don't matter but when you are talking about how to treat the patient when there's an interdisciplinary conference and the neurosurgeon and the neuro-oncologist is breathing down your neck and there are 20 people sitting in the same room and they ask you is this a recurrent tumor? Am I supposed to go in and do surgery? Is this pseudo-progression? Is this pseudo-response? That is the time you're supposed to take all the information. You find out what was the tumor agent that was given to that for treatment? What was the patient's genetic code? What was the tumor associated? So you gave a patient alkylating agents a temzolamide. You gave a patient who was unmethylated. Now that's not going to affect that patient. So you see changes in the brain after surgery and after treatment. Chances are this is a recurrent tumor. Whereas you gave temzolamide to a hyper-methylated patient. Chances are you completely treated that suppress the tumor and immediately in the near future post-treatment. If there are any changes in the surrounding brain pattern, that's more likely to be tumor treatment related rather than recurrent tumor. And you would hold back with an acrylcine. So that is why we are supposed to know what chemotherapy, how it acts and what is the genetic code tumor. This is a patient who was given chemotherapy. So this was a brain tumor, which initially showed some progression, but later on, involuted. And there's very little bisect surrounding white matter changes again as opposed to what you would see with radiation therapy. Next is you can use targeted therapy and into this falls that you've asked and where you're specifically going after factors that help tumor growth or something that is helping the two cells multiply. And then you suppress that factor. So you can go after specific antibodies or the receptors of the cell. Those are the things that you can do. It's common that you use for this is evastin where this is prevents the VEGF or vascular endothelial growth factor, which basically prevents new vascularity, reduces the effectiveness of gap junctions and creates fenestration and endothelium of existing brain capillaries. So all involved when you give the evastin, it looks as if you have involuted the tumor, the whole tumor just disappears. But it is a very, very false sense of safety that you're getting with this VGFB. You have to monitor it very, very closely. There are a few downsides. The most important being the pseudo response that you feel is false sense of response that the patient is invioluting, whereas it is actually not. Then the other thing is a patient who has already had hemorrhage is not a candidate for this. And the patient perfusion imaging becomes kind of unreliable in patients who have received evastin or VEGF inhibitors. And as such, perfusion is generally very unreliable in patients who have had hemorrhage in the past. So these are the downsides of getting evastin to the patient. And then also, once you start the patient on evastin, they get thrown out of a lot of clinical trials. So that is another issue that we encounter. They cannot get new research medications. So this was a patient who was started on evastin. You can see a GBM, which is intensely enhancing. This almost shows that it disappeared, the tumor disappeared and invioluted. But actually, if you see this was a pseudo response, the tumor was this before treatment and it has progressed overall. So this was the issues that we run into. Next is you can have immunomodulation where basically we understand that tumors are mainly because of patients' immunity being suppressed. So you can either boost their immunity or restore their immunity by vaccines and those things. Those are the other things that we are currently mainly in research trial, but are being used at our institution to repaint tumors. So this was a patient who was saturated with immunotherapy and initially progressed, but then later on it invioluted. The same thing with enhancement, the same which is over the period of time where you see the patient has overall to have a good response.  And then you give them anti-epileptic. There are tests we talked about that should be done before any intervention to identify the eloquent areas. So one of them is rather the most important of them is the functional MRI, where we use the bold technique to see the areas that have increased oxygen supply during activation. Whenever brain does a function, there are two ways there is nutrition increased to that part of the brain. One is vasodilation and the second is increased extraction. So the blood vessel from here to here gets dilated and then there's increased number of oxygen that is extracted. But one of the things that is different is the vasodilation is significantly more than the amount of extraction. So this is a normal state where you are supplying four oxygen and two oxygen. This is the arterial side and this is the venous side where two oxygen are remaining because of two oxygen being extracted. Now you make the patient do a function, you supply vasodilation, it multiplies by five times. So you have 20 oxygen being supplied and only extraction doesn't increase the same amount. So says five, arbitrarily say five oxygen come out, you are left with 15 oxygen. Now this is the ratio we want to do when you're doing the bold technique or comparing the function and giving the red color to that area of activation. If you do it on the venous side, you have a ratio of one is to five. I mean, on the arterial side, you'll have a ratio of one is to five approximately. And on the venous side, you end up with a higher ratio. So you want to see the comparison on the venous side and that is the side you calculate for. So this was a patient of polygodendroglioma, calcification, low grade tumor, narrow zone. This is the functional task where we did the motor and the language which consists of rhyming, word generation, listening task. And then this is the brain mRNA overlap with the function. Now here the motor task is distant from there. Now you need a gap of at least five millimeters to be completely safe during surgery. Whereas in language tasks, this is coming too close. This is almost less than five millimeters. And here it is almost overlapping on rhyming tasks. So if we take out a good margin, a clear margin of the tumor resection, he will end up with some deficits. So these are the things where you only do debulking of the tumor. So this is the issue that you run across later on. Visit completely accepted. This is what decides the performance of the tumor. The second thing that we do is the diffusion tensor imaging. Now this is something in research. This is not something billable. This is not something that you can defend in court of law. But this is frequently done to mark the white important white matter fibers where we use the diffusion technique. Like if you do it for diffusion technique, you do it two dimensional for stroke where you see the random motion. But all these random motion of molecules of water, but all these motion of molecules is finally directed along the white matter tracks. So this is what you're calculating along the Z axis. Also the third axis you are taking into account. And then you color coded to identify which are these are the most important, the archway fibers and the corticospinal tracks. These are the most important tracks that you identify. Now what pictures we give these pictures that we give to the clinician have no importance. They take this software, the digital information feed into to their own software during surgery, which is what they use to decide whether how close to the white matter fibers they are, what how close to the archway or corticospinal track fibers they are or visual track they are to before while they're surgery. Then the other thing that we do is a perfusion imaging. Now this is the same way what you use for strokes. You do the same calculation, the four parameters. The one we use for tumor is the area under the curve with the cerebral blood volume. So this is a tumor which is within the frontoparietal lobe has enhancement. So it's a grade three or grade four by imaging. And given its narrow zone of transition, we can talk about the IDH and all those things. But clearly this is not what we'll be talking about when we are giving out the diagnosis. But what is we are talking about here is the perfusion. There's intense elevated CBV in this tumor. So this is a kind of an aggressive tumor. This is perfusion imaging is what you will look for even when you are confused between radiation accrosus versus recurrent tumor. The recurrent tumor will have elevated CBV. As a physician, we all know what to do to treat a patient, but it is equally important for us to know what not to do to the patient because sometimes the cure can be more harmful than the disease itself. So when should we not operate on a patient? So if it is a low-grade tumor with all the nice characteristics like IDH mutant, co-deleted, TERT negative, ATR expressance, increased expression of P53 and MGMT, hypermethylated, all those things are present. And it's located in the frontal neoplasm far away from any eloquent area, not causing significant symptoms. Incidentally noted, patient came in with a trauma and we first saw the neoplasm. You don't need to operate that. You don't unnecessarily need to go in so that you will not want to operate. Then the flip side of that is if it is involving an important area, eloquent area, say completely involving the insular cortex or completely involving the motor cortex or the brain stem, you operate one of those that you give him a debilitating condition that is not just not worth it. He will live for five years with complete paralysis as opposed to you give him one year with completed retention of function, that is better. So this is finally between the patient and the clinician to decide. But those are the things where you do not operate. Then patients in overall poor health and poor compliance, those ones you tend not to operate. Then if there is, you change your treatment from aggressive surgery to radio surgery if there is less than two millimeter gap from important structure. So those are the things that you want to keep in mind for treatment. Talking to the neurosurgeon or the neuro oncologist, you will hear these terms that, oh, I was doing the surgery and then I got, I felt it was a bit too dangerous. And I stopped at this point. So, and then you see there is a residual tumor. So what made the surgeon stop at that point? These are the things that these are the four things that they use to decide when to stop. We talked about functional imaging, how close it is to the eloquent area. If it is overlapping, they debulk the tumor, they don't take out the whole tumor. That they use then the DTI, not the images. We give them the information that we give the digital information into their own software. And then they decide on that how close the white matter tract is to that and accordingly they operate. And the other, the two most important thing are these two where there's an electrophysiologist actually in the surgery room where they are stimulating the white matter tract and looking for a response in the distributing muscle by EMG or the other way around either side.  And this is where they know that they're getting to a very important area and they stop the surgery at that point. And lastly, sometimes the patient is awake answering the questions doing tasks during surgery and that is what when they see something changing, they stop at that point. So these are the four or five things that the surgeon takes during the OR to see how they can do for surgery. Lastly, we will talk about what we do for residual tumor. We talked about how do we identify with the residual tumors with the genetic code of that patient, what agent we use for treatment, the things that we talked about earlier. But immediately after surgery, if there is some tumor left, then you can either use new adjuvant chemotherapy or you can gamma knife that area or you can start him on research drugs, clinical trials. Those are the things immediately later on, if there is a tumor that comes back or residual tumor, you can either repeat surgery or you can use radiation surgery or you can use evastin. So this is the approach that the clinicians use with whatever is left after initial treatment. These are the most important things that we are supposed to know about tumors before we talk about tumors. The most important thing that I want you to take back from this lecture is the five molecular markers, IDH, P53, co-deletion and NGMT, hypermethylated and ATRX having a good prognosis, TERT having a poor prognosis. That and that alkylating agents use methylation as DNA harmful.  And that keeping in mind that evastin makes profusion imaging poor after treatment with that or under libel and the fact that you have to keep in mind about pseudo response that the tumor is actually going and not actually treated in a patient with evastin. So these four or five things you have to keep in mind if you are actually involved in tumor treatment. Thank you very much.


Today's video is brought to you by Picmonic. By far one of the toughest classes are the one responsible for the most hair pulling, hence the bald spot is pharmacology. But today we're gonna break down a few quick things you can do to make studying pharmacology a lot easier and more effective. Let's get into it. So step number one is to have both a forest and a tree approach. Often what makes pharmacology so overwhelming is that there's so much information, but also so many individual categories you have to remember. For example, for each medication you have to remember the name, any brand names, any dosing, how the medication works, who you use it for, side effects, and so many other factors. But to understand pharmacology well, you have to understand both of those individual facts as well as the big picture. And that's why one of my favorite ways to master pharmacology is to have a resource that can help you both master the tidbits as well as see everything together. And one of my favorite resources that I love to recommend is Picmonic. Now, if you're not familiar with Picmonic, they have hundreds and thousands of videos for every aspect of your medical journey. Today we're just gonna go ahead and touch on pharmacology. And something I really appreciate about Picmonic is that they nicely go ahead and separate based off the topic. So for example, if I'm learning about pharmacology within cardiology itself, I can click there and I can say, oh, tomorrow we're gonna learn about medications to lower your lipids or your cholesterol. Let's go ahead and watch a video about statins. Now, from personal experience as an internal medicine doctor, there are a lot of statins and a lot of things to actually remember about statins. But the nice thing about Picmonic is they nicely talk about statins all within a very short videos. This is only a minute 30. And then as you go through this video, it nicely breaks down basically into a story form where each aspect of the video is associated with a very fun and memorable image that represents something. So for example, here we have this image of this liver with this weird looking sludge representing hepatotoxicity. And you have to remember that statins do sometimes cause liver damage and it's something you have to keep in mind of your patients. And as I go further into the video, more memorable images are included. I represent and tell a story about statins that can ideally remember later. Now, each of these images represent the trees or the individual details about a specific medication. But the nice thing about Picmonic is that now you can go ahead and try to actually remember the entire picture and story together. So for example, using their review function, I can say, oh, do I remember what this individual image right here was? And I was like, oh, that's right. That's the sludge looking liver, hepatotoxicity, that's something I have to remember. In addition, I can actually quiz myself using either the images or just hide them completely and try to see if I can answer these questions. And the last tidbit or feature that I like to share is that once you watch a video and you feel like it's something that you've added into your review schedule, you can actually just add it to your own individual playlist. So if I was going through cardiology, I could add it here. If I was using it for step one or if I wanted to create a new one just for pharmacology, I could create it. Then I have a big video database with all the quiz questions from every video I've already watched. And then every time I watch a new one, I go ahead and add it to this playlist. So again, using the forest and tree approach, finding and all I want to resource that can help you find individual details, but also seeing all of it together. Super helpful. Picmonica is one of my favorite resources to recommend. And they are the sponsor of today's video. So if you guys are interested, you guys can check out the link in the description. Technique number two is to use space repetition predictably. Now, space repetition is something I cover a lot on this channel. One of my favorite techniques and tools to use is Anki. And just to show you an example, wouldn't it just be nice if all of your pharmacology topics that somebody else thought would be important were included in one place? So for example, if we open up Anki and I just pull up on one of my step one portfolios, then I can use this big pre-made deck. This is Anki that we use for medical school and the Anki deck. There are plenty you can find. If you just Google pharmacology Anki deck, you will find one that will likely go for you. So if you're in nursing school, if you're in PA school, if you're trying to be a dentist, you can find something. But just using this as an example, and one of my favorite things to recommend to students is to find these pre-made decks that they really enjoy and then find the relevant pharmacology deck either within the specific subject. So if you're learning cardiology, you could find the cards farm deck or just find the entire deck and try to move it out and make it a big deck. So for example, here, I have an actual individual pre-made pharmacology deck. And I can say every morning, I'm gonna go ahead and make a predictable schedule of doing this for 10 to 15 minutes. Often students get overwhelmed by the amount of cards that are in one of these pre-made decks because somebody has spent so much time doing this. And just to show you an example, this is a pre-made deck with 4,000 cards. So a lots of cards, but the goal is not to focus on getting through all the 4,000. Your goal is to focus on doing a specific amount or time every single day and making your pharmacology knowledge a little bit better. So in this setting, I may say I'm gonna commit to 10 to 15 minutes in the morning, maybe 10 to 15 minutes after lunch. And that'll be my pharmacology review. You can obviously make your own schedule, but doing that, I can have a timer and say, let's just try to do as much as I can. I'm not gonna focus too much on what Anki's recommending. I'm just gonna go ahead and do as many cards as possible. And so here is a card on levothyroxine or synthride used for the thyroid. And I can just continue to do these for 10 to 15 minutes. Now, depending on the pre-made cards and the deck that you use, you may have a lot of more stratification you can use to actually be able to study a specific topic. So I can go into custom study and this, and I can say, let's go ahead and review all the cards within a certain tag. And then using tag, if because somebody already made these cards, I can say, well, let's go ahead and do any cards that are related to pharmacology and cardiology. And then using these tags, and there is a lot more tags than usually are for another pre-made deck, I can say, let's go ahead and just do all of the topics that are related to cardiology farm, because that's what I'm trying to learn this week. And doing so, and this is, it's gonna show me that cards that are acceptable for that. So anti-acids, things like vomiting and going forward. Now, if you're new to Anki or if you gave it a shot in the past and it just hasn't quite worked out, make sure you check out this entire episode on how to use Anki like a pro step-by-step. I go all the way from the basics to advanced techniques. Essentially, it's the technique that I use to help me go from 10 to five hours of studying in medical school. So make sure you check that episode out. Lots of people have liked it, almost I think it's at five to 600,000 people. I've gotten lots of positive feedback for people that have seen the video on YouTube. So again, even if you've given Anki a shot and you haven't been able to quite figure it out, make sure you check out that episode and see if it'll help you on eat pharmacology or any related topic in your medical journey. Now, technique number three is to use a hit list method. Now, sometimes the hardest thing about pharmacology is that I'd get overwhelmed by the list of medications I have to know about the next quiz or test, but I just get paralyzed and anxious before actually doing anything. And so one thing that I started doing early in medical school is going very simple and creating essentially a word doc of all the medications that I needed to know. And I would put the category as one bullet point and then all the fair medications. For example, if I had inhalers because I was on the respiratory tract, I may say inhalers and then make a big list of the next 10 to 15 medications that I would need to know. And then if I needed to know something for pulmonary hypertension, I would add that as another category and then all of the fair medications that came from my slides, quiz questions, et cetera. So for example, here is a quick example of what a hit list may look like for a pharmacology block. You may have some of your initial medications that you're learning and then just adding each one you have to know in the list. Now, when I come to study, while it's overwhelming to see all these medications that I may not be familiar with, the next goal is essentially come up with what I want to know for each one. So for example, I may want to know the mechanism of action for the MLA. I may want to know who we use it for and then I may want to know common side effects. And using this as a structure, I'm like, fine, let's come up with those three bullet points for the next three to four medications or whatever I can do in the next 20 to 30 minutes. And these are things that you can use your slides, your lectures, et cetera, to fill in. So when you're going into lecture, you can essentially just add them into this section or after class, you can fill them in accordingly. But the nice thing about this is one, now you're just focused on the next thing on the list on a time basis. So instead of worrying about the eight medications I have left to do, I'm just going to move on to the next one and try to master the next thing on the checklist. The next thing that's nice about this is that once I have gotten the first review phase, if I'm coming back and trying to learn about Montelucast or Singular, then my goal is, okay, without looking at the answer. For example, maybe I could just go ahead and make all my texts white. So then it just disappears. I could have a blank piece of paper or try to talk out the answers, like, do you know the MOA? Do you know who you give it for? Do you know the side effects? And then I can just control Z or go ahead and make my texts black to essentially show myself the answer. It's a nice way, again, to collect all your information in one place and then use it as a quizzing. And if it's something that I did master because I knew all of them and I could say, perfect. Let's go ahead and just make all of this green and then move on. Let's say the next medication. And honestly, I've never heard of this one before. And I struggled with it. I can just go ahead and make this red. And it tells me the next day you come back to your review, go ahead and do your red ones first before you do the medications that you haven't reviewed quite yet. Next way to master pharmacology is to use the second brain method. Now, if you're not new to the channel, you know one of my favorite techniques to use to master something called the second brain is Notion. Quickly to explain second brain essentially means instead of trying to count on your brain to hold on to all this information, collect it into a nice database and then come back to it very periodically that you can continue to add to and review. So for example, here I have actually a database that I made for one of my coaching students, somebody who's going into residency and they wanna master everything needed for internal medicine. And so for this person, instead of forcing themselves to learn medications that they haven't prescribed, haven't actually interacted, it was like perfect. Let's make this actually usable. So maybe you're in a setting where you're gonna be treating something like hyponatremia. It's nice to go ahead and have a database where now you're gonna learn about hyponatremia. You're gonna go into this and then add all of your relevant information, any types of pictures or things that you find and then perfect. Then when you're asking yourself like, what do I use to treat hyponatremia, you're gonna come across naturally medications, dosage, prescriptions, side effects that are going to be relevant to that category. Using the second brain method, now I can go ahead and one, add those medications like salt tabs, Lasix, water restriction, which is not a medication itself, but is a treatment. I can add those into my hyponatremia section and then I can create another separate folder as she has done for things like hypotension or hypertension and then add specific medications as you're learning about it. It's much more natural use of pharmacology. So if you're somebody who is in nursing, PA school, medical school and you're learning about both the disease and the treatment, make it a very natural to the transition where you're learning about the disease and then the actual medications to treat it. So then you've already kind of connected the dots instead of trying to learn hypertension medications away from hypertension itself. And what makes the second brain method so effective is the next time I come across a medication of like, oh, there's a side effect that I actually didn't know about or I didn't actually write the dosage last time I learned it, you can find that chapter or create a new one and add it in. And this student as we've kind of created for them is essentially a checklist. So they have a schedule and every time they learn something they'd go ahead and click checkbox. And probably my favorite way of learning pharmacology is simply learning through mistakes. Often as a full-time physician, although I don't make mistakes by prescribing the wrong medication, but maybe I realized that there is a better option or a patient has a side effect that I wasn't aware of. It seems like, oh, that's actually related to this medication that you've been taking for the last two weeks. That's brand new. That is a great way. And as a student, one of the best ways you can learn through mistakes is by simply putting yourselves in quizzing and questioning environments. Whether finding a question bank particular to the class you're taking or using it all on a resource that we talked about like Pickle Honnick and there's tons out there that you guys can check out but making question a part of your daily basis. So you can use the flashcards that we talked about earlier but also start to incorporate things like practice questions where you have a lot more benefit. For example, when I do a practice question not only do I have to figure out what disease they're actually trying to tell me about but then I get to ask myself, okay, what's the treatment for it? So it's a nice twofold way of connecting against the forest and the trees altogether in one place. So for all the students that I work with, particularly the ones that tell me they're struggling in pharmacology, we make it a daily schedule to say, let's do five questions every single day and maybe two questions in the morning, three questions when you come home and then keep track of your mistake while doing the rest of the things that we talked about in today's episode. That's really where that person feels like, oh, a mastery of pharmacology is a lot more natural. I feel like I know the tidbits. I feel like I know when I don't know something and then I can use various different techniques to identify that and then come back to it on a predictable schedule. Now, if you enjoyed this breakdown to study pharmacology, then you'll enjoy this breakdown of every study strategy that's responsible for me to get 3.9 GPA. Make sure you guys check that out. If you're struggling, actually remember what you're reading. This episode is gonna help you with a step-by-step approach that is super effective. I'll let you guys enjoy those, but as always, thanks for being a part of my journey. Hopefully that was a little help to you guys on yours. I'll see you guys in the next one. Peace.


the petition 1567 petitioner in late december and this has been circulated to and I must say as a heart-rending description of a death of a young man which you know have every sympathy for the whole committee does for the mother of that young man last time we looked into at these petitions we agreed to like right to the lord advocate we asked him to uh for additional information regarding the safeguards that are currently in place to ensure that investigations into deaths by the police or the procurator fiscal reach robust and sound conclusions we also asked what powers families have to question the outcome of such an investigation the lord advocates responses attached in annex a and that to some extent reiterates information we have already received it also concludes includes reference to the new charter for brief families which sets out the different stages of an investigation process and confirms what information will be provided to brief families and when page four of the lord advocates letter also outlines the review and complaints process that are open to brief families disappointed with the investigation this is not the more formal process that the petitions appear to be asking for and the lord advocate makes it clear he is not contemplating any major legal changes in this area so can i have the members views on these petitions possible options are set out on page seven of the clerk's paper colleagues i wonder if the rest of the committee agree if there will be a last ditch if i can use this as well as maybe right to the cabinet secretary and asking if there are over any other reassurances that we've not had before which will maybe help us on us particularly we're getting divided over police uh investigation and decision by sir cup any other views that agreeable to the rest of the committee that we don't know it is yeah okay so we'll keep the position open and right to the cabinet secretary um for any other assurances and obviously some of these other petitions if they're still open they could form part of our legacy paper uh at the end of the session if there's still issues arising from that thanks colleagues and pe 1370 pe 1479 on the legal profession on the illegal aid time bar petitioner is asking that the time bar for making complaints against the legal profession be removed completely the scottish legal complaints commission has planned to increase the time bar from one to three years but the process has now been delayed while the slcc consults on the issues part of a wider consultation copy of the slcc's most recent correspondence with the committee is reproduced at an xe so therefore can i ask for a member's views on that so the expectation possible options are set out on pages 11 and 12 of the clerk's papers so can i seek views as to how we take this forward or i'm no longer of the view that there is really much merit in keeping this petition open seems to be slightly technical that the situation hasn't been resolved and appreciate we're back to the consultation phase of slcc but i'm not actually sure i mean it's been undoubtedly going to change at some point that keeping the petition open is actually serving useful purpose i tend to be of a similar view to yourself on that other audio bit john likewise convener can i also suggest that that we encourage active responses to the consultation but the consultation even isn't likely to address what this particular petitioner is wanting anyway too okay so we we agree to close this petition pe1 5 10 on the closure of police fire and non emergency centers north of dundee clerks paper discusses this petition along with pe1 5 1 1 since the committee's last consideration of the petition for the subcommittee has taken evidence from her managing inspector of concedery for scotland on his final report on call handling what mr pennman has to say set out on page 14 of the clerks paper and can i have members views on petition pe1 15 10 possible options being set out on page 13 John convener i'd be keen that they keep this position petition open i think it's a very much alive matter i know there's different interpretations of the outcome of the HMCC report i certainly took it as vindicating the retention of the control rooms but i think it's still part of an on-going process and i would hope that there would be a decision taken to retain them but i think it'd be appropriate to keep it open given the on-going events i just mentioned pe1 15 11 as well on closure of the fire and rescue control room in veneff uh members will recall that the issues highlighted in the petition were raised during our evidence session with the scottish fire and rescue service fire inspector and fire brigades union on the 28th of april last year and can i have other members on both maybe members views on both petitions as to whether or not we keep those both open or one open and not the other open agree with jones we should keep pe1 15 10 open anyway at present time i'm less sure about wanting to keep pe1 11 open 15 11 yeah okay i mean we've previously saw assurances from the fire service about petition pe 15 11 and why we've had some assurances and we've heard during the budget process some concerns about the impacts of these closures and i would keep both of them open at the moment yeah okay okay we'll agree to keep both of them just in terms of is there anything further that wants to do with pe 15 11 or we just want to keep it open at the moment in case we just just just keep it open don't take any further action okay that's great thank you very much and our final item today before we go into private session is the subordinate legislation and i think we more has caught up with our timetable then this is the management of offenders etc scotland act 2005 commencement number eight and consequential provisions order 2015 this instrument was intended to commence the remaining provisions of the 2005 act and to extend the multi agency public protection arrangements beyond registered sex offenders and restricted patients to include certain high risk offenders as you can see the delegated powers and law reform committee has drawn the instrument to the parliament's attention its main concern was that it was laid under the wrong procedure negative instead of affirmative scottish government has acknowledged this and has laid two replacement instruments dplr committee had a further concern that scottish government should have formally revoked the instrument the scottish government considered that this was not necessary all this is set out in some detail in the clerk's paper just before the end of the year the minister for parliamentary business wrote to the dplr committee the justice committee was copied into the letter which has been forward to members the letter essentially restates the scottish government's view that no further action on the instrument is necessary this instrument has been put on the agenda because the advice the convener received was that it was necessary to do so understanding orders however despite continuing disagreement between the scottish government and the dplr committee both sides agree that instrument is not law and will not become law replacement instruments have been laid and will come to this committee in due course at which point we can consider the issues of policy rather than procedure my suggestion is that we make no recommendation on the instrument agreed agreed good it's pretty rich that we've got such a mix oh yeah it really is unfortunate and quite unacceptable i think oh yes i think yeah i don't think we have any comment on the instrument in terms of procedure but it does seem fairly remiss of the government to submit an order of this under the wrong procedure okay that concludes the public part of the meeting and i i would ask members of the public to thank you very much