If you are reading this article, chances are you are done with PLAB 1 and are about to prepare for PLAB 2. Congratulations! If you are looking to gain an overview of PLAB 2 and high-yield resources to supplement your future revision, this article will also be useful for you.

As recommended by trusty seniors, I joined the Aspire Academy (not sponsored) and mainly used their study materials for the bulk of my preparation. Other sources that aided my revision included: Dr. Mo Shoby’s notes (shared by other candidates), Youtube videos and the NHS website.

What is PLAB 2?

It is a practical exam, which is usually undertaken after completing PLAB 1. PLAB 2 is essentially an OSCE (objective structured clinical exam), consisting of different scenarios to simulate cases and consultations that candidates might face at the level of a FY2 doctor when working in the NHS. The exam aims to test the candidate’s ability to apply their clinical knowledge and skills in terms of facilitating patient care according to existing NHS guidelines.

Please be informed that unlike PLAB 1, there are only two exam centers as of date, where both are located in Manchester, United Kingdom.

What to expect on exam day?

Since COVID, the number of test stations have decreased from 18 to 16 stations (two rest stations included), bringing the exam duration of 3 hours and 10 minutes down to 2 hours and 50 minutes. Each candidate is expected to spend 1.5 minutes outside each cubicle to read the task and case notes, followed by 8 minutes inside the cubicle to complete the station. Throughout the exam, a bell is played over a sound system that indicates when the candidate should enter the cubicle, are at the 6-minute mark of their consultation, and when the station has ended.

Please be aware that there are no breaks in between each station, however, there are two rest stations where candidates are allowed to use the loo and help themselves to some water and snacks.

The Grading Criteria

Each station is graded according to three broad components: data gathering, management and interpersonal skills. A maximum of 4 marks is given to each component, adding up to 12 marks per station, and 192 marks in total (16 stations).

Candidates need to pass at least 10 out of 16 stations, and score a total of at least 100 marks to pass PLAB 2. The passing mark for every exam differs (as it is determined based on all of the candidates’ performance on exam day), but it is usually an average of 100 marks, with ± 2 margin.

Preparation strategies, tips and useful links

Before diving into the resources I have used and some personal strategies and notes to aid your PLAB 2 preparation, I think it is only fair to provide you with a general idea of my clinical background and a summary of my PLAB 2 preparation.

My Background & PLAB 2 Story

For some context, I completed PLAB 2 in May 2022, after months of exam cancellations and booking delays due to various travel restrictions in 2021 when the pandemic was at its peak. This means I have been preparing (albeit inconsistently) throughout 2021, during which I was also studying for the MRCS Part A , but that too was delayed (let’s save that story for another time 😉).

As recommended by trusty seniors, I joined Aspire Academy and mainly used their study materials for the bulk of my preparation. Watching videos on Youtube also aided my revision.

I finished going through Aspire’s PLAB 2 book in 2021 (and attended their teaching sessions online). However, serious preparation only began when I attended the academy in-person, where I practiced cases with fellow doctors, and even developed personal strategies to approach different consultation scenarios. This took place in late March 2022, for a duration of around 2 months.

With regards to my clinical experience: I was a fresh graduate when I undertook my PLAB journey, with merely 12 months of pre-graduate internship, did some extra shadowing here and there throughout the clinical years of medical school, and had an expired BLS certificate.😂 In short, my clinical skills were average at best. Still, with the right strategies, I was able to pass the exam comfortably on my first attempt.

Did I doubt my clinical skills? Maybe, as my skills became a little rusty during the pandemic. Was I scared of failing the exam? No. Intimidated? Slightly. After all, it is best not to underestimate any exam.

The Strategy

On exam day, you are expected to face four main types of test stations: History-taking, Examination / Procedure (mannequin), Medical ethics / Counseling and Prescription writing. As PLAB 2 is used to assess the application of your clinical knowledge in different scenarios where you might face them during your practice in the UK, history-taking stations will make up the bulk of your exam; there will be a couple of examination / procedure stations where you are expected to conduct physical examinations or interventions on mannequins; one SimMan station to test your management skills on an acutely ill patient (which is not an actual patient, but a talking mannequin with vitals, palpable pulses, breath and heart sounds); a couple of medical ethics / counseling stations, and one prescription writing station. Please also note that ever since the pandemic, some of these stations might be held over telephone and video-call (i.e., telephonic consultations).

Now that you are aware of the different types of test stations, recognize the need to approach these stations differently. Yes, a structured consultation is still expected, but do not attempt them by blindly following scripts given by academies (a common pitfall observed among candidates who are keen on memorizing and regurgitating questions). The most appropriate approach to PLAB 2 stations is to handle them as though you are seeing a patient at work: calm, professional, empathetic and ensuring the consultation is patient-centered. For that, you are strongly encouraged to develop different structures tailored to each station, and make notes (ideally, if time permits).

For instance, in a station where the patient presents with signs of depression, you would not ask whether they have leg pain, as that is irrelevant to their history. Likewise, if a patient presents with excruciating abdominal pain, you would not offer them lifestyle advice to manage their condition, as that management plan is irrelevant to their presenting complaint (i.e., neither does it resolve the pain nor find out what is the cause). Additionally, in a medical ethics station where a patient refuses a certain medication or procedure, it is not appropriate to approach as though you are taking history from a patient coming in with urinary issues (i.e., a presenting complaint). As you can see, the main aim of developing specific structures to tailor to different stations is to ensure that you are asking relevant questions within a short span of time, as per exam condition. However, as important as it is to have a structured consultation, please be aware that the patient (a trained actor) might interject with their concerns. Depending on the urgency and relevance to their condition, you may either address them directly or mention that you would address them after gathering more information related to their condition.

Although time management is not heavily emphasized, you are strongly encouraged to complete every station within 8 minutes where possible, with examination stations being the exception (since you are expected to take a short history before examining the mannequin). As a rule of thumb, for history-taking stations, try to allocate around 3 to 4 minutes to order relevant tests, carry out management plans and address the patient’s concerns. It is important to ensure that some time is spent on management, as it is part of the grading criteria. For examination stations, try to spend 2 minutes on history-taking (or lesser, depending on the question, such as a teaching scenario), 4 minutes on conducting the physical exam, and 2 minutes on management. Please be informed that some questions might contain specific instructions such as, “spend 2 minutes to talk to the examiner about your differential diagnoses”, hence, ensure your consultation is wrapped up by then.

Personal tips and useful links

Now here’s the juicy bit. 😝 Under this section, you will find useful links and notes that aided my exam preparation, and hopefully yours:

• Academy attended: Aspire Academy, based in Oldham, Manchester, UK.
• Youtube videos for physical examinations and procedure stations: Ankur Garg (one of the lecturers from Aspire Academy), Geeky Medics, OSCE Data-base (PR exam and primary survey), University of Sunderland GP Team (testicular exam) and Nabil Ebraheim (orthopedic exams).
• Youtube videos that enhanced my communication skills and approach to medical ethics and counseling stations: Quesmed, Dr. Aman Arora — Arora Medical Education (e.g., breaking bad news, sign-posting, test result discussion, etc.), FrontLine Communication and Dr Erwin Kwun.
• Resources to determine management and treatment: NHS website — it also contains the conditions’ signs and symptoms, risk factors and possible red flags that hint at a more insidious underlying pathology.
• Youtube videos to refresh my medical knowledge: Osmosis, Zero To Finals, Medicosis Perfectionalis and Dirty Medicine.
• Link to my notes, containing trial and tested approaches and structures tailored to different test stations and presenting complaints, which are ideally used to supplement study materials from Aspire Academy. ⭐️
  I have received feedback that the notes were really helpful to recent candidates’ PLAB 2 prep! 😄

Personal revision tips:

• Do not blindly follow any academy’s study material (i.e., role-play scripts). Develop your own consultation structures based on the test station type and patient’s presenting complaint, and include questions pertinent to the patient’s condition.
• Likewise, do not attempt any consultation without a structure, as you may end up repeating questions, missing out certain important ones and just miss the diagnosis and management completely. I distinctively remember going into one of the telephonic stations on exam day and winged it. Needless to say, that station was a gone case.
• Make notes wherever possible — especially for the management section. It is impossible to cover every single degree of management from acute ones to giving lifestyle advice. Hence, recognize the relevance of each and apply them according to your patient’s condition and needs.
• After creating your consultation structures, put them to the test — practice offline and online with other doctors who are preparing for the exam, ideally with a timer (the PLAB2App was commonly used among candidates at the academy), to mimic test day. If you have the luxury of time, I would advise practicing with doctors from different backgrounds. More often than not, they provide you with lots valuable feedback. Also, having new practice partners is a good way to overcome any form of anxiety or shyness. Constantly putting oneself in such uncomfortable situations makes the exam appear less daunting.
• As you practice with other doctors, pay attention to your tone of voice. It is one of the many forms of non-verbal communication (others include facial expression, gestures and postures) that most of my practice partners tend to overlook. An appropriate tone of voice is essential in establishing clarity and adds meaning to your words — it makes a difference in conveying empathy when you say, “I’m sorry for your loss,” rather than bluntly stating it for the sake of scoring interpersonal (IPS) points. 😅
• When I took the exam, COVID-19 restrictions were still in place, which meant that masks and social distancing were required. If possible, practice your consultations while wearing a mask and consider how you would introduce yourself without shaking the patient’s hand, as well as how you would carry yourself throughout the consultation in general.
• Refer to physical examination and procedure videos prior to practicing them on mannequins. Dedicate a few days (depending on how confident you are with your clinical skills) to familiarize with the equipment, techniques and timing. Have one or two practice partners to provide feedback where possible.
• Being nice is not enough. Being polite is not enough. And unfortunately, inflating your IPS to the moon is not enough to pass PLAB 2. Contrary to the widespread myth I had heard countless times over the course of my exam preparation, PLAB 2 does not test how nice you are to the patient, as this is baseline behavior — you are expected to treat your patients with courtesy and empathy. In reality, the exam is a tool to assess whether you are able to hold a decent consultation (i.e., data gathering during history-taking where appropriate) and whether you are a safe doctor (i.e., proper management plans).

Is it necessary to attend an academy?

I have seen this question making rounds on Facebook groups, and thought it would be a good idea to shed some light after going through the exam myself.

In short: Yes and No.

I have heard of success stories where some candidates were unable to join an academy in-person, but passed the PLAB 2 with flying colors. However, they have several years of clinical experience under their belt, while some of them attended preparatory courses online. A common denominator was these doctors regularly practiced PLAB 2 cases with other candidates (online and face-to-face). If you are a fresh graduate with minimal to 12 months of internship experience, or do not feel confident in your clinical skills, I highly recommend attending an academy in order to get hands-on experience in performing procedures and physical examinations on mannequins. Besides, practicing and learning from other doctors is a very rewarding experience. Some of my most useful revision strategies were developed after interacting with fellow doctors from different parts of the world. Additionally, some academies may provide mocks (with feedback) that simulate test day, for which I highly recommend.

Overall, the PLAB 2 is not a difficult exam. You just have to learn the rules of the game. 😉

Wishing all plabbers the best of luck! 🍀

Love,
Alice

P.S.:
I took PLAB 1 in November 2020. On hindsight, it might not be ideal to write about my preparation strategies (and the revision sources used) for this exam now, as it might be outdated. 😅 However, if anyone wants some tips and advice, I am happy to write about my experience in a short blog. Just leave a comment!

An old drug with new tricks?

In 1957, Dr. Jean Strene, a French physician, discovered that Gallega officinalis, a herbal plant in medieval Europe, was capable of treating diabetes effectively. Goats hate this plant, so it is also colloquially known as “goat’s rue”. The herbal plant contains a unique biguanide compound, which is what we commonly know today as metformin, the anti-diabetic medication.

Metformin is an orally administered blood glucose lowering agent for non-insulin dependent diabetes mellitus (i.e., T2DM) by decreasing the cells’ insulin resistance and improving insulin sensitivity. Presently, it is the most commonly prescribed anti-diabetic medication worldwide, being the most preferred first-line of management for T2DM, after lifestyle modification.

Given the recent pandemic, scientists and physicians are looking at drugs — both new and old — that may stand a chance against the deadly virus. Surprisingly, metformin has been making rounds not only for its glucose-lowering abilities, but also its anti-inflammatory properties, which are the main points of discussion in this article.

What do we know so far? 💡

As metformin is widely known for its anti-hyperglycemic effects, let’s look at some of its mechanisms:

• Decreases glucose production
  By inhibiting mitochondrial enzyme (mGDP), which decreases gluconeogenesis (the generation of glucose from non-carbohydrate substances) in the liver. Inhibition of this enzyme activates AMP-activated protein kinase (AMPK enzyme), further decreasing glucose production.
• Enhances insulin sensitivity
  Metformin inhibits SHIP2 (a phosphatase enzyme abundantly present in skeletal muscles); by doing so, it induces glucose uptake, while enhancing insulin sensitivity. Recent studies also postulated that metformin may decrease the occurrence of diabetic nephropathy (kidney injury as a complication of diabetes) by inhibiting oxidative stress via AMPK activation in a T2DM rat model, while inhibiting SHIP2 activity. These mechanisms work together to prevent podocyte apoptosis (the death of specialized cells in the kidney).
• Increases glucose utilization
  By influencing the host’s microbiome composition, metformin is capable of modifying the composition of intestinal microbiota groups, which is linked to a reduction in both hyperglycemia and hyperlipidemia in insulin-resistant mice models. Additionally, metformin increases the production of intestinal GLP-1, an incretin hormone that regulates appetite and enhances the release of insulin.
• Suppresses inflammation
  Hyperglycemia predisposes one’s body to inflammation via inducing oxidative stress. By regulating one’s blood glucose levels using metformin, it invariably reduces inflammatory events from occurring.

When I first saw headlines reporting the use of metformin reducing COVID-19 mortality, I had an inkling it might be related to some form of inflammatory modulation, as COVID-19 is notorious for inducing cytokine storms leading to multi-organ failure. If that could be managed (or prevented), logically it would save COVID-19 patients from their demise. Additionally, the use of dexamethasone (a type of steroid medication) has been shown to reduce mortality in patients with severe COVID-19 disease, which further strengthened the notion surrounding immunomodulation.

As metformin improves glycemic control by maintaining normoglycemia, it abates some of the pathogeneses that contribute to COVID-19 disease severity, indirectly decreasing mortality. On the other hand, it is arguable that diabetic patients on metformin might be in their early stages of the disease; hence, they have less severe symptoms and would sustain fewer complications from COVID-19. In order to unravel the extent of metformin’s impact on diabetic patients with COVID-19, further investigations should be carried out.

Leaving that thought-provoking possibility aside, let’s look at the immunomodulatory effects of metformin.

How metformin mitigates COVID-19 💊

Several studies have reported lower mortality associated with COVID-19 patients with T2DM using metformin. A retrospective study in Alabama, America, analyzed over 25,000 participants of various ethnicities, observed a significant 67% reduction in mortality in comparison to COVID-19 patients with T2DM without metformin use. This finding is further supported by a meta-analysis, revealing its benefits of decreasing mortality associated with metformin use. Interestingly, a previous meta-analysis investigating the outcomes of diabetic patients with sepsis (a life-threatening condition secondary to a dysregulated immune response to an infection that damages tissues and organs) also reported similar findings.

With these results in mind, repurposing metformin in COVID-19 patients no longer seems like a far-fetched idea. However, the extent of mortality benefits from metformin use in non-diabetic COVID-19 patients, as well as repurposing it for its anti-inflammatory properties, still warrant further investigation.

To date, the following is a list of metformin’s protective properties that may potentially mitigate COVID-19 disease:

• ACE2 receptor phosphorylation via the AMPK pathway
  As metformin inhibits mGDP mitochondrial enzymes, it indirectly activates AMPK enzymes, leading to conformational changes of ACE2 receptors. These changes are known to disrupt the RBD (receptor binding domain) of SARS-CoV-2, which in turn inhibits its binding to the ACE2 receptors, overall reducing viral entry. Although the activation of AMPK enzymes also upregulates ACE2, it is unlikely to worsen infectivity due to the ACE2 conformational changes. Besides, a higher expression of ACE2 also prevents an imbalanced RAAS, avoiding the adverse inflammatory and fibrotic pathways.
• Inhibition of the mTOR (the mechanistic target of rapamycin) signaling cascade
  According to previous research on MERS-CoV coronavirus, the mTOR pathway plays a crucial role in its pathogenesis. It has been observed that inhibition of this pathway stops MERS-CoV from replicating in vitro. Coincidentally, metformin is able to indirectly inhibit this pathway via AMPK activation. Given its mechanism of action (and that both MERS-CoV and SARS-CoV-2 are very similar, belonging to the same family, Coronaviridae), metformin may play a therapeutic role in COVID-19.
• Clinically reduces inflammation
  With increasing recognition of metformin’s anti-inflammatory properties, investigations revealed that metformin is capable of suppressing markers of inflammation such as NLR (neutrophil-lymphocyte ratio), which is a prognostic indicator for COVID-19 severity, is used to detect early sepsis and systemic inflammation in ICU patients. Although neutrophils (a specific type of white blood cell) make up the first line of defense against infections, an uncontrolled neutrophilic response may trigger inflammatory cascades, leading to fatal outcomes.
• Reduction of NETosis
  Neutrophils kill microbes by releasing NETs (neutrophil extracellular traps) that contain compounds associated with inflammation. Despite it being a beneficial response against microbes, uncontrolled NETosis may propagate cytokine storms, microvascular thrombosis and ARDS, which are features observed in severe COVID-19 disease. With metformin use, the occurrence of NETosis is significantly reduced in patients with diabetes.
• Modulates immune cells
  Metformin increases the production of specific white blood cells: M2 macrophages and Treg cells (regulatory T cells). Treg cells are dysregulated in patients with diabetes, which result in uncontrolled immune responses and elevated T cell proliferation and cytokine release, contributing to inflammation and autoimmunity (a condition where the immune system attacks the body’s own tissues and organs). M2 macrophages are specialized immune cells that mainly secrete anti-inflammatory cytokines such as IL-10, IL-1ra and TGF-beta, which collectively reduce inflammation. Metformin has been shown to increase M2 macrophage polarization while decreasing the production of M1 macrophages (which are mainly associated with inflammation) in wound healing studies.
• Downregulates pro-inflammatory gene expression
  Metformin suppresses the transcription activity of NF-kB (nuclear factor kappa-light-chain-enhancer of activated B cells, a protein complex involved in the expression of pro-inflammatory genes that produce cytokines); this has been shown to significantly reduce levels of TNF-alpha (tumor necrosis factor) and other inflammatory mediators (i.e., IL-6, IL-8 and IL-1beta).
• Reduces oxidative stress
  As mentioned previously, hyperglycemia induces ROS production and metformin does the opposite: it suppresses mitochondria-induced ROS by inhibiting mitochondrial complex 1. This also disrupts macrophages from releasing inflammatory IL-6, as ROS is required to activate this mechanism. A primary research highlights that metformin provides antioxidative protective effects regardless of glycemic control, hinting at the potential benefits of adding metformin to T1DM treatment, as well as the management of autoimmune diseases.

Although metformin has a plethora of complex mechanisms of action that are capable of influencing multiple cell signaling pathways, it is assuring to note that they have been extensively researched prior to the pandemic. Presently, metformin is recognized for its therapeutic potential in managing diseases other than diabetes, such as PCOS (polycystic ovarian syndrome) and psoriasis (an autoimmune disease affecting the skin). For the past decade, it has also been clinically trialed as an adjunct in cancer treatment.

Repurposing existing drugs is not as uncommon as we think. Needless to say, thorough studies must be done rigorously to ensure its therapeutic efficacy, short-term and long-term adverse effects, as well as to elucidate its molecular mechanisms in SARS-CoV-2.

As a matter of fact, several randomized clinical trials are underway as we speak. Though it will take some time to procure substantial data, currently metformin is not approved for hospital use to manage patients with COVID-19. Still, knowing this brings hope — as one of these “old” drugs may very well be the next dark horse in our battle against COVID-19.

For now, get vaccinated, follow national healthcare guidelines, wash your hands, and don’t start taking metformin without your doctor’s advice!😉

Take care and stay safe.❤️

Love, Alice

Metformin: A Pharmaceutical Dark Horse in the Face of COVID-19 was originally published in Microbial Instincts on Medium, where people are continuing the conversation by highlighting and responding to this story.

How diabetes exacerbates COVID-19 on a biological level.

Diabetes is one of the top 10 leading causes of death worldwide, owing to its myriad complications. This chronic metabolic disease has become a cause for concern due to its rapid surge in prevalence over the past few decades. In 2019, its global prevalence is just shy of half a billion people (which is responsible for at least 1.6 million deaths). This number is predicted to rise by an additional 25% in 2030, surpassing half a billion of the world’s population.

Broadly, diabetes is divided into two categories: type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM), with the latter being more common. T1DM occurs when one’s pancreas is unable to produce sufficient or any insulin (a hormone that promotes the absorption of glucose from the blood to be stored in the liver, adipose tissues and skeletal muscles). T2DM occurs when one becomes resistant to the effects of insulin, causing the individual’s pancreatic cells (specifically beta cells) to overproduce insulin in order to mitigate resistance. Over time, prolonged insulin resistance causes beta cell dysfunction, which cripples insulin production.

What makes diabetes so deadly (even before the pandemic), are its adverse complications. Excess glucose in the blood, known as hyperglycemia, induces inflammation that damages blood vessels and nerves in every body part imaginable: the eyes (diabetic retinopathy), heart (coronary heart disease, diabetic cardiomyopathy), brain (stroke), kidneys (diabetic nephropathy), hands and feet (diabetic neuropathy, ischemia, ulceration); it may also increase one’s susceptibility to skin, gum and bladder infections. Not only do these complications substantially impact one’s quality of life, but they also take a toll on one’s physiologic reserve, which in turn increases mortality.

The Impact of Diabetes on COVID-19 Morbidity and Mortality 👥

Based on a nationwide retrospective study conducted in China, which analyzed over a thousand laboratory-confirmed COVID-19 cases, it was observed that patients with a single comorbidity (i.e., hypertension, diabetes, chronic kidney disease, COPD, malignancy, etc) had poorer clinical outcomes than those with none. Notably, diabetic patients with COVID-19 are predisposed to more severe disease presentation (34.6% versus 14.3%), admission to Intensive Care Unit (14.6% versus 5.5%), requiring invasive ventilation (8.5% versus 2.7%), and higher mortality (10.0% versus 2.5%), when compared to non-diabetic patients without underlying comorbidities.

Another study in 2020 with similar results conducted a meta-analysis that included 16,000 COVID-19 patients from America, China and France discovered that diabetic patients with COVID-19 are twice as likely to develop severe disease presentations (e.g., acute respiratory distress syndrome requiring ventilation and ICU care), with twice the mortality rate (two times more likely to die from COVID-19).

As these studies have highlighted associations between diabetes and COVID-19 severity and mortality, making it a strong indicator of poor clinical outcomes, it raises an important question: What are the exact pathogeneses (processes by which a disorder / disease develops) in diabetes that make it so deadly?

Diabetic pathogeneses that exacerbate COVID-19 disease severity🍬

Diabetes is a multisystemic disorder, where a state of persistent hyperglycemia affects multiple organ systems in the human body (hence the list of complications), by constantly inducing oxidative stress and inflammation. This happens via complex mechanisms, often affecting multiple regulatory agents.

Here, I would like to highlight specific pathogeneses that predispose people with diabetes to a higher risk of adverse outcomes from COVID-19.

1. Hyperglycemia-induced Endothelial Dysfunction 🏥

The endothelium is a single layer of endothelial cells that line the inner walls of blood vessels. In the presence of hyperglycemia, various endothelial metabolic pathways are affected.

To offer you some perspective, imagine your blood vessels are made of pipes filled with running water. When acid is dumped into the water, it gets contaminated. The acid then irritates the walls of the pipes, gradually wearing them down. As the pipes react with acid, by-products are released that further contaminate the water, which continue to react with other pipes along the way.

Similarly, on a cellular level, high glucose levels activate unfavorable pathways within endothelial cells resulting in the production of ROS (reactive oxygen species), AGEs (advanced glycation end products) and reactive dicarbonyl compounds, contributing to oxidative stress and inflammation.

At the beginning of the pandemic, there were numerous reports of COVID-19 patients suffering from thrombosis (i.e., blood clots) in various locations (e.g., lungs, brain, legs, toes). Though it has been postulated that direct injury to vascular structures could be the main cause of blood clots, predominantly due to SARS-CoV-2 targeting ACE2 receptors, which are present on the surface of endothelial cells. Damaged endothelium activates the host’s innate immune system to recruit platelets, which form clots at damaged sites. Despite its protective intentions of wound repair, when frequent, this increases risks of thrombosis (occlusion) and embolism (where the blood clot breaks apart, gets carried within the bloodstream, occluding a smaller blood vessel).

Aside from direct causes of blood clots, there have also been postulations of indirect causes. The diabetic endothelium produces ROI (reactive oxygen intermediates, which is a type of ROS). ROI has been observed to interrupt the functions of eNOS (endothelial nitric oxide synthase), which is an enzyme that synthesizes NO (nitric oxide).

NO is an essential cellular signaling molecule that maintains vascular tone via vasodilation (which in turn keeps blood pressure at a safe level); it is also an immunomodulatory agent that reduces the release of pro-inflammatory cytokines by macrophages and inhibiting platelet aggregation. Without sufficient NO, the aforementioned processes become dysregulated: absent vasodilation leads to vasoconstriction and hypertension, uncontrolled immune cells would worsen inflammation, and platelets would inappropriately aggregate, placing the individual in a hypercoagulable state (an increased tendency to develop blood clots), with higher risks of developing coagulopathies when infected by COVID-19.

2. Hyperglycemia induces Immune System Dysfunction 🐛

Aside from the vascular complications manifested in diabetes, infections are a particular concern to this population group, due to their immune system’s inability to effectively fight off pathogens. There are two broad categories which explain these immune dysfunctions; they are mainly: suppression of cytokine production and defective immune cells.

Several studies have observed that in individuals with diabetes, their immune cells produced significantly lower cytokines compared to healthy individuals. Interestingly, when white blood cells from healthy individuals were exposed to a high glucose medium, they produced less cytokines (IL-2, IL-6 and IL-10) when stimulated by antibodies. Another study exposed healthy individuals to a solution of glucose and octreotide (a hormone drug that suppresses insulin secretion, inducing a state of hyperglycemia), revealed reduced expressions in IL-6 and IL-17A by certain immune cells. In order to understand the significance of cytokines, we have to first look at the sequence of events when an infection occurs.

In the early stages of infection, pathogens and inflammation processes that damage host tissues would emanate signals that activate the innate immune response. This triggers a group of specialized white blood cells known as granulocytes, as well as NK cells (Natural Killer cells) — the latter mainly produce interferons (a type of cytokine) in order to activate other white blood cells, notably macrophages. Activated macrophages then synthesize other cytokines such as pro-inflammatory interleukins (IL-1, IL-6, IL-8, IL-12) and TNFs (tumor necrosis factors) in an attempt to fight off invading pathogens as an acute response, simultaneously mounting the body’s adaptive immune system.

Based on the aforementioned events, reduced cytokine release in the presence of hyperglycemia may attenuate the body’s immune response against invading pathogens. Interestingly, this observation has been made in France, where a study looked at the interferon responses in different COVID-19 patients. Apparently, patients with more severe forms of the disease had lower interferons compared to patients with milder symptoms. Furthermore, studies using mice models infected with SARS-CoV and MERS-CoV viruses have shown that a strong innate immune response is crucial in resolving infections, whereas a delayed or inadequate response would result in an adverse inflammatory immune reaction, known as a cytokine storm, which has been well-documented in patients with COVID-19.

Aside from a blunted initial response to pathogens, hyperglycemia also causes immune cell dysfunction. In one study, diabetic mice models that were infected with pneumonia bacteria mounted a less aggressive immune response to the infection, which was evident from the presence of fewer granulocytes observed in their lung tissues and reduced cytokine production, compared to healthy mice models. In other studies, hyperglycemia has been shown to impair phagocytosis by specialized white blood cells known as macrophages (observed in diabetic mice models) due to defects in their complement receptors. Additionally, a state of chronic hyperglycemia was observed to increase the polarization of M2 macrophages in mice models — this type of macrophage contributes to immunosuppression, which is hypothesized to weaken one’s immune system against invading pathogens.

The impact of hyperglycemia on immune cells has been studied extensively; although some of its mechanisms still remain elusive, numerous preliminary findings have pointed at its adverse effects on the immune system. By having a better understanding on these mechanisms, novel treatment modalities could be developed to better manage infections in patients with diabetes; thus, improving prognosis.

3. Hyperglycemia disrupts RAAS 🔍

In an animal study that looks at ACE2 expression in mice organs, a group of non-obese diabetic (NOD) mice was observed to have increased expression in the pancreas, liver and kidney. Although this finding may not accurately translate to humans, a study that investigated the relationship of risk factors and ACE2 expression in human lungs discovered that diabetes is causally associated with increased ACE2 levels. This indicated that people with diabetes may have more ACE2 receptors, making them more susceptible to COVID-19 infection.

Prior to the pandemic, I was only familiar with the concept of ACE2 being a protein that makes up RAAS (Renin-Angiotensin-Aldosterone System), an endocrine system for pharmacotherapeutic agents (i.e., ACE inhibitors, ARB, etc) to manage hypertension. However, to viruses such as SARS-CoV-2, ACE2 is a gateway for cell entry and infection. As the virus locks onto an ACE2 receptor, they enter the cell together, causing a down-regulation (depletion) of ACE2. With more cells infected, the amount of ACE2 receptors decrease, resulting in a dysregulated RAAS.

The above figure represents a part of RAAS, the Renin-Angiotensin-Aldosterone System. Note that ACE is abundant in the lungs. There are two pathways leading to completely opposite outcomes. In COVID-19 patients, down-regulated ACE2 would mean the ACE2/Ang-1(1–7) pathway (in blue) has been attenuated, and is less likely to produce protective effects. The system then shifts to the ACE/Ang II pathway (in red), which further causes vascular permeability contributing to pulmonary edema, and aggravates inflammation in the lungs, due to the nature of Ang II and AT1 receptors mediating inflammatory cells (e.g., macrophages).

With this adverse outcome in mind, imagine how disastrous it would be if compounded in diabetic patients who supposedly have more ACE2 receptors.

With the recent surge of COVID-19 cases in South Asia countries, I couldn’t help but wonder if ethnicity might have contributed to disease severity. Interestingly, several studies revealed that South and East Asians are prone to developing diabetes due to several biological factors such as genetics (eight novel alleles have been identified in East Asians with T2DM), reduced insulin secretory function, and smaller pancreatic beta-cell mass. When compounded with external factors like lifestyle changes, economic development and the impact of industrialization, these further fuel the rise of this chronic metabolic disease.

It is no surprise that India has been dubbed as “the world’s capital of diabetes”, whereby every one in six people with diabetes is from India. Unfortunately, India also has the most number of COVID-19 deaths among Asia countries, ranking third highest in the world with a death toll of 418,511, just behind Brazil (544,302) and America (625,363), at the time of writing this article.

Despite the contagious delta variant (B.1.617.2) first detected in India, which has since ravaged the country, it raises a possibility that the impact of this variant could be more devastating when combined with a baseline of diabetes. Nevertheless, other variables such as demographics, presence of comorbidities, socioeconomic status, blood glucose management, etc., should be taken into consideration if this hypothesis were to be investigated.

Amidst the grim reports of diabetes and COVID-19 mortality, a preexisting anti-diabetic medication has been making headlines: Metformin. This medication reportedly reduces mortality in COVID-19 patients, and may have properties beyond glycemic control (even capable of modifying the gut microbiome), which is definitely worth exploring. If this is right up your alley, stick around for the next update!

As always, stay safe.❤️

Love, Alice

Diabetes in the COVID-19 Era: How Deadly Is It? was originally published in Microbial Instincts on Medium, where people are continuing the conversation by highlighting and responding to this story.

A short guide for fellow doctors who are considering the OET, but unsure of where to start — personal resources & tips included.

What is the OET? 👀

OET, short for Occupational English Test, is an English language test that accesses the healthcare professional’s proficiency within an English-speaking environment. What makes this proficiency test stand out is the way it’s structured specifically for 12 types of healthcare professions, where their language abilities are tested with simulated scenarios of an English-speaking workplace.

Who is this test for? 👥

For healthcare professionals (specifically these 12 professions: medicine, nursing, occupational therapy, optometry, pharmacy, physiotherapy, radiography, speech pathology, podiatry, dentistry, dietetics, and veterinary science) who need to prove their abilities to communicate in a healthcare setting to regulatory healthcare boards, councils and hospitals. A comprehensive list of organizations that recognize this credential can be seen on the official website.

Who recognises OET? | OET, English Language Test for Healthcare

Test Structure 📜

The OET is available in three modes: A paper format at a test venue, a computer format at a test venue, and OET at Home (a new format that was implemented near the end of 2020 due to the COVID-19 pandemic).

The test comprises of four sub-tests that accesses the following domains of language:

• Listening (45 minutes)
• Reading (60 minutes)
• Writing (45 minutes)
• Speaking (20 minutes)

These sub-tests closely mimic real-life scenarios you’d encounter in the workplace — e.g., for the listening sub-test, you may be asked to listen a dialogue between a general practitioner and a patient with asthma, and tasked to fill in the blanks of the patient notes on your exam paper; for the writing sub-test, you may be asked to write a letter of referral to a specialist for a patient contemplating bariatric surgery. Samples of the question paper can be found on the official website.

GMC’s English Proficiency Requirements & OET vs. IELTS 🔥

At the beginning of 2020, I planned to sit for the OET after my clinical placement ended at Oxford, but due to the pandemic, my test was cancelled. As a result, it was unanimously deferred to a later date, in which afterwards, I managed to re-schedule it in my home country instead. Despite the setbacks and uncertainties, I obtained 2A’s and 2B’s, which are needed for PLAB application (Professional and Linguistic Assessments Board, the UK medical license exam) and GMC (General Medical Council) registration, where the minimum requirement is scoring B’s (350–440) for all sub-tests.

Alternatively, you may opt for IELTS (International English Language Testing System), where you need a minimum score of 7.0 in each domain (i.e., listening, reading, writing and speaking), and an overall score of 7.5 for GMC registration.

However, if you’re planning to apply for UKFP (UK Foundation Program) after completing PLAB, the minimum requirement is slightly higher than GMC registration — you’re required to score at least 400 for each sub-test for OET, while you need a minimum score of 7.5 in each domain for IELTS.

Although IELTS is much cheaper than OET (around 206 USD and 440 USD respectively), I personally recommend taking the OET for three main reasons:

1. You’re more likely to pass (i.e., get B’s for all sub-tests as per GMC registration requirement) within your first attempt, by practicing with the right sources (more on that below).
2. Studying the OET will feel like a breeze! 🙌 This test contains familiar topics you’ve dealt with throughout your medical school and have seen or heard during internships in hospitals. On the other hand, IELTS contains a wide variety of topics ranging from climate change to economics and technology, just to name a few.
3. Having done my research on both English tests and connecting with peers, as well as colleagues from online PLAB communities, I’ve seen my fair share of candidates investing a large sum of money (and time) in applying for re-checks (costing around 140 USD), as well as re-taking the IELTS altogether, but to no avail. Apparently, obtaining a score of 7.0 and above for the writing domain in IELTS is a difficult feat for numerous candidates, despite personally knowing how some of them are utterly fluent in the English language! As a result of the test’s stringent requirements, most candidates are often stuck with a score of 6.5 for the writing domain. Thankfully they took the OET afterwards, obtaining the scores they needed within a single attempt.

A Little Background & My OET Preparation 📝

• Despite studying in international schools growing up, I have horrible spelling habits (last time I checked, I wasn’t dyslexic).
• I prefer watching movies, reading articles and listening to songs in English — although being exposed to the language on a regular basis increases confidence levels and makes the test appear less daunting, it doesn’t mean I have an excellent command of the language. Practice makes perfect, which is one of the main reasons I started blogging. 😁
• Looking back, I spent close to 2 months preparing for OET, while juggling with PLAB 1 revisions and work. I remember doing one timed sub-test per day, and watched E2language / Youtube videos on areas that I was struggling at, while making notes.
  When I was down to 3 weeks till test day, I practiced full mocks every other day, while spending 45 minutes on a writing sub-test every day. Over the weekends I would practice the speaking sub-test with a friend via zoom, followed by a debrief session, pointing out areas needing improvement.
• Note that for the OET paper format at a test venue, the audio for listening sub-test is played with speakers, not headphones. During your practice, try to play the audio files via speakers as well, to mimic test day conditions.
• As the test center is located in another city, I made arrangements to arrive there a day before test day, and booked a quiet hotel room within walking distance to the test center.
  (I recall traveling being excruciatingly difficult due to the constant changing flight regulations at the start of the pandemic.)

How to Travel Safely During a Pandemic

Useful Resources & Tips for each Sub-test 🍭🍬

• E2language online course
  I signed up for the free course and found it sufficient for my preparation, though there are paid ones to tailor your needs. The free course consists of live classes, practice questions and lessons on test-taking methods.
• YouTube videos
  Personally, I found the writing and speaking sub-tests quite challenging; these videos have helped me on how to approach the writing task and what to expect during the speaking sub-test.
• If you have an E2language account, I highly recommend subscribing their newsletter — that’s how I found out about their mini-mock test for writing and speaking.
• Consider subscribing to quality writing and speaking services to gauge how well-prepared you are for the test.
• Alternatively, get someone to practice the speaking sub-test and ask for their feedback.
• After learning how the test runs at the start of your preparation, do a timed mock for all sub-tests, including speaking, if possible. (You may find free samples on the official OET website.) Identify your weakest sub-test, then work on improving it by watching the respective teaching videos on E2language or YouTube, while doing more sample questions.

Listening 🎧

• Parts A & B — Scan the notes (in part A) or questions and multiple choice options (in part B) first. Pay attention to key phrases (i.e., words alluding to the answer in the notes or question) as the audio plays. You’ll be able to pick up the answers with ease, if you know what you’re looking (more accurately in this case, listening) for. 😉
• Part C — I found this section the trickiest. Pay close attention to transitions in the conversation based on the questions asked; it is easy to miss out if you lose concentration here.

Reading 📖

• Part A — Scan the questions (not all at once, rather, work through this section block by block according to question type: e.g., for Questions 1–7, we’re asked to match the reading materials to each question), then scan the articles while searching for the answers.
• Parts B & C — Read the questions first, then read the respective paragraphs. Ensure you fully understand what the paragraph has discussed before matching it to the correct multiple choice answer.

Writing ✏️

• Make sure you know OET’s letter format by heart (i.e., the recipient’s address) and try not to exceed the word limit (180–200 words).
• If you’re taking the paper-based test, practice writing daily on lined paper with black or blue pen; if it’s the computerized version, practice typing on a laptop or computer.
• Start off your writing practice without a time limit for the first few sessions, then ease into a habit of completing the writing task within 45 minutes. This prepares you for the stress you’ll encounter on test day.
• Get a friend or colleague to hold yourself accountable (for your writing practices), who is willing to offer you constructive feedback according to the writing tasks’ model answers.
  Based on personal experience, I noticed my friend improving her letter writing drastically after doing this with her for 2 weeks! She passed all sub-tests as well!
• Get acquainted with writing different types of letters — e.g., letter of referral (most common), letter of transfer and a letter of discharge.
• When you feel relatively ready and would like to gauge your writing (and speaking) performance, sign up for mock tests (i.e., writing practice services) at least 2 weeks prior to test day, so you have sufficient time to catch up on areas that need improvement.

Speaking 💬

• It’s perfectly alright if you have an accent — just ensure you’re articulating and pronouncing the words clearly.
• Avoid medical jargon — refer to a list that substitutes medical jargon with layman terms recommended by E2language in one their speaking pdfs.
• Practice the sample speaking tasks with your friend or colleague, while adhering to the time limit (20 minutes). Refer to this video to get an idea of how the speaking sub-test is conducted.
• Similar to the writing sub-test, I highly recommend you to participate in E2language’s mini-mock test or quality speaking practice services to see where you stand, kinda like a forecast grade.
  Personally, the best part of these mocks was the feedback given by the examiner — they allocate points to a list of criteria, which makes it easy to identify parts that need polishing.

“Practice isn’t the thing you do once you’re good. It’s the thing you do that makes you good.” — Malcolm Gladwell

I hope this article gives you a better idea on the OET and that you’ll find these recommended resources helpful for your preparation! If you have any questions, feel free to leave comments here or get in touch with me via Instagram @alicehalim. 💌

Best of luck on your OET journey! 🍻

Love, Alice

How Your Gut Bacteria Influence Disease Development — Including COVID-19

A glimpse at the scientific milestones of gut microbiome over the years and what you can do to improve your gut health in times of COVID-19.

Coughing is one of the most typical respiratory symptoms of COVID-19. In fact, it is the most common presentation that warrants suspicion for a potential SARS-CoV-2 infection. However, when you suffer from a tummy ache, it is unlikely that “COVID-19” would be the first culprit on your mind, right?

Although gastrointestinal (GI) manifestations such as diarrhea and loss of appetite are the less commonly discussed symptoms of COVID-19, it is imperative for the public to be aware of its potential to spread via fecal-oral transmission and its link to unfavorable outcomes. A meta-analysis published in February 2021 investigated 125 scientific articles involving a total of 25,252 COVID-19 positive patients reported that 20.3% of them presented with GI symptoms.

That’s around 5,000 COVID-19 patients suffering from GI disturbance!

This article discusses how COVID-19 wrecks your gut, and sheds light on the intricate ecosystem that resides within your GI tract, as well as some dietary tips to improve your gut health.

The Gut Flora and its Microbiome 💩

Although the GI tract may not look like much (i.e., the intestine is basically a muscular hollow tube), do you know that around 100 trillion bacteria reside in your GI tract? These microbes, good and bad, are known as the gut flora (or the gut microbiota).

Microbes, together with their genes, living in our gut, are constantly interacting among one another as well as the cells lining our GI tract and the immune system; this fascinating ecosystem is collectively known as the gut microbiome, which plays a profound role in maintaining gut integrity, metabolism and immunity. Oftentimes, the composition of gut microbiota is dramatically changed upon subjected to antibiotic use, dietary interventions and disease exposure.

Some Milestones in History 🙌

Although one of the earliest descriptions of GI bacteria were made by an Edinburgh surgeon, Mr. John Goodsir in 1842, (interestingly, the implementation of gut microbes to treat food poisoning was first reported in ancient Chinese medicine some 1,700 years ago, more on that later), the gut flora remained an enigma until further investigations were conducted in the mid-nineteenth century.

Its turning point in medicine came when French pediatrician, Dr. Henry Tissier, with the use of anaerobic culture, discovered the Bifidobacterium bacteria in 1899. He observed that Bifidobacterium were present abundantly in the intestinal flora of healthy infants, while it was scarce in infants suffering from diarrhea. In one of his clinical trials, pure cultures of Bifidobacterium obtained from healthy infants were administered to children with diarrhea, who gradually recovered as their gut flora were restored.

With extensive research conducted on Bifidobacterium, this bacteria is known to produce beneficial compounds such as vitamins B and K, short-chain fatty acids (known for their anti-inflammatory properties) and lactate (balances the gut pH to create a friendly environment for good bacteria to thrive). At present, Bifidobacterium is one of the most widely used probiotics in the world, which are found in fermented foods like yogurt, kefir and sauerkraut.

What Are Bifidobacteria And Why Are They Important For Gut Health?

The procedure that Dr. Henry Tissier had done is what we presently call “Fecal Microbiota Transplant (FMT).” Interestingly, FMT has a long history of practice, tracing back to a Traditional Chinese Medicine doctor, Ge Hong, around 2,000 years ago in ancient China. It was reported that he used healthy human fecal suspension to treat patients with severe diarrhea and food poisoning. At that time, the fecal suspension, later dubbed as “yellow soup” for obvious gut-churning reasons, was known as a medical miracle, capable of bringing patients back from the brink of death.

Although the first reported use of FMT in modern medicine was carried out in 1958 to treat patients with severe refractory pseudomembranous colitis (the infectious pathogen, Clostridium difficile responsible for this GI disease was barely recognized then), this kick-started decade-long studies and clinical trials that described 81–100% of patients recovering from refractory pseudomembranous colitis after treating them with FMT. Fear not, by then, there was no “yellow soup” — FMT was administered via enemas.

Seeing how an imbalanced gut flora (scientifically coined as dysbiosis, where dys- meaning bad or difficult; -biosis meaning life) influence the progression of GI diseases, physicians and scientists began to wonder whether the gut microbiome was overhyped, or does it actually have a substantial impact on human health.

A Glance at Gut Microbiota in Extragastrointestinal Diseases 🔬

In 2013, the American Medical Association (AMA) officially recognized obesity as a disease. Although the primary cause of obesity is excess caloric intake and insufficient caloric expenditure, we cannot ignore the results of gut microbiome studies indicating certain bacteria groups predisposing individuals to obesity.

Within the same year, a transplantation study was conducted where researchers inoculated germ-free mice with gut flora obtained from obese and lean human twins, respectively. These mice were given equal amounts of food (low fat and high plant-based carbohydrates) and water. At the end of 7 days, it was found that the gnotobiotic mice carrying the obese twin’s gut flora had increased adiposity while mice with the lean twin’s gut flora remained phenotypically lean.

As mice have coprophagic (feces eating) habits, the researchers decided to house both groups of mice together for 15 days to observe if the composition of their gut flora would alter from consuming the feces of mice from the opposite group. Intriguingly, mice with the obese twin’s gut flora that were exposed to cohabitation, had a significantly lower increase in adiposity, in comparison to the same group of mice that were not exposed to cohabitation. In contrast, no changes in adiposity were observed from the group of mice containing the lean twin’s gut flora after cohabitation.

Further analysis revealed the obese mice adapted metabolic features of the lean mice’s cecal microbiome (a part of the large intestine) post-cohabitation, where a significant amount of Bacteroidetes bacteria were present, which were hypothesized to have been colonized by the lean mice’s gut flora fecal-orally. This research highlights a strong link between obesity and intestinal flora, with the lean phenotype being more resistant to gut microbiome changes.

Apparently, discovering this association was just the tip of the ice berg. Over the years, various bacteria groups and their influence on different organ functions via endocrine, immune and neural pathways have been increasingly studied. It has become a notable phenomenon to observe reduced gut flora diversities in the presence of obesity, old age, chronic antibiotics use and infectious diseases. In turn, this affects the development and maintenance of the host’s immune system. Germ-free mice were observed to have decreased immune cells in various organs throughout their development compared to gnotobiotic mice colonized with gut flora from healthy human donors.

Additionally, certain bacterial strains that make up the gut flora (e.g., Bacteroides fragilis, indigenous Clostridium species, segmented filamentous bacteria, etc.) played vital roles in regulating immune functions by directly inducing the responses of white blood cells and increasing the expression of genes that are associated with favorable antimicrobial properties.

Without these beneficial bacteria in our gut, we would probably suffer worse outcomes as a result of an impaired immune system. Speaking of which, brings us back to the elephant in the room: the COVID-19 pandemic.

How does SARS-CoV-2 affect the gut? 🤢

By now, it is no surprise that cells with ACE2 and TMPRSS2 receptors are prime targets of the novel coronavirus, SARS-CoV-2. These receptors are not only present in the lungs — they are also found throughout the gut: in the esophagus, liver, small intestine and colon. Upon infection, inflammation occurs, leading to intestinal problems and simultaneously affecting the gut flora, causing an unpleasant imbalance of the gut microbiome, known as dysbiosis.

One of the earliest reports from the pandemic observed decreased gut flora diversity and lingering dysbiosis after the clearance of SARS-CoV-2 via throat swabs and the resolution of respiratory symptoms. Aside from that, patients were also reported to shed the virus in their feces throughout their hospitalization; as some patients stopped shedding the virus earlier than others, the study further compared their gut microbiome composition. Fourteen bacterial species were identified to bear significant associations with fecal viral load in COVID-19 patients. Notably, a high viral load was inversely correlated with the amount of four types of Bacteroides species. What’s even more fascinating was the function of these Bacteroides: they are capable of downregulating ACE2 expression in murine colons.

This means that healthy levels of Bacteroides in the gut would keep ACE2 expression low. With the presence of fewer ACE2 receptors in the gut, this may prevent the binding of SARS-CoV-2 virus onto human cells, hence potentially protecting the gut from the novel coronavirus.

Throughout this pandemic, we were constantly informed that the elderly population has higher morbidity and mortality rates from COVID-19. Aside from old age, patients with underlying chronic diseases (such as obesity, diabetes, high blood pressure and coronary artery disease), which are associated with higher inflammatory states, are also at risk. Interestingly, the aforementioned population groups share a common similarity: they have a lower baseline of Bacteroides in their gut flora, which highly suggests that one’s gut microbiome makeup may implicate the severity of COVID-19 and overall disease outcome.

Referring to a meta-analysis that investigated over 20,000 COVID-19 positive patients, a higher incidence of fecal viral shedding was noted in patients who have experienced GI symptoms, ranging from nausea, vomiting, loss of appetite to diarrhea. This alluded that patients with SARS-CoV-2 in their GI systems may appear asymptomatic, until confirmed with either an anal swab or fecal test. Though the significance of viral shedding remains unclear (i.e., whether the feces contained live viruses at a high enough load to spread via fecal-oral transmission), and questions concerning public safety on whether a negative nasopharyngeal swab was sufficient enough for patient discharge — this prompted a number of hospitals to implement anal swabs and fecal tests as part of their management plans for COVID-19 patients.

From a clinical perspective, patients with GI symptoms reportedly experienced more adverse outcomes associated with ICU admission and increased mortality. Despite other human coronaviruses (e.g., SARS-CoV-1 and MERS-CoV) have also been known to affect the GI tract similarly, what sets COVID-19 apart was the pathological changes observed from these patients’ intestinal samples. While no obvious pathological changes were noted in SARS-CoV-1 and MERS-CoV viruses, considerable mucosal damage and erosions were observed throughout the GI tract in COVID-19, as well as the presence of numerous infiltrating white blood cells within the stomach, duodenal and rectal walls.

Principally, COVID-19 is a respiratory illness. However, we cannot ignore the increasing evidence pointing to the gut potentially having a hand in this disease. Having acknowledged this fact, what are some steps we can take to mitigate the effects of COVID-19 if, God forbid, we contract it one day?

Eating your way to a strong immune system 😋

Prior to the vaccine breakthrough, the best advice I learned about surviving this pandemic (aside from social distancing and mask wearing) was to strengthen my immune system by getting sufficient sleep, exercising daily and taking enough vitamin D (around 1000 IU per day, as I was not getting much sunlight from being indoors most of the time). Knowing that the gut microbiome may influence disease outcomes, it is essential to eat healthy as well.

In order to achieve a balanced gut microbiome, here are some dietary tips you may consider adopting:

• Probiotics — supplements or fermented foods containing live bacteria that are beneficial for your gut and protects you from inflammation; these include: yoghurt, cheese, kimchi, miso, sauerkraut, kombucha, tempeh, kefir, etc.
• Increase your fiber intake with prebiotics — the beneficial bacteria (and probiotics) in your gut feed on prebiotics to thrive. Prebiotics are non-digestible carbohydrates rich in fiber, often found in plant-based foods like: wheat, whole grains, mushrooms, rye, barley, legumes, garlic, onions, apples, bananas, carrots, etc.
• Reduce your sugar intake — studies have shown that the small intestine is unable to absorb excess sugars; once they make their way into the colon, this facilitates the growth of harmful bacteria while inhibiting the growth of beneficial bacteria, resulting in gut dysbiosis.
• Avoid processed foods — these foods are often high in fat, which has been shown to increase the levels of harmful endotoxin-producing bacteria in the gut flora, contributing to intestinal inflammation.
• Avoid using painkillers frequently — specifically NSAIDs (non-steroidal anti-inflammatory drugs), which are observed to alter one’s gut microbiome with chronic use and may adversely irritate your gut lining.
• Refrain from taking antibiotics unnecessarily — antibiotics kill bacteria, this includes the good ones residing in your gut, inducing dysbiosis and antibiotic resistance. Only take them as prescribed by your doctor.

Aside from these dietary tips, please be reminded to practice proper hand hygiene to avoid introducing unwanted pathogens into your gut or any part of your body.

The gut microbiome is fascinating, with much room for discovery thanks to the leaps and bounds of technology, from its breakthrough of culturing anaerobes in 1944 to genome sequencing and present-day metagenome-assembled genomes. Although the gut microbiome is by no means a magic bullet, knowing more about it will establish its role in diseases, as well as prompt future conceptions of effective treatment modalities.

In the meantime, feed your gut well. Since, quite literally, “you are what you eat”. ❤️

Love, Alice

How Your Gut Bacteria Influence Disease Development — Including COVID-19 was originally published in Microbial Instincts on Medium, where people are continuing the conversation by highlighting and responding to this story.

This is more than your average self-help book.

I didn’t expect myself to be here writing book summaries / reviews after a decade of graduating from middle school (yes, it has been that long). But this is a really good book, and I figured why not take this opportunity to make some notes for myself and simultaneously inspire others who happen to be reading this.

Couple of weeks ago, I planned to read Austin Kleon’s ‘Steal Like an Artist’, but ‘Show Your Work’ caught my eye, and since I’m on this blogging journey, reading the latter first seemed more apt.

What is this book about? 📖

‘Show Your Work’ is a brilliantly written 224 pages long, pocket-sized book containing 10 chapters filled with timeless quotes and practical advice accompanied by impactful illustrations (most of which I call them newspaper poems) to literally, show your work, without shoving it up people’s noses, and using the network, instead of wasting time networking. Austin’s idea revolves around the concept of “stealing” — by generously letting readers into his creative process, he allows them to “steal” from him, and from there, grows a like-minded audience while gaining feedback, fellowship and even, patronage.

For a person who is private about her work, I thought that is quite an interesting concept.

What are my thoughts after reading this? 👀

Initially, I thought the only way to promote one’s work was to actually get things done. Even better, accumulate a mountain of things and gradually (read: stingily), share them bit-by-bit (pun intended) on the internet. This misconception has held me back from setting an online presence more times than one. One of the best takeaways I’ve learnt was that our work is a never-ending process — we can (and should) share the various stages of our creative process from start to finish, this includes our thoughts, the things and people that inspire us, our interests, obstacles on the journey, the final product, etc., — which was what I did recently.

On a research network, I openly shared for the first time ever, what I was up to — what exam I was studying for and what research topic I planned to work on. To my pleasant surprise, within a week of updating my profile, I received an email from a professor asking if I were interested in collaborating with him based on my field of interest.

“Huh,” I thought to myself, “this book really works.” ✨

Who should be reading this book? 😁

• Anyone who is interested in creating an online presence
• To the painfully shy who needs a nudge to step out of their comfort zone
• To the networking enthusiast with no idea where to start
• Anyone with anything to share — if you think at least one person on this earth will benefit from it (or even put a smile on their face), then by all means, get your content out there. (I think Ali Abdaal said this)❤️

If you identify with any of the above (or even none at all), this book is bound to show you wonders.

My favorite quotes & some takeaways 💖

Disclaimer: Each chapter has multiple sub-headings; I selected a one to two concepts that deeply resonated with me.

Chapter 1: You don’t have to be a genius. 😜

Rather, be an amateur.

There’s a certain beauty to being an amateur — for one, you’ve newly experienced a phase (or currently on it) of a journey that others are about to embark. As the things you’ve just learnt are still fresh, you’ll be able to teach it far better than an expert, who has long forgotten these struggles.

Besides,

“Raw enthusiasm is contagious.” — Austin Kleon.

By making the effort of learning in the open and sharing your progress and enthusiasm, others with the same interest will end up finding and learning from you.

Chapter 2: Think process, not product. 💭

“In order for connection to happen, we have to allow ourselves to be seen — really seen.” — Brene Brown

Have you ever wondered how your favorite YouTuber creates their videos? What about your favorite comic artist and their stories — where did they get their ideas from? How do they design their characters?

Humans are naturally curious creatures — by unfolding what goes on behind the scenes, you’re connecting with your audience, not only with your work, but also as another human being. So, become a documentarian: start documenting the process of your work. Even if you’re not sharing it. This puts what you’re doing into perspective, allowing you to see how far you’ve come and appreciate the simple things in life.

“And when you’re ready to share, you’ll have a surplus of material to choose from.” — Austin Kleon

Now, how wise is that!

Chapter 3: Share something small every day. 💝

“Carving out a space for yourself online, somewhere where you can express yourself and share your work, is still one of the best possible investments you can make with your time.” — Andy Baio

I’ve been a passive bystander almost my entire life, which is quite ironic, given I’m the ‘radio’ in the family: constantly telling stories over dinner during my primary school days. Makes me wonder how I’ve lost that spark…

When I stumbled upon Ali Abdaal’s blog on an interview with David Perell, he mentioned, “To spend your life as a passive consumer and never step into the arena as an active creator is setting yourself up for a life of regret.” That quote hit me hard. And that’s how I started writing on Medium. 😄

Besides, by putting your work out there, you know what sucks and what doesn’t. Over time, you’ll perfect your craft from the feedback and reaction you receive, and eventually meeting amazing people.

Chapter 4: Open up your cabinet of curiosities. 🚪

Similar to the old adage — “You are what you eat” — you create what inspires you: from the books you read to the music you listen. Don’t feel guilty liking what others think of as ‘garbage’.

I remember being made fun of for reading, “How to Win Friends and Influence People” by Dale Carnegie, to which I was called ‘a manipulator’. Looking back, it was nothing to be ashamed of. I had awkward social skills and needed some help. I’m proud to say this book has added much value to my life, and I even revisit it time after time.

We should have courage to keep loving our garbage — this makes us unique. By being honest and open about our interests, we not only unlock space for creativity, but also become a connector to people who care about the same things too. From there, we branch out into deeper topics and discover new ‘garbage’. ✨

Chapter 5: Tell good stories. 💬

Contrary to the famous quote, “a picture tells a thousand words”, by adding a personal story to your work, it allows your audience to understand it better, and depending on how much they resonate with your story, affects the extent they value your work.

This was such a powerful realization.

“Personal stories can make the complex more tangible, spark associations, and offer entry into things that might otherwise leave one cold.” — Austin Kleon

Chapter 6: Teach what you know. 📝

This chapter really hits close to home.

Growing up in a competitive environment, I used to think that if you share your ‘secrets’, you’re inviting more competition into your niche. However, during university, after attending numerous teaching sessions organized by my seniors, and even being coaxed into teaching, I realized that life is not a competition for fixed pie. There’s always room for everyone. And by sharing resources, we encourage others to do the same; by working together, we expand the pie and eventually everyone has more to eat.

“Teaching people doesn’t subtract value from what you do, it actually adds to it. When you teach someone how to do your work, you are, in effect, generating more interest in your work. People feel closer to your work because you’re letting them in on what you know.” — Austin Kleon

Chapter 7: Don’t turn into human spam. ⚡️

I recalled reading Dale Carnegie’s ‘How to Win Friends and Influence People’ in my first year of uni. An advice from the book stuck with me: “To get people to like you, first you must be genuinely interested in other people.” When I expressed my interest in what my peers were doing, listened attentively to their endeavors and checking up on them once in a while, they in turn started showing interest in my work.

“If you want to get, you have to give. If you want to be noticed, you have to notice.” — Austin Kleon

It’s a simple two-way street.

Chapter 8: Learn to take a punch. 👊

It’s often too easy to identify ourselves with our work — especially for creators. By putting our content for the world to scrutinize, we invite room for praises and criticisms. It’s important to remember that our work is something we do; it does not define who we are.

“The trick is not caring what EVERYBODY thinks of you and just caring about what the RIGHT people think of you.” — Brian Michael Bendis

Yes, receiving negative comments suck. But bad criticism isn’t the end of the world. 😌

“As far as I know, no one has ever died from a bad review. Take a deep breath and accept whatever comes.” — Austin Kleon

Chapter 9: Sell out. 🔥

Remember that when we make it, we should lift up those who have helped us along the way. Pay it forward. Get into a mindset of gratitude and generosity — whatever you give abundantly, comes back unexpectedly.

“Above all, recognize that if you have had success, you have also had luck — and with luck comes obligation. You owe a debt, and not just to your goals. You owe a debt to the unlucky.” — Michael Lewis

Chapter 10: Stick around. 🙆

Persevere.

“The people who get what they’re after are very often the ones who just stick around long enough.” — Austin Kleon

It’s easy to burn out or feel like you’ve exhausted all your creative sources after actively churning out work after work around the clock. That’s when we should step away for a breather, to get inspired again.

Interestingly, when we feel as though we’ve learned all there is to learn, we shouldn’t be content with it. Rather, pick up something new. Become an amateur again. This helps us to keep growing and improving.

“Anyone who isn’t embarrassed of who they were last year probably isn’t learning enough,” — Alain de Bottom
(creator of The School of Life on Youtube — his philosophies are eye-opening).

If this post doesn’t convince you to pick up a copy of Austin Kleon’s “Show Your Work” nor does it get you motivated to kick-start your dreams of becoming an active creator, perhaps this part from the book might:

“Imagine if your next boss didn’t have to read your resume because he already reads your blog. Imagine being a student and getting your first gig based on a school project you posted online… Imagine turning a side project or hobby into your profession because you had a following that could support you… All you have to do is show your work.” — Austin Kleon

Hopefully this post inspires you, like how I was after reading the book. 💖

Looking forward to sharing more things in the future!

Love, Alice

For generations to come, there is no doubt that 2020 will be branded as the year of the pandemic. Perhaps 2020 will also make us realize how little we know about the coronavirus and post-viral smell loss. It took us by surprise when the majority of COVID-19 patients reported this unusual symptom, and we hardly know what to do about it.

Although it is established that COVID-19 (the disease), specifically, SARS-CoV-2 (the virus), causes respiratory symptoms (shortness of breath) by primarily infecting one’s lungs; an insidious finding has been reported in more than 50% of COVID-19 patients: anosmia (the loss of smell). Anosmia is also frequently accompanied by dysgeusia, a distortion of taste.

This makes sense if you think about the nose being linked to the windpipe, down the lungs, right?

Here are three possible mechanisms describing how SARS-CoV-2 causes anosmia, as well as potential treatment options to restore the sense of smell.

How does SARS-CoV-2 invade cells? 👽

In gist, SARS-CoV-2 has spike proteins on its surface. These spike proteins bind onto ACE-2 receptors present on the human cell membranes, facilitating cellular entry and infection, leading to the shedding of new virions. These ACE-2 receptors are abundant in a number of organs such as the lungs, small intestine and blood vessels, as well as cells present in the nasal cavity.

Infection mechanism may influence recovery speed 📈

I. Nasal congestion 😷

Imagine having a stuffy/runny nose from catching a cold. It’s difficult to pick up the smell of your mom’s cooking, and your favorite food doesn’t taste the same. Nasal congestion may contribute to a temporary loss of smell. However, this is the least likely cause of anosmia given the high incidence of COVID-19 patients reporting an absent stuffy/runny nose.

As such, researchers proposed that SARS-CoV-2 may instead target cells involved in scent detection as well as the neurons that perceive them.

II. Cellular damage 😡

This study investigated the expression of ACE-2 receptors in the scent detection region of the nasal cavity: the olfactory epithelium, comprising of olfactory sensory neurons (short for OSNs, which are responsible for detecting and transmitting odor information to the brain) and a group of supporting cells (i.e., basal stem cells and sustentacular cells).

Mouse models and human autopsies revealed that ACE-2 receptors are highly abundant in supporting cells, in contrast to OSNs, where none are present. This prompts a strong possibility that SARS-CoV-2 infect supporting cells, which in turn damages the OSNs, resulting in transient anosmia. This is a temporary phenomenon as supporting cells do regenerate.

Another proposed mechanism contributing to anosmia is the inflammatory response elicited by vascular cells upon SARS-CoV-2 infection. This causes collateral damage to the olfactory bulb neurons due to diffused vascular inflammation. As seen in the image below, the vascular cells and neurons are in close proximity. Once the inflammation resolves, patients gradually recover their sense of smell.

On a molecular level, this inflammatory response may also occur in supporting cells within the olfactory epithelium, where inflammation triggers the release of certain molecules (e.g., type I interferon) that down-regulate the expression of odor receptors in OSNs.

Without these odor receptors, the OSNs can’t detect scent particles that have entered the nose — this information won’t be delivered to the brain, resulting in anosmia. Similarly, once inflammation resolves, patients gradually regain their sense of smell.

III. Cell death 💀

If the infection is severe enough, it’ll cause cell death to either OSNs or supporting cells, which is the mechanism hypothesized in patients with long-term anosmia lasting longer than 4 months.

However, data from this study reassuringly reported that more than 90% of their patients eventually regain their sense of smell after 6 months.

What does this mean for COVID-19 patients? 👃

Interestingly, the majority of COVID-19 patients (85%) presented with anosmia tend not to develop severe respiratory symptoms, although some may experience mild bouts of dry cough. Note that they are still contagious at this stage and ought to follow self-isolation and mask-wearing regulations.

Despite the fact the olfactory epithelium has one of the fastest regenerating cells in the human body, ranging from days to weeks, reports have shown that, on average, COVID-19 patients recover their sense of smell within 3 weeks, while some as long as 6 months.

Don’t they regenerate super fast? Why does it take so long to recover?

Researchers have narrowed this phenomenon down to two reasons: Genetic predisposition of the host and genetic variation of the virus.

The former hypothesized that individuals with different genetic polymorphisms of SARS-CoV-2 entry proteins (i.e., ACE-2 and TMPRSS-2 receptors) in cells lining the olfactory epithelium are predisposed to the virus, resulting in larger viral loads and more cell deaths. This is highly plausible given the dense concentration of SARS-CoV-2 entry receptors present in supporting cells of the olfactory epithelium. With more cell deaths, it would take longer for these cells to regenerate, hence a longer period of anosmia.

The latter suggested that mutated SARS-CoV-2 viruses may have a stronger affinity to olfactory epithelium cells, leading to severe inflammation that inhibits the regeneration process, leading to prolonged anosmia.

Studies on Recovery 🔬🌷

Although olfactory impairment is not life-threatening, it could cripple one’s quality of life, especially to patients who rely on them for their livelihoods, such as chefs.

Presently, experts are looking into treatment modalities such as olfactory training to strengthen the remaining olfactory function. Olfactory training involves repeatedly sniffing a set of essential oils (e.g., lemon, rose, eucalyptus and clove scents) for 20–30 seconds, twice a day, to stimulate various olfactory receptors and establish new neural pathways to the brain’s olfactory center, essentially retraining how the brain perceives odors.

Previous studies have shown promising results of substantial olfactory improvement in (non-COVID-19) post-infectious patients who underwent 3 months of olfactory training.

In addition, given the inflammatory havoc SARS-CoV-2 is notorious for, researchers are investigating the role of systemic and intranasal corticosteroids in COVID-19 patients to mitigate inflammation. Without inflammatory components flooding the nasal epithelium, the regeneration process will no longer be inhibited, which by theory, should gradually restore one’s sense of smell.

Other medications previously used in post-infectious patients that are now under investigation for patients with anosmia due to COVID-19 include:

• Intranasal sodium citrate spray that was trialed to improve olfactory function by modulating cellular signal transduction cascades.
• Adjuvant use of intranasal vitamin A to promote neuron growth.
• Omega-3, as an adjunct to olfactory training, for its anti-inflammatory properties.

Given the magnitude of this pandemic and the high prevalence of COVD-19-related anosmia, of which at least 10% of these patients continue to suffer from anosmia longer than 6 months, finding effective therapeutics capable of restoring olfactory function is all the more important now.

This is my first time attempt at writing a scientific topic on Medium. Hopefully, you found it as interesting as I did!😄 On that note, I would like to end this post with a quote by UN Secretary-General Antonio Guterres:

“We are in this together — and we will get through this, together.”

Please, take care.⭐

Love, Alice

P.S.: I have another interesting COVID-19 related topic lined up.💩💩

COVID-19 and Smell Loss: What is Known about Mechanism and Recovery? was originally published in Microbial Instincts on Medium, where people are continuing the conversation by highlighting and responding to this story.

Essentials for the digital era.

Having spent the past six years studying in Shanghai, China, I’ve come to realize how much my life has revolved around smartphone apps. Don’t get me wrong, I’m neither addicted nor dependent on them, it’s just that having them around has made my stay in China exceedingly convenient. Except for a few must-haves — which I find essential to my survival.

Without further ado, here are the top 10 apps you should be downloading before coming to China in order to have that smooth transition experience:

1. To breach ‘The Great Firewall of China’: NordVPN 🌐🔥

China is infamous for its strict internet censorship policy. For years, they’ve had an impenetrable firewall, where you won’t be able to access basic search engines of the web from within the country, like Google & Wikipedia, and neither would you be able to share pics of that stinky tofu you were coaxed into devouring on Instagram and Facebook, nor would you be able to tweet about it on Twitter!

Thankfully, a handy tool known as VPN, allows you to bypass that firewall. VPN is short for Virtual Private Network. It connects your laptop, smartphone or tablet to a server in another country so that you can browse the web anonymously via that country’s internet connection. It’s as if you are from another country, and could assess websites you normally wouldn’t be able to due to internet censorship. Besides that, a VPN keeps your data secure from less trusty public Wi-Fi hotspots when you surf the web at your local coffee shop.

Having experimented with both free and paid VPN services over the past 5 years, and often grunting in frustration at the slow connection speed free VPNs had offered, I finally settled on the most reliable and great value for money VPN service: NordVPN!

I’ve been using this VPN for years now, and have never encountered any problems, unlike a couple of other paid services I’ve used in the past where slow or choppy connections discouraged me to continue using them. NordVPN has a practical interface and it allows you to connect up to six devices, which is a pretty good deal to share with family and friends who want to keep their data private and / or stream Netflix from different countries.

By the way, it’s NordVPN’s birthday and they’re offering a whooping 68% discount for their 2-year package!🎉 Can you believe that?

Please note that it’s an affiliate link, so you’ll be doing me a favor if you purchase it here. ❤️

NordVPN: Best VPN Service Provider | #1 Editors' Choice

To dearest readers based in China, the above links might not work. Please scroll down to the bottom of this post to get your special NordVPN link.❤️

2. Social Media: WeChat 📱💬

Imagine the popular Whatsapp, now combine it with Facebook’s media and status sharing features, and top it up with a money transfer function akin to Paypal. There you have it: WeChat (微信).

“When in Rome, do as the Romans do” — when in China, make sure you have WeChat. As an undergrad, be prepared to have class announcements and documents delivered via WeChat. If you don’t have it installed, you’ll miss out a lot of things, including the fun stuffs like virtual red packet snatching during the lunar new year in group chats and sending customizable stickers / emojis.

3. To get around: Gao De Di Tu🚶🚍

I’m not sure why but I’ve never used Google Maps to navigate my way around Shanghai before, though my friends have used them and it was pretty accurate. I can only assume that a local app would be more reliable, so I stuck with Gao De Di Tu (高德地图). And boy was it good.

I would bike around Shanghai with an earpiece to listen directions from the app. Aside from my clumsy navigation skills and the lack of chill when I needed to make a turn (where all of a sudden, I developed two left hands, or better yet: two left hemispheres), this app always got me to where I wanted to go via the shortest paths. As a bonus feature, it also calculates the amount of calories burnt (if you’re walking or cycling) and would share random facts once you’ve traveled a certain distance. I vividly remember biking back to the dorms from the Pediatrics hospital, which was an hour by subway; half-way through my journey, the app happily shared that I’ve rode 3 times around the Tian’anmen Square (which is a monument, and also a national symbol, in Beijing, China’s capital city).

That was my most unforgettable experience with Gao De Di Tu. Please note that this app’s interface is displayed in Mandarin.

4. Dictionary: Wang Yi You Dao Ci Dian, Pleco, Google translate 📖

For aspiring medics wanting to study MBBS in China, Wang Yi You Dao Ci Dian (网易有道词典) will be your best friend (especially during internship) as, at least 90% of the time, it correctly translates drug names into their proper English versions. Not some quirky mistranslation that’ll send you hurling with laughter. This dictionary app also includes multiple languages such as German, French, Japanese and Korean, and has other unique features like my favorite scan-and-translate, and real-time voice translations. What makes Wang Yi You Dao Ci Dian unique is its customizability — when you first download it, you get to choose what you’ll be using this app for according to your needs — i.e., are you a middle schooler, undergraduate, postgraduate, etc. Please note that the app’s interface is in Mandarin.

Next in line is my daily go-to: Pleco — partially because I’ve just gotten so used to using it, but mainly for its simple user interface, and that I can check the words’ pronunciation and their usage in sample sentences. Besides, you don’t need an active internet connection to access it.

Google translate also works offline as long as you download the language pack. As it has significantly improved over the years, and even incorporated AR technology (i.e., translating words real-time through your phone’s camera lenses), I do highly recommend it.

5. Join in the Online Shopping Cult(ure): Taobao, Jing Dong 💻📦

China has seriously given the word, ‘convenience’, a massive upgrade.

I was initially skeptical at the launch of Taobao (淘宝) near the end of my 2nd year of uni, as the app was fairly new then; plus, I was not convinced of the quality that comes with cheap prices. To my surprise, friends around me shared what I was missing out: apparently there were tons of good quality products (if you know where and how to look), and a number of companies opened their virtual shops on Taobao, such as Uniqlo, Hotwind, H&M, Decathlon, etc.

During the annual singles day (11th November), numerous shops would offer tempting sales and massive discounts! I kid you not: I actually shopped a year’s worth of supplies on Taobao during singles day. For items that weren’t to my liking (i.e., poorly fit shoes and clothes), the app offers free pick-up refund services where the delivery guy collects the items right at my doorstep! It’s really not an exaggeration when I say that you don’t need to leave your house to shop in China.

You can find almost everything on Taobao: clothes, books, cleaning supplies, electrical appliances, tour packages, and even food and snacks! Note that electrical devices like laptops and hard drives are best bought on Jing Dong (京东), abbreviated as JD, as it is known to be more reliable. I bought my laptop from JD in 2019 and have been using it since without any problems — I even got a promotional offer that upgraded my disk space for free!

6. Food Delivery: Eleme, Meituan 🍜🍕🍛

This has to be the highlight of living in China: the food delivery culture.

When I crave for some variation outside of cafeteria food, I’d whip out the ‘OG’ Eleme (饿了么) app and order munchies ranging from the snow city up North, Harbin’s famous classic savory wrap, Chun Bing, to a simple box of Korean fried chicken drizzled with honey mustard sauce or my all-time favorite, Domino’s potato bacon pizza (yes, that’s a thing in China, and it’s absolutely scrumptious). As these shops were within range, they would take no more than 30 minutes to arrive at the dorms. However, if the delivery guy has not been to campus before, I had to describe in Mandarin how he can get here, which more often than not ended in him asking passers-by and security guards for directions. I’ve also bought groceries from Carrefour and Aldi on Eleme.

If I couldn’t find food stalls with free delivery, I’d switch to the Meituan (美团外卖) app, and vice-versa.

Note that both interfaces are in Mandarin.

7. For the Foodie at Heart — Review app: Da Zhong Dian Ping ☕️

Whenever my buddies and I are planning a surprise birthday dinner, or just want to visit some place new over the weekends, Da Zhong Dian Ping (大众点评) is our go-to app for the occasion.

Here, we find reviews full of photos and videos of restaurants, bars, pet cafes, museums, KTV (karaoke bars, where you sing till you lose your voice) and even amusement parks, which often comes with pictures of their menus / pricing, an online booking option and discount coupons.

Similar to the previous apps mentioned, Da Zhong Dian Ping also operates in Mandarin.

8. Cashless is the New Cash: Alipay 💳📲

I can’t remember when or how exactly ‘cashless’ became a thing; I probably downloaded Alipay (支付宝) when the nearest Family Mart (an ubiquitous mini mart) offered discounts if I purchased my favorite coffee via the Alipay app. Then it pretty much snowballed from there.

When you download Alipay, it’ll be linked to your China debit card (or an overseas bank card of your choice), which would also be linked to your China phone number and passport details. On the app, an option is provided to either top-up money into Alipay to make payments, or have the amount directly deducted from your bank card every time the cashier scans a QR code generated from the app.

I’ve to admit: it is pretty handy, and quite similar to the contactless payment system in UK, except you don’t need to pull out a card, just your phone. Let’s be real, that device is practically an extension of your body. WeChat pay is the payment system on the WeChat app, which works in a similar manner.

Both of these apps allow you to top-up your phone credits too! How convenient is that?

I almost forgot to mention that you can even purchase movie tickets (as well as train and flight tickets) on Alipay. They usually come with discounts and popcorn coupons!

9. Cabbing / Taxi apps: DiDi, Di Da Chu Xing 🚕🚗

Sometimes, cabbing / getting a taxi is cheaper than taking the subway, especially when you’re traveling in groups of four. In the west, Uber is a very popular option in America, but in China, DiDi takes the trophy.

The DiDi app is available in both Mandarin and English. From personal experience, DiDi drivers are more common than Uber drivers, although some drivers have both apps. Imagine my surprise when a DiDi driver cancelled on me, only to re-appear on my friend’s Uber app instead! On average, I wait around 5 minutes to be picked up, though the waiting time may stretch up to 20 minutes on a rainy day.

If you have to travel long distances via cab / taxi, I highly recommend the local carpooling app, Di Da Chu Xing (嘀嗒出行). I’ve used it many times ever since I was first introduced to it to get to the airport. Di Da Chu Xing was at least 3 times cheaper than DiDi! It has saved me a lot of money! Besides, it was a safe app, and I was never late to the airport, despite the driver picking up and dropping off passengers while I was on board. I particularly liked the booking function, where I can contact the driver a day before departure to discuss my itinerary and the number of baggages I’d be bringing.

Do note that DiDi also has a booking function! And, heads-up: Di Da Chu Xing operates in Mandarin.

10. Shared Bikes: Ofo, Mobike, etc. 🚲

When the army of little yellow bicycles first flooded the streets of Shanghai, I was beyond relief, as my bicycle was stolen at the end of first year in university, and I was extremely hesitant to get myself another one.

Ofo was the original bike sharing company to first hit the streets of China. Just download the app, register with your ID (i.e., passport or student card), wait for a couple of hours to have your identity verified, and you should be good to go! If I’m not mistaken, only students were not required to pay a deposit during registration at that time. When you need to unlock a shared bicycle, simply open the app to scan the QR code on it. Back then, a 4-digit code would appear for us to manually punch in the key pad. Nowadays, the app switches on your phone’s Bluetooth to unlock the bicycle automatically. Real smart huh?

I recall when Ofo started out: numerous bicycles were stolen and vandalized. As stricter rules were imposed, the numbers of bicycles dwindled. There was even an article reporting that Ofo was on the brink of bankruptcy, though I can’t say for certain if that had happened. Update: Ofo is no longer a bike sharing company; it is now a shopping app.

Troubled bike-sharing company Ofo is now a shopping app

As time passed, more bicycle sharing companies emerged. A personal favorite of mine is Mobike (摩拜), mainly for its sleek design and durability. I honestly found the orange Mobike bicycles more comfortable and easier to bike on as well as the ease in adjusting the saddle’s height, in comparison to rusty ol’ Ofo bicycles with their frequent broken chains and dented frames. Mobike operates slightly differently: no deposit was required during registration, but a small fee is charged every time you use a shared bicycle, which would be around 1 to 2 RMB (equivalent to 0.15 to 0.31 USD).

During my last year of uni, I’ve noticed that the digital payment app, Alipay, and the food delivery app, Meituan, launched their line of shared bicycles too. Looking back, it’s quite a cheeky move, as consumers don’t need to download new apps to use these bicycles if they already have the pre-existing Alipay and Meituan apps downloaded, which I’m fairly confident that most of them do.

There you have it: my top list of apps for you to download (and familiarize with) before setting foot in the ‘Middle Kingdom’. If these are too much for you, at least download the three essentials: NordVPN, WeChat and Eleme.

Oh, did I mention that Whatsapp is blocked in China? Make sure to download NordVPN here before you go!

NordVPN: Best VPN Service Provider | #1 Editors' Choice

Once again, this is an affiliate link — you’ll be doing me a huge favor if you purchase it here.😊

As always, I hope this has been a helpful read. See you around! ❤️

Love, Alice

P.S.: To all my dear readers based in China who need to download NordVPN, I got your back! 😉 Here’s a special link for you:

NordVPN | Online security for everyone

Life of an International Medical Student in China

A post-graduation personal reflection.

I remember my first day in university like it was yesterday: the thrill of being in a new country, the excitement of meeting my classmates for the very first time, laughing at the prison-like cafeteria trays (that have since become a daily staple), exploring Shanghai over the weekends and even getting lost on campus (yes, my sense of direction was beyond catastrophic). Fudan University was where I’ve found life-long friends and met amazing mentors. It has become my home from home. ❤️

For someone who rarely journals, this has been a wonderful opportunity to introspect and reflect upon the past 6 years of my university life.

Echoing Socrates’ renowned dictum, “The unexamined life is not worth living,”

Hopefully by sharing some snippets of my Fudan University life, it’ll offer you a sneak peek of the MBBS program and what to expect if you decide to come here. 😄

To read about my impressions of living in Shanghai, please click on the link below. 👇

6 Years in Shanghai: Thoughts

Impressions of the University 🏫

Expectations vs. Reality 👓

To be fair, when I entered medical school in 2014, I did not carry any expectations at all, except for the fact that once I’ve graduated, I’d be able to practice as a doctor. At that time, the MBBS program at Fudan University was fairly new — most of the teaching materials were translated versions of what the local students studied, with heavy emphasis on basic science in comparison to clinical medicine. Given my naïve mindset, and the professional procrastinator that I was, for the majority of my uni years, I mainly focused on nailing exams after exams. Unfortunately, this meant a whole lot of senseless memorization and cramming. It was only until the second half of med school, where I had the realization that my study techniques were flawed as I barely retained what I had learned. If I knew any better, I would’ve structured my studies differently. Thankfully, better late than never, my circle of friends shared sources they were using to study for USMLE (United States Medical Licensing Examination), such as: Kaplan, Sketchy, Boards and Beyond, Anki cards, etc., where I finally made sense of a lot of the theories I’ve memorized (or the lack thereof) earlier on.

One of the biggest misconceptions I’ve had for the longest time was the belief that the things I’ve learned from classes were enough to pass license exams and become a doctor. Unfortunately, this was a far cry from reality. Lectures essentially highlight important topics from textbooks — it is realistically impossible to squeeze 100 pages of text into 100 slides. This is a really silly epiphany, but reading additional references and watching external sources of lectures do not signify your unfaithfulness to the program (nor does it diminish its quality), but rather, you should embrace the uncomfortable awareness of the gaps in your knowledge, and are doing something about it, rather than letting that gap magnify over years to come.

Everything you learn in med school, be it the theories in class or even the study techniques you’ve developed, will be applicable for the rest of your life in one way or another.

I vividly recall an instance in fourth year when I blamed the school for unengaging lecturers and messy teaching materials. It was as if they did not care about our education since we were foreign students; when in reality, it was merely a handful of mediocre lecturers that fostered my disinterest. There was so much pent-up negativity that instead of spending time consulting other learning sources, I found myself constantly lamenting. Looking back, what had happened was beyond my control. Instead of playing the ‘blame game’, I should have actively sought for solutions in the face of adversity.

My Thoughts on The Learning Environment 📝

Teachers, Classmates & Friends 👬👭

From what I’ve noticed, the majority of medics around me were fairly individualistic — this was either a direct impact of the ‘bell curve’ normal distribution grading system (where only the top 30% of the class would receive an ‘A’ grade for each subject), or we’re simply hardwired to be competitive in nature — this resulted in most of us studying alone and solving things on our own, when in fact, asking for help and engaging in meaningful discussions were better options. I came to realize this during my fourth year when I studied alongside my buddies who were preparing for their license exams. Initially I couldn’t imagine that to be possible, as the three of us usually studied on our own. To my surprise, I learned a lot from them and never expected their friendship to play such a huge role in my uni life. ❤️

All teachers are required to conduct their lessons in English. However, bear in mind that English is their second language. Oftentimes, they appeared unenthusiastic and seemingly, blatantly, read from the slides as they teach; when the truth was they’re simply not confident with their command of the language. Interestingly, when we ask them questions using Mandarin, it was as if they’ve received the breath of life, and proceeded to explain flawlessly at rapid-fire speed.

The majority of our lecturers are either physicians or researchers. In China, or at least in Shanghai, publishing research articles is a prerequisite for physicians to be promoted. This means a ton of opportunities for undergrads to participate in research (and hopefully publish a scientific article while you’re at it).

Doing research during MBBS — yay or nay?

Facilities, Courses & Opportunities ⛳️

Aside from the major glow-up that our medical campus had after the construction completed in 2018/2019, which birthed a beautiful library, swimming pool, running track and an indoor gym, some improvements were also made to our curriculum: the introduction of PBL (Problem-based learning) classes, Clinical Skills elective and summer hospital electives — these changes were brought about by our amazing student organization and a very supportive administrative figure. I was lucky to experience some of these improvements, especially the Clinical Skills elective, which gave me confidence when carrying out procedures on patients during my internship year.

Despite the fact that the university’s MBBS program is taught in English, knowing the Chinese language opens up numerous opportunities outside the classroom ranging from participating in research to exploring club activities and joining seminars. You may even make voluntary trips to the university’s affiliated hospitals to shadow doctors and practice interviewing and conducting physical examinations on patients during your free time.

A night to remember

Personally, it has been a memorable 6 years in Fudan University. I couldn’t imagine being here today without the support of the school as well as the valuable friends, seniors and mentors I’ve met along the way. And of course, my dearest family, who always has my back.❤️

In my future posts, I’ll be sharing in-depth about my internship life in Fudan University, and life after graduation — this includes topics such as UK’s medical licensing exam (PLAB, short for Professional and Linguistics Assessments Board) and the Occupational English Test (OET) for doctors.

Do hang around a little longer — your company is always appreciated. 😌

See you in the next post!

Love, Alice

Top Tips to Kick-Start Your Very First Scientific Publication — part III

Things you’ll want to know before starting out.

In this final post of a “three part series”, I’ll be sharing my personal tips about research and publication that nobody has ever told you in med school, in hopes that somebody reading this will benefit from it. 🙈

Over the years of carrying out primary research during my undergrad years, I’ve acquired a list of things that anyone can do when aiming to publish a research paper within a relatively short span of time.

1. “Hop on a bandwagon” 💃

Do you know someone who is currently writing a research paper? Say, a lecturer, classmate, senior or a post-grad?

Express genuine interest in their work and ask if they need help with writing or editing, in exchange for an authorship. This is one of the quickest ways to obtain a publication as an undergrad. Sure, you may fall short in the experience and knowledge sector, but you have strong linguistic skills (especially if you’re an international student in a country where English is not their mother tongue, for instance, China) and grit — use those to your advantage.

Speaking from experience, when I was an MBBS student in China, almost all of the doctors I’ve shadowed and worked with had ongoing research projects. Apparently having research publications is a prerequisite for promotion.

This may sound unconventional to some of you, but at the end of the day, it’s a win-win for everyone.

2. Be proactive 🙋

Speak to doctors who are currently working on research projects and are keen to publish within 1 to 2 years. Express your need for a publication. E.g., to make your C.V. more competitive, increase your chances of getting a scholarship, etc.

Like the famous quote, “You miss 100% the shots you don’t take.”

Don’t hesitate to ask; chances are these doctors were once in your shoes and would more often than not resonate with your interests.

The worst thing that could happen is getting rejected. That’s perfectly fine.

Set your sights on the next target and move on.

3. Find a partner (or partners) 🙌

Doing research and writing a manuscript all on your own can be a very daunting and time consuming task. If you could find a friend or a group of friends who share the same goal as yourself, don’t hesitate to partner up!

Two heads is better than one. You’ll get the job done faster.

4. Apply for university grants 💰

If you happen to be in a similar boat as I was, conducting a primary research during undergrad, I strongly advise you to seek for university research grants. Although reagents are pricey, aside from the monetary factor, competing for a grant puts some perspective into your research as you are constantly introspecting. Besides, now you have a proud milestone on your C.V.

From personal experience, a portion of the grant would be allocated to your mentor for lab and equipment maintenance. Without a doubt, this acts as an incentive that prompts your mentor to offer you more support along your research journey.

5. Journal requirements & Literature Matrix 💎

Prior to writing your manuscript, make sure you’ve understood the journal’s format requirements (click here for an example). It is helpful to browse through previously published articles and pay attention to the headings and sub-headings.

Once you’re ready to start reading literature for your manuscript, create a literature matrix, which is essentially a table, to organize the information you’ve read and considered including into your manuscript. Ensure you’ve included the hyperlinks, titles, authors and year of publication in your table.

I found this a very effective way to organize massive amount of papers I’ve had to read when writing my research article. It also enables me to cite them with ease during the writing process.

6. Use online citation generators 💻

I remember the dread I’ve felt when learning how to cite resources during my last year of high school. No offense, it was one of the most useful classes I’ve had, but why do it yourself when an AI can do it for you ten times quicker and more accurately?

Before plugging your citations into the online generator, make sure you know which referencing format is required by the journal (e.g., Vancouver, MLA, APA, etc.,). Tons of citation services are available online, but my favorite is www.bibguru.com, as it has a super user-friendly interface. You may even create an account to save your list of references that can be conveniently exported in various formats.

Did I also mention that it’s ad free? 😜

7. Check your final draft with an online plagiarism checker 🔍

Prior to submitting your manuscript to the journal for a preliminary quality check, I highly recommend you to run your draft in an online plagiarism checker, like https://www.duplichecker.com, which I have been using, to ensure you do not copy another researcher’s work word-for-word, whether intentionally or unintentionally. Usually, a similarity of 12–15% and below is acceptable by journals. Personally, I try to keep it around 5–10%.

Bear in mind that plagiarism is a crime. Kinda like copying your friend’s homework and getting punished by the teacher when the cat’s out of the bag. You may risk getting sanctioned.

Congrats, you’ve reached the end of this series! 🎉 Although this has been a lengthy read (I’m assuming you devoured all three posts in one go), I genuinely hope you find these tips helpful in getting your very first publication.

Wishing you the best of luck. Until next time! ☺️

Love, Alice