VOLUME IV ISSUE I || OCTOBER 2013
THE END OF
GENE PATENTS
The Onset of Myriad Options for Genetic Testing | PG 8
VOLUME IV ISSUE I || OCTOBER 2013
4
Google Glass: A Future Vision
14
The Truth About Panic Attacks
6
It’s Time To Get That Mole Checked Out
16
Medical Tourism in America
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Strong Roots, Tall Shoots
20
Catholic Charities Free Health Care Center: Filling the Gap
8
Rushi Patel
Sara Myers
The Onset of Myriad Options for Genetic Testing
Jason Naughton
Zaid Safiullah
Yash Pandya
Lauren Hasek
11 13
Antibiotic Resistance: A World At Risk Prasad Kanuparthi
Rachel Kosciusko
More Than Weight: The Unhealthy Bias Janine Talis
EDITOR IN CHIEF
PUBLISHER
BEVERLY HERSH
NIAZ KHAN
EDITORS
LINDSAY ALLEN IMAZ ATHAR MELLISA CARLSON JESSICA CRAIG NATALIE ERNECOFF ELIZABETH FUGA SARAH WENRICH
LAYOUT EDITOR DANIELLE HU
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The Syrian Terror Jad Hilal
ART & DESIGN TEAM: DANIELLE HU* MANISHA KINTALI MADHUR MALHOTRA ANGELA RYU ABIGAIL WANG
DISTRIBUTION TEAM: IMAZ ATHAR* MADDY EDARA RUHEE JAIN RACHEL KOSCIUSKO LAUREN MCNEIL
PUBLIC RELATIONS TEAM: ELIZABETH FUGA* MADDY EDARA JENNIFER HSU LAUREN MCNEIL JANINE TALIS
STUDENT OUTREACH TEAM: JESSICA CRAIG* JESSICA COLLINS JENNIFER CORTES MADDY EDARA RASHMI SAGRAM TADHG SCHEMPF
WEB DESIGN TEAM: JASON NAUGHTON* JASON TAYLOR
CURRENT EVENTS CHAIR PRASAD KANUPARTHI
PHOTOGRAPHER MANISHA KINTALI
WRITING COACH LINDSAY ALLEN
*INDICATES TEAM LEADER
STAFF WRITERS HAADI ALI JESSICA COLLINS JENNIFER CORTES ASHLEY DRAWAL MADDY EDARA LIA FARRELL RORY FLEMMING ZANETA FRANKLIN
2
OANA GRIGORAS LAUREN HASEK JAD HILAL ELYSSA JOHANNESEN SYED KALEEM PRASAD KANUPARTHI MANISHA KINTALI RACHEL KOSCIUSKO
RASHMI KUMAR BAILEY LEIN VIVIAN LIANG MARIA MARCOS NICHOLAS MOORES SARA MYERS JASON NAUGHTON YASH PANDYA
THEPITTPULSE.COM
ROHAN PATEL RUSHI PATEL SWATI RAJPROHAT ANGELA RYU ZAID SAFIULLAH RASHMI SAGARAM NEVIN SASTRY CLAIRE SCHAFER
TADHG SCHEMPF IVY SHI LAURA SPILKER JANINE TALIS VIGHNESH VISWANATHAN ABIGAIL WANG YIHAO ZHENG
A Letter From the Editor: With the beginning of the Fall 2013 semester here at the University of Pittsburgh comes the re-introduction of The Pitt Pulse. We have seen our staff more than double in size, and within a constrained time frame we have successfully created an infrastructure we believe will utilize our newly acquired talents to outstanding effectiveness, allowing us to produce the most engaging, relevant, and design savvy issues in our history. These pages hold enlightening information that ranges from medical history, to current events, to future applications of developing technology, spanning lifetimes of medical discovery and progress. We are happy to share our research, interests, and personal experiences with you. We encourage you, our reader, to respond to what is essentially our new publication. Your feedback is a valuable asset in our continuing effort to improve and perfect The Pitt Pulse. With rejuvenated inspiration, Beverly Hersh Editor in Chief
The Pitt Pulse Officers 2013-2014
From left to right
Top: Jessica Craig, Sarah Wenrich, Mellisa Carlson, Danielle Hu, Lindsay Allen. Bottom: Imaz Athar, Niaz Khan, Beverly Hersh, Natalie Ernecoff, Elizabeth Fuga.
3
Google Glass A Future Vision It’s
eight o’clock
on a Saturday evening. The hospital receives a call about a serious car accident on the Pennsylvania Turnpike. The paramedics rush to the scene. There they find an unconscious six-foot five-inch, 40-year-old male pinned under the car. He seems to have a broken leg. They cannot find his ID. The paramedics turn to facial recognition technology to identify the patient. They then use remote access to check for previous medical conditions. Simultaneously, a doctor at the hospital is virtually observing the scene and assists the paramedics so they can maximize the chances of saving the patient’s leg. The medical team at the hospital now has a better idea of the nature of the incident and mobilizes for surgery before the patient even
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By Rushi Patel arrives. Back at the scene, the patient is loaded into the ambulance. He regains consciousness but doesn’t speak English. He responds to questions in Polish, and the paramedics get a live language translation to their earpiece. When the ambulance arrives at the hospital, the patient goes directly into the operating room. During the surgery, the surgeon realigns the leg but misses an attachment. A virtual surgeon assistant informs the surgeon of his error. This scenario may sound like something from a futuristic movie. The reality is that developments in new technology may eventually lead to its application within the medical field in scenes such as this. All this is due to a single device called “Glass.” First introduced in June 2012 by the
Project Glass team at the annual Google I/O conference in San Francisco, Glass has been described as one of Google’s newest and finest products in the technology realm. Following the announcement, Glass was made available to a limited group of developers as a preliminary study for testing the device and designing applications. Glass isn’t your normal pair of glasses. Instead, it has built-in HD display, camera, speaker, microphone, and WiFi/Bluetooth connection. The premise of Glass is that it allows users to take advantage of these smartphone-like features hands-free. The user can execute operations such as taking a picture or video, searching information on Google, or sharing live stream video, all with simple voice commands. Although these
Table 1. Google Glass as an aid in personalized healthcare for patients Use:
Example:
Smarter Grocery Shopping
Provide feedback whether a specific food product fits a person’s diet
Diet Tracking
Automatically track the number of calories a person ate in a day
Health Warnings
Warn a person when he is accidently consuming allergic food
Medication Information
Tell a person to take his medicine at the appropriate time
Physical Disabilities
Convert verbal messages into transcript for a deaf person to read
Table 2. Health care support for medical professionals Use:
Example:
Virtual Medicine
Provide patient with care in the comfort of the patient’s home on-demand
Drug Information
Check for appropriate dosage of medication or drug interactions
Patient Education
Teach using a live case study of patient treatment, including communication skills, to a large medical student group
Translation
Listen to live translated English from a patient’s native language
Surgery Education
Show first person video of a live surgery for medical student education
features are currently being developed for consumer friendly purposes, they have the potential to be highly advantageous to the medical community. Glass could be customized for specific medical purposes and change the way medicine works in many aspects. In the opening example alone, Glass helped identify the patient, provide patient history, translate a language, provide a remote surgeon with a first person view of an accident scene, and introduce a virtual surgeon, all in the setting of emergency medicine. The technology can also be implemented in many other aspects of medicine, broadly changing the way practices are run today. Table 1 shows some of the ways healthcare may evolve for medical professionals and patients with Glass. The possibilities for using Glass are only limited by the creativity of the innovators, and have the potential to bring about a major change in the evolving medical field. These potentialities include, but are not limited to, helping prevent medical errors, improving efficiency, and allowing the best collaboration between health care professionals for exceptionally high levels of care. Considering that Glass is still in the ex-
perimental stage for non-medical purposes, it will take time before we see its impact in hospitals. The imperfections of the technology make it difficult for medical professionals to implement just yet. As seen with iPhones, Siri, the voice command technology, often misinterprets the commands. The correction technology for these errors hasn’t reached the caliber for medical use, which will be necessary before Google can implement Glass in hospitals. In addition, specialized software that ensures a high level of patient data security, following the legal prerequisites hospitals must meet, and designed specifically for the health care sector will need to be developed. This kind of functional development often requires months to years for production, testing, and implementation. Overcoming these barriers may take years before Glass becomes part of common medical practice. Nonetheless, at the current rate of technological development, we may see healthcare providers wearing Google’s Glasses within the next five to ten years.
(Opposite) Google Ambassador at Pitt, Zach Alcorn, modeling Google Glass
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It’s Time to Get That There
are very few things
that I enjoy doing more than laying in the sun with a good book on a hot sunny afternoon. As a child, taking time to put on sunscreen meant less time playing outside. Now, I put on at least a little sunscreen for one main reason—I do not want wrinkles. Developing melanoma has been of little concern to me, but in the medical world, it is a top priority for dermatologists. MelaFind is a new handheld device recently approved by the FDA used for detecting early stage melanoma. It uses light waves from visible to near-infrared wavelengths. When the device is placed against a mole, the light reflects back into the device and shows all the different molecules within the mole. This image is then compared to thousands of
pictures of melanoma on a specialized computer. Within minutes, MelaFind can determine if the mole requires further biopsy or if the mole is benign. In a clinical trial performed using MelaFind, the device missed only two percent of moles that were later found to be melanoma. Like all forms of cancer, early detection for melanoma is the key to becoming a cancer survivor. Before MelaFind, biopsies were always performed to determine if a mole was
In a clinical trial performed using MelaFind, the device missed only two percent of moles that were later found to be melanoma.
cancerous, involving painful incisions and leaving scars, while MelaFind is completely noninvasive. After reading about MelaFind, I had one concern: Would a device that makes early detection so simple and painless make people less careful in the sun? With MelaFind making early detection so easy, there would be fewer issues preventing many people from getting a mole checked then they would if a biopsy was involved, but it could also lead to less precautions taken while out in the sun; for example, not wearing sunscreen. So is MelaFind actually as good as it sounds? To answer my question, I spent an afternoon walking around
Photo courtesy of Me
Survey Results: How often do you use sunscreen?
31%
Have you ever had a mole looked at by a dermatologist?
Would you have a mole looked at if no painful incision was involved?
32% 26%
55%
68% 14%
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74%
t Mole Checked Out By Sara Myers
68 percent told me they have never had a mole checked out nor did they plan to any time soon. Hillman Library to ask as many people as I could a few basic questions: 1. How often do you use sunscreen? 2. Have you ever had a mole looked at by a dermatologist? 3. Would you have a mole looked at if no painful incision was involved? 4. Would you wear sunscreen less if early detection were made simple? 5. On a scale of 1-10, how likely do you think you are of getting melanoma? It seems that the majority of
people have the same feelings towards skin cancer as myself. During my afternoon of surveying, I talked to a total of 136 students of all race and gender and found that sunscreen is not too popular among our student population. 42 said they wear sunscreen everyday, while 75 said they only use sunscreen when they are in very strong sunlight. The remaining 19 students said they never wear sunscreen. Sadly, even given the large group of students that do not use sunscreen regularly or at all, I was not surprised when 68 percent of them told me they have never had a mole checked out nor did they plan to any time soon. The only piece of information that really surprised me in conducting this survey was that the average answer to “How likely do you think you are of getting
melanoma?” was “very unlikely.” However, in all of this bad news came some good news for MelaFind; students greatly preferred a method for early detection that did not involve pain, and some even changed their minds about possibly getting checked by a dermatologist. After my survey of the Pitt students, my question remained unsatisfactorily answered. As many of the students were more pleased with MelaFind as opposed to traditional biopsy, it seems that the device could end up helping many more people detect their melanoma in the early stages. However, for this to occur, attitudes regarding skin care need a drastic makeover. Perhaps it is time for me to use my sunscreen for a reason other than wrinkle prevention.
elafind / Melafind.com
Would you wear sunscreen less if early detection were made simple?
On a scale of 1-10, how likely do you think you are of getting melanoma? 8.8% 5,8.8% 8.8% 1, 8.8% 4,9.6% 9.6%
0%
14%
20%
3, 25.0% 25%
47.8% 2, 47.8%
66%
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The Onset of MYRIAD
OPTIONS
for GENETIC
TESTING
By LAUREN HASEK
8
The human genome in its entirety – all 20,000 genes – can be sequenced for less than double the cost of sequencing merely two genes with BRACAnalysis.
Y
our driver’s license is a personal identification card that has no real intimate tie to you: your name can be changed, your birthday is shared with thousands, and your height and weight are rounded. For legal purposes, a driver’s license provides adequate and immediate identification. Imagine if your genome – something entirely unique – could be referenced just as fast, with the swipe of a card. Scientists have the capacity to sequence the human genome for medical use, individualizing treatment and identifying potentially problematic genetic sequences. Both the existence of this amazing technology and restrictions on its widespread use can be attributed in part to gene patents. Gene patents serve the purpose of any other patent, protecting an invention or discovery by allowing the holder to exclude others from its use or sale for a limited period of time. The Human Genome Project in the 1990s started the rush to patent the human genome. The medical community was originally
optimistic, believing patents would encourage private companies to invest in diagnostic development. As of June 2013, over 20 percent of the genome was under patent. Unfortunately, the exclusive right to naturally occurring genes resulted in company monopolies on the tests for specific gene sequences. These monopolies drove the price of genetic testing up and discouraged sharing of results. While thousands were receiving genetic tests, test results were recorded in private, company databases. Consequently, further improvements in the test for a gene or discoveries of potential gene/disease correlations were restricted to the parent company. As successful as patents were for stimulating investments in research and product development, the resulting genetic tests were too expensive to be widely accessible. This June, the Supreme Court ruled on The Association of Molecular Pathology v. Myriad Genetics, decidedly abolishing gene patents. For the past 15
years, the molecular diagnostic company Myriad Genetics has held a monopoly on the laboratories and tests needed to screen for an increased risk of breast and ovarian cancer. Myriad’s BRACAnalysis uses cut and spliced complementary DNA (cDNA) to identify abnormalities in the BRCA1 and BRCA2 genes. The genes are tumor suppressors that directly encode proteins responsible for repairing damaged DNA. More specifically, mutations in these genes predict an up to 85 percent chance of developing breast cancer. Myriad’s monopoly on the isolated BRCA genes made a hefty payday. While the test is covered under most insurance plans, its $4,000 price tag restricts low and middle-income women from assessing their risks. Additionally, the patent on the BRCA genes forced healthcare providers to use multiple companies when performing comprehensive genetic screens on a patient; each gene required a test from the company that held its patent. As a result, the process was
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lengthy, expensive, and inefficient. The human genome in its entirety – all 20,000 genes – can be sequenced for less than
This June, the Supreme Court ruled on The Association of Molecular Pathology v. Myriad Genetics, decidedly abolishing gene patents. double the cost of sequencing merely two genes with BRACAnalysis. In fact, in 2012, genetics companies announced that nearly all 3 billion base pairs could be sequenced for under $1,000 within the next few years. The goal of reaching such a low cost figure, along with the ability for further genetic analysis, hinged upon the abolition of gene patents. Since 2009, Myriad Genetics has fought to maintain its patent on the human BRCA1 and BRCA2 genes. Despite the ruling against Myriad Genetics, stock in the company rose eight percent the morning of the Supreme Court decision. While naturally occurring human gene sequences are no longer patentable, artificially synthesized DNA like cDNA, a key to drug and diagnostic development, can still be patented. Myriad has a head start in the genetic diagnostics game despite losing the Supreme Court battle. They will remain prominent player in what promises to be a more open and competitive field. The Supreme Court ruling did succeed in opening the market, bringing genetic sequencing closer to widespread realization, and genetic testing to thousands who previously could not afford it. Less than 24 hours after the decision, other companies announced they would be offering BRCA gene testing for $995, a quarter of the cost of Myriad’s BRACAnalysis. Competition will make the tests affordable, while an increase in consumer demand for diagnostic gene screening for a number of diseases will drive continued innovation, and furthermore, broaden the spectrum of services offered by companies; screening is just the beginning. Safe storage of the human genome is where personalized genetics encounters a roadblock. Whole genome sequencing
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will soon be offered for under $1,000 and take only one day to analyze. However, the process requires one terabyte of data (1000 gigabytes) per person. Falling prices encourage an increase in gene sequencing but this boom is only sustainable if storage infrastructure is in place to support it. Here is where health cloud computing plays a role – a projected $5.4 billion industry by 2017. Improvements in sequencing, analysis, and storage capacity developed independent of widespread genetic testing. The Supreme Court ruling fosters “a positive competitive dynamic” that will push genetic testing into the mainstream –
More specifically, mutations in these genes [BRCA1 and BRCA2] predict an up to 85 percent chance of developing breast cancer.
cutting the cost of accessing an individual’s chemical makeup as well. Improved efficiency of genetic testing and use of the service is part of a package of innovations that will fuel the field of personalized medicine. Once a large enough cohort of patients begins accessing their genome as a tool for treatment, researchers can finally assess the potential for highly specialized medication – a field made possible by both the initiation and elimination of gene patents.
The location of BRCA 1 and BRCA 2 on chromosomes 17 and 13 respectively.
Drawing courtesy of Lauren Hasek
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B
efore going on a vacation with his family, Dr. Alexander Fleming stacked several cultured plates of Staphylococcus bacteria in a corner of his laboratory. Upon returning, he realized that a fungus contaminated one of his cultured plates and destroyed his bacterial colonies. After culturing the fungal mold and extracting the substance it produced, Dr. Fleming used it to treat various bacterial cultures, only to realize that the extracted substance was highly toxic to many bacterial colonies. Upon realizing this substance’s toxic effect on multiple forms of diseasecausing bacterial strains, he named the substance penicillin, after the mold that houses it. Penicillin was a global gamechanger in the fight against bacterial infections. Contemporarily, the story is changing. Through gradual evolutionary changes, bacterial pathogens have evolved to become resistant to antibiotics, including penicillin. As Dr. Fleming stated in a lecture
given shortly after his Nobel Prize in 1954 for this very work, “The time may come when the ignorant man may easily under-dose himself, and by exposing his microbes to non-lethal quantities of the drug make them resistant.” Dr. Fleming, in essence, correctly predicted the future in which we live today. The gene for penicillinresistance existed within the bacterial population before penicillin’s inception. As such, the emergence of a pharmaceutical industry that mass-produces antibiotics has led to natural selection in favor of those bacteria possessing antibiotic resistance (see Figure 1). This emergence of bacterial resistance has the potential for uncontrollable infection among individuals living in areas of poor sanitation as these ‘superbugs’ are rapidly transmitted from person to person. In response to the growing incidence of antibioticresistant bacterial infections, researchers have developed
varieties of antibiotics. These different classes of antibiotics are grouped according to their structure and mechanism of action. Some of them, like
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ampicillin and amoxicillin, are similar in action to penicillin. Others, such as the class of antibiotics termed carbapenems, inhibit a broad range of various antibacterial activities. Unfortunately, despite the development of these novel antibiotics, their widespread and inappropriate use have developed strains resistant even to the most potent, last-resort antibiotics. An example of a highly dangerous bacterial infection is methicillinresistant Staphylococcus aureus (MRSA) (See Figure 2).
MRSA is a particularly relevant infection within the clinical setting. Hospitals often treat multiple patients with weakened immune systems simultaneously, use intravenous instruments that ‘open’ the body to the outside world, and often have patients in close proximity to one another. These factors could increase the risk of contracting MRSA. It is
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difficult to treat the thousands of infections that occur in the hospital setting each year due to the deadly strain’s resistance to conventional antibiotic treatment. In fact, a sizeable proportion of the patient population already possess Staphylococcus aureus bacteria on the surface of their skin. A potentially fatal infection develops when the bacteria find their way inside the patient’s body and replicate therein. In addition, unnecessary prescriptions for antibiotics increase a patient’s probability of developing antibiotic resistant bacteria (an insufficient dose simply encourages resistant bacterial growth). To combat the increasing misuse and improper prescription of antibiotics for afflictions not requiring antibiotic treatment, researchers are aiming to develop tools to determine the source of a patient’s illness. For example, researchers at Duke University have developed a novel blood test to identify whether a patient’s respiratory symptoms are caused by either viral or bacterial infection. The test utilizes the fact that viruses cause specific genes to be activated in the immune system that are not activated by bacteria. Since antibiotics have no effect on viral infections, other forms of medicine can be prescribed instead, eliminating the unnecessary use of antibiotics. This will hopefully curb the rate at which antibiotic-resistant bacteria proliferate. Prime examples of the overuse of antibiotics are common viral infections such as the common cold. Individuals with symptoms of the common cold may request, or may be incorrectly prescribed, antibiotics. Using antibiotics unnecessarily eliminates nonresistant bacteria and therein
selects resistant bacteria to develop. This is a potential future threat to the patient’s health. It is the hope of researchers at Duke that widely implementing accurate blood testing will reduce the number of improper prescriptions for antibiotics, thereby reducing the number of cases of antibiotic-resistant bacterial infections. On a global scale, as these techniques are further developed, these tools can be implemented in areas without proper healthcare, such as in third world countries. For example, reduced manufacturing costs, less expensive alternatives, or more information on proper sanitary habits can all work together to reduce the spread and occurrence of these deadly pathogens. This ensures that these vulnerable individuals do not succumb to the very real threat of antibiotic-resistant bacterial infection as bacteria continue to evolve. It is our duty to safeguard future generations from the potential pandemic of antibacterial resistance by furthering Dr. Fleming’s work in using innovation to combat infection.
MORE
THAN
W EI G
By JANINE TALIS
E
ach person walks through life with his or her own ideas, perceptions, and biases. For the most part, bias develops through influence from parents, teachers, friends, media, or personal experiences. Over time, surrendering that opinions may be based on incomplete evidence can be difficult to accept. Many biases are developed superficially, where appearances generate preconceived notions that are mistaken for complete knowledge of a person. Bias is not inherently misguided. However, there are some preconceptions that can be harmful, particularly in health care. Several recent studies have revealed bias among doctors and medical students against overweight and obese patients. Such preconceptions include assuming patients are lazy or unlikely to follow treatment. Additionally, this research suggests that healthcare professionals are generally nicer to patients with a lower body mass index (BMI). In a study conducted at Johns Hopkins, researchers found that the standard of care did not vary significantly based on weight. However, upon reviewing transcripts of physician-patient discussion, they found that doctors were much more willing to provide encouragement and were overall more empathetic toward the patients with a healthy BMI. A study conducted by Wake Forest School of Medicine revealed that
T
H
The Unhealthy Bias
among medical students observed, 40 percent had a bias against the overweight that they were not previously aware of. Regardless of the origin, it is important for students to be aware of potential biases and how to manage them by being empathetic. While the quality of care is important, empathy is also an important factor for treatment success. Patients are more likely to retain their doctors, or maintain treatment regimens, if they believe their physicians care about their wellbeing. Patients can become frustrated with health care professionals who seem distracted by their weight. When a patient comes in with an issue unrelated to their weight, they would prefer doctors not become preoccupied with their body mass. This has led to the phenomenon of doctor shopping. The phenomenon was described in a second Johns Hopkins study, which suggests that overweight and obese patients are more likely to switch primary care physicians several times more frequently than their lower weight counterparts. Overweight patients are also 85 percent more likely to visit an emergency room when compared to individuals of healthy weight, possibly because they are less likely to have regular primary care physicians. This increased likelihood to switch doctors could be due
to an offhand negative comment or perhaps something outside of the doctor’s control (such as the blood pressure cuff not fitting). But when obese patients are reminded of the negative stereotypes they are faced with, they try to switch to more conscientious practitioners, which can be difficult to find. At times patients stop seeing doctors altogether. In a New York Times article, a woman so frustrated with physicians’ lack of considerate behavior regarding her weight stopped going even when she developed a breast tumor, seeking treatment only when it became advanced. Obese women are generally less likely to make regular appointments with their obstetrician/gynecologist, allowing illnesses such as cervical cancer to progress without early treatment. Arguments about the dangers of obesity aside, treating patients less empathetically based on a predisposition can be hurtful, and is not likely to improve patient care. People, including physicians, go through life accumulating preconceptions and misperceptions, and a lack of empathy may arise consciously or otherwise based on these biases. Despite ingrained notions, confronting personal bias exhibits respect and empathy toward all people and should be a staple of practice for medical professionals.
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THE TRUTH ABOUT By JASON NAUGHTON
W
e have all been there before: the all-night study session for the midterm exam, the crunch to finish off that final paper, the extended naps in the library ending with a polite but firm nudge by the janitorial staff reminding us that, “the library is now closed.” Such is the struggle of the undergrad biomedical student; stress, it seems, has become second nature. It’s nearly impossible to sit through a lecture without eavesdropping complaints about the course load, professors, or lab hours. “I’m, like, having a panic attack,” we hear over the drone of the classroom whispers. The truisms of panic attacks and panic disorders have been blurred through cultural norm. The term “panic attack” has morphed to encompass ordinary stressors, like an unexpected quiz at the beginning of class, or losing your car keys, or struggling to make it to work on time from your afternoon meeting. However, the difference between a nervous situation and a clinical panic attack is not a matter of mental taxation or stress, but of a severe
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and painful physiological reaction. Many of those who experience their first panic attack often mistake them for a heart attack, and in truth - the symptoms are nearly identical: rapid and fluttering heart rate, chest pain, numbness in the left arm, sweating, stomach upset or dizziness, shortness of breath, tremors, and twitches. There are a few distinctions: the chest pain of a heart attack radiates from the center, in a crushing sensation, which usually last longer than 10 minutes, while the chest pain associated with a panic attack is sharp and usually localized over the heart. Likewise, while a panic attack may cause nausea, vomiting is only common during a heart attack. Perhaps the most important distinction between panic attacks and heart attacks is the cause: heart attacks are a result of coronary circulation failing—busted or clogged pipes around the heart, if you will—while panic attacks are entirely mental. During a panic attack, your body is thrust
Forty million U.S. adults suffer from an anxiety disorder, and 75 percent of them experience their first episode of anxiety by age 22.
into its “fight-or-flight” response and naturally dials up the adrenaline. In fact, many doctors have compared this spike in adrenaline and heart rate to that of cardiovascular exercise. The obvious good news is that, unlike heart attacks, panic attacks are not fatal. In fact, although panic attacks can be painful and debilitating, they are also quite treatable. Sometimes it is not as simple as breathing into a plastic bag or counting to ten. Likewise, the cause is not always readily apparent. Sure, most of those students that experience panic attacks have increased instances of panic around midterms or finals. However, there may be more underlying causes, in which case patients could suffer at seemingly relaxing times. According to the Anxiety and Depression Association of America, “Forty million U.S. adults suffer from an anxiety disorder, and 75 percent of them experience their first episode of anxiety by age 22.” The ADAA also notes that a 2008 Associated Press and mtvU survey of college students found that 80 percent of participants said they frequently experience daily stress. Only a third of those suffering seek treatment, even though a majority of conditions are perfectly treatable. Luckily, the University of Pittsburgh offers a number of options for students who suffer from panic attacks or general anxiety disorders. The Counseling Center offers free counseling services by psychologists, counselors, social workers, and psychiatrists for conditions including depression and anxiety. Everyone’s body reacts to stress differently. Having a panic attack is not indicative of any fault or weakness, nor is it necessarily an indication of an abnormal amount of stress or taxation. Panic attacks may have many underlying causes—some severe, some otherwise innocuous—but it is vital that students identify stressors early on and seek help to prevent longterm anxiety and panic-related issues.
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By ZAID SAFIULLAH
T
here has been a sharp increase in the cost of health care in the U.S. over the past few years. Many Americans have sought alternatives to expensive medical treatments outside of the country and, consequently, medical tourism has gained popularity, its market growing 25 percent annually. So what is medical tourism, and what factors contribute to a decision to seek treatment abroad? Medical tourism, in the broadest sense, refers to seeking health services outside one’s native country. The most common health services sought after abroad are cosmetic surgeries, dental procedures, cardiovascular operations, and fertility solutions. These procedures are quite costly in the U.S. and have large out-of-pocket costs for the patient even after insurance coverage. According to the Healthcare Blue Book, the average cost of a routine coronary bypass surgery is $70,000. The out-of-pocket expense can be upwards of tens of thousands of dollars depending on the insurance provider. This huge expense propels patients to seek similar services abroad. In addition, patients may seek international medicine for novel treatments not available domestically, such as stem cell therapy. The countries most visited by costdriven and procedure-driven medical tourists include Brazil, Costa Rica, India, Korea and Malaysia. While searching for a destination, the patient must consider insurance coverage, quality-of-care, and the rights of an international patient. The medical tourist industry has spurred the growth of international insurance firms whose coverage extends to medical institutions in Europe and the Far East. Several preexisting insurance providers, such as Cigna
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and Blue Cross Blue Shield, now offer coverage of international medical services. As medical tourism grows, so will competition in the international insurance market, likely resulting in more complete coverage for those seeking international medical treatment. The company Patients Beyond Borders provides a network of resources for medical tourists seeking a destination. They offer a search tool making it possible to search by medical treatment, specific procedure, institution, or country. They also provide testimonials for many of their treatment destinations. However, all of the options available to the tourist raise the question of quality: how do medical tourists know which tourist destination is right for them? The answer can be found in a foreign medical institution’s international accreditation. The international accreditation standards were established by the U.S. Joint Committee International (JCI) in 1999. In order for an international hospital to receive accreditation by the JCI, they must satisfy a long list of patient - centered and management - centered requirements that are outlined in the JCI’s annual publication. These requirements and standards are quite similar to those required for accreditation by medical hospitals and institutions in the United States. This system of international accreditation helps ensure high quality-of-care for patients going abroad for treatment and allows the patient to make an informed decision based on a standard comparable to a U.S. hospital. Like any domestic medical treatment, there are
similar risks involved with foreign medical procedures. Risks of malpractice and surgical complications exist no matter the location of the procedure; however methods of compensation in light of an unfortunate event differ. In the U.S., patients are lawfully allowed to sue their physician due to malpractice and are also protected by information privacy laws passed by the Congress. The absence of universal patient rights is the toughest challenge advocates of medical tourism are faced with today, and can be a deterrent to seeking medical treatment abroad. For example, countries like Malaysia, Brazil, and India operate under a different set of patient rights legislature, preventing a medical tourist from receiving fair compensation for malpractice as they would in the U.S. Third-world countries, like India, do not have laws yet to hold physicians liable nor do they have regulation of patient information similar to the U.S. Health Insurance Portability and Accountability Act (HIPAA). This places a greater burden on medical tourists to make sure their destinations have patient-friendly health care laws. The decision to seek international medical services is undoubtedly risky. One must weigh the affordability of a procedure, the quality of care offered by a foreign institution, and limited patients’ rights. The expanding medical tourism industry has spurred the growth of international insurance, and a vast array of resources are now available that can help a patient make the most informed decision in a global sense.
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By YASH PANDYA “Hmmm, let’s see… I have two options here. I can either spend the summer traveling, or working at Polio Foundation in my native, beautiful homeland of India. Tough choice. What should I do?” In retrospect, I am quite glad I made the better choice. *** Polio Foundation is a courageous effort to offer low-cost consultations, treatments, and surgical corrections for conditions such as poliomyelitis (polio) and cerebral palsy. Located in the vibrant city of Ahmedabad in the state of Gujarat, India, Polio Foundation has greatly expanded its initial mission of serving patients with polio to treating ailments such as cerebral palsy, diabetes and its complications, along with procedures that include kidney dialysis and reconstructive plastic surgery. With the support of the state government and private donors, this institution works selflessly to relieve the difficulties
A cerebral palsy patient undergoing physiotherapy
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of those who are not otherwise able to afford treatment. While treatments for both polio and cerebral palsy are highlighted at Polio Foundation, there are some key differences between the diseases. Polio primarily involves problems with body movement due to deficits in the spinal cord, while cerebral palsy is a form of brain malfunction induced during, before, or immediately after birth that can lead to issues with body movement as well as brain development. In both of these conditions, movement is impaired, moderately or severely affecting the ability of the patient to function independently. The medical staff at Polio Foundation commits to the role of helping patients journey from illness towards recovery. The staff ’s willingness to help their patients understand the importance of effective treatment goals makes all the difference in patient compliance. To illustrate, Polio Foundation provides two to three afternoons of free physician consultations every week to patients afflicted with polio. Orthopedic surgeons altruistically donate their hours for these interactions. Similarly, individuals with conditions such as cerebral palsy and muscular dystrophy (progressive musculoskeletal function decline) are cared for by orthopedic surgeons who specialize in their management. In conjunction with the delivery of medical care, the administrative affairs streamline the entire process for the comfort and ease of the patients. From the solid infrastructure to the safe ambiance, Polio Foundation has become a mecca for patients in need of care and support.
[The staff ’s] indifference to financial compensation reinforces compassion and selfless service as building blocks in the medical field.
*** One Monday afternoon’s two-hour-long clinic consisted of 50 patients, a higher than usual number of consultations. When several patients were left unchecked at the end of the two-hour duration, the orthopedic surgeons stayed overtime to see through to the completion of the check-ups, making any further arrangements at their own private clinics. The attention given to each patient showcases the staff ’s commitment at Polio Foundation. Their indifference to financial compensation reinforces compassion and selfless service as building blocks in the medical field. Furthermore, the manner of staff conduct reflects the fundamental skills for supporting the health and well-being of the patient, always making the patient the first priority. Observing procedures in the surgical wing of the institution can solidify a resolute appreciation for Polio Foundation’s service. Equipped with a stainless steel modular operation theater and an expert surgical team, the operating room inspires a sense of confidence and trust for the patients. World-class surgeons perform lifechanging procedures ranging from clubfoot and joint deformity corrections for polio patients to muscle release and lengthening procedures for cerebral palsy patients. Everyday wide smiles adorn the faces of the surgical patients as they see their straightened limbs for the very first time upon recovering from anesthesia, bringing great joy and satisfaction to the treating surgeons. The gratitude reflected on the patients’ faces demonstrates how the ambition of improving the lives of those suffering from debilitating illnesses is being accomplished gradually, yet formatively, at Polio Foundation. *** While I am here in the United States, going about my routine college life, I frequently reminisce about the rural patient just finding out about a surgical procedure to correct his or her deformed limb, and I am filled with happiness and appreciation for such a noble cause. I eagerly look forward to returning to India and to see firsthand the new heights Polio Foundation will have reached through its strong roots and confident passion.
Cerebral palsy patients participating in recreational activities
THE PITTSBURGH-GLOBAL POLIO CONNECTION
While the incidence of polio has been greatly reduced since the introduction of the polio vaccine in the 1950s by Jonas Salk at the University of Pittsburgh, there are still some developing countries, such as India, that have patients with lingering polio who suffer from its complications. In these countries, the efforts of institutions like Polio Foundation are noteworthy, as they take the initiative of providing health care services at a nominal cost.
Polio Foundation serves as a global role model and motivator for other nations plagued by polio, encouraging them to take the first step towards eradication, as well as learning and implementing effective treatment. Starting 25 years ago, Polio Foundation has progressed and expanded at an impressive rate, reflecting their dedication and commitment to improving patient care.
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Catholic Charities Free Health Care Center Filling the Gap
O
nce Idida’s kidney disease required dialysis three days a week, she was no longer able to go to work, leaving her with no job or dental insurance. However, in order to receive the transplant she had been waiting for, it was crucial that she receive routine dental care to remain free of infection. Idida is certainly not alone in her struggle to afford health care. In fact, she represents a sector of the population that all health care providers should be aware of when practicing in their community. Far too often when someone develops a severe illness, he or she loses the ability to go to work, leading to a loss of their private insurance and/or the income necessary for sufficient medical care. Others are frustrated because
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B y Rachel Kosciusko they work at a job that does not provide health benefits and earn just enough money to keep them from qualifying for government programs such as Medicaid, but not enough to be able to afford their own insurance. Workers in service jobs such as construction, food production, and housekeeping often fall victim to this dilemma. In fact, numerous studies have reported that when a large sample of people who have declared bankruptcy are surveyed, about 60 percent state that the reason is a direct cause of high medical expenses. Idida found access to dental care at 212 Ninth Avenue in downtown Pittsburgh, with the Catholic Charities Free Health Care Center. Since its doors opened in November 2007 the clinic has had over
30,000 patient visits, caring for over 13,000 individuals. With regard to the eligibility requirements the clinic upholds, this staggering number of 13,000 are people who have no coverage under any other health insurance plan for the service provided, have a household income that does not exceed 200 percent of the poverty level, and do not qualify for Medicaid, Medicare or any other government programs. The numbers not only show the colossal need for cities to acknowledge people who cannot access health care, but they also demonstrate how much of an impact free clinics can make when this gap is acknowledged. Of course, with today’s political climate, free health care is no foreign idea. The Affordable Care Act is in full swing and is
In fact, numerous studies have reported that when a large sample of people who have declared bankruptcy are surveyed, about 60 percent state that their reason is a direct cause of high medical expenses.
expected to be making a huge impact this October with the Affordable Insurance Exchange. Sister Carole Blazina, a registered nurse practitioner and the clinical director of the health care clinic, commented that these changes may affect the financial situation associated with the clinic’s patient population, but will certainly not eliminate the need for the clinic. “That gap that people will fall into will be different,” she states, “but the gap will still be there.” In October 2012, a match was found and Idida received two kidney transplants. She has since reported she is doing “just great” and is grateful for the free dental care she received while waiting for the crucial surgery. But how can all of this health care remain free of charge without the federal government backing it up? The clinic is sustained through state-funded grants, private and public foundations and corporations, and individual donors. Patients are able to fill their prescriptions through pharmaceutical assistance programs or through the generic programs at their local Giant Eagle. Giant Eagle gift cards are provided when the generic programs pose a cost is-
sue. Most importantly, it is the vast number of doctors, nurses, pharmacists, receptionists, and other dedicated workers volunteering their time that form the foundation and allows the clinic to stay up and running. While a growing amount of government programs and tempting affordable insurance commercials may fool us into believing that everyone can access health care, it is crucial that those involved in medicine understand the real need for the services that free clinics like the Catholic Charities Free Health Care Center provide. “It is just amazing to stand in the hallway and watch the volunteers and the patients,” says Sister Carole. “Even if the patients are worried about their dental procedure or a serious illness, they still have the comfort of knowing they are being cared for and cared about, which can even be a bigger gift than the health care provided.” The Catholic Charities Free Health Care Center continues to thrive today, reminding future health care providers of the need to reach out to these invisible patients and fill the gap.
Since its doors opened in November 2007 the clinic has had over 30,000 patient visits, caring for over 13,000 individuals.
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I
magine living day to day in an environment where you could be killed at any moment by something completely undetectable. Imagine “the bodies of the dead lined up on hospital floors, those of the living convulsing and writhing in pain,” as described by Mark Mazetti and Mark Landler from a personal account in the New York Times. Imagine the thoughts of Zeina Karam and Kimberly Dozier of the Associated Press who protest the “photographs of many of the dead wrapped in white sheets,” and the “dozens of videos showing victims in spasms and gasping for breath.” This is not a description of the work of bullets, missiles or even suicide bombers. Instead, a different monster walks the streets of Syria, the new great fear of the Middle East – the neurotoxin sarin gas. For Syrians, sarin has been a difficult and horrifying reality for the past two years of their
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civil war, and the toxin is only preceded by an equally evil past. The use of this illegal weapon of mass destruction has drawn international attention and has sparked an issue of enormous controversy over whether the United States has the responsibility to act as a guardian of ethics, or as President Obama would say, a preserver of the “blurred red line.” For now, one of the great responsibilities we can take as Americans is the step of information: know the enemy. In truth, sarin has only served as a mere symbol of death and destruction, but perhaps there is more to it. Knowledge really is power, for knowledge of sarin could lead to more peaceful conversation concerning solutions to the violence. To fully understand sarin, we must consider an important property it possesses as a chemical that is often overlooked. As Ian Sample
of The Guardian has pointed out, sarin is not actually a gas at room temperature, but a liquid (possessing a boiling point of 158˚C). However, to create maximum damage, sarin is vaporized and released in gaseous form, making it fine enough to enter the respiratory system. Why does this matter? A toxic chemical that takes a liquid form in a common environment means that it can linger in exposed areas for a much longer period of time than chemicals that are present in a gaseous form – months longer. Therefore, sarin’s impact lasts far past an attack. Even though the Syrian government is allegedly chemical-free, the Syrian streets still contain the traces of sarin. Understanding sarin’s activity on a biochemical basis is the best way to determine how to fight it’s effects. Sarin is known as a nerve agent or neurotoxin, taking its toll on
the nervous system. Typically, the cause of death due to sarin is from the inability to relax contracted muscles, in particular the diaphragm, which can ultimately lead to suffocation. For any muscle activity to occur, the brain transmits electric signals through neurons, almost like a telephone wire, until the message is finally relayed from a neuron to the targeted muscle tissue. For the electrical signal to be transferred from either neuron to neuron or from neuron to muscle, a chemical neurotransmitter must be used. A neurotransmitter serves as a messenger, carrying the message from the electrical impulse to the next cell and triggering it to act. Neurotransmitters have corresponding inhibitors that cause the message to cease and eventually the action to stop. Typically, the neurotransmitter acetylcholine would work to contract muscle tissue and its corresponding inhibitor, acetylcholinesterase, would break down the acetylcholine to stop the
contraction. Instead, sarin disables acetylcholinesterase, binding to it and preventing it from binding to acetylcholine. Ultimately, this results in a continuous, deadly contraction of muscles – so deadly that it takes no more than a single milligram of sarin to kill the average human being. Fortunately, there is an antidote. The Center for Disease Control and Prevention has identified pralidoxime, an agent that displaces sarin from acetylcholinesterase by binding to both the enzyme and the poison. When pralidoxime binds to the sarin/acetylcholinesterase complex, sarin changes conformation, loses affinity for acetylcholinesterase, and is released in complex with the antidote. After chemical attacks in Syria, the short supply of pralidoxime quickly ran out. Thanks to agreements with Russia, the use of chemical warfare in Syria seems to have been curtailed and focus can shift to providing the antidote.
Syrians no longer have to live in great terror of another attack, and the affected can begin to heal. Perhaps now, with less turmoil and destruction, pralidoxime and ultimately peace can be the new agent filtering itself throughout the streets of Syria. Neuron
Muscle
Neuromuscular Junction Sarin blocks acetylcholinesterase, prolonging the effect of acetylcholine in the junction which leads to sustained muscle contractions.
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OCTOBER 2013
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