The Medical Decoder Winter 2019

Volume 11

BITCOIN TO HEALTHCARE Navigating the Maze of the U.S. Healthcare System page 10 Healthcare’s Entry into Blockchain page 12

IN THIS ISSUE Science & Technology 4

Learning About LEARN Written by Trisha Kaundinya Northwestern University '21

Designed by Joshua Winograd Northwestern University '21

8

Antibody Drug Conjugates: One Step Closer to the Cure Written by Srijit Paul Northwestern University '20

Designed by Meera Ganesh Northwestern University '21

12

New Kid on the Block: Healthcare's Entry into Blockchain Written by Anthony Kang Northwestern University '20

Designed by Cindy Luan Northwestern University '19

Health Care & Policy 10

Navigating the Maze of the U.S. Healthcare System Written by Raviraj Rege Northwestern University '21

Designed by Harcourt Allen Northwestern University '20

Human Interest 6

The Mystery and History Behind the Hippocratic Oath Written by Troy Biermann Northwestern University '20

Designed by Katherine Liu Northwestern University '20

2 • The Medical Decoder • Winter 2019

Editors-in-Chief

Christina Liu Evan Sitar Carson Wilmouth

Creative Director

Mariam Ardehali

Managing Editor

Troy Biermann

Design Manager

Anthony Kang

Outreach/PR Director

Trisha Kaundinya

LETTER FROM THE EDITORS

Dear readers, Welcome to the eleventh edition of The Medical Decoder!

Writing Staff

Troy Biermann Anthony Kang Trisha Kaundinya Srijit Paul Raviraj Rege

Editing Staff

Monica Juarez Anthony Kang Srijit Paul Elizabeth Sager Charles Schwartz

Design Team

Mariam Ardehali Harcourt Allen Katherine Liu Cindy Luan Joshua Winograd Meera Ganesh

We journey with you in this edition from the ethics of medical philosophy, through to complexities of early diagnosis and tailoring individualized therapies, and all the way to the future intricacies of healthcare as technology continues to evolve.

The path to a career in medicine begins early on with an oath historically taken by physicians, which Troy Biermann details his article, “The Mystery and History Behind the Hippocratic Oath.” We then dive into what the future holds for improving patient diagnosis and treatment.

Trisha Kaundinya, in “Learning about LEARN,” offers a window into the neuroscience underlying language and reading development, as well as improving awareness of language disorders for early intervention and diagnosis. Continuing on the theme of patient therapy, Srijit Paul in turn focuses on implementation of antibody drug conjugates as an individualized, adaptive treatment in addressing a variety of cancer types. We then zoom out and look to the field of technology-based medicine. Anthony Kang discusses the many ways blockchain, a type of technology that paves way for cryptocurrencies like Bitcoin, might be utilized by healthcare systems in the future. Finally, we turn to the issue of health policy as Raviraj Rege breaks down the evolution of healthcare in America in his article “Navigating the Maze of the U.S. Healthcare System."

We are extremely proud of this issue, as we worked hard to incorporate as many different perspectives as possible. Thank you to our dedicated writers, designers, staff and readers for continuing to grow this publication. We hope this edition serves to guide you through your various steps on the journey as a contributor to the healthcare sphere. Happy reading!

Sincerely, Carson Wilmouth, Evan Sitar & Christina Liu Editors-in-Chief medicaldecoder@gmail.com Letter from the Editors • Volume 11 • 3

LEArniNG ABOUT by trisha kaundinya At an academically rigorous institution like Northwestern, it is easy to take reading for granted. Most college students see it simply as a tool to complete more complicated tasks: to get through dense textbooks, to critically analyze points of views, and to efficiently comprehend material at the level of the text and beyond.

But the act of reading a language like English is a complex task, a challenge and virtually a miracle in and of itself. It is a challenge that the department of Communication Sciences and Disorders is intensely investigating at Northwestern.

The Roxelyn and Richard Pepper Institute of Communication Sciences and Disorders is home to over 50 faculty and two dozen clinical research labs all working on the mechanics and pragmatics of language and communication.

Some, such as the Central Auditory Physiology Lab, approach it from the angle of hearing language and ASL, while others, such as the Aphasia and Neurolinguistics Laboratory, study the degeneration of language in America’s aging population. Many labs work alongside the Campus Clin-

ic across the street from Francis Searle to recruit patients for studies.

The LEARN, or Language, Education and Reading Neuroscience Lab headed by Dr. Norton is focused on the beginning of language development from infancy to toddlerhood. This timeframe is a true mystery to study because there is no single section of the brain devoted to reading because they were not made for reading.

Each person forms a totally new and unique reading circuit in his or her brain. The neuroscientific and environmental changes that children undergo during this time to build their reading circuits are essential for setting them up on a successful trajectory to transition from “Learning to Read” to “Reading to Learn.”

Dr. Elizabeth Norton has called Northwestern home for the past couple years, but her journey to study language development in children began long ago. Growing up in a small farm town in New Hampshire, she developed a passion for reading and used to carry as many books as she could each week from the library. In school, she noticed that children learned

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LE

to read and advanced in their reading at vastly different rates.

She was intrigued by this variability and the ways teachers went about helping students.

She later attended Dartmouth to study Language and Brain Development, pursuing a research thesis and two independent projects under Laura-Ann Pettito regarding a neural basis for spelling1. After, she pursued teaching children with reading difficulties in Massachusetts for a year and gained exposure to the practical applications of her studies. Dr. Norton came back to a university setting, attending Tufts to pursue a PhD and MIT to pursue a Post-Doctoral degree, researching in Dr. Wolf’s lab and Dr. Gabrieli’s respectively (both are leading researchers in language and reading development).

At Northwestern, Dr. Norton is an assistant Professor of the Department of Communication Sciences & Disorders Principal Investigator, director of the Northwestern Institute for Innovations in Developmental Sciences Neurodevelopmental Resource Core, and the principal investigator for the LEARN Lab. Her lab contains

EARN several PhD students including Silvia Lam, graduate students and undergraduate students including Emily Harriott and Shelby Isaacs, all passionate about discovering how to help children learn to read well. The research that Dr. Norton and her lab colleagues have conducted from years of study involve reading development with the integration of brain and fMRI studies, with important takeaways being made related to the diagnosis of dyslexia.

Children who have a family history of dyslexia have a lower degree of organization and volume in the arcuate fasciculus, a structure that connects Wernicke’s Area and Broca’s Area in the brain2.

This difference is not something that emerges due to lower reading exposure or a lack of effort, as prior research may have suggested—it is a biological difference in the chain that sets children up to have greater difficulties. Children also have different patterns of activation in their dorsolateral prefrontal cortex, activation that correlates with phonological awareness. The challenges that children face with recognizing and manipulating phonemes in

words is a key predictor of reading fluency or lack thereof.3 In addition to phonological awareness, dyslexic children struggle with the task of Rapid Automatized Naming (RAN), which is the ability to efficiently name aloud a series of familiar objects or words. It is separate from verbal IQ or other predictors of reading development because it requires a particular pattern of encoding, recall, and verbalization.4 There is a gradient of dyslexic children, with different degrees of deficits in phonological awareness, RAN, and both tasks together5. This is part of the reason why each case of dyslexia should be considered independently, thoughtfully and comprehensively.

Current grant awards are working towards studies that use brain imaging technologies such as fMRI, fNIRS and EEG to help identify children who are at risk for reading disorders earlier than traditional behavioral methods would allow, so that earlier intervention can be provided. The studies are targeting analysis of environmental factors such as socio-economic status and parental input in conjunction with reading

development.

The LEARN lab’s neuroscience work and research presentations have inspired their engagement with the greater Chicagoland community to improve awareness of language disorders and to make sure students are given the services and help they deserve to clinical work consistent with research. Dr. Norton is a strong advocate on boards such as LEAP reading initiative in Chicago and the National Reading Panel.

As someone who still loves to read, Dr. Norton and her LEARN lab are working towards a future where early diagnosis and targeted treatment can allow all children to succeed and love reading.

It is one of their first tasks to feel empowered in their capacity to learn through reading.

Interested undergraduate students need only to email the lab to get involved.

See page 15 for References.

Science & Technology • Volume 11• 5

The Mystery and History Behind the Hippocratic Oath By: Troy Biermann For many, the Hippocratic Oath has been seen as a pillar of the medical community as well as a philosophical rock for physicians around the world.

However, it is important to recognize that, historically speaking, the Hippocratic Oath has not been some untouched piece of literature. In fact, it has seen a widely varying amount of popularity in its active use, and there exist a large number of alternate versions or revisions of the oath for modernized purposes. Regardless, in order to fully understand what role the Hippocratic Oath has or

deserves in today’s society, it would first be important to break down its contents as well as its historical significance.

The earliest known fragment of the Hippocratic Oath was found amongst a set of manuscripts called the Oxyrhynchus Papyri and is dated around 275 CE; however, it is likely that it was written in the 5th or 4th century BC.1 In this text, the author presents a series of standards that physicians must swear to follow as a requirement for their positions. Among many things, this oath requires that a physician assist their patients to their greatest ability and without any intention of harm. Additionally, it demands that a physician freely impart their knowledge of health to others. Ultimately, what the Hippocratic Oath emphasizes is that a physician should be selfless in their duty and dedicated to the greater good, not only of whom they treat but of the public as a whole.

Although the Hippocratic Oath is traditionally attributed to the

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Greek physician Hippocrates, historical evidence suggests that it was written later than Hippocrates, though it has been found to draw major influences from his ideals.2 Regardless, the Hippocratic Oath played a major role in the philosophy of early Greek medicine. However, with the waning of Greek political power in the 2nd and 1st centuries BC, the Hippocratic Oath fell out of active use. Even so, it was not completely forgotten, as it was maintained as a piece of history within a great body of text known as the Hippocratic Corpus. It was not until 1508 that the Hippocratic Oath reemerged in a meaningful way, when the University of Wittenberg administered it to its students during a graduation ceremony. Over the next several hundred years, this oath was increasingly used, though still somewhat sporadically, with ~20% of medical school using the oath in their graduation ceremonies by 1928.3 However, following World War II (and perhaps prompted by the medical

atrocities committed under the Nazi regime), the message behind the Hippocratic Oath gained a newfound importance within the global medical community. By the mid-1990’s, most American medical schools had veered away from using the original Hippocratic Oath and instead used some sort of revised version of the oath.4 There exists an ongoing debate on the modern-day relevance of the Hippocratic Oath. Many scholars have asserted that, while parts of the original Hippocratic Oath are somewhat outdated and must be revised or removed in accordance with current times and practice, it provides an important base for contemporary medical philosophy. One of the most widely used revisions, the Declaration of Geneva, which originally drafted by the World Medical Association in 1948 and most recently amended by the same organization in 2017, includes additional sections, among several changes, on respect of the autonomy and

dignity of one’s patient as well as attention to a physician’s own health.5 Others, such as Dr. Robert Orr, a Professor of Medical Ethics at Loma Linda university, have argued that the addition of more and more revised versions have detracted from the original message of the Hippocratic Oath.

In fact, when helping to rewrite the medical oath for Loma Linda’s medical school, Orr was deliberate in adding a section about an “oath to God” in the same vein as the original Hippocratic Oath, which began with a pledge to the Greek gods and goddesses.6 Regardless of which side one chooses to take within this debate, the role that the Hippocratic Oath has played in shaping what it means to be a doctor is undeniable. Regardless of whether or not the original text itself will withstand the tests of time, we can expect its influence shall not fade in the near future.

See page 15 for References.

Human Interest • Volume 11 • 7

ANTIBODY DRUG CONJUGATES By: Srijit Paul

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The use of antibody drug conjugates (ADCs) is an emerging approach in cancer research based on a rather simple mechanism of the immune system. Antibodies are selective proteins that track down specific targets within the body. ADCs use special antibodies that find and attach to markers on certain types of cancer cells. The antibody carries a cytotoxic element which then kills the cancer cell [1]. This is a rather ingenious concept and is far more specific than any other major treatment.

Other popular treatment options have many pitfalls and are not as targeted than ADCs. Chemotherapy is one of the most well-known treatments available to cancer patients. However, chemotherapy raises concerns due to its multitude of adverse side effects, ranging from hair loss to fatigue and nausea [2]. Radiation therapy also has many side effects and can damage surrounding tissue, leading to further problems [3].

Surgery is another route taken often in cancer treatment. There are clear complications in this method as it carries the risks of any surgery [4]. Additionally, there is a risk of perioperative tumor growth. This means that after the surgical removal of a tumor, there is the risk that surrounding tissue will actually promote the growth of new tumors [5]. These treatments are not the most appealing options, but the advent

of antibody drug conjugates have shown the potential to revolutionize the field of cancer treatment.

ADC research has given rise to a variety of products on the market.

However, scientists need to perform further research to develop more robust ADCs. The focus for the next generation of ADCs is on making more adaptive treatments that can address the immense diversity of cancers. These changes are necessary since current drugs only use two types of cytotoxic elements. Another area of focus involves improving the linker protein that holds the cytotoxic element to the antibody, as this is a crucial part of the drug.

The linker protein must be able to bind the cytotoxic element to the antibody long enough to be taken up by the target cancer cell. Further studies are working on developing a robust linker protein that functions without failure [6].

Having a good idea of how to better ADC therapy is promising for the future of cancer treatment.

Even the financial markets are reflecting the great promise of this field. Financial analysis has shown that the market for ADCs is expected to grow significantly within the short span of 2017 to 2023, based on successful clinical trials by biotechnology companies such as Seattle Genetics, Pfizer Inc., and Bayer AG. In addition, the drugs which have been approved show success, even within

the small sampling of commercially-used ADCs such as ADCETRIS, Kadcyla, and Mylotarg [7].

ADCETRIS (Brentuximab vedotin) is a notable ADC that has been approved by the FDA. The drug targets Hodgkins Lymphoma with a 38% rate of remission in patients, and a higher-than-normal percent of patients remain cancer-free over a span of 5 years following treatment with ADCETRIS [8].

Promising drugs like ADCETRIS show that ADCs have the capability to redefine the cancer treatment market and provide better treatment options for patients.

With the great deal of successes seen within the field of antibody drug conjugates and the production of various ADC drugs within the mainstream medical field, there is little doubt that the usage of older, more invasive treatments will be greatly reduced.

The remarkable aspect is the rapid pace with which the ADC treatment is becoming a viable option for future cancer patients.

New biotech companies are adding new ADC products in their FDA approval pipeline with great urgency, indicating its promise.

The hope is that ADCs will help reduce the fear associated with cancer and someday eradicate its position as the one of the great barriers of modern medicine.

See page 15 for References.

Science & Technology • Volume 11 • 9

G N I T M A E F T G O I S V E Y A Z S N A E E M R G A E TH ALTHC AJ RE R E I H V .

A S R .

U Y B E TH For individuals voting in the 2018 Midterm Elections, many polls taken by different organizations have shown that the most important issue on voter’s minds is healthcare 1. It can be agreed that our healthcare system is still nowhere near perfect, and it requires much reform and change before it meets the needs of all Americans. Much of the reason for this is partly because it is so challenging to understand exactly how our system works because of how inherently messy it is.

Most individuals, in the early part of the twentieth century, received healthcare from their employer as one of their job benefits. However, many of those that were unemployed, self-employed, or retired did not have access to basic healthcare coverage. It also became less incentivized for employers to give working-class individuals healthcare benefits because of how costly healthcare

became, so a lot of these Americans with jobs did not have the benefit of healthcare coverage.

This is why in recent years, the government has attempted to step in and provide access to more affordable forms of healthcare. In 1965, President Lyndon B. Johnson signed into law the bill that created the programs we know today as Medicare and Medicaid.

These were designed to provide basic primary and out-of-hospital care to those that were out of the workforce or lived at or below the poverty line, respectively.

However, many individuals still remained uninsured and, with the growing costs of healthcare, only visited doctors when conditions became dire and required trips to the E.R. It wasn’t until the passage of the Patient Protection and Affordable Care Act in 2010 by President Barack Obama – more commonly known as the ACA or Obamacare - when a piece of leg-

10 • The Medical Decoder • Winter 2019

islation was authored to attempt to expand access to affordable, high-quality healthcare.

Prior to the passage of the ACA, roughly 32 to 50 million people were uninsured2. The ACA created health insurance marketplaces, essentially virtual spaces run by state or local governments. These marketplaces listed plans and prices offered by insurance providers with ACA-approved plans, which planned to allow people to qualify for lower premiums. Two key provisions in the law also banned providers from refusing to insure those with pre-existing conditions and allowing children under age 26 to remain under their parents’ health insurance.

It’s been over eight years since the ACA was signed into law, and there have been some mixed views on how it has changed the healthcare system. One major critique of the law was how it actually made healthcare more unafford-

able. In 2016, healthcare spending accounted for almost eighteen percent of our nation’s Gross Domestic Product 3. In addition, because so many individuals with pre-existing conditions signed up for insurance plans through Obamacare, providers had difficulty making profits, so many insurance providers in recent years have decided to leave the marketplace entirely. This led to fewer competition among providers in the marketplace and, hence, more expensive premiums for individual Americans. In states like New Hampshire and West Virginia, there is only one remaining insurance provider 4. However, the largest criticism of the Affordable Care Act was the implementation of the Individual Mandate. This essentially forced individuals to purchase some sort of ACA-approved healthcare plan – otherwise there would be a penalty levied, which was gut-wrenching for some individuals to pay. It’s clear that there needs to be change to the ACA – so how do we go about fixing our healthcare system?

One alternative is to replace the free-market system of the ACA with the concept of the single-payer healthcare system. Politicians such as Bernie Sanders and Alexandria Ocasio-Cortez have advocated for a version of this system – expanding Medicare to all Americans. They believe that implementing this so-called “Medicare-for-all” system, using an already working program in Medicare, would improve upon our current system. A sheer benefit of the Medicare-for-all system is that every citizen has health insurance and no individual is denied coverage. Another is that the

money spent simply on administrative costs are entirely diminished because money moves directly from the government to the physicians – in essence, the need for the middle-man (insurance companies) is gone. However, issues remain in terms of quality of care patients receive as well as the large costs associated with funding a massive government system like single-payer. In Canada, its single-payer system has been called into question because of how long wait-times are for procedures that are less urgent such as hip or knee replacements or even visits with specialists, with the country ranked nearly last among the developed countries 5. While a recent study funded by the conservative-leaning Mercer Institute showed that the institution of a single-payer healthcare system may actually save up to two trillion dollars compared to our current system 6, some of the potential up-front costs with shifting over to this system may be too much to handle for the taxpayer funds.

A proposal by the Congress in 2017 attempted to repeal and replace the entire Affordable Care Act – known as the American Healthcare Act or Trumpcare.

This bill – which never reached the President’s desk – kept many of the positive aspects of Obamacare, such as protection for pre-existing conditions and allowing those under the age of 26 to rely on their parents’ health insurance. It also would have gotten rid of multiple taxes and the Individual Mandate, thus potentially reducing the financial debt significantly. This was believed to allow individuals to, once again,

have more choices in insurance providers. A major criticism of the bill, however, was the fact that the non-partisan Congressional Budget Office released a report 7 stating that twenty million new individuals would be uninsured by this proposal. This fact ultimately led to the bill’s failure in the Congress.

There are some more middleof-the-road plans to provide universal, high-quality healthcare for Americans. One proposal – more recently reiterated by Texas congressman Beto O’Rourke – allows for Medicare to be added to the healthcare exchanges, which could potentially promote competition among insurance providers, lower prices, and still guarantee healthcare to all individuals. Another proposal – made by South Carolina and Louisiana senators Lindsey Graham and Bill Cassidy – allowed for individual states to decide whether they should remain on the Obamacare exchanges or not. States like New York or California – where Obamacare is working more effectively – can choose to stay, while states like West Virginia or New Hampshire – where it is crippling many citizens’ pockets – can choose to leave the Obamacare exchanges.

With increasing technology and biomedical research, the types of treatment and quality of care has never been better. We are discovering new drugs that can potentially treat and even cure life-threatening diseases. We are more aware of how certain lifestyle choices can affect our own health. We just need a health insurance system that works for all of us.

See page 15 for References.

Health Care & Policy • Volume 8 • 11

When the value of bitcoin jumped near-exponentially last year, “blockchain” and “crypto” became household words overnight, despite decentralized and secure cryptocurrencies like Bitcoin having existed for nearly a decade. Amidst this crypto frenzy, blockchain, the underlying technology that grants Bitcoin its features, has recently begun to garner more interest from an expansive range of industries, especially healthcare.

At its core, a blockchain is a permanent digital record that stores transaction data (or any type of data describing

an event) in a chain of digital “blocks” using cryptography, or virtual encryption secured by complex algorithms. Each block holds this data along with a pointer to the location of the previous block, which links the two blocks in a chain. Before being permanently added to the blockchain, each block must be time-stamped and cross-checked with thousands of decentralized, backed-up copies of the blockchain, preventing duplication of an already-existing block in the chain (in bookkeeping, this averts an issue known as “double-counting”)6. This system

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thereby forms a highly accurate historical record of transactions, from the present exchange all the way to the very first transaction approved on the blockchain1.

In this way, the blockchain keeps its data traceable and immutable, necessary features for keeping track of important chronological records.

So how does blockchain apply itself from digital crypto-currency to the seemingly dis-parate field of healthcare? Many research groups have proposed using blockchain to store health data, among a variety of other potential uses; in recent years, innumerable

hospitals have pushed towards transferring patient health data to electronic health records (EHRs). However, amongst other challenges, the implementation of EHRs has been widely fragmented; in Boston alone, 26 different EHR systems are in use across all the hospitals throughout the city2.

Consider that most patients likely visit multiple medical facilities and receive care from numerous healthcare professionals throughout their lifetimes. Even with EHRs, keeping track of a patient’s his-tory currently requires manual verification and consolidation of data from health records at various institutions, including hospitals, insurance companies, pharmacies, private clinics, and labs, which can be inefficient and prone to errors and data loss2,4.

In response to this issue, a group between the MIT Media Lab and Beth Israel Deaconess Medical Center proposed and built a preliminary blockchain solution called MedRec. This private blockchain, built on the open-source Ethereum blockchain platform, allows different insti-tutions to update a central “health record” blockchain containing a patient’s medication history. Similar to a Google Doc, this blockchain can be accessed by multiple collaborators (as well as the patient in question) who can then upload information about the patient’s prescribed medications to the blockchain.

This creates a consolidated and

permanent chronological record that accurately keeps track of the patient’s medical history with each visit and prescription2,3,5.

As Dr. Halamka, a physician on the MedRec team, explains, blockchains like MedRec aim to work in tandem with existing EHR systems rather than replace them entirely. No single institution connected to the blockchain claims sole ownership over the record, and the unified system grants patients better accessibility to their medical data. Ultimately, the blockchain serves to consolidate data from different EHR systems into a more functional and robust health record, while also providing the patient easier access to their own information3,4.

While the first iteration of MedRec only focuses on medication data, this blockchain system can eventually be expanded to manage data pertinent to patient visits, medical conditions, and other aspects of traditional health records. By facilitating access to this information across institutions, blockchain systems like MedRec can streamline patient

care by making health records more accessible and continuous for physicians and patients alike.

The MedRec team also envisioned their blockchain system for use in providing clinical trial data. Much like how Bitcoin rewards miners (computers linked to the blockchain) with amounts of bitcoin for solving cryptogra-phic puzzles to verify transactions, MedRec also incorporates incen-tivization for clinical researchers’ computation resources to main-tain the blockchain. In exchange for linking their computers to the blockchain network, MedRec provides researchers with aggre-gated, anonymized data from patient data for specific queries, such as the blood test results for a certain demographic of patients collected within a specified period of time2,3.

One of the primary challenges that blockchain faces inhealthcare lies in privacy regulations and HIPAA compliance.

Here the distinction between security and privacy becomes especially important: blockchain

"The blockchain keeps its data traceable and immutable, necessary features for keeping track of important chronological records."

Science & Technology • Volume 11 • 13

time passes, the decryption given to the researchers self-destructs, thereby terminating access to the data. Smart contracts are already in place via Ethereum for regulating transactions and exchanges on the blockchain and could potentially provide a stepping point for future privacy solutions1,3.

Nevertheless, at its current stage, blockchain is not quite ready for adoption by healthcare systems today. With further development of solutions tailored to comply with HIPAA regulations, a blockchain system suitable for optimizing patient care could be successfully implemented, and as discussed above, many efforts by groups like the MedRec team are making notable headway to-wards this direction.

Given that much of healthcare has historically been conservative towards technological adoption, the blockchain movement may face further obstacles along its journey to fruition in medicine, but the recent interest in the medical community towards blockchain’s potential may signal evolving and more technologically receptive attitudes in healthcare. Only time will tell how technologies like blockchain may shape the trajectory of med-icine in the future.

transaction visibility and integrity as opposed to data privacy, which entails limiting access to data to specified parties. For storing sensitive data security like health records, a much higher and privacy level of privacy than presently in becomes especially place must be ensured to protect important: blockchain securely patients’ identities and personal stores transaction data, meaning information. MedRec manages that the data added to the to circumvent this concern by blockchain is maintained in the testing their platform on private record permanently with virtually blockchains (accessible only no risk of modification by other be-tween specific users) using users or corruption by malware. less sensitive data limited to 3 Recall that blockchain medication information . Given accomplishes this by adding data- the restricted scope and security of storing blocks to the chain only data on private blockchains (since after the data in the blocks has the data is no longer cross-verified been verified by thousands of with thousands of distributed copies of the blockchain spread copies), this workaround may not across a decentralized network. be scalable for widespread use.

One solution that addresses This network sends the data to multiple user computers to these privacy concerns, described check and ensure its integrity. by the MedRec team and a group Therefore, every transaction at Thomson Reuters, includes stored on current blockchain the use of smart contracts, models is secure and tamper- or contracts enforced by an resistant but ultimately trans- automated system, to regulate parent due to the extensive data access between groups. distribution and verification For example, only researchers of the transaction data before specified in a smart contract See page 16 for References. being added to the record. would receive access to encrypted subject data for a certain As a result, current iterations of blockchain prioritize amount of time; once the allotted

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REFERENCES Learning About LEARN

1. Norton, E. S., Kovelman, I., & Petitto, L. A. (2007). Are there separate neural systems for spelling? New insights into the role of rules and memory in spelling from fMRI. Mind, Brain, and Education, 1(1), 48-59.

2. (Saygin, Z. M., Norton, E. S., Osher, D., Beach, S. D., Cyr, A. B., Ozernov-Palchik, O., Yendiki, A., Fischl, B., Gaab, N., & Gabrieli, J. D. E. (2013). Tracking the roots of reading ability: White matter volume and integrity correlate with phonological awareness in pre- and early-reading kindergarten children. The Journal of Neuroscience, 33(33), 13251-13258. (*Co-first authors)).

3. Kovelman, I., Norton, E. S., Gaab, N., Christodoulou, J., Triantafyllou, C., Lieberman, D. A., Lymberis, J., Wolf, M., Whitfield-Gabrieli, S., & Gabrieli, J. D. E. (2011). Brain basis of phonological awareness for spoken language in children and its disruption in dyslexia.

Cerebral Cortex, 22(4), 754-764.

4. Norton, E. S., & Wolf, M. (2012). Rapid automatized naming (RAN) and reading fluency: Implications for understanding and treatment of reading disabilities. Annual Review of Psychology, 63, 427-452.

5. Norton, E. S., Black, J. M., Stanley, L. M., Tanaka, H., Gabrieli, J. D. E., Sawyer, C., & Hoeft, F. (2014). Functional neuroanatomical evidence for the double-deficit hypothesis of developmental dyslexia. Neuropsychologia, 61, 235-246.

The Mystery and History Behind the Hippocratic Oath

1. Jouanna, Jacques. Hippocrates. Johns Hopkins University Press, 2001.

2. Bailey, Ian. “Who Wrote the Hippocratic Oath.” West of England Medical Journal 106.4 (1991): 91–92.

3. Smith, Larry. “A Brief History of Medicine's Hippocratic Oath, or How Times Have Changed.” Otolaryngology-Head and Neck Surgery 139.1 (2008): 1–4.

4. Orr, Robert D. “The Hippocratic Path: Is It Still Relevant?” Center for Christian Bioethics, Update 14.1 (1998).

5. “WMA Declaration of Geneva.” World Medical Association, Oct. 2017.

6. Bailey, Melissa. “Medical Students Revise Their Hippocratic Oath to Reflect Modern Values.” STAT, 21 Sept. 2016.

Antibody Drug Conjugates: One Step Closer to the Cure

1. Zolot, R. S., Basu, S., & Million, R. P. (2013). Antibody–drug conjugates [News]. https://doi.org/10.1038/nrd3980 2. Love R. R., Leventhal H., Easterling D. V., & Nerenz D. R. (2006). Side effects and emotional distress during cancer chemotherapy.

Cancer, 63(3), 604–612. https://doi.org/10.1002/1097-0142(19890201)63:3<604::AID-CNCR2820630334>3.0.CO;2-2 3. Radiation Therapy. (n.d.). [cgvArticle]. Retrieved April 7, 2018, from https://www.cancer.gov/about-cancer/treatment/types/ radiation-therapy 4. Surgery. (n.d.). [cgvArticle]. Retrieved April 7, 2018, from https://www.cancer.gov/about-cancer/treatment/types/surgery 5. Neeman, E., & Ben-Eliyahu, S. (2013). The perioperative period and promotion of cancer metastasis: New outlooks on mediating mechanisms and immune involvement. Brain, Behavior, and Immunity, 30(Suppl), S32–S40. https://doi.org/10.1016/j. bbi.2012.03.006 6. Beck, A., Goetsch, L., Dumontet, C., & Corvaïa, N. (2017). Strategies and challenges for the next generation of antibody–drug conjugates. Nature Reviews Drug Discovery, 16(5), 315–337. https://doi.org/10.1038/nrd.2016.268 7. Research and Markets ltd. (n.d.). Global Antibody Drug Conjugates Drug Sales, Pipeline Analysis (By Phase, Linker, Technology, and Indication) & Global Market Forecasts to 2023. Retrieved March 28, 2018, from https://www.researchandmarkets.com/ reports/4462607/global-antibody-drug-conjugates-drug-sales 8. Chen, R., Gopal, A. K., Smith, S. E., Ansell, S. M., Rosenblatt, J. D., Savage, K. J., … Younes, A. (2016). Five-year survival and durability results of brentuximab vedotin in patients with relapsed or refractory Hodgkin lymphoma. Blood, 128(12), 1562–1566. https://doi. org/10.1182/blood-2016-02-699850

Navigating the Maze of the U.S. Healthcare System

1. Kirzinger, A., Hamel, L., DiJulio, B., Muñana, C., &amp; Brodie, M. (2018, October 19). KFF Election Tracking Poll: Health Care in the 2018 Midterms. Retrieved from https://www.kff.org/health-reform/pollfinding/kff-election-tracking-poll-health-care-in-the-2018-midterms/ 2. Amadeo, K. (n.d.). Obamacare: Simple Enough to Explain to Your Kids. Retrieved from https://www.thebalance.com/obamacare-explained-3306058 3. NationalHealthAccountsHistorical. (2018, January 08). Retrieved from https://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html 4. Semanskee, A., Cox, C., Claxton, G., Long, M., & Kamal, R. (2017, November 16). Insurer Participation on ACA Marketplaces, 20142018. Retrieved from https://www.kff.org/health-reform/issue-brief/insurer-participation-on-aca-marketplaces/ 5. Simpson, C., Walker, D. M., Drummond, D., Sinclair, D., Wilson, R., & Health Services and Policy Research. (2018, October 24). How healthy is the Canadian health-care system? Retrieved from https://theconversation.com/how-healthy-is-the-canadian-health-caresystem-82674 6. Nichols, J. (2018, August 02). Thanks to the Koch Brothers, We Have More Proof that Single Payer Saves Money and Cares for All of Us. Retrieved from https://www.thenation.com/article/thanks-koch-brothers-proof-single-payer-saves-money/ 7. H.R. 1628, American Health Care Act of 2017. (n.d.). Retrieved from https://www.cbo.gov/publication/52752

References • Volume 11 • 15

REFERENCES 8. G., & L. (2017, September 13). S.Amdt.1030 to H.R.1628 - 115th Congress (2017-2018) - Amendment Text. Retrieved from https:// www.congress.gov/amendment/115th-congress/senate-amendment/1030/text

New Kid on the Block: Healthcare's Entry into Blockchain

1. Nugent, T., Upton, D., & Cimpoesu, M. (2016). Improving data transparency in clinical trials using blockchain smart contracts.

F1000Research, 5, 2541. doi:10.12688/f1000research.9756.1 2. Orcutt, M. (2017, September 22). Blockchain technology will revolutionize medical records-just not anytime soon. Retrieved March 29, 2018, from https://www.technologyreview.com/s/608821/who-will-build-the-health-care-blockchain/ 3. Azaria, A., Ekblaw, A., Vieira, T., & Lippman, A. (2016, 22-24 Aug. 2016). MedRec: Using Blockchain for Medical Data Access and Permission Management. Paper presented at the 2016 2nd International Conference on Open and Big Data (OBD).

4. Halamka, J., Lippman, A., Azaria, A., & Ekblaw, A. (2017). The Potential for Blockchain to Transform Electronic Health Records.

Retrieved March 29, 2018, from https://hbr.org/2017/03/the-potential-for-blockchain-to-transform-electronic-health-records 5. Mougayar, W. (2016, September 6). Explaining the Blockchain via a Google Docs Analogy [Web log post]. Retrieved April 3, 2018, from http://startupmanagement.org/2016/09/06/explaining-the-blockchain-via-a-google-docs-analogy/ 6. Nakamoto, S. (2009). Bitcoin: A peer-to-peer electronic cash system.

16 â&#x20AC;˘ The Medical Decoder â&#x20AC;˘ Winter 2019

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