By Jessica Craig Staff Writer
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ost pre-medicine and undergraduate students have heard stories of interns and new residents being harassed, publicly embarrassed, or mistreated by older doctors and even their peers. Some stories are more extreme, but all can make aspiring doctors a little more anxious about medical school, internships and residency. How much truth lies in these accounts, and what is it like to be a real intern or resident? In 1991, the American Medical Association conducted a national survey of the treatment of first-year residents across the country. The survey was mailed to 10 percent of the nation’s second-year residents, asking them to report about their experiences as a first-year resident. Of the 72 percent that responded to the survey, an astonishing 93 percent reported at least one incidence of mistreatment or harassment; 63 percent of female residents reported an incidence of sexual harassment; and over 70 percent of residents reported incidences of working under impaired conditions, namely sleep deprivation. The Association of American Medical Colleges now conducts yearly surveys to monitor the treatment of medical students, interns and residents. Many well-known teaching hospitals and medical schools such as Johns Hopkins and the University of California at San Diego have taken great legal strides to prevent mistreatment of new doctors. Despite these efforts, more than half of second year residents still report incidents of mistreatment. These include physical violence, public embarrassment, bullying, harassment, and forcing interns to perform non-medically related tasks for their older resident. Why do older residents and doctors resort to such extreme measures to teach the incoming class? The longevity of the mistreatment might signify that, in some way, it helps teach young doctors how to work under extreme pressure or how to handle the social interactions that being a doctor demands. Doctors justify the harsh conditions by telling trainees that every new doctor goes through this. In this way, the mistreatment parallels hazing that might be seen in fraternities or the military. It is also a common belief that these conditions expose
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Photo courtesy of United States Navy
MISTREATMENT OF MEDICAL INTERNS AND RESIDENTS April 2013
Volume III Issue IV
Featured Article
Xenotransplantation
new doctors to such extreme emotional and psychological stress that it helps to remove emotions from their work, reinforcing impartial judgment. Some doctors even believe that the mistreatment ensures that doctors are truly dedicated and passionate about their jobs; the harsh conditions “weed out” weak doctors. Is the tradition of mistreating interns and residents really the most effective way of teaching and training new doctors, or
“I learned more about how unworthy and stupid I was than I did about medicine and surgery.” is it causing undergraduates and medical students to rethink their occupation choice? One aspiring doctor in the University of Virginia’s medical program found that his original ambition was not worth the abuse. After graduating from the University of Maryland with a bachelor’s degree in chemical engineering, Dr. James Clark† attended medical school at the University of West Virginia, in hopes of one day becoming a general surgeon. After medical school, Clark found himself in the General Surgery Residency Program at UVA. Describing his experience as a surgical resident, Clark stated that every day of his internship, he felt “that he was a completely unworthy human being, … an incompetent doctor.” He understood that, as a resident, he truly had very little knowledge about medical practice and surgery, but the harsh, constant reminder of this made him feel unmotivated and hopeless. “The doctors and surgeons I worked under made me feel as though I didn’t
deserve to be a doctor,” he said. “During my entire first year as a resident, I learned more about how unworthy and stupid I was than I did about medicine and surgery.” After his first year of residency, Clark left medicine and pursued a career in chemical engineering. But his work there was unfulfilling. Now, three years later, Clark has reapplied to residency programs and plans to try again in June 2014. When mistreatment of residents surfaced as a major problem in the medical field (notably after the 1991 survey), psychologists, medical schools and hospitals across the country began conducting their own surveys and interviews to explore the psychological effect of abuse on young doctors. One survey conducted at Rush Medical College in Chicago, Illinois, showed astonishing data. Psychologists and other researchers found that over 40 percent of interns and residents experienced reoccurring bouts of depression and extreme anxiety. In almost all of these cases, interns changed areas of specialty, changed hospitals or residency programs, or took time off before returning to complete their residency or fellowship. About 20 percent of these interns and residents left the medical field completely and pursued other jobs. In about 1.2 percent of these cases, interns and residents either committed or attempted suicide. While he is now entering a specialty typically considered less competitive than surgery, Clark admits he is nervous about returning to medicine and facing the conditions he remembered. But he hopes that, in light of the recently published surveys and studies, conditions will have since improved. Research suggests that the problem has been identified; but in this area, the field of medicine has yet to undergo the major reform it needs.
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†
Name has been changed by request
pg. 10
Could these pigs be the future of organ transplantation?
Purchasing and Practicing Intelligence pg 3 Tips on Thank You pg 5
Nanoscale MRI pg 6
Xenotransplantation pg 10
The Stem Cell Race pg 8
Since 1989, the gap between the number of patients waiting for organs and the number of donors has grown.
Mistreatment of Medical Interns and Residents pg 12
Telemedicine pg 4
Editor in Chief Deborah Chen Assistant Editors Niaz Khan Beverly Hersh Layout Editor Danielle Hu
Staff Writers:
Haadi Ali Imaz Athar Jessica Collins Jessica Craig Natalie Ernecoff Lauren Hasek
Do you have an idea you’d like to contribute to The Pitt Pulse? Contact our editors at thepittpulse@gmail.com Make sure to visit our website : www.thepittpulse.com
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Prasad Kanuparthi Belinda Lao Yash Pandya Swati Rajprohat Zaid Safiullah
The fact that pigs can provide an unlimited supply of organs is significant on its own. Yet another advantage of using a pig xenotransplant is that doctors will not have to worry about whether or not the pig organ carries infections that can harm the patient. With human donors, doctors have to remove the organs within 24 hours of death, and they only have a few hours to determine whether or not the organs carry disease. At times, according to Cooper, risks have to be taken or else there would not be any donors at all. This worry is partially alleviated with pigs because they can be raised in clean conditions. They would be kept in separate groups and breathe filtered air; their food would be sterile, and their caretakers would wear suits to eliminate any direct contact with the pigs. This would hopefully mean that the pigs would not contract infections, and produce only non-infected organs. This way, patients would avoid complications that arise from inheriting an unhealthy human organ. Pigs can be a source of a variety of organs that could potentially help millions of patients with a number of health problems. Despite this, there are people opposed to xenotransplantation because they believe genetic engineering is a violation of animal rights. In fact, in 1999, People for the Ethical Treatment for Animals called xenotransplantation
“Frankenstein science” and asked the FDA to ban it. Although the FDA did not ban xenotransplantation, they asked that xenotransplant patients be closely monitored throughout their lives. Despite critics like PETA, Cooper believes that we need to measure the usage of animals against the outcome it can have for humans. “We can either sit and watch [people] die, or do something about it,” he said. Cooper disagrees with PETA’s description of xenotransplantation. According to him, the genes that researchers are knocking out (or in) in pigs have “no real effect” on their behavior or wellbeing. Others protest against xenotransplantation because they are worried about the pigs’ living situation. However, according to Cooper, the pigs that would be used for xenotransplantation would be treated with respect because they are “commercially valuable.” They would be housed in “perfect” conditions, unlike pigs that are passed through slaughterhouses as sources of food. Organ-source pigs will be anesthetized like humans, euthanized humanely, and die a more “honorable” death than the 100 million pigs that are slaughtered for food each year in the United States. There are also those that question xenotransplantation for fear that the
“We can either sit and watch [people] die, or do something about it.”
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Photo courtesy of Brian Scott, United States Army
In This Issue of The Pitt Pulse...
Today, many people in need of an organ transplant cannot get one - there simply are not enough organs available.
endogenous retroviruses in pig organs, cells, or tissues will grow in humans. Cooper does not believe that this will happen. In fact, virologists at an FDA committee that Cooper attended stated that the retroviruses, in Cooper’s words, “won’t do any harm.” Others were worried that xenotransplantation could cause an AIDS epidemic, but Cooper also finds this “exceedingly unlikely.” Despite the evidence that xenotransplantation has the potential of benefiting thousands – if not millions – of patients, the critics remain. But there are always critics. It is the enduring vision that is important. In the late 1970’s, the mortality rate for patients of human heart transplants each a year was extremely high—according to Cooper, it was 50 percent or more. Although this incited criticism, researchers and doctors stuck to their vision, and the mortality rate for patients who receive these transplants is now quite low. This kind of perseverance is significant, and with the amount of research Cooper and others have conducted, and the number of advances that have been made, Cooper believes xenotransplantation will revolutionize medicine and might become commonplace in even just 50 years.
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XENOTRANSPLANTATION The Future of Organ Transplantation?
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hile primates are more immunologically similar to humans than pigs are, throughout history, humans have not picked up any serious infections from pigs. Pigs can also be bred in larger groups. This is extremely important; pigs could provide an almost unlimited supply of organs. According to Cooper, an unmodified pig heart lasts only five to 10 minutes in a baboon or human. This is because all pig cells have a galactose component. Three to four months into human development, we create anti-galactose antibodies in our bloodstream to fight disease. When a pig heart is transplanted into a human, these anti-galactose antibodies bind to the galactose components of the pig cells, initiating a process called complement cascade activation, which destroys the pig organ. Cooper and other researchers have corrected this problem by genetically engineering pigs so that their cells do not express galactose sugars. Furthermore, research groups in Minneapolis and in Cambridge, England, have developed genetically engineered pigs that possess human complement-regulatory proteins that also protect the pig organ. With both of these factors combined,
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Pigs may be the future of organ transplanation.
Cooper has found that a pig heart can last six or eight months without rejection in a baboon. Although the baboon does not reject the pig heart, blood clotting still occurs. In order to reduce the rate of clotting, Cooper and researchers have put a human coagulation-regulatory protein in the pig. Although this has yet to completely eliminate the clotting, Cooper believes more coagulation-regulatory
Pigs could provide an almost unlimited supply of organs. proteins will prevent this complication. Although there is still progress to be made, six or eight months is already a significant increase in survival rate from five to 10 minutes.
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winging a bat, riding a bike, typing, and playing a musical instrument show neuroplasticity, commonly referred to as muscle memory, in action. All four tasks improve when repetition leads to motor learning, following the “practice makes perfect” mantra engrained into every budding musician or athlete. Does muscle memory function in the brain, for intelligence, like it does in muscles for motor function? Imagine if playing online games to build intelligence was equivalent to going to the gym to build muscles or the batting cages to practice your swing. The latest workout fad extends the concept of neuroplasticity to mental capacity, offering to make you smarter through the use of online brain-training games. Brain-training games are projected to be a 3 billion dollar industry by 2016. Advertisements for companies such as Luminosity, Nintendo’s Brain Age, Fit Brains, and Brain Metrix are inundating social media with promises of improved memory, attention, and cognitive function in all age groups. This new industry begs the question: is there any true validity in these claims? Can purchasing an online subscription make you smarter? Might it have some greater value for our society? Brain-training programs target the recent findings that improving short-term (“working”) memory through control of attention may produce an increase in fluid intelligence. Fluid intelligence can be conceptualized as thinking ability, or how well the brain works through problems. Imagine you are asked to solve a logic problem you have never encountered before. All the information you need is given; it does not rely on any prior knowledge of the subject. Your short-term memory is the scrap sheet of paper where you work through the problem. Fluid intelligence defines how efficient you are at using that paper to sort and process the given information to solve the problem. This problem-solving exercise is modulated by your concentration and attention toward the task.
Diagram Courtesy of Lauren Hasek
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ob suffers from heart disease and is in dire need of a transplant. Unfortunately for Bob, receiving a transplant isn’t so easy. First off, doctors need to run a series of tests to see if he is a suitable candidate for heart transplantation. There are times when the patient fails these examinations and is deemed ineligible for a transplant, but let’s say Bob passes them. Now, doctors need to find the ideal heart for Bob. His blood type, heart size, and his degree of sickness are only a few of the factors that come into play in this decision. There are approximately 3,500 people in the United States that are waiting for a heart, and there aren’t nearly enough donors to meet this demand. As a result, Bob is placed on the waiting list. The amount of time he’ll have to wait is uncertain—it could be months, or even over a year. In the meantime, Bob may have to spend days in the hospital to receive medical treatment that will support his ailing heart. Not only is this inconvenient for him, but realizing that he could die while waiting for a vital organ is tremendously frightening. Imagine if Bob could avoid the long, life-threatening wait. Imagine if he could receive a clean, disease-free heart within days. Dr. David Cooper, of the Thomas E. Starzl Transplantation Institute in Pittsburgh, believes that this may become a reality. The potential solution? Transplanting a pig’s heart into a human, through a process known as xenotransplantation—the transplantation of living organs, cells, or tissues from one species to a different species. Currently, there are close to 110,000 patients waiting for an organ donation. However, only around 30,000 organs are transplanted each year. The gap between patients on the waiting list and
By Lauren Hasek Staff Writer Photo courtesy of United States Department of Agriculture
By Imaz Athar Staff Writer
the number of donors has increased dramatically since 1989, when there were roughly 18,000 patients waiting and a little over 13,000 transplants (much closer to a 1:1 ratio). As a heart transplant surgeon, Cooper realized that the supply of heart donors did not meet the demand. When running a heart transplant program, Cooper could already only choose 70 patients out of the 140 that were referred to him each year. However, according to Cooper, “well under half ” of the 70 patients were actually able to receive a transplant “because [they] didn’t have enough donors.” According to him, the other half “would generally die unless they could be staggered on for another year or so.” It became clear to him that it was important to direct his attention towards finding a different source of organs, cells and tissues. And the surprising candidate? Pigs.
PURCHASING AND PRACTICING INTELLIGENCE
Overall intelligence quotient tests are a way of quantifying fluid intelligence. They are given at a young age, and provide a standardized point for comparing social potential. High scores are desirable because they are strongly correlated to future
Repeatedly playing brain-training games will improve performance on those games, but it does not necessarily transfer to unrehearsed mental tasks. academic achievement and professional success. This is because IQ tests do not measure facts or depth of knowledge, but rather comprehension, judgment and reasoning. In 2008, Jaeggi et. al found significant improvements in fluid intelligence following regimented training on working memory.
The training consisted of a task as simple as asking subjects to remember and recall auditory cues and visual sequences in tandem. This requires the participant to remember two different types of stimuli at the same time: one that they hear and one that the see. These findings challenged the longstanding assumption that fluid intelligence is a static trait sculpted soon after birth by largely genetic and environmental factors. Since fluid intelligence is correlated with success, it is not surprising that the study has since sparked the creation of IQ training. But follow-up studies have shown mixed results. Longitudinal studies are now underway, investigating how long these supposed gains in fluid intelligence last, and if they are linked to gains in job or scholastic performance. Meanwhile, Jaeggi’s training has been adapted into games by companies such as Luminosity and Nintendo. For a set monthly fee (usually around $15), braintraining websites offer personalized training programs “built on proven neuroscience research.” Luminosity offers customer testimonials that translate their time playing the website’s games to real-world improvements in job performance, as well as in mental and physical aptitude. While many of the websites target working-age adults, others claim to prevent memory loss in aging populations or boast
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* Problem-solving ability dependent on the capacity to reason abstractly and perceive relationships “independent of previous specific practice or instruction concerning those relationships” * An inherent, largely genetic quality that declines after 3040 years of age * Not previously believed to be modifiable by practice or education * Intelligence Quotient (IQ) Tests: provide a standardized comparison of professional and scholastic potential by quantifying comprehension, judgment, and reasoning ability
TELEMEDICINE By Natalie Ernecoff Staff Writer
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oday’s medical practice provides many enticements for the budding medical student, from intricate surgeries to fine-grained imaging. Medicine provides access to the sleekest technologies that would not be encountered in most any other setting. There is no doubt that the attractiveness of new and different technologies will continue driving medicine into the future. Therefore it is wise for those entering the field to stay up-to-date on the technological progress that will affect them in years to come, its impressive implications, and the risks it may pose. Telemedicine is one of the technologies that are now being integrated into modern medical practice. Telemedicine is defined as the use of audio-visual technology to provide medical services from a distance. It
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Photo courtesy of Samantha A. Lewis, United States Navy
Entering the Workforce as a 21st Century Doc
Telemedicine can be useful in evaluating post-operative patients remotely, saving them the time required to travel to their specialist.
offers individuals in remote communities access to health care that they might not otherwise receive. With the assistance of a local nurse or primary care physician, remote specialists can observe and interact
with their patients via a video monitor in addition to more discrete monitoring of real-time vitals statistics of in-patients. For example, a neurologist can observe a patient with potential motor damage
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“Stem cells are the agent that can rejuvenate your body.”
Photo Courtesy of Dr. QIang Shi
FLUID INTELLIGENCE
This could explain the increased IQ reported by the study. Repeatedly playing brain-training games will improve performance on those games, but it does not necessarily transfer to unrehearsed mental tasks – the problem solving that involves fluid intelligence. Just last year, two studies were published that failed to reproduce the effect of training on fluid intelligence. If brain-training games don’t improve cognitive performance, what does? Substantial literature supports the positive effects of acute exercise on cognitive performance. Around 150 minutes of moderate physical activity each week increases immediate mental and physical well-being, and reduces risk factors for heart disease, stroke, and dementia. Preliminary findings from some of the first longitudinal studies on lifetime exercise suggest regular physical activity throughout life leads to improved cognitive function and memory, and may reduce the risk of developing dementia later in life. Tired or stressed? Buying into the gimmicks of the gaming industry may not be the best way to clear or re-energize your mind. But exercise may be.
potential therapeutic uses for embryonic stem cells in individuals with heart or lung damage, or even for burn victims that need their bodies to repair damaged skin cells. The pluripotent potential of embryonic stem cells might even lead to organ generation if the cells are differentiated correctly. When asked about the importance of his research, Dr. Qiang Shi of the Texas Biomedical Research Institute responded, “The only problem we have in the future is that you are getting too old, you want to survive, and you want to lead a better life. Stem cells are the agent that can rejuvenate your body.” While this research is regarded as highly valuable to the field of medicine, the issues associated with embryonic stem cell research are difficult to surmount. Getting FDA approval as well as financing for this type of research is no easy task. A common ethical debate is whether embryonic stem cells should be understood as life or as scientific property. Does life begin at conception, or after fetal development? Because of this argument, many U.S. citizens do not approve of using human embryonic stem cells for research, causing the f low of money, both public and private, to avoid this field. The lack of successful evidence involving embryonic stem cells is also inhibiting public support. There is hope that with more research, more trials will be approved and eventually translated into treatment options for injuries and diseases. According to Shi, the key is to do research in a primate model
Dr. Qiang Shi, a stem cell researcher at the Texas Biomedical Research Institute.
because the findings are most accurate for translational medicine. Mice and rabbits, commonly used animals in research, are smaller in size and have shorter life-spans – and thus different cellular metabolic properties. Since baboons and monkeys are more anatomically similar to humans than any other animal, they are the ideal model for medical research. While this is a huge issue with animal rights groups, this is the quickest path to take to translate laboratory results into health care practices, particularly with regard to stem cell treatments. As Shi puts it, “Stem cells are fantastic. Stem cells are the future. Stem cells are the next generation of medicine.”
Diagram Courtesy of Niaz Khan
integration into nursing home programming. Brain training is often seen as a preventative measure to help an aging mind stay sharp. However, for younger generations, the push is proactive; Nintendo markets “devilishly tricky training for the modern mind” through its Brain Age series for kids, teens and young adults. What these companies forget to mention is that the science behind brain-training games is not 100 percent proven. If brain-training games produce improved memory, attention and cognitive function as they advertise, those who play brain-training games should show a measurable increase in IQ. While the Jaeggi et. al paper reported an increase, the study had a number of fundamental flaws. The IQ test administered in Jaeggi’s study was given for 10 minutes, as opposed to a full 45 minutes. Critics argued that the study participants were therefore not given the opportunity to perform the most difficult parts of the test, and so the assessment did not challenge their fluid intelligence. Additionally, the version of the IQ test administered contained two workingmemory tasks, one of which was very similar to the procedure all the participants were trained on.
President Obama came into office, the cuts that the Bush administration put on embryonic stem cell research were repealed. This change in policy has opened a new door for many scientists who could not previously explore the capacities of embryonic stem cells. In a recently published paper, a team of scientists from the Texas Biomedical Institute, with help from faculty at the University of Pittsburgh, completely repaired a segment of baboon artery in just two weeks, using stem cells. The research group made this repair by differentiating baboon embryonic stem cells into endothelial cells specific to the vasculature, called endothelial progenitor cells. A damaged section of baboon femoral artery was excised, and the inner cell layer of the artery was removed. The progenitor cells were then added and bathed with a growth media in a bioreactor, to allow the cells to form a new cell lining inside the artery. The medical implications of this research are vast. From this project alone, we can see that the future may hold new treatment options for patients with vasculature damage or who suffer from heart attacks and other circulatory problems. The findings also suggest that stem cells could be used to repair multiple areas of the body, so long as the embryonic stem cells were differentiated appropriately. These cells could be used to repair a variety of damages, like those associated with spinal cord injuries, neurodegenerative diseases, diabetes, eye disease or arthritis. There are
Pluripotent embryonic stem cells were induced to become endothelial progenitor cells (EPC’s). The EPC’s were then placed, ex vivo, into a baboon artery whose endothelium had been surgically removed. Within 14 days, the EPC’s had differentiated into a new endothelial layer.
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THE STEM CELL RACE
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ecent headlines featuring Peyton Manning and Kobe Bryant seeking medical attention outside the U.S. have caught the attention of sports enthusiasts and news followers alike. They are just two of the many individuals who have sought out stem cells in hopes of getting back in the game. Lately, there has been a surge of professional athletes leaving the country in search of stem cell therapies to treat their injuries. This fad, known as “medical tourism,” is becoming more and more popular as word spreads of the wide range of injuries and diseases being treated in other countries with stem cells. This is a rapidly growing industry in many countries, like Mexico, Costa Rica, Ukraine, China, and India. In the small country of Costa Rica alone, medical tourism made revenues of $60 million in 2008.
Why aren’t these treatments offered in the U.S.? Because they have not yet been FDA approved. Various groups within the U.S. offer services to find stem cell clinics in one of these countries that will provide the desired treatment for clients. Diseases currently being treated abroad with stem cells include diabetes mellitus, multiple sclerosis, Parkinson’s disease, Duchenne muscular dystrophy, and cancer, as well as a wide range of injuries. Why aren’t these treatments offered in the U.S.? Because they have not yet been FDA approved. For the FDA to approve a course of treatment, the method must first undergo multi-stage, human clinical trials that prove the treatment positively inf luences the patient’s disease or injury. Currently in the U.S., hematopoietic stem cells from bone marrow and umbilical cords are being used to treat patients
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Diagram Courtesy of Niaz Khan
By Jessica Collins Staff Writer
with leukemia and lymphoma. While there is a lot of research going on both in the U.S. and other countries using adult stem cells, only a few companies in the country have been approved to do human trials using embryonic stem cells – most notably, Geron and Advanced Cell Technology. Geron received FDA approval to begin trials on patients suffering from spinal cord injuries in 2009. In 2010, ACT announced that the FDA had approved human trials for macular dystrophy treatment. Compared to other countries, such as Ukraine, El Salvador, and China, the U.S. seems to be lagging in the field of embryonic stem cell research and therapy. While there are many reasons for this slow development, politics has been a key issue. During the Bush administration, federal funding was limited to specific, pre-existing embryonic stem cell lines. When
moving through a battery of diagnostic tests from afar. These remote exams take minutes to an hour to complete, and may save patients hours to a day of traveling. Research on the practice of telemedicine is expanding, and a portion of it is being conducted at the University of Pittsburgh’s School of Medicine and Graduate School of Public Health. Dr. Jeremy Kahn, a professor of Critical Care, Medicine and Health Policy, studies health care delivery where efficiency and quality intersect – including the field of telemedicine. He explained that there are different types of telemedicine used to care for remotely-located patients. One type is called “store-and-forward,” where some clinical data is stored and sent over some distance, with a separation in time as well. “So the classic example would be
Through a series of cell divisions, stem cells can replenish cells of their own kind (“selfrenewal”), or become further differentiated. Some multipotent stem cells will divide into progenitor cells, destined to become a specialized cell type.
KEY TERMS Stem cells: Cells which are able to differentiate into many different types of specialized cells and are capable of self-renewal and unlimited cell division Totipotent: Can develop into all cell types in the body, plus cell types of extra-embryonic tissues Pluripotent: Can develop into all cell types in the body, not including extra-embryonic tissues Multipotent: Can develop into more than one cell type in the body Endothelial cells: A thin layer of epithelial cells that line body cavities, blood vessels, and lymph vessels Embryonic stem cells: Pluripotent cells derived from embryos that are capable of dividing for a prolonged period and developing into cells of the three primary germ layers Endothelial progenitor cells: Cells that circulate in the blood and are able to develop into endothelial cells Adult stem cells (Somatic Cells): Cells with the ability to differentiate into the various cell types that comprise a specific type of tissue Induced pluripotent stem cells: Adult stem cells that have been re-programmed to enter an embryonic stem cell stage Hematopoietic stem cells: Multipotent blood stem cells that develop into other blood cells (myeloid
and lymphoid cells)
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Telemedicine can save a long-distance trip, a day taken away from work, and the costs associated with these ventures. an x-ray or a pathology slide that’s read from a distance,” Kahn said. “The kind of telemedicine I’m more interested in is the remote consultation type where there’s actually a live patient encounter.” The real-time encounters Kahn speaks of aid individuals in out-patient and in-patient settings. For the out-patient seeking a specialist, telemedicine can save a long-distance trip, a day taken away from work, and the costs associated with these ventures. Patients simply travel to their local practitioner, where they are presented to a specialist via an audio-visual encounter and can be examined in a matter of an hour. However convenient out-patient telemedicine services may be, the capabilities this technology holds for inpatients are even more beneficial. ICU patients, who may be hospitalized for days or weeks on end, can stay in local hospitals; this allows their families to stay in their own beds and saves them the costs and stresses of traveling to a specialized care center. Intensive care physicians at a remote specialty center can still monitor these patients’ diagnostic and treatment information, while the physical care is enacted locally by general practitioners or another care provider. The advantages offered by telemedicine are appealing, and students entering medicine in the coming decade will want to be educated on the implications this
technology has for their careers and practices. According to Kahn, since many facets of telemedicine are relatively new to the market, Medicare, Medicaid, and other private insurers are reluctant to cover such services. They may hesitate due to a lack of evidence on efficacy, or the fear of overutilization of expensive specialist resources if they become too easily accessible. Another possible implication is that telemedicine will require more time from specialists, who are already spread too thin among face-to-face patient encounters. After all, the complexity that technology and distance adds tends to make telemedicine appointments longer. Perhaps most important for new and future physicians to consider with respect to telemedicine is the availability of training during medical school. As Kahn notes, “Only in the last 10 to 15 years has medical education said, ‘Look, we need to teach people how to communicate with patients.’ And we’ve spent a lot of time incorporating it into medical school curricula, for teaching the physician-patient encounter. “Now we’re going to have to build on that even more. Not only do we have to make you a good listener and a good communicator in person, but we have to make you a good listener and communicator remotely. And it’s wrong to think those skills are going to translate right away.” There are also some distinct barriers to implementing telemedicine. Not only must physicians be trained to communicate well, but patients must become comfortable sharing their sensitive medical information across technology, distance, and multiple providers. Instead of sharing with one doctor behind a closed door, Kahn explains that now “you’re introducing more people into it because it has to be facilitated on the local end and the [specialist] end.” He then puts it in perspective: Would you be as open about your health issues to someone who’s on the other side of a screen – a sort of disembodied face – as you are a person? Overall, telemedicine is glamorous at face value; it offers varied benefits to patients, like saving a person time and money. But it also faces a set of barriers, including the need for social acceptance and comfort, the cost of implementation, and added patient load to already fully-booked specialists. The complexity of these variables requires serious evaluation as to how this technology should be implemented and how to maximize efficiency as it evolves. The expansion of telemedicine is likely inevitable, given the infiltration of progressive technology into modern medicine. As Kahn puts it, “We need to not necessarily put the brakes on this, but [to] think through the issues.”
TIPS ON THANK YOU By Belinda Lao Staff Writer
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hether you are the seasoned applicant who has weathered the application process all the way up to the sweet ecstasy of opening your acceptance letter, or a hopeful student who is currently applying, recommendations from faculty and mentors are a critical part of most applications. Professors can spend hours writing recommendations on behalf of multiple students for professional school, so it is important to remember to send a thank you card for their hard work. Here are several guidelines for you. • Paper is preferable. Sending thank you letters by email can often be considered impersonal, insincere, or even downright rude. Taking the time to write a handwritten card to your recommender shows that you appreciate their efforts. They will appreciate the tangible token of your thanks. • Let them know what’s up! Have you heard back from all of your programs yet? Where were you accepted? Wait-listed? Have you made a decision on which one you will choose? In general, professors like to hear how their students are doing and where they are headed next. • Quality over quantity. Above all, a thank-you should be sincere. Short and sweet is perfectly adequate in showing your appreciation for their contributions to your success. • Follow up if needed. It is perfectly fine to send a thank you note even before you have heard back from the programs that you applied to. If you include a promise to let them know if you are accepted, make sure to actually follow up on that promise! Remember that all situations are unique, so these suggestions are only meant to be a rough guide. We wish you good luck in all future endeavors.
Congratulations to you, future health professionals!
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provides information on the presence of any abnormalities or injuries that lay within the patient’s meshwork of tissue and bone. But how can we improve MRI further? As the complexity and variability of ailments that people obtain has increased, so has the need to diagnose disease earlier. This has demanded an equal, if not greater, response from the biomedical community, who has, in recent years, driven the production of many medical tools to better the
Photos Courtesy of 1James Heilman, 2Ranveig Thattai, 3Nevit Dilmen, 4Alzheimer’s Disease Education and Referral Center
By Prasad Kanuparthi Staff Writer
ow does a physician, attempting to diagnose a patient with a sensitive condition, peer into the patient’s inner physiological framework without damaging his already precarious state? Since the latter half of the 20th century, imaging techniques have offered non-surgical methods of examining various portions of the body. Of these scans, magnetic resonance imaging is very useful when analyzing specific portions of a patient’s body. This technique
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Photo courtesy of 1Gregorio Wielgoszewski, 2Wikimedia Commons
Innovation in Medical Imaging
On the left is a sample diagram of the nanoscale MRI. A laser shoots a beam of light (electromagnetic radiation) at the sample surface, exciting the atoms around the cantilever tip. On the right is a molecular diagram of a nitrogen vacancy in the diamond structure that composes the cantilever tip. This nitrogen vacancy is the sensor that ultimately allows for the production of highresolution images. (V = vacant carbon atom)
light, a source of electromagnetic energy, the technique forces surrounding atoms to absorb the energy and spin in a new direction. It turns out that these NV’s also have a spin and are affected by the changing states of the spins of the adjacent atoms on an unimaginably small scale. A scanner picks up how these NV’s are affected by the surrounding atoms’ fluctuating spin states and produces an image through mathematical modeling. This image can be continually generated over the surface that the diamond tip travels over. If this tip travels over tissue, for example, or is adapted in the future such that it scans underneath skin at the tissue below, then a real-time image of the molecular mechanisms occurring on the cellular level in the patient may be obtained and used to create an accurate diagnosis. For example, a significant cause of cancerous growth in the body stems from mutations of various
proteins, termed tumor suppressor proteins, which normally work to regulate the division and proliferation of cells. Perhaps, with development, the nanoscale MRI may one day be able to non-invasively screen a portion of a patient’s body to identify whether or not he possesses any uncontrolled cellular division or a mutation of a tumor suppressor protein. This analysis would contribute to early detection of possible oncogenic activity, which would translate to saving countless lives. The limits on application of this novel medical technology are yet to be seen. In the same way this technology stemmed from conventional MRI and highresolution microscopy, hopefully more novel technologies will emerge from this innovation, leading to newer and more effective biomedical applications.
Photos Courtesy of AThomas H. LaBean, BKatherine Sanderson
NANOSCALE MRI
condition of society. Of these tools, nanoscale MRI is a landmark advance that could prove to be a foundation for future medical imaging technology. Through a cooperative research initiative, researchers at both the City College of New York in New York City, and the University of Stuttgart, in Stuttgart, Germany, designed this new process. As Dr. Carlos Meriles – head of the initiative – stated in an interview from 2013, “It’s bringing MRI to a level comparable to an atomic force microscope … standard MRI typically gets a resolution of 100 microns; nanoscale MRI would have a resolution 1,000 to 10,000 times better.” This improvement, which increases the resolution from the width of a human hair to the diameter of red blood cells, could one day allow physicians to measure how the very molecules composing a tissue are behaving. By understanding whether abnormal proteins are being produced, if DNA contains mutations, or if cancerous cells are dividing rapidly, physicians would be able to visualize the molecular basis of human pathology. This could potentially allow them to diagnose the patient’s ailment on the actual biological basis and not just on symptoms of the ailment. The nanoscale MRI operates on generally the same principles as conventional MRI, but applies a different model to image the target substance. Unlike conventional MRI, which uses large magnets, a large chamber, several coils, and radio waves, nanoscale MRI uses a small diamond tip, called a cantilever, as an extremely sensitive scanner to pick up the changes in the relative energies of the molecules around the diamond tip. In essence, the nanoscale MRI uses principles from atomic force microscopy, a subset of electron microscopy, combined with that of the conventional MRI to obtain an innovative means of improving magnification, sensitivity, and resolution. A scanner detects alterations in the way certain atoms spin and oscillate, a tendency known as resonance. These measured resonances are received by the scanner and transformed into a visible, highly resolved image. Diamond is composed entirely of carbon atoms in its purest form. However, on the small tip used in the nanoscale MRI, sometimes a carbon atom “falls off” its place in the diamond structure and a nitrogen atom lodges itself in a spot adjacent to where the carbon atom fell off. This forms what is known as a nitrogen vacancy (NV). These NV’s act as extremely effective sensors on the atomic scale, detecting the resonances of the atoms that surround where the diamond tip with the NV’s is placed. By bombarding the atoms surrounding the diamond tip with
The image on the left (A) shows an image of the proposed nanostructures of DNA within a cell. The image on the right (B) shows an atomic force microscope image of the same DNA nanostructures in vitro. Nanoscale MRI would provide similar resolution.
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