Emory Health Digest Summer 2020 by Emory University

COVID’S NEW FRONT LINE | 8 BRING IN THE LASER | 26 BUILDING A BETTER MOUSE | 2 BRAIN HEALTH FOR VETERANS | 39

travel well

contents

Making the Leap 18 With urbanization, climate change, and humans encroaching on animal habitats, zoonotic diseases transmitted from animals to humans—like COVID-19—are becoming more frequent. What can we do to lessen their impact?

“WE ARE AT A CRISIS POINT. If we don’t radically change our attitudes toward the natural world, things are going to get much, much worse. Pandemics will become increasingly common. What we are experiencing now will seem mild by comparison.” –Thomas Gillespie, associate professor in Emory’s Department of Environmental Sciences and

Rollins School of Public Health.

Emory Healthcare workers take a knee in memory of George Floyd and others at the White Coats for Black Lives demonstration June 5 on the Emory Quadrangle.

Bring in the Laser 26 Intractible epilepsy doesn’t respond to medication. Ja’Lisa Thomas decided to try laser ablation brain surgery—and her seizures stopped.

contents

MUST SEE TV

The Emory Brain Health Center and Georgia Public Broadcasting (GPB) are partnering on an Emmy-nominated news magazine, hosted by Emory’s Jaye Watson. Go to emry. link/yfmepisodes.

Emory Health Digest Jonathan Lewin Exec VP for Health Affairs, Exec Director of the Woodruff Health Sciences Center, and President, CEO, and Board Chair of Emory Healthcare. Mary Loftus Editor Peta Westmaas Art Director

32 Building a Better Mouse 32 Because mice share more than 95 percent of our DNA, researchers can modify mice DNA to mimic and learn more about human diseases.

Long Road Home 39 Facing pain, depression, and trauma, veterans find help through an intensive program combining therapy, a community of peers, and a holistic view of wellness.

Jack Kearse Photography Director Janet Christenbury, Gary Goettling, Molly Dunham-Friel, Shannon McCaffrey, Damon Meharg, Stacia Pelletier Contributors Becca Moszka 21C, Megan Hockman Editorial Interns John Mills Online Communications, Senior Director Stuart Turner Production Manager Jarrett Epps Advertising Manager Wendy Darling Web Specialist Vincent Dollard Associate VP, Communications Jennifer Checkner Executive Director of Content Dave Holston Associate VP, Creative

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the well

and more

To Our Readers 4 A message from Jon Lewin, executive VP for health affairs, executive director of WHSC, and CEO of Emory Healthcare.

Patient POV 48 Inflammatory Bowel Disease isn’t the easiest thing to talk about. But when it started taking over her life, Molly Dunham-Friel (left) set about building a community.

The Well 5 Health equity dashboard, Emory’s new president, testing in rural Georgia, mapping pollution with NASA, expecting during COVID.

Policy Wise 50 Society must address the uneven delivery of and access to epilepsy care.

Emory Health Digest is published twice a year for patients, donors, friends, faculty, and staff of the Woodruff Health Sciences Center. © 2020 Emory University Emory University is an equal opportunity/ equal access/affirmative action employer fully committed to achieving a diverse workforce, and complies with all applicable federal and Georgia state laws, regulations, and executive orders regarding nondiscrimination and affirmative action in its programs and activities. Emory University does not discriminate on the basis of race, color, religion, ethnic or national origin, gender, genetic information, age, disability, sexual orientation, gender identity, gender expression, or veteran’s status. Inquiries should be directed to the Office of Equity and Inclusion, 201 Dowman Drive, Administration Bldg, Atlanta, GA 30322. Telephone: 404-727-9867 (V) | 404-712-2049 (TDD). 20-EVPHA-EVPHA-0010

travel well

INNER VISION SARS-CoV-2

The Virus that Paused the World

Surface of cultured cells

Colorized electron microscope image. Photo Credit: NIAID

Within weeks after the pandemic began, researchers across Emory mobilized resources and expertise to combat COVID-19—from advancing understanding of the SARS-CoV-2 virus to coming up with quicker, more accurate tests to finding treatments and a vaccine. For more: links.emory.edu/ covidroundup.

SUMMER 2020

to our readers

Jonathan Lewin, executive VP for health affairs, executive director of the Woodruff Health Sciences Center, and president, CEO, and board chair of Emory Healthcare.

We have been battling COVID-19 for the past several months and have seen the destructive power of this new threat to our communities and especially to communities of color.

In the midst of the hard work, stress, and fear of the pandemic, the resurgence of highly publicized acts of racism is a painful and difficult reminder of an ongoing struggle in those same communities. I believe that here, in the Woodruff Health Sciences Center—whether in the clinical setting, research laboratories, or classrooms—our diversity of backgrounds is one of our greatest strengths, and I am so proud of Emory’s many achievements in addressing COVID-19. But I also have never been so personally disappointed and outraged as I am now by the recent senseless and inexcusable racist actions across our nation and even in our own state. The names Ahmaud Arbery, Breonna Taylor, and George Floyd are the latest in what has been a continuous series of reprehensible actions across this nation. None of us were naïve enough to imagine that racism did not exist before these horrific incidents, and many in our community have personal experience with racism and bias. Indeed, our nation’s ongoing history of structural and sustained racism, along with

EMORY HEALTH DIGEST

systemic disparities of justice and health care, have resulted in far too many examples of violence and injury against people of color, and this fundamental injustice is deeply distressing and must be ended. Our aspirations for a racism-free world seem so very, very far away. For that, we should all be sad, angry, and at the same time energized to do all that we can to serve as forces of change. To support each other, regardless of race, and to confront both racism and the racists who would seek to divide and damage. Senseless acts of violence strike at the heart of Emory’s commitment to upholding equity, diversity, and inclusion, and we must stand together in solidarity with the Black community against racism and injustice. Our sense of purpose and common commitment to our work has allowed us to provide outstanding care to our patients during the pandemic. And I am more determined than ever to ensure that our Emory community continues to confront and address racism as we strive to embody the best values of our institution and of our nation. Jon Lewin evphafeedback@emory.edu

plan well

KNOW WHAT’S HAPPENING FIRST PICK YOUR STATE

COVID-19’s burden has not been spread equally. Some communities—particularly those with a large minority population—suffer high infection rates, hospitalizations, and deaths. To shine a light on the virus’ differential impact, researchers at Emory have developed the COVID-19 Health Equity Dashboard. “Our goal was to go beyond describing COVID-19 incidence in communities. We wanted to fill in the gaps about the interplay between the health outcomes and the underlying social determinants and other vulnerabilities, such as diabetes and obesity,” says Shivani Patel, assistant professor of global health at Emory’s Rollins School of Public Health who leads the team that developed the dynamic dashboard. On the homepage, users can see a snapshot of COVID-19 deaths across the country. Selecting a state brings up a map displaying mortality by county. Drilling down, users can select a county to see how it compares to the rest of the state and to the country in average daily cases and deaths, and in social characteristics, such as percentage of residents who are African American, percentage who live in poverty, percentage who are obese, percentage who have diabetes, and more. The dashboard allows users to compare counties within the same

THEN DRILL DOWN ON THE DATA

The color-coded map allows users to visualize the relationship between the virus’s impact and social determinants of health at a state-by-state, or even a county-by-county, level. covid19.emory.edu

SUMMER 2020

plan well

state, aggregating key metrics that tell a story of a community’s social and economic health. For each state, dashboard users can select a COVID-19 outcome measure—total, average, or per-100,000 COVID-19 cases or deaths—and a social determinants measure—household income, population density, percentage African American, among others. The result is side-by-side, color-coded maps that allow users to visualize the relationship between the virus’s health impact and social determinants of health at a county level. Going forward, Patel and her team plan to parse that data into a sub-county level to see how communities within the country are being impacted differently. In Georgia, for example, Patel is working with the Georgia Department of Public Health to break down COVID-19 cases, hospitalizations, and deaths by demographic categories, such as race, age, and neighborhood. “We see this as an evolving resource for a variety of audiences, including policy makers, public health practitioners, researchers, and maybe even clinicians,” says Patel. The dashboard, she says, could help officials assess whether local response to COVID is equitable across communities and tailor responses accordingly. It could also provide quick access to data to decide where it’s feasible to reopen businesses and where it’s not, where testing sites should be located, and—when a vaccine becomes available—which populations should be prioritized. “There is no onesize-fits-all approach to combat this pandemic,” Patel continues. “To predict how it will unfold and to prepare for the future, it’s critical to understand Shivani Patel, assistant the underlying risk factors that lead to professor of global higher incidence and health at Emory’s mortality.” EHD Rollins School of Public Health. ILLUSTRATION BY MICHAEL KONOMOS

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EMORY, PARTNERS GET COVID GRANT Emory is sharing in a $31 million federal grant designed to rapidly transform innovative technologies into widely accessible COVID-19 diagnostic testing. The supplemental award from

the National Institutes of Health (NIH) will go to researchers at the Emory School of Medicine’s Department of Pediatrics, Children’s Healthcare of Atlanta, and the Georgia Institute of Technology. In April, the three institutions were selected to lead a national effort in testing validation through the Atlanta Center for Microsystems Engineered Point-of-Care Technologies. The goal of the national initiative, known as the Rapid Acceleration of Diagnostics (RADx) program, is to make millions of accurate and easy-to-use COVID-19 tests available in time for flu season. The award to the Atlanta center is the largest in the RADx program and the largest NIH grant received by Children’s or Emory in a single budget cycle. “The one-time NIH supplement covers the course of one year, which means we have a lot of exciting and fast work ahead of us,” says Lucky Jain, chief academic officer of Children’s and chair of Emory Pediatrics. “We are confident in our team’s ability to make this a huge success and thrilled to see them at the frontline, leading the way in such a historic initiative.” As one of five NIH-funded point-of-care technology centers within the Point-of-Care Technologies Research Network, the Atlanta center will lead testing validation and work closely with partners across the country—including technology developers and others in the medical diagnostics industry. “We will vet and whittle down thousands of COVID-19 diagnostic tests the NIH receives from across the country to 10 to 20 meritorious projects, which our center will shepherd toward manufacturing and scale up with the objective of national deployment this fall,” says Wilbur Lam, associate professor of pediatrics and principal investigator. EHD

lead well

Welcome, President Fenves Gregory L. Fenves, president of the University of Texas (UT) at Austin, was elected as the 21st president of Emory University by a unanimous vote of the Emory Board of Trustees, and assumes office August 1.

Fenves succeeds Claire E. Sterk, who announced her retirement as Emory’s president in November 2019 after serving since 2016. “We are tremendously excited about the appointment of Greg Fenves, a world-class educator and brilliant leader,” says Bob Goddard, chair of Emory’s Board of Trustees and of the Presidential Selection Committee. “We wanted someone with deep experience leading a major research university and a stellar record of scholarship. We also sought an inspirational leader and a person of impeccable character. Greg Fenves embodies all that we hoped to find.” The committee led an international search that included more than 40 listening sessions throughout the Emory community and confidential interviews with diverse and prominent candidates. “I am deeply honored to be named president of Emory University by the Board of Trustees,” Fenves says. “It has been a privilege to lead UT Austin, which I believe is among America’s best public institutions of higher education. I am excited to join one of the country’s finest research universities and optimistic about Emory’s future. I am convinced that, working together as one university, we’ll move Emory from the outstanding institution it is today to one of eminence.” Fenves says the

challenges universities face today are extraordinary. “Courageous health professionals and brilliant scientists are caring for the stricken and searching for a vaccine, while our faculty are educating students at a distance,” he says. The selection committee was impressed with the impact Fenves had on UT Austin during his 12 years, first as dean of the engineering school, then as provost, and finally as president. Under his leadership, UT Austin prioritized its outstanding faculty, cross-disciplinary research, diversity and inclusion, and student success and engagement. It also launched the first new medical school at a top-tier research university in nearly 50 years. Fenves is married to Carmel Martinez Fenves, a textile artist and former small business owner. They have two daughters, a son-in-law, and a granddaughter. “My wife, Carmel, and I look forward to beginning the next phase of our lives at Emory.” EHD

“The board believes with Greg Fenves as our next president, we will have the key components to make significant advancements as an institution. And we are proud of what he has seen in Emory and that a university leader of such stature is attracted to the opportunities here.” —Bob Goddard, chair of Emory Board of Trustees and of the Presdential Selection Committee.

SUMMER 2020

test well

The New Front Line

Testing for COVID in Rural Georgia by Shannon McCaffrey • Photos by Jack Kearse It’s a sunny spring morning when Jodie Guest and eight graduate students from the Rollins School of Public Health arrive at a parking lot in North Georgia. Each pulls on a full suit of personal

protective equipment (PPE), making them nearly indistinguishable inside their pandemic uniforms-—gown, mask, gloves, plastic face shield, and hairnet. There isn’t much time for small talk as they settle in under portable shelters stocked with vials and swabs. Guest checks her team’s PPE and confirms everyone is in place before a long day of testing begins. The group is setting up about an hour’s drive north of Emory University, where they study and work. Here, in the foothills of the Blue Ridge Mountains, is one of the newest front lines in the fight against COVID-19. Even as the virus shows signs of ebbing in some hard-hit urban centers, it is flaring in rural pockets of

EMORY HEALTH DIGEST

the country, where rates of poverty are high and health care resources scarce. One of those outbreaks is here in Hall County, where so many chicken plants dot the landscape that the county seat of Gainesville calls itself the “Poultry Capital of the World.” Providing public health assistance is the goal of a new partnership between Rollins and the Georgia Department of Public Health. Launched with a $7.8 million grant from the Robert W. Woodruff Foundation, the Emory COVID-19 Response Collaborative (ECRC) is designed to bolster response and surveillance efforts around Georgia. Guest, vice chair of Rollins’ department of epidemiology, is part of the collaborative. She was tapped to lead the response in Gainesville before the new project was announced, but it is proving to be a model for what some of their work will

test well

look like moving forward. “We are putting boots on the ground,” Guest says. “The aim is to be nimble and learn where the needs are in the communities we support while building trust. We want to determine the extent of infection in this high-risk community, gauge awareness of the need to take precautions, and explain to families how they can remain safe and well during the pandemic in ways that are culturally sensitive and easily accessible.” Poultry plants have been deemed essential during the pandemic because of their key role in the food supply chain. But rising infection rates among plant employees have alarmed public health officials, who worry that the close working conditions make poultry workers particularly vulnerable to COVID infection and the likelihood of rapid spread of the disease high. Guest knows the challenges in reaching these underserved rural communities. She leads the Emory Farmworker Project in South Georgia, after participating in it since 2007. The agriculture industry is enormous in Georgia. Even as Atlanta and other urban areas have grown in size and influence, agriculture remains the single largest engine of the state’s economy. Jodie Guest is planning to take lessons learned Every year tens of thousands in Gainesville and apply of farm workers come to Georthem in other areas of Georgia where the need is gia to work the state’s plentiful high, with a focus on fixing crops—Vidalia onions, tomatoes, blueberries, pecans, and peaches, systemic inequities.

to name a few. Many of the workers are itinerant, moving from place to place in a rhythm dictated by the harvest cycle. At the chicken and meat processing plants, workers tend to be more settled. But beyond that, the barriers to health care outreach are similar. Many speak only Spanish and reading levels are minimal, with children often serving as interpreters for their family. These workers may reside in crowded, multifamily homes where social distancing is nearly impossible. Then there is a lack of access to health care and insurance. “This is a marginalized population, an unseen population,” Guest says. More than 40 percent of the population in Gainesville is Hispanic, according to recent census figures.

Guest has been working with school districts to distribute prevention materials in Spanish, with a heavy focus on graphics. “The best public health messages do not work if they cannot be read,” she says. In Gainesville, the approach is two-pronged—testing and education. Guest and her team ride the school buses that bring breakfast and lunch to children, connecting with this established and trusted distribution system. They hand out prevention messages explaining the importance of social distancing, wearing a mask, and testing. On their recent May 22 visit, they were providing tests at Vital Foods, one of Gainesville’s many chicken plants. A steady stream of workers at Vital Foods filed through the makeshift testing center in the parking SUMMER 2020

test well

lot that was one minute in the beating sun and the next in a storm that whipped tents over. Juan Carlos Llomas, CEO of Vital Foods, welcomed the fleet of public health workers. Already, Llomas said, employees are wearing face masks and spreading out in the plant, and equipment is being sanitized. But workers are still scared. With just under 400 employees at two plants, a single asymptomatic carrier could infect many other workers, conceivably bringing the whole operation to its knees. This is why Llomas connected with Guest to bring testing directly to his company.

“We wanted to have a safe environment for our employees,”Llomas says. “They aren’t afraid to go to work now. This is good for our employees and good for our company.” Over three days, Guest and her team tested some 450 workers, family members, and other contacts. Roughly 25 percent tested positive and

were notified after the results came in a few days later. Llomas says workers who tested positive are paid while they quarantine at home and can return to work after testing negative. The Emory team is also working to validate whether a new saliva COVID-19 test and an anterior nares swab works as well as the standard nasal swab. The newer testing modalities are less invasive, require less PPE, and can be self-administered. Each worker who arrived was tested with the standard clinical test and one of the research tests to see if the results matched. Guest says early results are promising. Despite the demand of the work, Guest and her team also found time for a little fun, posting a video to Tik Tok where they busted out some dance moves to the Weeknd’s “Blinding Lights.” Guest plans to take the lessons learned in Gainesville and apply them in other areas of Georgia where the need is high. “I hope a benefit to come out of this pandemic will be a focus on fixing the systemic inequities that have placed excess risk with some of our most vulnerable populations,” she says. EHD

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work well

Emory’s graduate, professional schools ranked among best by US News

• Emory’s Nell Hodgson Woodruff School of Nursing Shout-Out to Nursing Excellence Emory Johns Creek Hospital has received Magnet recognition by the American Nurses Credentialing Center’s Magnet Recognition program, the most esteemed honor given to a health care organization for nursing excellence and patient outcomes. “We’re so proud of this outstanding achievement after the extensive work, countless hours, and relentless dedication demonstrated by our incredible nurses, staff, physicians, and leadership team to provide world-class care in a community hospital,” says CEO Marilyn Margolis (above, left, with EJCH staff before the pandemic). About 8 percent of US health care organizations earn Magnet recognition. Georgia has 10 Magnet-recognized hospitals, now including four Emory Healthcare facilities: Emory Johns Creek Hospital, Emory University Hospital, Emory Saint Joseph’s Hospital and Emory University Orthopaedics & Spine Hospital.

master’s program ranks fifth in the nation. The school’s doctor of nursing practice program is eighth. Among its master’s programs, nursing administration ranks eighth; family nurse practitioner, fifth; nurse practitioner: adult/ gerontology, primary care is seventh and acute care, fifth; pediatric, primary care, 11; nursing-midwifery, eighth.

• Emory School of Medicine ranks 24 among research-oriented medical schools and 25 among primary care schools.

• In medical specialty rankings, Emory’s surgery program

is 14; radiology, 14; pediatrics, 19; anesthesiology, 20; and internal medicine, 18. Emory School of Medicine’s doctoral program in physical therapy is eighth and its physician assistant master’s program, not newly ranked this year, remains fifth.

• The Wallace H. Coulter Department of Biomedical

Engineering PhD program, a joint effort between Emory School of Medicine, Emory’s Laney Graduate School, and Georgia Tech, ranks second.

• Emory’s Rollins School of Public Health, not newly ranked this year, remains fifth.

Atlanta Health Care Heroes 2020

A Continuing Investment in Public Health Construction has begun on the R. Randall Rollins Building, a 10-story facility that will significantly expand Emory’s Rollins School of Public Health complex, providing new space for learning, training, and conference opportunities for faculty, researchers, and students. Plans for the new building were revealed last spring, with a $65 million pledge from the O. Wayne Rollins Foundation to help construct a third Rollins public health building on the Emory campus. The new facility will provide flexible spaces for distance-learning, training, study, and offices, as well as larger rooms for professional and community events.

The Atlanta Business Chronicle selected several Emory faculty and health care providers as Health Care Heroes: Colleen Kraft (below), associate chief medical officer at Emory University Hospital, associate professor of infectious diseases and pathology, and medical director of Emory’s microbiology laboratories, who is on the state’s COVID task force, won the Physician Category. Kate Pettorini, Emory Healthcare nurse educator, won the Nursing Category for training nurses and mission work in Bolivia. Justine Welsh, assistant professor of psychiatry and behavioral sciences and director of addiction services for Emory Healthcare, won the Rising Star Category. Brian Vickery, associate professor of pediatrics and director of the Food Allergy Center at Children’s Healthcare of Atlanta, won the Health Care Innovator/Researcher Category.

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breathe well

Emory has helped NASA develop a device that will capture satellite images of air pollution routes across the earth’s surface so scientists back on earth can study it.

EMORY HEALTH DIGEST

breathe well

Emory scientists work with NASA to map air pollution’s impact on health How can data from outer space be used to impact human health? NASA’s Multi-Angle Imager for Aerosols (MAIA) mission will study how different types of airborne particles affect human health over the short term, the long term, and during pregnancy. “This is the first time NASA has ‘baked’ societal benefits and public health applications into a mission’s DNA,” says Yang Liu, professor in the Gangarosa Department of Environmental Health at Rollins School of Public Health. An expert on air pollution, Liu helms an Emory team that is part of an international consortium of scientists and health organizations designing and implementing the scientific objectives of the $100 million MAIA mission, scheduled to launch in 2022. Emory’s team secured $2.1 million of the research budget to create algorithms that will convert MAIA’s satellite imagery from low-Earth orbit into maps of air pollution composition and concentrations over a dozen global megacities, including the Atlanta-Birmingham-Huntsville complex. The maps will distinguish between such pollutants as sulfate particles from power plant emissions, nitrates from

traffic emissions, and organic carbon from different sources, including fossil fuels and wildfires.

“More than 90 percent of the world population breathes polluted air, which is associated with numerous adverse health outcomes,” Liu says. The pollution maps will be combined with population health records to assess potential connections between site-specific particulate mixes and health problems such as cardiovascular and respiratory diseases. “We selected the Atlanta region because the Southeast has a unique combination of particles, a robust base of health datasets, and a strong cohort of epidemiologists to analyze the data,” Liu says. His lab is developing algorithms for integrating satellite-based models with data from the growing number of low-cost pollution sensors coming online. “Communities put up their own monitoring networks but lack the expertise to analyze the data,” he says. “We’re developing tools for them to use. This has significant implications in the citizen-science movement.” EHD

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live well

‘Science of Grief’ As COVID-19 devastates communities around the world, Emory faculty and health care providers collaborated with Science Gallery to host a virtual program exploring loss, hope, and creativity. Watch here: links.emory.edu/scigallery.

The Rollins Earn and Learn (REAL) program provides partners with the opportunity to hire an experienced graduate student for a fraction of the cost. Rollins School of Public Health pays 50% of the student’s salary and you pay the remaining 50%.

WHAT CAN A REAL STUDENT DO FOR YOU? HIRING? BECOME A REAL PARTNER. HIRE A REAL STUDENT.

Learn more sph.emory.edu/REAL Contact us real@emory.edu

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REAL students contribute master’s level education, analytical and research skills as well as transferable program development skills that can be utilized within various industries or organizations. From writing grant proposals to analyzing data, REAL students have skills applicable beyond public health.

sense well

COVID-19’s New Symptom: Four Qs A SUDDEN LOSS OF SMELL, ESPECIALLY IN AN AREA WITH HIGH INFECTION RATES, IS MORE LIKELY ASSOCIATED WITH COVID-19 THAN

ILLUSTRATION BY LIGHTSPRING

ANYTHING ELSE.

Epidemiologist Maria Sundaram, of the Rollins School of Public Health, answers questions about a newly added symptom for COVID-19: loss of the sense of smell. Why did the CDC recently add “a new loss of taste and smell” to the list of symptoms for COVID-19? Medical providers were seeing this condition in their patients. While rare, this unusual symptom was thought to be worth identifying as part of the COVID-19 differential diagnosis. Researchers are still looking into COVID-19’s impact on our senses, but there are smell receptors in the back of our nostrils that send neural messages to our brains. It is possible that COVID-19 is looking for different epithelial cells to infect and sees these epithelial cells right next to the neurons and thinks, oh, this is a great environment for me. But you can lose your smell from a regular flu or cold as well. How is this different? You lose your smell in those cases because your nose is stuffy and you’re having a hard time getting air into your nasal passages. For COVID-19, it may occur in people who don’t have nasal congestion.

What about your sense of taste? Why is that affected? The senses of taste and smell often function together. There’s an interaction between the air that goes into your nose and the air that goes into your mouth. There’s also interaction in our brain. If you can’t smell your food, you have a hard time tasting your food as well. Should I get tested for COVID-19 if I lose my sense of smell or taste? A sudden and complete loss of taste and smell may signal a need to be tested for the coronavirus. The good news is if COVID-19 is to blame, it’s likely that your senses of smell/taste will return. However, this is a new and unusual outcome, and we don’t know enough about it right now to say definitively the degree to which, or the time scale on which, this might happen. EHD

EARLY STUDIES INDICATE ANOSMIA SEEN WITH COVID-19 IS PRESENT IN

30%-98% OF INFECTED PEOPLE SEEN IN HOSPITALS.

THOSE WHO DEVELOP THIS COVID-19–RELATED SYMPTOM EXPERIENCE AN AVERAGE LOSS OF CLOSE TO

80% 69% OF NORMAL

OF NORMAL

SMELL

TASTE

FUNCTION

FUNCTION.

SOURCE: SCIENTIFICAMERICAN.COM

Maria Sundaram, post-doctoral fellow, Rollins School of Public Health.

SUMMER 2020

be well

New use for baby monitors: Connecting patients and family members separated by COVID-19 Mary Beth Krivanek, a senior chaplain at Emory Saint Joseph’s Hospital, has been using a baby monitor and her cell phone to connect families with their loved ones in the ICU.

Often used as a link between a newborn and its parents, baby monitors now serve a novel purpose in Emory Healthcare intensive care units (ICUs).

The cheap, portable devices—along with smart phones, tablets, and other modes of electronic communication—are being used to link patients in isolation due to COVID-19 with their families and loved ones. And sometimes, for staff members to communicate with each other. “With HEPA (high-efficiency particulate air) filtration in place in COVID ICU rooms to trap and filter air, the noise of the filtration sometimes makes communication difficult between staff working inside the rooms, who are dressed in full PPE (personal protective equipment), and staff assisting outside of the rooms,” says William Bender, assistant professor in the pulmonary,

EMORY HEALTH DIGEST

allergy, critical care, and sleep medicine division at Emory School of Medicine and site director for critical care at Emory Saint Joseph’s Hospital. “As we thought about a solution, one of our nurses suggested baby monitors.” The staff had been writing on the ICU glass windows to communicate with colleagues. But baby monitors seemed “a simple way to improve communication,” says Tanya Snipes, a relief charge nurse at Emory Saint Joseph’s Hospital. “We place the unit that would normally be in a baby’s room in the ICU room, always keeping it turned on, and the parent unit outside of the room. This allows staff to press a button

and talk to those inside. Staff outside of the room can hear what’s needed inside the room without entering, which helps conserve PPE.” And family members who can’t visit patients in the ICUs because of visitor restrictions during the COVID crisis also benefit. “Families are so appreciative of the opportunity to speak to their loved ones,” says Mary Beth Krivanek, a senior chaplain at Emory Saint Joseph’s Hospital. “The baby monitors are helping us provide that special connection between patient and family to help in the healing process.” Baby monitors are now in use in all COVID-designated ICUs throughout Emory Healthcare. —Janet Christenbury

be well

Expecting During COVID? Whether planning a pregnancy, newly pregnant, or ready to deliver, a pandemic can be a scary time to have a baby.

“For those who are currently pregnant, the main guidance is to take measures to avoid becoming infected with COVID-19 by social distancing, practicing good hand hygiene, and wearing masks,” says Emory ob/gyn Denise Jamieson, whose research focuses on emerging infectious diseases in pregnancy. An article on caring for pregnant women during the COVID-19 pandemic, coauthored by Jamieson and a colleague, was published online June 5 in the Journal of the American Medical Association (JAMA). “Although considerable data on COVID-19 are available, we do not have much data on COVID-19 related to pregnancy, including if pregnant women are more susceptible to this illness,” says Jamieson, the James Robert McCord Professor and chair of the Department of Gynecology and Obstetrics, Emory School of Medicine. “Thus far, it does not appear that pregnant women with COVID-19 are at an increased risk for severe disease compared with the general population.” Little is also known about the likelihood of trans-

mission of the virus from a COVID-19 positive mother to her fetus or newborn. While there have been some reports of preterm or low-birthweight newborns born to mothers infected with the virus during pregnancy, it is unclear if these outcomes were because of COVID-19. “We need more data to understand if there is any correlation to intrauterine transmission, also known as vertical transmission across the placenta, related to COVID-19, and if transmission can occur through breastmilk,” says Jamieson. For those women with COVID-19 infection admitted to the hospital to deliver their babies, early recognition of an infected patient is necessary to initiate appropriate infection control practices. “Hospitals may consider swab testing pregnant patients for COVID-19 when admitted for delivery,” she says. The Centers for Disease Control and Prevention (CDC) and several professional organizations such as the American College of Obstetricians and Gynecologists (ACOG) have developed guidelines for diagnosing and caring for pregnant women with COVID-19. Jamieson was one of several experts who helped write the Practice Advisory national guidelines for ACOG. One of the more difficult issues is determining where to care for the newborn following delivery of a woman with known or suspected COVID-19. The authors recommend shared decision-making between the mother and her care team. Options include placing mom and baby in separate rooms temporarily to protect the baby. A mother with COVID-19 who chooses to room with her newborn should wear a face mask and practice good hygiene before breastfeeding. Newborns born to mothers with COVID-19 at delivery should be considered to have suspected COVID-19 and should be isolated from healthy newborns, the authors write. “We know that information on COVID-19 changes rapidly as additional data become available,” says Jamieson. “That means recommendations may change. We hope to soon have more information and data from upcoming clinical trials on pregnant women with COVID-19 and their newborns.” EHD

ZOONOTIC DISEASES

How Pathogens Jump Species IT STARTS WITH AN ANIMAL.

Not a specific kind of animal, and

generally not one that is trying to do any harm. But inside that animal lies a pathogen—a microscopic parasite that has spent lifetimes reproducing inside its animal carrier—primed by evolution and ready to take on a new host, should the opportunity arise. With the growing human population, cities and towns popping up in previously untouched areas, farms and livestock encroaching on wildlife habitats, and rapid climate change, these opportunities abound. The good news is that zoonotic pathogens are making the leap from animals to humans under the spotlight of unprecedented scientific observation. “We can’t afford to just focus on one pathogen or one animal.

It’s really important to get a general understanding of the interactions of different species and how changes in the environment are driving zoonotic disease transmission,” says Thomas Gillespie, a disease ecologist in Emory’s Department of Environmental Sciences and the Rollins School of Public Health. “The majority of emerging infectious diseases are coming from wildlife, and most of that wildlife is in tropical forests.”

by Megan Hockman • Illustration by Brian Stouffer

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Some scientists seek to predict the future of outbreaks with sophisticated mathematical tools and programming. Others go directly to outbreak sites to track, and attempt to contain, the spread of the disease. Still others focus on the mechanisms that allow the pathogens to make jumps between seemingly disparate species. All seek to protect humans from the next unknown threat, whenever and wherever it inevitably emerges. This emergence is a byproduct of contact with infected animals as well as the nature of viral evolution. Most viruses are programmed for survival within a certain host. This includes factors like the virus’ ability to attach to host cells. Like a microscopic lock-and-key mechanism, proteins on the surface of virus particles are shaped in specific ways that allow them to bind with receptors on host cells. These interactions can be very specific—they determine which cells are bound (infections of cells in the respiratory tract may cause a cough, while those of the stomach can cause nausea and diarrhea) and which organisms the virus can infect. If that key changes shape because the virus has mutated, it may be able to open new locks, infect a new host, and cause an outbreak. “How an emerging pathogen spreads through a species tends to be ‘a black box’ until it causes an outbreak among people,” Gillespie says. The Zika virus, for instance, was first identified in monkeys in Uganda in 1947 but was not widely studied until recently, after it started sweeping through human populations.

PREVIOUS CORONAVIRUSES

COVID-19 is not the first deadly coronavirus to make the jump from animals to humans. Both severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) are coronaviruses classified as zoonotic viral diseases, meaning the first humans infected acquired these viruses directly from animals. SARS was initially present in an as-yet unknown animal reservoir, perhaps bats, and was

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passed to civet cats, relatives of the mongoose. Evidence shows that as it circulated in the civet cats, it gained mutations that allowed it to cross over into humans in 2002–2003. More than 8,000 people worldwide became sick with SARS and 774 died. Larry Anderson, Marcus Chair of Infectious Diseases at Emory and a member of Emory’s vaccine research center, was with the Respiratory and Enteric Viruses branch of the Centers for Disease Control and Prevention (CDC) at the time of the 2002 SARS outbreak. Like many new diseases, he says, “SARS started out as a disease of unknown etiology.” After a doctor identifies a new disease, scientists must figure out the causative agent. From there, it’s a matter of controlling spread. The ease of this control depends on the severity of disease. In the case of pathogens like Ebola, people have severe symptoms. Those exhibiting these symptoms can be quarantined and healthy individuals can avoid contact.

In the case of diseases like the current COVID-19, “transmission happens before serious illness does, which means it’s much harder to use classic public health measures,” says Anderson. Some people who are sick are asymptomatic, so they can spread disease without knowing it. Evidence suggests that MERS, first identified in 2012 during an outbreak in the Arabian Peninsula, was transferred from bats to camels to humans. Since then, the virus has been endemic in camels of that area and has infected more than 2,000 people and caused more than 700 deaths.

WHEN VIRUSES JUMP SPECIES

Normally, we have specific mechanisms to avoid mutations as our cells reproduce, aptly named cellular proofreading. Viruses, however, are not programmed in this way—they accumulate mutations rapidly and in a variety of ways. Imagine a genome as an instruction manual, each chapter detailing how to assemble part of a machine. During infection, these chapters tell the cell how to make an entire virus. As the virus replicates inside of a cell, it copies down this manual thousands of times and packages it into new virions which carry those instructions. During the copying process, however, mistakes happen. Influenza virus, for example, makes approximately one error per new genome—that’s the equivalent to one miscopied word per new instruction manual. In a viral context, that miscopied word can have a big impact and result in the encoded machines severely malfunctioning. A virus can also swap out entire sections of its genome with other viruses of the same type, like swapping entire chapters of the manual. Usually, this is bad for the virus—the new parts don’t fit together and the virus can’t form a productive infection. Sometimes, however, this works to the virus’ advantage. That’s how the swine flu outbreak occurred in 2009. By swapping sections of its genome, a virus can combine parts of machinery that fit different hosts and subsequently cross species borders, provided that these parts work together successfully. The mistakes made during replication, whether to a single piece of one protein or in exchange of entire sequences, are random. It’s difficult to know which viruses will evolve to infect new hosts and which species will be responsible for outbreaks.

FLIERS AND FAST BREEDERS

Many animal species harbor pathogens—some of which they live with and are largely unaffected by. A common example is bats. “One quarter of mammal species overall are bats, and each of these myriad bat species carries a suite of different pathogens,” says Gillespie. “Bats are able to host different viruses without getting sick. So bats, and the pathogens that bats carry, are numerous. And bats and humans are both mammals. This relatedness means we’re more likely to get a pathogen from a bat than from a cricket, for instance.” But bats are far from the only reservoirs of zoonotic pathogens. Influenza virus is housed primarily in aquatic birds, but in 2009 emerged from swine into humans, causing a global pandemic. The “swine flu,” caused by the H1N1 virus strain that started in pigs, killed hundreds of thousands of people worldwide during the first year the virus circulated. Unlike COVID-19, 80 percent of H1N1virus-related deaths were estimated to have occurred in people younger than 65 years of age—primarily children and young and middle-aged adults. Rodents are another common host and make particularly good reservoirs, possibly because of their “live fast, die young” strategy.

Thomas Gillespie, disease ecologist and associate professor of environmental health.

Larry Anderson, professor of pediatric infectious disease and a member of Emory’s Vaccine Research Center.

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Quantitative disease ecologist Sarah Bowden, an adjunct professor at Emory, says “fast-living species that reproduce quickly and frequently tend to be better reservoirs for pathogens.”

Sarah Bowden, quantitative disease ecologist, adjunct professor at Emory and CDC data scientist contractor.

Robert Breiman, infectious disease epidemiologist of Emory’s Global Health Institute.

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A case in point: Deer mice, which were linked to a hantavirus outbreak in 1993 that caused severe pulmonary disease. “Previously hantavirus had not been associated with a pulmonary condition,” says infectious disease epidemiologist Robert Breiman of Emory’s Global Health Institute. “It was a virus that hadn’t been identified before, and it appeared in these deer mice.” Wild animals that migrate or have large territories also make effective vectors. “If you cover a broader area, you’re inherently more likely to encounter more species you can transmit pathogens to,” Bowden says. Zoonosis is a widespread, complex, and multifaceted phenomenon. It does not discriminate between borders, and by nature does not always discriminate between hosts. Humans, agree scientists, have created conditions for these pathogens to thrive, and rapid human expansion will undoubtedly contribute to the emergence of new diseases. In some places, it is common to hunt wildlife for food. Rural communities may rely on meat from local forests and savannas—whether chimpanzees, bats, rodents, or other species. These animals can be carriers of diseases, including Ebola, Marburg, HIV/AIDS, and anthrax. “Anthrax is primarily zoonotic and wouldn’t cause human disease unless there was close contact [between animals and humans],” says Breiman. Whether an individual is hunting, butchering, or consuming these animals—or is, perhaps, a child just playing near their habitats— pathogens have ample opportunity to cross over and wreak havoc. Public health workers focus on educating and developing safer practices for hunting and butchering. But domesticated and farm animals can transmit disease as well. Pigs, chickens, turkeys, and waterfowl transmit swine and avian flus. Cows and camels play host to bacterial species like Brucella. “In parts of East Africa, people really love unpasteurized milk from both cows and camels,” says Breiman, who spent nine years in Kenya as an epidemiologist. “Both animals, if infected with Brucella, can excrete it into the milk,” which can infect those who drink it. To add to the problem, livestock rarely show symptoms of infection with Brucella, so it’s hard to know that the milk poses a risk. Even if an animal appears sick, that is no guarantee it won’t be consumed. “There will be all sorts of clues that an animal was sick and died, but [people] will go ahead and eat it because it’s nutrition and it

costs money,” Breiman says. In “wet markets” around the world, animals alive and dead, including wild and exotic species, can be purchased for consumption or for use in traditional medicines. Civet cat, for instance, is a delicacy in some parts of China. “I was told people would eat it in the winter because they felt it increased their immunity to respiratory disease,” Breiman says. The scales of the pangolin—an armadillo-like animal also sold in “wet markets” that may have played a role in the emergence of the new SARS-CoV-2 coronavirus in humans—are used in medicines. “The meat is thought to have all sorts of benefits,” Breiman says. Animals in these markets are caged next to each other, which allows them to share pathogens. In the wild, many of these animals would never be close enough for this transfer to occur. The adaptations that happen during infection of a new host can have the unwanted side effect of making them able to infect people, too. Humans have created an environment in which this is possible, and multiple outbreaks have occurred as a result.

CONNECTIVITY AND CLIMATE CHANGE

Sometimes, however, our encounters with animals are unintentional—a result of rapid human expansion and the resultant narrowing of animal habitats. “We are in an extremely connected world, a world that’s vastly more connected than it was even back in the early 2000s when the SARS epidemic happened,” Bowden says. “That is just going to inherently increase the likelihood of new people coming into contact with new things that can make them sick.” While there are many species known to transmit diseases to humans, there are plenty that we haven’t encountered yet. That is changing as we travel more and expand our reach into untouched areas with remote species and pathogens.

“Things are already there and primed to go, and the storm sort of comes together at the perfect moment,” Bowden says. But that doesn’t stop researchers from trying to predict outbreak likelihoods from what we do know. Researchers like Bowden have adapted mathematical modeling techniques to better understand where risk of an outbreak lies. “Prediction allows us to look at the relative risk or the likelihood of a pathogen emerging in different areas of the world,” she says. She looks at different factors—the risk landscape on a spatial scale (where on a map is infection most likely), different known reservoirs (which animals are common carriers, and where they are located), and different pathogens (what germs/diseases are commonly found in an area).

“We can drill through these and look for places where risk is high on all three planes,” Bowden says. “That allows us to say, ‘Relative to everywhere else in the world, given the large players in a disease outbreak, here’s where we think risk is highest.’ ” Many of these factors are changing rapidly, however, and models will have to change to account for that. Climate change, Bowden says, is “a huge consideration in disease ecology. It is causing species’ geographic ranges to expand or shift. They can bring new pathogens with them or come into contact with ones they hadn’t encountered before. In both cases, we’re likely to experience unforeseen outbreaks.” EHD SUMMER 2020

SARS-CoV-2 is the latest in a long list of pathogens that have jumped from animals to human beings, triggering pandemics that have killed hundreds of millions. by Bryan Walsh, first published in Axios

COVID-19 underscores the urgent need to understand and control the intersection of animal and human health. Genetic analysis of the virus shows it likely took a single spillover event from an infected animal to a human to start the pandemic.

Nearly 1.7 million as yet undiscovered viruses are believed to exist in wildlife, and Thomas Gillespie, a disease ecologist at Emory, notes that we still lack data for almost 90% of zoonotic viruses in wild mammal species.

By one count 70% of emerging diseases can be traced back to wildlife, and since 1980 the number of outbreaks per year has more than tripled.

The 21st century has already experienced four major spillovers: SARS (horseshoe bats via civet cats), H1N1 flu (pig), MERS (bats via camel), and COVID-19 (bats via an intermediate).

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WILD VECTORS Bats Pangolins Mice Camels Wild boar Monkeys Civit cats

Humans and animals share this planet, and increasingly they share deadly pathogens as well. If we don’t fully recognize that shared threat, COVID-19 won’t be the last zoonotic pandemic. Instituting buffer zones between wild animal and human habitats could decrease human-animal contact events.

INDUSTRIAL LIVESTOCK VECTORS Chickens Pigs Cows

The growing industrialization of meat production around the world plays a role as well, as pathogens pass from wild animals into packed livestock farms, where the viruses can be amplified as they burn through domestic animals.

Buffer zones serve the dual purpose of “extension buffering”—extending core habitat areas for animals—and “socio buffering” to provide goods and services to humans. Allard Blom, Yolande Munzimi, Jeffry Oonk and Marlene Azink of CARPE/US AID. [Public domain], via Wikimedia Commons

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IMAGES (TAKEN BEFORE PANDEMIC) FROM GPB AND EMORY’S YOUR FANTASTIC MIND SERIES EMORY HEALTH DIGEST

BRING IN THE LASER

Precise ablation technique shows progress in treating intractable epilepsy by Gary Goettling SUMMER 2020

Ja’Lisa Thomas was preparing dinner when the seizure struck. She fell forward, unconscious, over the hot electric stove. Only the quick reaction of her father, in pulling her to safety, prevented a catastrophe. I ended up burning my shirt and my arms, but luckily it was nothing too serious,” she remembers. “It could’ve been so much worse—the house could have gone up in flames.” surgery and professor in Emory’s Department of Thomas had her first seizure eight years ago, Neurosurgery. “If you go into a theater and some while living in Delaware and eight months pregpeople are whispering in a low voice, there’s no nant with her daughter. problem. If everyone whispers the same thing at “I was sitting at my computer searching for the same time, the sound would be deafening.” information on the internet when my mother There is no medical cure for epilepsy, which noticed that I had zoned out and was staring at affects an estimated three million people in the the ceiling,” Thomas recalls. “She said I began to convulse and gasp for air. She called for my father US, although sometimes it goes away on its own. By the time Thomas was diagnosed, her to help get me to the floor and on my side.” seizures were occurring several times a month, Neither she nor her doctor knew the cause sometimes back to of this or subseback, even while she quent seizures. They “We start with the description from slept. One medication thought there might after another was be a connection to her the patient of his or her own seizures tried, but nothing pregnancy. But the and then we bring them into the hospital worked. She could seizures persisted after no longer drive, and her child was born, and allow or even provoke them to she couldn’t work slowly increasing in have their typical seizures while we because her condition frequency. forced her to take too In 2013 Thomas and videotape them.” —Robert Gross many days off. her family moved to The worst part, the east metro-Atlanta area, and she sought answers at Emory, where she Thomas says, was the effect her medical problems were having on her daughter, a toddler at received a diagnosis of epilepsy. the time. Epilepsy is characterized by seizures that may “She was getting worried about me to the result in a loss of consciousness, involuntary jerkpoint where she felt she had to take care of me,” ing movements of the arms and legs, temporary Thomas recalls, “and that broke my heart.” confusion, or a staring spell. The episodes can last Something had to change. anywhere from a few seconds to several minutes. Having exhausted the standard options, The symptoms appear to be a loss of control or function, suggesting disorganized cellular sig- Emory neurologists referred her to Gross, who specializes in “intractable” cases—the one-third naling in a particular part of the brain. In fact, it or so of epilepsy patients for whom medication is just the opposite: the neurons are too aligned doesn’t work, leaving surgery as the only course and are all firing at the same time and overloadof action. ing the nerve pathways. The pre-surgical process, which can take be“Think about it this way,” says neurosurgeon tween six months to a year or more, begins with a Robert Gross, MBNA Bowman Chair in Neuro-

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Epilepsy patient Ja’Lisa Thomas comforts her oldest daughter, Vaydah, from her hospital bed. “She was getting worried about me to the point where she felt like she had to take care of me,” Thomas recalls, “and that broke my heart.”

combination of tests and clinical considerations to determine where the seizures are likely to be originating. “We start with the description from the patient of his or her own seizures and then we bring them into the hospital and allow or even provoke them to have their typical seizures while we videotape them,” Gross says. During this process, electroencephalography sensors are positioned on the patient’s scalp to reveal correlations between the onset of seizure behaviors and neural activity in specific parts of the brain. “We also perform MRI scans to see if there are any structural abnormalities in the brain,” Gross says. “Sometimes we see a lesion of some sort, a scarring or even a tumor or some other developmental abnormality that helps us develop our hypothesis as to where the seizures are arising. Sometimes we see no abnormalities at all.” Further tests look for metabolic changes in brain areas that show correlations, and “we use neuropsychological tests of patients’ strengths or weaknesses with respect to their cognitive, emotional, and other neurological functions that can also help give us more clues as to where the

seizures might be originating.” This data is put together to form testable hypotheses as to which areas of the brain are responsible for the seizures and whether surgery would help. With the brain’s suspected problem areas mapped out on a computer in 3-D, tiny holes are drilled into the skull at those areas. In Thomas’ case, 15 openings were made, and electrodes were inserted into her temporal, frontal, and parietal lobes to monitor brain activity and map seizures to either confirm or disprove the physicians’ hypotheses. This process takes weeks in the hospital under 24/7 videotaped monitoring. During the monitoring period, electrical stimulation mapping is also performed, in which a small amount of electrical current is passed through the electrodes to “map out” the function of the brain near those electrodes. Sometimes, with the patients’ consent, doctors may use this opportunity to conduct memory tests connected to other research projects (see sidebar, p. 31). At this point, all the clinical information is presented and reviewed at a comprehensive SUMMER 2020

Thomas, above, plays board games with her father, Alvin Thomas, and her daughter Vaydah; and right, poses with Vaydah and her youngest daughter, Zaraiyah.

geons in the world to adopt the procedure and reepilepsy conference attended by the neurologists, mains a leading proponent for its use. “It allows us neurosurgeons, and neuropsychologists. to accomplish the same end but with a minimally In Thomas’ case, two small areas in the frontal invasive and minimally destructive approach.” and temporal lobe were identified as the areas As with any kind of brain surgery, laser where her seizures were originating. ablation carries a Then came the certain level of risk, intervention: While “Laser ablation is much more tolerable but the risk has to be Thomas was awake and comfortable for the patient, and that weighed against the and being monitored reward, notes Gross, for effects, those spots helps to increase the willingness of patients whose surgical were heated and to undergo what is, in the end, life-altering success rate hovers destroyed, using radio around 65 percent. frequency waves—a surgery, and for neurologists to refer “In my group, we laser ablation them for it.” —Robert Gross have demonstrated technique that can that in certain scenarbe sufficient to stop ios, there’s a decreased risk profile with ablation some patients’ seizures. In Thomas’ case, over the as compared to an open surgical treatment,” he next twenty-four hours she continued to have says. “And laser ablation is much more tolerable seizures. More needed to be done. and comfortable for the patient, and that helps So, a few days later, she was placed in the MRI to increase the willingness of patients to undergo scanner where the electrodes were withdrawn what is, in the end, life-altering surgery, and for and replaced with a catheter containing a strand neurologists to refer them for it.” of glass optical fiber through which intense laser Thomas’ surgery was performed in May 2018. light is shined. This allowed for precise ablation of “My life has changed a lot since then,” she the epileptic brain tissue. Thomas’ procedure lasted about ten hours, but she was able to go home in says. She is driving again and found a job as an administrative assistant. Best of all, she is seizure a few days. free. “Things are mostly back to normal, and I’m Until the advent of laser ablation about very happy about that,” she says. “It was depressseven years ago, the go-to surgical procedure ing to have to depend on other people to help me was an open brain resection, such as frontal or all the time, but I’m doing a lot of things on my temporal lobectomy, which involved opening a section of skull and physically removing suspect own now.” EHD brain tissue. “Ablation via precisely positioned lasers has Watch Thomas’ story on Your Fantastic Mind, Episode 12, at: links.emory.edu/hthomas become a more and more prevalent technique,” says Gross, who was among the first neurosur-

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RESEARCH

A ‘Memory Pacemaker’ While in the hospital, Ja’Lisa Thomas volunteered to participate in the Restoring Active Memory program, a research project intended to study the electrophysiological signals associated with memory. “We want to see if we can do something about improving those signals and memory functions,” says the project’s principal investigator, Robert Gross, MBNA Bowman Chair in Neurosurgery and professor in Emory’s Department of Neurosurgery. “Epilepsy patients with electrodes going into their brain recording their brain activity, and who are also amenable to being stimulated electrically as part of routine epilepsy monitoring and care, are the perfect test subjects for learning about brain structures. ”Launched in 2013 under the auspices of DARPA (Defense Advanced Research Projects Agency), the program’s goal is to develop an implantable, closed-loop neural interface capable of restoring normal memory function—in effect, a memory pacemaker. Intended to help military personnel overcome the effects of brain injury or illness, the device could find wide civilian applications, assisting individuals with Alzheimer’s and other forms of dementia or deficits arising from traumatic brain injury. Emory is one of eight institutions across the country involved in the collaborative effort. Thomas participated in a memory test where she memorized lists of words and then, after a distraction, was asked to recall as many of the words as she could. Throughout the process, neural activity in specific areas of her brain known to play a role in memory was monitored and recorded. The test was repeated several times with different words. Sometimes memorization was conducted while the memory-related areas were stimulated; other times, it was conducted without stimulation. The idea behind the research is to determine the conditions under which targeted electrical stimulation of specific brain cells improves memory. The DARPA program memory tests dovetail with other research conducted by Gross and his team on the potential benefits of deep-brain stimulation. In a study published in 2018, principal investigator and neurosurgeon Jon Willie, assistant professor in Emory’s Department of Neurosurgery, working with Gross and others, shared results showing that stimulation of the brain’s amygdala can improve memory function. EHD

Ja’Lisa volunteered to be part of a study to learn more about brain structures and memory.

Robert Gross, MBNA Bowman Chair in Neurosurgery, says laser ablation can be “life-altering.”

Jon Willie, assistant professor of neurosurgery, studies ways to improve memory function through brain stimulation. SUMMER 2020

MICE HAVE BRAINS JUST A FRACTION OF THE SIZE OF HUMAN BRAINS. THEY SCAMPER AROUND ON FOUR FEET AND LIVE FOR JUST ONE OR TWO YEARS. BUT THEY’RE A LOT MORE LIKE US THAN WE REALIZE. by Becca Moszka • Illustrations

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by Patrick George

In fact, mice have many of the same genes as humans and can develop the same diseases we are susceptible to, like Alzheimer’s, hypertension, influenza, and various cancers. Medical researchers use mice to model how diseases can be treated in humans. Researchers have the ability to formulate “mouse models”— that is, representations of diseases via the DNA of mice—to study human diseases. Why are mice so beneficial to the study of human disease? They are cost effective, easy to house, and breed rapidly, making it convenient to observe many mice over a short period of time. And because they share more than 95 percent of our DNA, researchers can modify the DNA of mice to mimic the effects of certain human diseases, bringing them closer to a potential treatment or cure. Sometimes, regular mice won’t do for a specific experiment: special mice are called for, with certain traits or attributes. Genetically engineered mice are actually quite common—and valuable. For example, to study COVID-19 in mice, the mice must have a humanized ACE2 gene—the molecule that allows coronaviruses in (see sidebar). At Emory, several researchers have modified mice to further understand the inner workings

COVID-19 and Mice Researchers in laboratories across the country are quickly attempting to develop vaccines for COVID-19. The usual first step is to test promising vaccines on animals, often starting with mice. There’s just one problem: coronaviruses don’t make normal mice sick. While SARS-CoV-2, the virus behind COVID-19, has no trouble latching onto human cells and getting inside to start multiplying, it isn’t so good at invading mouse cells. Mice have to be genetically engineered to be susceptible to the virus. In the past, mice were used to study SARS, another coronavirus-related illness. The type of mouse that is of use to coronavirus researchers needs to have a humanized ACE2 gene—the molecule that allows coronaviruses in. Since producing a new generation of mice with the genetic modification takes about three months, breeding enough mice to meet the demand takes time. Because of the rush to produce a viable vaccine for COVID-19, several biotech companies are skipping animal testing, or doing animal testing in tandem with human testing. In these cases, many of the human clinical trials are using drugs that have already been proven to be safe. In March, Phase 1 of a COVID-19 human vaccine trial for volunteers ages 18 to 55 began at Emory, which is part of the Infectious Diseases Clinical Research Consortium (IDCRC). In April, Phase 1 of the trial was expanded to volunteers ages 56 and older.

of human disease and even the human brain. SUMMER 2020

MICE BRED OVER GENERATIONS TO EXHIBIT DEPRESSED BEHAVIOR ACT IN WAYS REMARKABLY SIMILAR TO CLINICALLY DEPRESSED PEOPLE.

Take, for example, a mouse model of depression. Depressed mice—or, at least, mice that have been bred over several generations to exhibit depressed behavior—act in ways that are remarkably similar to clinically depressed people. They isolate. They move more slowly. They sit in a corner of the cage instead of exploring. They aren’t as quick at cognitive tasks. They show little interest in food or sex. Some Emory researchers study depression itself with these mice models, while others come at it through corresponding disorders or emotions—fear, anxiety, post-traumatic stress, inflammation, heart disease, epilepsy. Special populations with depression are being considered as well, including children,

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teenagers, veterans, new mothers, octogenarians, and adults who were abused as children. And it’s not only depression. Some researchers study infectious disease or the efficacy of vaccines in mice. Others study neurological disorders, like ALS or dystonia or epilepsy. Still others study the microbiome of mice raised in completely sterile environments. The following is just a sampling of the important work Emory researchers are doing with mouse models. The mice, says one, are “outstanding at what they do.” So here’s to the mice—and to the humans whose lives they save and improve.

OF MICE AND MUSCLES

llen Hess, a professor in the departments of pharmacology and chemical biology and neurology at Emory’s School of Medicine, studies dystonia in mice. Dystonia, a disorder where the muscles of the body contract involuntarily, can cause a person’s body to twist into unnatural positions and often results in pain. Hess says dystonia is a “defect in communication between brain regions”—and since it is not a degenerative disorder causing the deterioration of neurons, the possibility of returning the brain regions to their normal-functioning abilities does not seem too far off. “We can use mouse models of dystonia to understand how the problem starts, what is going wrong in the brain to cause dystonia, and to discover new treatments,” Hess says. Using a mouse model of DOPA-responsive dystonia (DRD)—a term for multiple types of dystonia— Hess can study how brain defects lead to the disorder and search for new forms of therapy to treat it. “DRD mice recapitulate the human disorder from genes to behavior, making them very useful for understanding the brain defects that give rise to dystonia and for the development of therapeutic strategies,” Hess says. To successfully model DRD in mice, the mice must have the gene defect that causes DRD in humans. In creating these “knock in” (or KI) mice, Hess and her team must insert new gene sequences into the mice, effectively allowing them to develop dystonia.

These modified mice are not simply bodies to house dystonia— they have also contributed to the discovery of a fundamental aspect of DRD. Researchers in the past have debated which regions of the brain are involved in dystonia. “This is surprising,” Hess says, “because the brain regions involved are fundamental to understanding a neurological disorder.” In studying their modified mice, Hess and her team have discovered that dystonia can stem from different brain regions or miscommunication between the basal ganglia and cerebellum.

Ellen Hess studies dystonia—which causes muscles to contract involuntarily—in mice to discover more about the disorder in humans.

THE REGIONS OF THE BRAIN ASSOCIATED WITH FEAR, TRAUMA, AND PTSD CAN BE INVESTIGATED IN MOUSE MODELS.

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Yerkes researcher Brian Dias holds a mouse at Emory’s Yerkes National Primate Research Center. Dias discovered how fear of certain smells trained into one generation of mice can be passed to the next generation without direct conditioning.

FEAR FACTOR

B Brian Dias studies mice to learn about the areas of the brain associated with fear, trauma, and anxiety.

Shannon Gourley studies adolescent mice to understand more about adolescent humans.

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rian Dias is no stranger to working with animals. “I’ve worked with rats, birds, fruit flies, lizards, and now mice,” he says. “Due to wanting to describe biological phenomena from a causal perspective, I’ve always done work with a variety of species.” Dias, a researcher at Yerkes National Primate Research Center and an assistant professor of psychiatry at the School of Medicine, specifically studies fear in mice. In fact, one of his most recognized research findings is that a fear of certain smells can be trained into one generation of mice and passed down to the next generation without direct conditioning of the younger mice, a phenomenon known as “epigenetic inheritance.” Using chemogenetics and optogenetics, two techniques that allow researchers to understand the relationship between brain activity and matter, Dias can inject animals

with drugs that will either activate or inhibit the firing of cell populations in their brains. In doing so, Dias and his team can model human fears like PTSD or anxiety in these mice—and delve deeper into unfamiliar regions of the brain that may be associated with trauma or stress-related conditions. In particular, Dias considers the zona incerta, a region of gray matter in the brain likely linked with pain that “modulates fear-related behaviors.” “When we need to look at [PTSD or anxiety], we’ve always traditionally focused on a few regions,” Dias says, citing the amygdala, hippocampus, and prefrontal cortex as major regions in the study of trauma. “Now, with new technologies, we are able to investigate brain regions we knew little about and broaden the neuro landscape. It points us in new directions that allow us to eventually come up with better therapeutic outcomes.”

DANGERS OF ADOLESCENCE

hannon Gourley’s research is concentrated in behavioral neuroscience. An associate professor of pediatrics at the School of Medicine and a researcher at Yerkes, she is interested in depression and addiction—specifically, why adolescent humans are more vulnerable to depression and addiction than humans in other stages of life. Using mice, Gourley can begin to tackle this complicated problem. Like humans, mice also have an adolescent period, although this period lasts for a much shorter time. “We can study adolescent mice in a month,” Gourley says, which makes them the ideal candidates for her research. She adds that researchers “can ask mice to make very complex decisions.” In observing mice—both adolescent and adult—making these decisions, Gourley and her team can observe the differences and investigate how certain genes impact decision-making behaviors that can lead to depression or addiction. Such observations could lead to a pivotal finding: a step toward developing better antidepressants. “Classic antidepressants are effective for about half the population,” Gourley says. “That’s not very good.” But new evidence might help. As it turns out, exposing an animal to prolonged stressors can actually change the shape of neurons in the brain. As a result, some neurons in the brain will grow and others will shrink. “We know that neuron shape changes occur in the case of adolescent stressor exposure, and that these changes can be really persistent even after the stress has ended,” Gourley says. “Perhaps, if we

instead make chemicals that act on the building blocks of the neuron structure, we might be able to create new antidepressant strategies that are better.” With the help of some mice, Gourley’s team set out to test whether drugs that act on the proteins that influence neuron shape can have antidepressant-like properties. Indeed, the team has found one compound that has such properties. “We published that literature,” says Gourley says, who hopes this discovery will lead to clinical trials for these compounds. The mice in Gourley’s research, she says, are outstanding in what they do. “It’s pretty amazing that, if we are clever enough, we can design tasks that allow our mice to speak to us without words,” she says. “Using the mouse as a model, we can begin to understand the actual neuro changes that are occurring as a result of problem solving. The mice can show us through their actions how they solve complex problems.”

LIKE HUMANS, MICE ALSO HAVE A PERIOD OF ADOLESCENCE, BUT IT LASTS FOR A MUCH SHORTER TIME.

SUMMER 2020

A MOUSE IN A GNOTOBIOTIC FACILITY HAS NO GERMS ON ITS SKIN, IN ITS NOSTRILS, OR IN ITS GUT.

STERILE MICE (AND NOT IN THE WAY YOU THINK)

Rheinallt Jones, a gastroenterologist who studies the microbiome, developed Emory’s gnotobiotic mouse facility.

Andrew Neish, a pathologist, studies how bacteria contribute to intestinal health by using germ-free mice.

EMORY HEALTH DIGEST

mory’s gnotobiotic mouse facility was developed by gastroenterologist Rheinallt Jones, assistant professor of pediatrics at Emory School of Medicine, for his studies into the microbiome’s influence on host physiology. “My research includes discovering the molecular mechanisms whereby beneficial bacteria known as ‘probiotics’ elicit their positive influences on health and disease,” Jones says. Emory’s Gnotobiotic Animal Core offers investigators the opportunity to experimentally manipulate the microbiomes of mice in a controlled environment to gain insight into important biological mechanisms.

The average mouse, like the average human, is home to trillions of bacteria and viruses. But a mouse in a gnotobiotic facility has no germs on its skin, in its nostrils, or in its gut. Its food, water, and bedding is heated to more than 100°C to kill bacteria and viruses before being delivered to the mouse’s cage through a sterile system. “This facility provides a germ-free environment, so you can study the biology of whole organisms with a complete absence of bacteria,” says pathologist Andrew Neish, professor of pathology and laboratory medicine. His research looks at how bacteria contribute to intestinal epithelial integrity and healing. In the gnotobiotic facility, the microbiome of test animals can be manipulated and defined by researchers. For example, researchers have used these mice to study the microbiome’s influence on neural development: in other words, the gut’s influence on the brain. The more we discover from mice and their interactions with the environment, the more we learn, in turn, about ourselves. EHD

Long Road Home Facing chronic pain, depression, and trauma, veterans find help through an intensive program that includes therapy, a community of peers, and a holistic view of wellness.

by Stacia Pelletier

As many as 20 percent

of Iraq and Afghanistan war veterans suffer from PTSD,

according to the US Department of Veterans Affairs. SUMMER 2020

The numbers are staggering. More than 5 million post-9/11 service veterans have transitioned from the military back to civilian life, an average of 200,000 veterans each year. The transition isn’t always an easy one. the Emory Healthcare Veterans program at Emory’s Brain Health of January 1, 2018, and said to herself: Center. In the two weeks of intensive Something’s got to give. outpatient treatment that followed, Medically retired from the US she began to write a new chapter for Army since 2011, Baker was spiraling her life. “Mental health and physical downward. Chronic pain, post-surhealth are inseparable,” she says. gery complications, and post-trau“It’s like peeling back matic stress disorder an onion.” (PTSD) had eroded In January, the her ability to navigate American Journal of the daily demands Preventive Medicine of work and life. The published the results more time passed, the of a survey thatfound worse her situation bethat for veterans, came. For a time, she health remained the was “houseless,” as she top concern both at calls it. Her only major three months and six possession was her car, months following and even that wasn’t their return home. Of in her name. survey respondents, “I didn’t know who 53 percent reported I was after I left the Army Veteran Candace a chronic health military,” Baker, now Baker experienced chronic condition, 33 percent 38, says. “The army was pain and PTSD, but tried to reported a mental all I’d ever wanted to tough it out. health condition, and do. It was my dream approximately 40 percent reported job. I needed something that would a chronic pain condition. The report force me to deal with everything I’d concluded that there is a need for lived through. When I heard about the Emory program and how intense “bolstered support” to prevent the development of “chronic readjustit was, I said, ‘That’s it. That’s what ment challenges” in the veteran I need.’ ” population. Shortly thereafter, Baker joined

CANDACE BAKER woke up the morning

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The health care needs of this growing veteran population, especially for

those with PTSD and another common wartime condition, traumatic brain injury (TBI), continue long after their first year back on home soil.

SUMMER 2020

Navy Veteran Trent Burgess, below and with his daughter, who “has her dad back” after his work to overcome PTSD.

Emory health care providers, researchers, and educators are helping to create a healthier long-term future for veterans. Across the Woodruff Health Sciences Center, faculty are pioneering holistic and increasingly personalized treatments. And they are strengthening alliances with the Atlanta VA Health Care System and other partners. As many as 20 percent of Iraq and Afghanistan war veterans suffer from PTSD, according to the Veterans Affairs Department.

TRENT BURGESS was on deployment

with the US Naval Civil Engineer Corps in Iraq when he witnessed a child’s violent death in the middle of a crowded city street. He was 21 at the time and what he saw unmoored him. He didn’t talk about it afterward. That was the culture of the navy, he says. “I never talked about it, my unit never talked about it, the guys who watched it happen never talked about it,” he says. Returning home, he went 12 years without talking

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about it. He tried to resume a normal life but couldn’t find his footing. By 2018, PTSD had him at a breaking point. “I was having trouble at work, in my marriage,” he says. “I was isolating myself. I ended up divorced. That was a real eye-opener.” He tried to treat his symptoms on his own, but nothing worked. Finally, Burgess called Emory. That call, he says, changed everything. Launched in 2015, the Emory Healthcare Veterans program has served more than 2,000 veterans, according to Barbara Rothbaum, professor of psychiatry, Paul A. Janssen Chair in Neuropsychopharmacology, and director of the Trauma and Anxiety Recovery program. The Emory Healthcare Veterans program is part of the Warrior Care Network, a national initiative funded by the Wounded Warrior Project that works to meet the needs of thousands of post–9/11 veterans suffering from PTSD and traumatic brain injury, regardless of where they live or their ability to pay. “PTSD is a disorder of avoidance,” says Rothbaum. “Traditional treatments for veterans with PTSD have a dropout rate of around half. Our program has a 90 percent completion rate.” What’s more, veterans are maintaining the gains they made even after they leave the program. Approximately 88 percent of veterans who participate in the program’s clinical research say they have maintained their gains a full year after they graduate. And the 12 percent who did not maintain their gains say they still are better off than they were prior to enrolling. “Veterans are learning how to apply the tools we taught them,” Rothbaum says. “They are building back their lives over time.” Burgess went through the twoweek intensive outpatient program

for PTSD (the program has since expanded to offer an additional track for veterans with traumatic brain injury). He remembers with gratitude the veterans and active service members he met and bonded with during those weeks and has stayed in contact with several of them. Another highlight, he says, were the in vivo sessions, a form of prolonged exposure therapy where veterans are introduced to environmental stressors they otherwise might avoid. “I don’t like having my back to the door,” he says. “And the first thing they did, they had us sit with our backs to the door. So I had to get used to that. I also don’t like crowds. So we went to Walmart. And I had to learn—okay, crowded, yes; bad situation, no. I had to train myself to see that there’s a difference.” Now, a year and a half later, Burgess has regained stability and recovered his confidence, though he says he’s still a work in progress. He works at a construction supply company in Alpharetta and is a proud father to an eighth-grade daughter. “I’m back to being the person I wanted to be,” he says. “My daughter can especially tell the difference. She’s got her dad back.” Burgess hopes other veterans and active-duty service members will take advantage of the resources available to them. “It’s hard to admit you need help,” he says. “For me that was one of the hardest things. But once you’ve admitted it, a weight is off.” For Baker, the army veteran, asking for help after her medical discharge proved difficult. Not only did she face bureaucratic challenges to getting the care and social services she needed, she confronted an even more insidious obstacle: her own internal critic. “In the military,” she says, “everyone tries not to be the weakest link. Being able to hold your own—that’s

everything.” When her physical condition first began to affect her ability to perform her army duties—she was an Avenger systems repairer at the time—Baker ignored the warning signs and pushed through the pain. Her physical health deteriorated. Her emotional health suffered also. Baker didn’t want to be perceived as the problem child—and still doesn’t, she says: “If a bone isn’t sticking out in the army, they don’t think you’re hurt. I would have rather lost a whole limb than deal with all the other things I was dealing with back then.” Too many veterans drop out of treatment for PTSD and other chronic conditions because accessing care over time can pose a logistical challenge. Sheila Rauch, the Mark and Barbara Klein Distinguished Professor in Psychiatry and the deputy director of the Emory Healthcare Veterans program, is tackling the accessibility question at Emory and at the Atlanta VA Medical Center, where she is director of research and program evaluation for the VA’s mental health service line. “The biggest barrier,” Rauch says, “is getting the treatments that work out to veterans where they are.” To that end, she’s developing and testing telemedicine and primary care treatment models for PTSD, so that veterans can receive the best evidence-based care without having to seek out a specialty mental health office. In fact, during the COVID-19 pandemic, much of the program has switched to telemedicine and virtual contact. “We are continuing to serve veterans, just teleworking. We are still conducting intakes. We are seeing outpatients via telemedicine. And we just had our first fully telemedicine cohort for the intensive outpatient program,” says Rothbaum.

They quickly developed a remote intensive outpatient program “that delivers life-transforming care in the comfort and privacy of the warrior’s home,” she says. “This option is currently available for those warriors residing in Georgia, but we hope to expand to other states.” The social work and wellness team compiled a library of online resources to help warriors practice mindfulness, develop listening skills, manage family

Barbara Rothbaum, professor of psychiatry and director of the Trauma and Anxiety Recovery program.

Sheila Rauch, professor of psychiatry and deputy director of the Emory Healthcare Veterans program.

SUMMER 2020

Lieutenant General (ret.) William “Burke” Garrett III is executive adviser to the Emory Healthcare Veterans program and uses outdoor and peer therapy, among other tools, to help veterans heal.

stress, and strengthen resilience. And veteran outreach coordinators set up virtual meet-ups to help warriors connect with each other in real time. Rothbaum has long been a pioneer in virtual reality therapy for patients with phobias, anxiety, addictions, or PTSD, such as veterans. Virtual reality exposure therapy involves having patients describe aloud their most traumatic memories while the therapist matches those descriptions using a computer-generated 3D environment. “The virtual reality exposure system provides an effective treatment and

EMORY HEALTH DIGEST

allows for controlled delivery of sensory stimulation by the therapist,” she says. Follow-up care for veterans who do participate in intensive treatment programs remains key. Each Warrior Care Network site has a VA-based social worker on the team who helps veterans with continuity

of care, even after they have returned to their regular health care provider. “We need to get the message out to veterans,” Rothbaum says. “You can take your life back.” TIMOTHY BANIK entered the US Marine

Corps when he was in high school. He was 18 and wanted to follow in his brother’s footsteps. “I wasn’t ready for college,” he says. “I didn’t know what I wanted to do, but I knew I wanted to test myself. So I picked the Marine Corps, and I picked the infantry.” He started boot camp in 2006 and served in the marines for four years, including two overseas deployments in combat zones. He was emotionally unprepared to handle what he saw when he arrived at his first post in Fallujah, in Iraq’s Anbar Province. “My first sight was of a destroyed city,” he says. “After that, I just wanted to make it home alive.”

By his second deployment, Banik wasn’t sure he would make it to his next birthday. He’d faced combat firsthand. He’d watched a badly wounded friend being transported to emergency medical care on a Black Hawk helicopter. He’d seen the bloody aftermath of improvised explosive devices. Those sights would haunt him. “Maybe I’ll make it to 21 so I can get home and have my first legal drink,” he remembers thinking. Discharged in 2010, Banik did take that first legal drink. Then he took another. He wound up relying on alcohol to self-medicate his symptoms of depression and PTSD. He suffered from suicidal thoughts. He sought help but says the medication prescribed made him feel even worse. “I called the suicide hotline at the VA countless times,” he says. Not until his wife learned about the Emory program and urged him to enroll did he begin to chart a way forward. Banik completed the intensive outpatient program in February 2018. The program taught him that what he had experienced in war did not have to control or define him. He found the psychotherapy component of the program transformative. “I had to believe that I deserved a better life,” he says. “That was hard at first.” Today, at 32, Banik is a secondary market analyst at a bank. He and his wife recently bought a home. They have a dog, and they’re thinking about starting a family. Banik has started sharing his story with other veterans, connecting with General Garrett and volunteering with him

to lead a recent hike up Kennesaw Mountain. Afterward, they took everyone out to breakfast and shared their stories. “So many vets believe someone else deserves the help more,” Banik says. “I had to learn that if you think you need help, you deserve the help. End of story.” For some veterans, ethical and theological reflection become an important part of the healing process. After Emory PhD candidate MICHAEL YANDELL, a former bomb disposal technician for the army, had his story published in 2018, Emory Healthcare Veterans Program leaders reached out with an invitation: Come facilitate a peer-processing group. As a soldier, Yandell survived exposure to sarin gas while retrieving an explosive device from Baghdad Airport Road. He later received a Purple Heart medal. As a PhD student in the Graduate Division of Religion, Yandell has grappled with a different opponent: the experience of moral injury, which he defines both as a sense that one has failed to live up to one’s values and a recognition that the values themselves might rest on false or deceptive premises. “I was heavily armed when I went to war,” he writes in the preface to his dissertation. “My least potent weapon was my rifle.” Yandell says he went into the conflict armed with patriotic ideals coupled with a strong religious faith. “I carried the passion of youth and a feeling of invulnerability,” he says. “I went to war with the blunt instrument of certainty that I was doing God’s will.” By the time he was medically discharged in 2006, those certainties were gone. Yandell is now a pastoral consul-

tant for the program, leading weekly group conversations for veterans and active-duty service members. The goal? To help veterans make meaning of their service. Sometimes that includes acknowledging where traditional beliefs and convictions no longer provide answers. “Some veterans don’t feel at home in their faith communities anymore,” Yandell says. “They want to ask more questions than their churches will allow.” He praises the Emory program for providing treatment at no cost to the veteran. He says he can see positive changes in participants. “They have a lighter countenance by week

Top: Timothy Banik (second from left) poses with Iraqi children and fellow marines during his military service. Photo courtesy of Banik. Above: Emory PhD candidate Michael Yandell, a former bomb disposal technician for the army, is a pastoral consultant for the Emory Veterans program and leads a peer-processing group. .

SUMMER 2020

two,” he says. “They come in hopeless, and they leave with hope.” Georgia State Senator Tonya Anderson, who has visited and learned about the Emory Healthcare Veterans program, praises its willingness to tackle tough issues. “This program has launched into the deep!” she says. “The deep things that concern veterans. It’s about mind, body, and soul. Thank you for listening to our veterans and getting it right!” Listening to veterans also means acknowledging that wounds of war do not come from combat alone, says Ursula Kelly, a nurse scientist at the Atlanta VA Health Care System. Kelly is pioneering research into the effects of trauma-sensitive yoga for veterans who have experienced PTSD from combat or from military sexual trauma. “There are differences between PTSD caused by combat and PTSD caused by sexual trauma,” she says. “Both are life-altering, but military sexual trauma often involves a deeply personal betrayal. These are the people— fellow service members and superiors—who were supposed to have your back. With PTSD related to military

EMORY HEALTH DIGEST

sexual trauma, not only are veterans dealing with the stigma of having PTSD, but there is the added stigma and victim-blaming associated with women’s sexual assault.” The VA defines military sexual trauma as sexual assault or ongoing threatening sexual harassment while serving in the military. It is now so common that the VA routinely asks all veterans if they have experienced it. Between 20 percent and 40 percent of female service members report having experienced military sexual trauma, depending on what study is being cited, according to Kelly. Male service members also experience military sexual trauma, but their reporting rates are much lower—3 percent to 4 percent—though experts believe their actual rates are actually similar to women’s. In research funded by the VA, Kelly and her colleagues are comparing the effectiveness of trauma-sensitive yoga to evidence-based psychotherapy for PTSD. She believes yoga, as an embodied treatment, offers an important tool for healing over the long term. How does yoga help? The answer might seem counterintuitive, she says. Yoga works precisely because it does not require the patient to retell their story, at least not right away. Kelly’s theory is that yoga has the opposite effect of PTSD on the nervous and immune systems—and provides a noncognitive pathway to healing. “For some survivors,” she says, “exposure therapy just isn’t possible right away. They’ve usually experienced multiple traumas throughout their lives. The complexity is just too great. ‘Telling your story’ is exceedingly difficult for these women.” The results of her research to date are promising. Trauma-sensitive yoga is proving to be as effective as evidence-based psychotherapy (specifically, cognitive processing

therapy) for treating PTSD and co-occurring depression in women with PTSD and military sexual trauma. Kelly isn’t looking to replace psychotherapy. But she thinks yoga could provide an alternative or serve as an additional treatment. Yoga helps people learn to regulate their emotions through their bodies, rather than through their thoughts and memories. At the Emory Healthcare Veterans program, yoga is offered to participants as a valuable general practice, though not as a specific treatment for PTSD. Virtual reality therapy also is among the treatments offered to veterans in the program with military sexual trauma–related PTSD. According to research conducted by Rothbaum’s team, virtual reality therapy holds promise for providing relief for veterans grappling with this particularly difficult set of experiences. Kelly’s work at the VA serves as a reminder of how important skilled nurses and nurse scientists are for veterans’ health care nationwide. Emory is one of 18 US nursing schools competitively chosen by the Department of Veterans Affairs to participate in the VA Nursing Academic Partnership for undergraduate nursing students and graduate nurse practitioner students. The program trains nurses to understand the unique and often chronic issues within the veteran population. Lisa Muirhead, associate professor of nursing at the Nell Hodgson Woodruff School of Nursing, serves as principal investigator for both programs. “I’ve been most inspired by the willingness that veterans have shown to share their stories with our nursing students,” she says. “I’m also inspired by the growing interest in caring for veterans that our students express as

The National Center for Veterans Analysis and Statistics estimated that nearly 700,000 veterans were living in Georgia in 2018.

they are immersed in the provision of veteran-centered care.” Since its launch in 2013, the VA Nursing Academic Partnership program has graduated more than 100 nursing students. More than 20 graduate nurse practitioner students have graduated since 2015, the start of the graduate arm of the program. Muirhead says training programs like these are making meaningful change, helping build a robust nursing workforce capable of addressing the complex needs of veterans. “It’s essential that schools of nursing integrate veteran-centered concepts within their curriculum,” she says. “Our nation’s heroes deserve no less.” Georgia State Representative Josh Bonner also toured the Emory Healthcare Veterans program as part of a legislative visit and has a personal perspective on the importance of its work. “It is clear that Emory is all-in for our warrior community,” he says. “As a 23-year army veteran, I encourage all of my brothers and sisters in arms

to consider reaching out in your time of need.” There’s a lot that being in the military can and does prepare you for, says Banik, the marine veteran. “But they can’t teach you how to deal with the outcomes of war or what you might see in wartime situations. I want my fellow veterans to know that help is possible. Mental health is possible. “Reaching into the deepest parts of your soul, that’s harder than battle. But it can be done,” Banik says. For her part, army veteran Baker credits the Emory team with introducing her to additional veteran service organizations after she graduated from the program. She now volunteers with the Mission Continues in her Virginia hometown. When asked how she feels about the military today, she fights back tears. “It’s a double-edged sword,” she says. “I will never love anything like I loved the idea of the military. Some days I think I will never love anything that much again. But I can’t go back. I have to move on.” EHD

Ursula Kelley, a nurse scientist at the Atlanta VA Health Care System, is doing research on yoga with veterans.

SUMMER 2020

PAT I E N T P O V

GOING PUBLIC

Living with Inflammatory Bowel Disease NE WEEK AFTER COLLEGE GRADUATION FROM THE UNIVERSITY OF VERMONT, I MOVED TO ATLANTA. NOT LONG AFTER THE BIG MOVE, I STARTED EXPERIENCING SEVERE GASTROINTESTINAL SYMPTOMS. My symptoms

Years passed. I had good days and bad days but felt relatively normal for quite a while. I changed jobs, moved around Atlanta, received my master’s degree, and more.

progressed and increasingly interrupted my daily life. I realized that something was terribly wrong. I went to my primary care doctor who referred me to a gastroenterologist who sent me for a colonoscopy. The biopsy results changed my life. At age 23, just months after moving 19 hours away from home, all alone in a big city, I was diagnosed with ulcerative colitis. Prior to this, I had never heard of ulcerative colitis and had no idea what it meant for my future. After the initial shock and tears, I figured I would start treatment and go back to my normal daily routine. I quickly learned that was not to be the case. Ulcerative colitis is a type of inflammatory bowel disease (IBD). IBD commonly manifests as either ulcerative colitis or Crohn’s Disease. Both are inflammatory conditions of the gastrointestinal (GI) tract. Both are chronic diseases with treatment options but no known cure. It took me a great deal of time to come to terms with having an incurable, chronic illness. The words, “Why me?” filtered through my mind, and still come and go along with my symptoms. For the first few years after my diagnosis, I felt physically and mentally defeated and broken. But, despite my diagnosis and the embarrassingly painful GI symptoms, I put one foot in front of the other. I went from doctor to doctor searching for someone who would listen. I was desperate to find a provider that wouldn’t dismiss my symptoms and was dedicated to advocating for my health. After trying a few different medications, I accumulated some additional diagnoses, including irritable bowel syndrome (IBS).

EVERYTHING CAME CRASHING DOWN Fast forward to 2016. No matter what I ate or did, I was feeling sick more often than not. I underwent another colonoscopy to find not much had changed. I was referred to a dietitian and began the low-FODMAP (low short-chain carbs) diet to help with my IBS, which completely failed. I underwent further expensive testing with another provider, who put me on expensive probiotics and other supplements. The one test that was really worth it was for small intestinal bacterial overgrowth (SIBO). My test showed hydrogen-dominant SIBO, which correlated with my digestive symptoms. Amidst all my doctors’ appointments, I didn’t feel like myself or the person I wanted to be. I was weak, lethargic, and having unpredictable GI distress. I tried so many different things with the hope that something would magically work. I changed my diet several times and was even put on a liquid diet for a time. I had to stay home from work because I was too weak or needed to be close to the bathroom. In an effort to heal myself naturally, I went to see a naturopath, which was expensive and resulted in taking so many supplements I couldn’t keep them all straight. About a month or so in, I had the worst ulcerative colitis flare-up I had ever had. I couldn’t leave the house and was losing blood more than 20 times a day. I was exhausted and in pain. I could barely eat. I went to urgent care to make sure I didn’t have an obstruction, and they gave me a

EMORY HEALTH DIGEST

prescription for extra-strength Imodium. That Monday, my provider was out so I had a new provider who had old-school ways of treating IBD. As scared as I was, I left with steroids, which were my saving grace to getting out of that flare. As a follow-up, I had a sigmoidoscopy, which is just like a colonoscopy except it doesn’t survey the entire colon just the bottom part (sigmoid). This procedure found inflammation was still present, possibly in my transverse colon, which was higher up than previously reported. I was crushed. I had tried so many things, supplements, doctors, diets, acupuncture, frequency-specific microcurrent treatment, detox foot baths. I was working hard to get well and none of it was helping.

WHEN ALL ELSE FAILS, TAKE A DAY I cried in my gastroenterologist’s office as she talked to me about escalating my therapy to a biological medication. As soon as I got home, I collapsed on the floor with my cat and cried After suffering silently with inflammatory bowel disease, Molly and cried and cried. Then, I ate real pizza for Dunham-Friel, above, started a support group, Better Bellies by Molly, to advocate for heath policy reform, spread awareness, the first time in over a year. I ate a cookie, and build a community of “IBD and IBS warriors.” too. One with gluten. Yup, that is what happened. I allowed myself to have that day to be sad because I knew that the next day was time to pick up the pieces and keep fighting like reform, spread awareness, and build a community hell for my health. of IBD and IBS warriors. I created a website with After returning to my original provider, who had a blog, Instagram, and Facebook page to bring been out on maternity leave, I shared my treatment people with similar struggles together to support attempts and test results. We did yet another round one another. of treatment for my SIBO, which helped tremenI’ve connected with amazing people from across dously. With my provider’s permission, I continued the globe, whom I never would have met if I hadn’t to experiment with different probiotics to see how let myself be vulnerable in sharing my story and the my body would react. I focused on stress reduction embarrassing reality of life with IBD and IBS. Since and eating well but not within any specific guidecreating Better Bellies by Molly, I’ve become a lines. I accepted that I may need to take a biologmoderator for the Atlanta Crohn’s & Colitis Founical medication one day. Living with these unpredation’s support group and met with legislators in dictable conditions over eight years has taught me Atlanta and on Capitol Hill to advocate for health so much, and has molded me into a more compaspolicy reform impacting IBD patients. sionate and understanding person. I’ve learned the I’ll leave you with this: Whatever struggle you power of community and advocacy are facing, don’t go it alone—especially now that we are all isolated in multiple ways. Find a virtual INVISIBLE ILLNESSES DESERVE AWARENESS TOO community to lean on, or build your own. As hard A few years ago, I realized I didn’t want to live with as sharing your journey can be, you never know these conditions in solitude any longer. I founded who you might inspire, or even save, along the way. Better Bellies by Molly to advocate for health policy It might even be yourself. EHD SUMMER 2020

POLICY WISE

Improving Health Care for Every Patient with Epilepsy

ILLUSTRATION BY SORBETTO

COLLECTIVELY, EPILEPSIES ARE THE FOURTH MOST COMMON NEUROLOGICAL DISEASE AND AFFECT PEOPLE OF ALL AGES. The epilepsies have

many different causes and a broad spectrum of severity, but in general they are a group of neurological disorders that all share spontaneous seizures as a hallmark symptom. Epilepsy often goes undiagnosed or misdiagnosed. And, even when diagnosed, that doesn’t mean there will be an effective treatment or cure: 30 percent of those living with epilepsy do not have full seizure control despite treatment. I am one of the 30 percent. I’ve been living with epilepsy for 14 years, and my seizure frequency has varied throughout that time—some years just five seizures; other years more than 60 seizures, and this past year, 21 seizures.

EMORY HEALTH DIGEST

Alison Kukla 18MPH is program manager for National Programs and Services at the Epilepsy Foundation.

My seizures all have one thing in common: they happen without warning, which is the scariest part for me. Once while traveling for work, I was at the airport alone waiting to head home from a conference. I was sitting at a work area catching up on emails and then, the next thing I remember, I was sitting at the gate talking to my very worried fiancé on the phone. There was a span of 25 minutes between those memories. I’m almost certain no one observing even knew I’d had one, since my type of seizure, focal impaired awareness, can be confused with someone daydreaming or staring off into space. That’s just one example of when I’ve had a seizure in public, but there have been many others— on public transit, walking alone to meet friends, and at work. (If you ever witness someone having a seizure, make sure to stay with the person and time the seizure. You want to keep them safe and turn them on their side. The Epilepsy Foundation offers more information about Seizure First Aid.) I only recently started seeing an epileptologist (epilepsy specialist) at the end of 2018 when a colleague made the recommendation after hearing me share my epilepsy journey. I wasn’t aware that I should seek specialized care or that it was even an option. My doctor recommended I do a presurgical evaluation to see if I’d be a candidate for surgery, which I started January 2019. This consists of a variety of tests, the most recent being a stereo-EEG that kept me in the hospital for 16 days. That test showed I have a second place in my brain where seizures start—they take place in both my left side and right side. Because they take place in both sides, I’ve learned I’d be a good candidate for an RNS device, which is similar to a heart pacemaker. It can monitor brain waves, then respond to activity that is different from usual or that looks like a seizure. I’m still deciding if I want to move ahead with this surgery. But I’ve learned so much about my epilepsy since consulting with a specialist, and my care has already improved. I want to help bring system-level change for other patients and families. There is a need to address the wide variations in the delivery of epi-

lepsy care in clinical practice, the unequal access to specialized care, and the higher rates of death and disability than in the general population. I joined the leadership team of the Epilepsy Learning Healthcare System, a patient-centered network and exciting new model that addresses the unmet need to improve epilepsy care for all. The model includes patients and families, health care providers, and researchers working together as equal partners to improve both the quality of epilepsy care and outcomes. Our vision is for all those with epilepsy to live their highest quality of life, striving for freedom from seizures and medication side effects, and we won’t stop until we get there. Thirteen epilepsy centers in the United States are partnering with the Epilepsy Foundation and other community services and professional organizations to learn from every patient at every visit. This will allow for: n Centers across the country gathering data into a central registry and the analysis of this data to identify gaps in care or outcomes. n Site improvement teams at each center generating and testing new ideas using the Institute for Healthcare Improvement’s interactive Plan-DoStudy-Act cycles. n Members sharing successes and improvements during monthly webinars and twice-yearly learning sessions. n Patients and families participating at every step to drive priorities, design new initiatives, and provide feedback. n Work with health care providers, community services teams, researchers, and pharmaceutical companies to optimize seizure control and quality of life. I’ve already benefited from the work being done, and so many more people with epilepsy will have improved health and quality of life because of our network. We’re always looking to grow our community, so if you’re a person with epilepsy or a family member, health care provider, or researcher and are interested in improving care, visit epilepsy. com/elhs or contact us at elhs@efa.org. EHD

SUMMER 2020

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TESTING FOR COVID IN RURAL GEORGIA Epidemiologist Jodie Guest and a team of graduate students from the Rollins School of Public Health tested more than 400 people at a poultry plant in Hall County, Georgia, for COVID-19. Page 8

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