UChicago PULSE Issue 7.1: Autumn 2020

PULSE VOLUME 7, ISSUE 1. AUTUMN 2020.

TAKING A LOOK AT THE EXTENSIVE IMPACTS OF COVID-19

from the editors-in-chief Dear Reader,

In these times of significant and rapid change—politically, scientifically, and seasonally— it may be worthwhile to take some time to wind down and process what has happened over the course of these several months. Met with many challenges imposed by the advent of COVID-19, much of society has had to adapt and overcome difficult situations; and in the process, everyone experienced many consequential transformations. Nevertheless, one thing that remains constant is PULSE’s mission to deliver insightful and up-to-date information, from a student’s perspective, on the remarkable progress being made in areas of policy, research, medicine, and other sections of society.

On that note, we are proud to present you with yet another exciting issue that covers timely developments in artificial intelligence and Nobel Prize winning discovery of HCV. This year’s Autumn issue also explores the extensive impact that COVID-19 had on changing the landscape of healthcare ethics of CPR, patient diet and treatment methods, and the environment due to ocean acidification. Finally, we raise renewed concerns about the opioid crisis and prevalence of ASD, while investigating potential solutions to these ongoing global health problems.

As we prepare to travel and settle into our respective homes over break, we want to encourage everyone to always stay mindful of those around you by socially distancing, wearing masks, and following local guidelines on reducing transmission. We hope that you enjoy this issue while feeling the comfort of your family and friends, and we look forward to greeting everyone back after break!

(We can at least yearn for some level of “normalcy”, right?)

With Regards, Linus Park and Sophia Cao

editors

writers

Anna Argulian EJ Beck Amanda Calipo Sophia Carino Riley Hurr Maha Khan Emory Kim Marissa McCollum Helen Wei Rachel Zhang

Aman Agarwal Ashley Chen Shayna Cohen Meagan Johnson Areeha Khalid Sarah Kim Jack Osborn Chloe Palumbo Sanjana Rao David Yao

production Sophia Cao Linus Park

cover design Olivia Shao

other contributors MCAT-prep.com Kaplan Test Prep The Princeton Review

pulse - autumn 2020

CONTENTS EDUCATION 5 ESSENTIAL TIPS FOR MEDICAL SCHOOL INTERVIEW YOUR MCAT NOTEBOOK BOOKLET KAPLAN MCAT PRACTICE PROBLEM

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POLICY THE NAVAJO NATION'S UPHILL BATTLE WITH COVID-19 TROUBLE ON THE FRONTLINES: ETHICS OF CPR THE RADIUM GIRLS DIVERSITY AND INCLUSION IN HEALTHCARE

8 10 13 16

RESEARCH NOBLE PRIZE WINNERS BRING LIGHT TO HEPATITIS C GOOGLE'S DEEP DIVE INTO HEALTHCARE USING AI

20 23

CLINIC COVID-19 AND THE "FAT" PARADOX TREATING AN INVISIBLE CONDITION: ASD DIAGNOSIS

26 30

CURRENT EVENTS COVID-19 UNDER THE SEA A CRISIS WITHIN A CRISIS: OPIOID AND COVID-19

34 37

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5 ESSENTIAL TIPS FOR YOUR MEDICAL SCHOOL INTERVIEW Admissions officers use the medical school interview to identify candidates with maturity, empathy, and superior interpersonal skills. They already know your credentials. Now they want to know what kind of person you are and how you relate to others.

Interview policies vary. Most committees are comprised of faculty members and representatives from admissions and student affairs. Some progressive schools ask upper-level med students to take part. Formats differ as well. Some medical schools have separate, one-on-one interviews; others interview by panel. At some schools you’ll interview alone, at others you interview along with a group of other candidates. No matter what type of interview you encounter, these essential tips that will help you prep for the best med school interview possible.

1.

Be Prepared

Unless you read tea leaves, there's no way to predict all the questions you'll be asked. But that doesn’t mean you can’t come to the table prepared for likely interview topics. Be ready to discuss your: • academic background • extracurricular and leisure activities • employment and research experience • views on medical problems or relevant ethical issues • why you want to become a physician

Here's a list of 16 classic medical school questions that you could be asked. Practice crafting substan- tial responses to questions related to these areas along with concrete (and memorable!) examples.

1) How has your undergraduate research experience, if any, better prepared you for a medical career?

2) How have the jobs, volunteer opportunities, or extracurricular experiences that you have had better prepared you for the responsibilities of being a physician?

3) Thinking of examples from your recent past, how would you assess your empathy and compassion?

4) As a pre-med, what skills have you learned to help manage your time and relieve stress?

5) What excites you about medicine in general?

6) What do you know about the current trends in our nation’s healthcare system?

7) What do you feel are the social responsibilities of a physician?

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8) What do you consider an important/the most important social problem facing the United States today and why?

9) Are you aware of any current controversies in the area of medical ethics? List and discuss some of these.

10) Have you personally encountered any moral dilemmas to date? Of what nature?

11) If you are a minority candidate, how do you feel your background uniquely prepares you to be, and will influence your role as, a physician?

12) If you are not a minority, how might you best meet the needs of a multiethnic, multicultural patient population?

13) What special qualities do you feel you possess that set you apart from other medical school candi dates? What makes you unique or different as a medical school candidate?

14) Pick any specific medical school to which you are applying and tell the interviewer about it. What makes this school particularly desirable to you?

15) Discuss your decision to pursue medicine. When did you decide to become an MD, and why?

16) How have you tested your motivation to become an MD? Please explain.

2.

Take Your Time

If you find yourself in this position, try to relax. Interviewers don't expect you to have a ready answer for every question, but they do expect you to be able to think on your feet and give a considered response. If a question catches you off guard, don't be afraid to take a moment and formulate an answer before you open your mouth. If a question seems ambiguous, ask for clarification. By taking the time to make sure that your response is well-conceived and well-spoken, you will come across as thoughtful and articulate—two characteristics essential in a good doctor.

3.

Ask Great Questions

Some schools use the interview to see how well you function under stress. They deliberately put you in an uncomfortable position to observe how you act and speak under pressure. Typical tactics include asking questions about sensitive or controversial topics, delving into personal matters, rattling off a series of game show-like trivia questions or showing disapproval at almost everything you say.

The best interview is a dialogue with considerable give and take. Approach the interview as a conver- sation and not a Q&A. You should already know a lot about the school, so don't ask a question that you could easily find the answer to on their website or in their brochures. Instead, take the opportunity to learn more about faculty, research opportunities, access to internships, or anything that else that is important to you when considering a medical school program.

4. First Impressions Matter

The tone of an interview is usually set in the first few seconds. Don't forget that you're there because you are being strongly considered. Be on time and look the part. Dress conservatively. Get your docu- ments ready in a portfolio. Make eye contact and use a firm handshake (if its in-person). Smile and be positive. In a group setting handshake (if its in-person), where the committee talks with more than one candidate at a time, you will be observed not only when you answer a question, but also when your fellow applicants are speaking. Keep alert and show interest. After all, you never know what you may learn that you can use in your next interview.

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5.

After The Interview

Don't forget to send a thank-you letter after each interview. You can write several individual letters or one that addresses the entire committee. It's a good idea to take a few brief notes right after you leave, such as the interviewers’ names and some of the topics covered in your conversation.

If the school is still not sure whether they want to admit you, they'll place you on a "hold" list. This means that they want to see what the rest of the applicant pool looks like before accepting you.

If you're on the hold list, you can send in supplementary material to bolster your application. If you have recent academic or extracurricular achievements that didn't appear on your application, write a short (less than one page) description and send it to the school.

Want to learn the tactics to score higher and get real admissions tips from our expert instructors? JOIN US FOR OUR MCATÂŽONLINE FREE WEBINARS

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YOUR MCAT NOTEBOOK BOOKLET Some students are surprised to receive a laminated notepad and a marker (“wet-erase pen”) instead of scratch paper with a pen or pencil when they take their computer-based MCAT at Pearson VUE. A few tips and a little familiarity with your new exam tool will help you to treat it like a friend and not like your enemy!

1

What does the noteboard look like?

The current booklet is laminated, 8.5” x 14” with spiral binding. The printing is double-sided composed of a cover page and 9 pages with graph paper. You are also provided with 1 fine point marker: a Staedtler Lumocolor non-permanent marker.

All of your calculations and notetaking must be done in your booklet.

What if I run out of space or my marker dries up?

2

Raise your hand! If you require an additional marker or noteboard during the exam, raise your hand to alert the test center administrator, and they will make an exchange providing you with a new one.

Of course, it is preferable not to waste precious exam time waiting for an administrator to arrive! A simple tip: Always cap your marker when not in use so that the risk of drying out or leaking is minimized. You should have ample space with 1 noteboard but, just to be sure, use your space efficiently.

3

So it’s “wet erase,” does that mean that I’m allowed to erase?

No! Despite being a “wet-erase” marker and an “erasable notepad,” do NOT lick your finger and erase during the real MCAT! It is considered to be an act of misconduct.

If you make a writing error, just cross it out and continue on another line.

Additionally, you may not rip or separate the notepad or try to conceal or remove any part of it.

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Are left-handed people at a disadvantage?

For the most part, not really. On the other hand (he he), left-handed people whose palms sweat excessively when nervous will have set the conditions for instant wet erase! But to be practical, most people’s palms won’t sweat that much and so a little smudging is more likely than real-time erasure!

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Any suggestions to make my MCAT

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noteboard experience more friendly?

Two words of advice: Brain dump! Once your exam section begins, write down all the pertinent equations that you can remember or the 1-letter amino acid abbreviations or any other relevant information that you have identified during your MCAT prep. Doing so adds a sense of familiarity and comfort as you start attacking the questions, and it may increase your overall time efficiency.

The erasable notepad and marker may not be used before the start of the exam.

More tips: Delineate your writings by drawing lines separating work done for different questions. Consider writing the question number in a circle. With these simple techniques, your work becomes more clear which reduces the risk of error and permits you to review your work at the end of that section, if time allows.

Of course, everyone is different: some students barely use their noteboard while others almost fill one up.

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How can I get an MCAT noteboard to practice with?

Easy! Improvise, make one or buy one!

Although it’s not exactly the same as laminated graph paper, some students just purchase a small whiteboard ($6-$10) and fine point marker (Staedtler; $2-$4 each) from Walmart, Staples or Office Depot. Others would get a local photocopy shop to laminate some 8.5” x 14” graph paper. Some students just don’t want to get used to doing calculations on paper!

MCAT-prep.com includes a noteboard with a Staedtler marker for Home Study packages. You can also purchase the MCAT Noteboard on Amazon.com for $19.99 or less (available separately).

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How can I optimize the use of my MCAT simulation noteboard at home?

Unlike during the real MCAT, you can erase your erasable noteboard at home!

However, after each practice exam section, you may want to take mobile phone pics of your work for later practice test assessment before erasing. Then you can start each new exam section with a clean notepad to further simulate the real exam.

Don’t clean your noteboard in a bathtub! Water will seep in between the lamination and make it unusable. Clean it gently with a damp cloth or paper towel. Some students find that the marker stains the lamination over time. That will usually clear up with a multipurpose cleaner like Windex®.

Some students give up on their practice markers really quickly! If you made the mistake of not capping it when not in use and it seems dried up, try writing on some regular paper and, more often than not, your marker will be resuscitated! Of course, you are not allowed to do that during the real exam, so just raise your hand and you will get a new one.

Conclusion?

Of course, knowledge and problem-solving skills are essential for MCAT success. However, your MCAT noteboard can serve as a friendly companion on test day.

Good luck!

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Kaplan MCAT PRACTICE PROBLEM QUESTION A medical student is feeling a high level of stress due to upcoming exams and pressure from his family to engage in activities at home. He chooses to go the gym for a workout to help himself relax. This workout is which type of stress?

A. Hassle B. Frustration C. Distress D. Eustress

THINK YOU’RE READY FOR TEST DAY? Find out with this fun and FREE way to tackle practice MCAT questions from Kaplan Test Prep. Register to receive one sample question a day for the next three months. You’ll get: • A new MCAT-style question each day to test your knowledge and skills • Complete explanations and expert strategies with every question • Compete against your friends to see who’s really ready for test day To get started go to: https://www.kaptest.com/mcat/mcat-practice/free-mcat-practice-question-a-day

D. A positive stressor creates eustress. Because workingi out is used to relax, it is considered a eustress. Hassle, choice (A), and frustration, choice (B), are both types of distress, choice (C), or negative stressors.

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THE NAVAJO NATION'S UPHILL BATTLE WITH THE COVID-19 PANDEMIC By

Aman Agarwal Marissa McCollum

While the Navajo Nation’s spring COVID-19 outbreak received plenty of nationwide coverage, the epidemic within the community is often presented as a single aberration, fully divorced from systemic problems and cultural context. This way of framing the problem of COVID19 in the Navajo Nation is actively harmful, as it makes current “solutions” like the federal government’s $600 million CARES grant for “necessary expenditures incurred due to the [Navajo] public health emergency” seem like reasonable responses, when in reality they completely ignore the key factors that initially triggered the outbreak. The uniquely vulnerable position of the Diné, as the Navajo people call themselves, is a product of long-term social, economic, and historical conditions that must be addressed for meaningful and lasting change to be brought about.

The CARES grant has certainly helped the Diné, but community leaders had to fight a month-long legal battle to secure funding initially allocated to for-profit Alaskan corporations, and when it was finally given, it came with an important stipulation: all the money must be spent by the

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end of the year. This seemingly arbitrary restriction prevents the Diné from investing in longterm public works projects that can improve quality of life—and therefore community health—on the reservation, and it serves as yet another example of misguided federal policy that deprives the Diné people of autonomy, self-sufficiency, and public infrastructure.

In 1864, the United States government implemented the “Long Walk,” forcibly removing the Diné from their Arizonan settlements in which they lived for generations to eastern New Mexico. A few decades later, the government slaughtered the vast majority of Diné livestock, claiming that the animals’ grazing eroded tillable soil. These destructive incidents, along with many others, greatly reduced Diné wealth and negatively affected their way of life.

The historic mistreatment of the Diné people has real material consequences that affect the modern-day community. More than 44% of people on the reservation live under the federal poverty line, and at least one third of all households lack either running water or electricity. The presence of nuclear energy reactors and

coal mines on the reservation have exacerbated these problems, as arsenic, uranium and other poisonous elements have been detected in groundwater on Diné land. Because there are only thirteen grocery stores in the territory (which is roughly the size of West Virginia), the reservation has been classified by the U.S. Department of Agriculture as a food desert, making it exceedingly difficult for Diné to obtain nutritious food. Additionally, like many other Native American tribes, the Diné suffer not just from material deprivation but also cultural deprivation. During the late 19th and mid-20th centuries, Diné children were sent to boarding schools in an effort to “kill the Indian, save the man.” In practice, this meant that Diné children would be stripped of their traditions, culture, identity, rituals, and language. The multigenerational trauma from Indian boarding schools has inflicted lasting damage on the community as a whole.

Due to this historic social, cultural and economic deprivation, Diné suffer from significantly higher rates of diabetes mellitus, hypertension, and obesity: chronic conditions that greatly increase the

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COVID-19 social distancing and mask wearing protocols issued by the Navajo Nation, which these signs outside Black Rock, Arizona highlight, were integral to slowing the spread of the disease through the community.

risk of COVID-19 complications.

Furthermore, high incidences of heart disease, atherosclerosis, depression, suicide, and cancer have contributed to the lower lifespan of Diné. Such biological problems put the Diné community in a precarious position as it navigates the challenges of the coronavirus pandemic. All the systemic problems of the Diné are compounded by the inadequate healthcare the federal government’s Indian Health Services (IHS) provide. Before the pandemic, IHS only received one-third of the per capita funding of the Department of Veteran Affairs and Medicare.

For this reason, the hospitals in the Navajo Area Indian Health Service region were notoriously underfunded and understaffed.

Once COVID-19 spread to the Diné, cases immediately snowballed, resulting in overfilled hospitals and a lack of supplies and healthcare professionals to adequately treat native patients.

In May, the Diné Nation had the highest per capita infection and fatality rates in the United States: 1 in 43 Diné on the reservation had contracted the virus. Even today, COVID-19 continues to ravage the community.

The Diné knew that coronavirus posed a great threat to their community, so they prepared for and responded to the pandemic better than many American states. Preventative measures were adopted in early March, making the reservation one of the last places in the United States to report an official case. Lockdown measures, mask mandates, and weekend curfews were imposed in an effort to prevent the virus from spreading to the Diné community. When coronavirus cases were detected on the reservation, Jonathan Nez, the president of the Diné, and other tribal leaders were proactive in securing help and petitioned nearby nongovernmental organizations and universities for COVID-19 tests and medical aid. Partnering with UCSF, the tribe created a robust testing program and became one of the United States’ most prolific testers.

The efforts of the Diné to control the coronavirus are laudable, especially since the community was clearly working at an extreme disadvantage, but despite the community’s best efforts, it has suffered greatly during the pandemic. The plight

of the Diné indicates that the federal government must engage in widespread systemic change to ensure that a similar situation will not occur in the future. Only longterm investment in better public infrastructure and healthcare services will adequately address the pervasive disparities in Native American health outcomes.

Becenti, Arlyssa. “Curfew Is on through October.”

Navajo Times. Navajo Times, October 14, 2020. https://navajotimes.com/coronavirus-updates/ curfew-is-on-through-october/.

Diamond, Frank. “Q&A: How Navajo Nation Dealt With COVID-19.” Infection Control Today.

Infection Control Today, September 10, 2020. https://www.infectioncontroltoday.com/view/qand-a-how-navajo-nation-dealt-with-covid-19.

Interview conducted with Jonathan Iralu, MD. Dooley, Sunny. “Coronavirus Is Attacking the Navajo 'Because We Have Built the Perfect Human for It to Invade'.” Scientific American.

Scientific American, July 8, 2020. https://www. scientificamerican.com/article/coronavirus-isattacking-the-navajo-because-we-have-builtthe-perfect-human-for-it-to-invade/.

Mozes, Alan. “COVID-19 Ravages the Navajo Nation.” WebMD. WebMD, June 9, 2020. https://www.webmd.com/lung/news/20200609/ covid-19-ravages-the-navajo-nation.

Nelson, Cody. “Covid Ravages Navajo Nation as Trump Makes Election Play for Area.”

The Guardian. Guardian News and Media, October 8, 2020. https://www.theguardian. com/us-news/2020/oct/08/navajo-nationcoronavirus-pandemic.

Image Credit: Abou-Sabe, Kenzi, Cynthia McFadden, and Didi Martinez. “Vulnerable Navajo Nation Fears a Second COVID-19 Wave.” NBCNews.com. NBCUniversal News Group, August 3, 2020. https://www.nbcnews. com/specials/navajo-nation-fears-secondcovid-19-wave/index.html.

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TROUBLE ON THE FRONTLINES THE ETHICS OF CARDIOPULMONARY RESUSCITATION DURING COVID-19 By

Shayna Cohen Riley Hurr

Eight months after the World Health Organization (WHO) officially declared the COVID19 outbreak as a pandemic, the impact COVID-19 has had on the lives of physicians, patients, and their families has been immense and profoundly tragic. As of November 10th, there have been over 240,000 deaths from COVID19 in the United States alone, which comes along with another sobering statistic: 1,361 US healthcare providers (HCPs) caring for COVID-19 patients have died.

With national PPE shortages and

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COVID-19 cases continuing to surge in many places, putting stress on critical care resources, the ability for frontline workers to protect themselves while adequately serving patients seems more and more difficult. Along with potentially exposing themselves and their families to an incredibly infectious virus, HCPs are also evidently struggling with seeing the harsh realities of the pandemic firsthand, and as a result some have experienced significant struggles with their own mental health. Broadly, the COVID-19 pandemic is forc-

ing HCPs and their institutions to radically redefine what it means to provide treatment in a time of crisis. Specifically, withholding cardiopulmonary resuscitation (CPR) from COVID-19 patients has been up for discussion in some hospitals since CPR requires close proximity to a patient and can lead to more airborne transmission.

For the hospitals considering policies like withholding CPR, there are a number of reasons why this could be advantageous.

Primarily, withholding CPR from COVID-19 patients seems to be

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the way to objectively save the most lives. If a HCP gets COVID19 from a patient, they would be unable to take care of other patients for an absolute minimum of 14 days. If life-saving measures are not performed on COVID-19 patients, it would be less likely for an HCP to contract it from the patient in the first place. Additionally, CPR can also cause sputum and other bodily fluids to escape, since oftentimes recovery after being resuscitated involves coughing and possibly even throwing up. Even with all the precautions taken, there is still a risk that the SARS-CoV-2 virus could be airborne and transmitted not just to frontline workers but to other patients in the hospital, especially if there aren’t enough ICU beds or negative pressure rooms to effectively isolate COVID-19 patients.

Outside of the sheer number of lives saved, resuscitation efforts do not seem to be all that successful at saving the lives of the COVID-19 patients themselves. It has been reported out of Wuhan, China that, of the COVID-19 patients who experienced cardiac arrest and needed CPR, there was only a 2.9% survival rate after resuscitation measures were performed.

Finally, although frontline workers surely have some kind of

obligation to help those seeking treatment, it is worth saying that it seems unreasonable to expect or mandate physicians to put their own lives at risk to treat anyone else.

On the other hand, there are a number of ethical problems that come about with refusal to resuscitate any COVID-19 patient.

Namely, COVID-19 is by no means a monolithic disease, and individuals who become sick with COVID-19 and may need to be hospitalized can be from a wide range of demographics with a variety of possible comorbidities.

As a result, there are a number of considerations that would likely need to go into determining who should and shouldn't be eligible to receive resuscitation efforts, and there is the possibility that such policies could unintentionally lead to ageism and ableism in medical care. These disparities in treatment already exist to some degree due to limited ventilators and the very nature of COVID-19 but would likely be even further exacerbated by institutional policies on resuscitation. Additionally, there are many questions related to the autonomy of patients and their families. While some patients may opt for a do-not-resuscitate (DNR) order, there are undoubtedly

many patients who would want to receive CPR and other life-saving measures. Is it unjust for HCPs to deny care to someone who actively seeks it, regardless of the risk to themselves or others?

With all of these considerations in mind, it seems that the best course of action for frontline workers and their patients is for CPR to be given to COVID-19 patients only after the code team has donned appropriate PPE. If appropriate PPE is not available, hospitals and clinics should not require frontline workers to administer CPR without the proper protection. This framework accomplishes two key things: 1) it protects the autonomy and safety of the frontline workers treating COVID-19 patients, and 2) it allows for COVID-19 patients to be treated by all HCPs when PPE is available or perhaps by some HCPs who still wish to offer CPR even without proper PPE. Ultimately, autonomy of frontline workers and their patients ought to be prioritized above all else. Respecting the autonomy of healthcare workers means that they should not be forced to provide close-contact care without proper PPE, but at the same time, no one should actively prevent them from providing that care if

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they wish to do so and understand the risks. This allows the HCPs to make the decision based on what they feel most comfortable with while still ensuring that COVID19 patients may still receive CPR under the right conditions. In a situation as complex and sobering as the COVID-19 pandemic, it is incredibly important that all those directly involved have a say in the prescription of treatment protocols, especially protocols like CPR. By honoring the autonomy of both the HCPs and the patients, healthcare institutions may be able to reconcile competing wishes into a situation that respects everyone’s boundaries while still fulfilling the mission of providing as high quality care as possible.

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University of Michigan. “Cardiac Arrest, Poor Survival Rates Common in Sickest Patients with COVID-19.” Accessed November 13, 2020. https://labblog.uofmhealth.org/rounds/ cardiac-arrest-poor-survival-rates-commonsickest-patients-covid-19.

"CPR in the Covid-19 Era—An Ethical Framework." NEJM. Accessed November 13, 2020. https://www.nejm.org/doi/full/10.1056/ nejmp2010758.

Harkin, Denis W. “Ethics for Surgeons during the COVID-19 Pandemic, Review Article.” Annals of Medicine and Surgery 55 (July 2020): 316–19. https://doi.org/10.1016/j.amsu.2020.06.003.

Kapoor, Indu, Hemanshu Prabhakar, and Charu Mahajan. “Cardiopulmonary Resuscitation in COVID-19 Patients – To Do or Not To?” Journal of Clinical Anesthesia 65 (October 2020): 109879. https://doi.org/10.1016/j. jclinane.2020.109879.

The Guardian. “Lost on the Frontline: US Healthcare Workers Who Died Fighting Covid-19.” Accessed November 13, 2020. http://www.theguardian.com/ us-news/ng-interactive/2020/aug/11/ lost-on-the-frontline-covid-19-coronavirus-ushealthcare-workers-deaths-database.

Modes, Matthew E., Robert Y. Lee, and J. Randall Curtis. “Outcomes of Cardiopulmonary Resuscitation in Patients With COVID19—Limited Data, but Further Reason for Action.” JAMA Internal Medicine, September 28, 2020. https://doi.org/10.1001/ jamainternmed.2020.4779.

Shao, Fei, Shuang Xu, Xuedi Ma, Zhouming Xu, Jiayou Lyu, Michael Ng, Hao Cui, et al. “In-Hospital Cardiac Arrest Outcomes among Patients with COVID-19 Pneumonia in Wuhan, China.” Resuscitation 151 (June 2020): 18–23. https://doi.org/10.1016/j. resuscitation.2020.04.005.

Sher, Taimur, Charles D. Burger, Erin S. DeMartino, Alice Gallo de Moraes, and Richard R. Sharp.

“Resuscitation and COVID-19: Recalibrating Patient and Family Expectations During a Pandemic.” Mayo Clinic Proceedings 95, no.

9 (September 1, 2020): 1848–51. https://doi. org/10.1016/j.mayocp.2020.06.035.

Thapa, Shrinjaya B., Tanya S. Kakar, Corey Mayer, and Dilip Khanal. “Clinical Outcomes of In-Hospital Cardiac Arrest in COVID-19.” JAMA Internal Medicine, September 28, 2020. https://doi.org/10.1001/ jamainternmed.2020.4796.

Thorne, C.J., and M. Ainsworth. “COVID-19 Resuscitation Guidelines: A Blanket Rule for Everyone?” Resuscitation 153 (August 2020): 217–18. https://doi.org/10.1016/j. resuscitation.2020.06.013.

Umpierre, Ana. “Protecting Health Workers on Puerto Rico’s Covid-19 Frontlines.” Direct Relief (blog), September 24, 2020. https://www. directrelief.org/2020/09/protecting-healthworkers-on-puerto-ricos-covid-19-frontlines/.

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THE RADIUM GIRLS A DYING FIGHT FOR JUSTICE By

Meagan Johnson Amanda Calipo

You may remember “The Jungle” by Upton Sinclair, the classic novel exposing the appalling working conditions in the meat-packing industry at the beginning of the 1900s. However, a lesser known tale exposes a mass coverup affecting occupational safety in the workplace. It is a tale of hundreds of working-class women flocking to factories to join the elite subset of clock dial painters, a tale where women will die while fighting for their basic human rights to well-being. A tale of litigation and painful death. Unfortunately, this “tale” became reality for hundreds of women in the 1920s, infamously known as “the Radium girls.”

After World War I was declared and it became

increasingly evident that America would become involved, women rapidly became the face of the industrial complex.

Suddenly taking over traditionally male jobs, a select few women began working as painters for watches and military dials using the latest element, Radium. This position was amongst the most selective in the United States, landing a spot on this assembly line would put you in the top 5% of female workers nationally.

This job was seductive.

It provided women with a sense of economic freedom during a time of burgeoning female empowerment, appealed to the artistic and creative individuals, and allowed the women work with the revolutionary “glow in

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the dark” objects. These girls made the most of their “elite” status, often wearing their Sunday’s best to complete a day’s work. They worked alongside their mothers, sisters, and closest girlfriends. It was a tight-knit unit. After a long shift, the girls would stampede to the dancing halls. The best thing yet: they could shine as they danced, a product of the radium.

Despite knowing little about the dangers of radium, each woman was told the radium-laced paint was virtually harmless. For the best result, the women needed to place the brush to their lips to maintain a fine stroke. After they were done or needed a break, they were more than welcome to paint their nails, apply it to their faces, and luminant their teeth. At the same time, the U.S. Radium Corporation had already distributed findings to the medical community stating that radium had its dangers: it was “injurious” and potentially fatal with long-term exposure. As soon as radium poisoning began to set

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in and gruesome symptoms began to plague the girls, the nation’s outlook on occupational diseases turned its course. Their unfortunate reality can not only teach us about our increasing exposure to false-information campaigns, but also about the faculty and agency of women. The women who would soon spend their last days fighting for justice.

Painting watch dials with radium was a war strategy; it enabled troops to navigate through the dark and radium was very low-cost, in terms financial concerns. However, radium is a highly toxic illuminant with a halflife of 1,600 years. radium had only been discovered 20 years before the first girls entered the dial factories, so knowledge of its toxicity was limited. However, a researcher by the name of Dr. H.S. Martland studied the impacts of radium of the women’s health and noticed a large portion of the women had a serious condition, which he later coined “Radium Jaw.” This Radium

Jaw defined the indigestion and later absorption of radium into an individual’s bones. Eventually, necrosis of the mandible (the lower jawbone) and the maxilla (upper jaw) would set in and subsequently constant bleeding of the gums and eventual distortion of the bone due to tumors would begin. The Radium girls began to die prematurely and almost always met the same eventual fate. “One woman tried to have a tooth pulled and the dentist ripped out her entire jaw”, says Deborah Blum, author of the Poisoner’s Handbook. She continues, “others saw their legs break from beneath them and their spines collapse.”

The last Radium girl died in 2014, a woman by the name of Mae Keane. She lived until the ripe age of 107, solely because she was fired from her dial painting job for not meeting performance expectations. She refused to put the brush to her lips to create that fine stroke, claiming she didn’t like the gritty taste. Acknowledging that

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this ultimately saved her life, Keane stated in a recent NPR interview “I often wish I had met him [her boss] after to thank him, because I would have been like the rest of them.” The “rest of them” who died at young ages will glow in their graves.

As word began to spread amongst the women that their elite jobs were slowly and horrifically killing them, their employer, the U.S. Radium Company decided to hire their own experts to falsify these salacious rumors. Unfortunately, when their own researchers confirmed the link between the radium and the women’s illnesses, the company became outraged.

The president, in a desperate attempt to cover-up these findings, paid for new studies to be published that claimed the opposite. However, the women were fed-up with lies. A group of five women employed from a New Jersey branch, sued their employer under the state’s occupational injury law. In citing gross miscon-

duct in part of a large corporation, the women found it difficult to find a lawyer willing to take on the U.S. Radium Company. Despite these hardships, the women eventually won the case and established legal precedents that govern labor safety standards, including the later formation of the Occupational Safety and Health Administration (OSHA) a few decades later.

The Radium girls dying fight for injustice holds an important place in history for both health and labor rights. Although hundreds of women died gruesome deaths, the litigation changed working standards and conditions for the better.

The women became a fixture in the health community to express the dangers of radium, which is less commonly used today. The girls made their voices known and showcased the faculty of women.

Society today should remember these women as we constantly face mis-information campaigns and live in a world where the impacts of factory emissions still remain

unknown on our long-term health.

The story of the Radium girls allows us to look inside the world of cover-ups and the deadly effects of false advertising. These girls should be remembered because they may soon represent every one of us.

Moore, K. (2019, April 04). The Forgotten Story Of The Radium Girls, Whose Deaths Saved Thousands Of Lives. Retrieved October 23, 2020, from https://www.buzzfeed.com/ authorkatemoore/the-light-that-does-not-lie Johnson, M. (2014, December 31). 2014 was the year the last of the 'Radium Girls' died.

Retrieved October 23, 2020, from https:// www.bizjournals.com/bizwomen/news/ out-of-the-office/2014/12/2014-was-the-yearthe-last-of-the-radium-girls.html?page=all (n.d.). Retrieved November 23, 2020, from http:// waterburyobserver.org/node/586 Johnson, M. (2014, December 31). 2014 was the year the last of the 'Radium Girls' died.

Retrieved October 23, 2020, from https:// www.bizjournals.com/bizwomen/news/ out-of-the-office/2014/12/2014-was-the-yearthe-last-of-the-radium-girls.html?page=all

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DIVERSITY AND INCLUSION IN HEALTHCARE AN ONGOING EFFORT By

Areeha Khalid Emory Kim

Imagine that you have been invited to a dinner party. You get all dressed up, you are super excited...and then when you arrive at the venue, you notice that all the seats are filled. You are standing there in an expensive suit after spending twenty minutes on your hair only to realize there is nowhere for you to sit.

Not pleasant, right?

Now, imagine this one more time. Except this time, you are a doctor, the dinner party is the hospital, and the featured dish is your patients. If there is no room for you at the table, will you ever get to the meal?

Diversity and Inclusion in Healthcare These days, the terms “diversity” and “inclusion” are often used interchangeably. However, they do not mean the same thing.

Diversity is the incorporation of all different types of people into a group. In the scenario above, this means inviting people to the dinner party. By issuing more invites to all kinds of guests, you increase the diversity of people present.

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Inclusion means having equal opportunities and spaces to express your ideas within the larger group. If you are at the dinner party but there is no room for you to participate in the conversation or get to any of the dishes, then you are not “included” in the main space. This means that just because a space is diverse does not automatically mean it is also inclusive.

Oftentimes, we get caught up in making sure things are outwardly diverse, whether that be through “cancel culture” on social media or excessive political correctness.

However, these reactions are not necessarily the best way to bring about lasting change.

When it comes to healthcare specifically, inclusivity needs to be a foundational part of the system.

This means creating open environments in medical schools and research where diverse healthcare providers can learn to cater to diverse patient populations. From there, inclusivity will extend to hospitals through methods such as anti-racist practices, diverse hires, and culturally-sensitive training for current staff.

Diverse and Inclusive Patient Populations Dictate Medical Training and Research In debates about diversity and inclusion in healthcare, many argue that because doctors are trained to treat all humans, factors such as race, gender, or socioeconomic status should not affect their ability to provide necessary care. For example, a prevalent perspective in the U.S. right now is the idea of being “colorblind,” where one believes that since all humans are equal, disparities based on race should not be taken into account.

The colorblind perspective is problematic because it instills a false sense of diversity that sounds more helpful than it is. However, research consistently shows that by ignoring diversity in medical training, doctors are actually less able to effectively treat patients.

For example, many American dermatological textbooks are limited in the photos they contain of skin conditions on people with darker skin. Based on the colorblind perspective, this should not affect the quality of dermatological

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care because all human skin “is the same.” However, it turns out this is not the case.

According to Dr. Lynn McKinley-Grant, a dermatology professor at Howard University, medical students are trained from their first day in “pattern recognition,” or to learn how to identify an illness consistently and treat it. But if a skin condition that looks red on white skin is purple on darker skin, doctors may struggle to identify that condition on a darker-skinned patient because they have been trained exclusively on light-skin pattern recognition. This results in misdiagnoses, or a failure to notice an illness altogether.

In addition to diagnoses, diversity and inclusion is equally as important when it comes to treatments for illnesses. Although

many hospitals and labs already consider race in tests and medication dosages, we need to take a closer look at whether these existing practices are truly effective and accurate.

For instance, kidney filtration problems can be detected through blood tests that measure the amount of creatinine present in the body, where low levels of the protein indicate the patient may need further medical attention. Typically, a score of 30 or fewer would prompt a primary care doctor to refer a patient to a kidney specialist.

In these tests, race is seen as a proxy for genetic differences, and automatically factored into a patient’s final score. This can be dangerous, as exemplified by a 2019 study by Eneanya, Yang, and

Reese, which found that while a white patient may score a 28, a Black patient with the same level of creatinine might score a 33 and not be referred to a specialist.

Further, this same race correction might mean that a Black patient will not be eligible for a necessary kidney transplant, as one needs a score of 20 or less to qualify.

These are just some examples that illustrate the harmful effects of overfocusing on race or overlooking it altogether when it comes to healthcare. We need diversity and inclusion in the types of people medical students study, as well as the way medical treatments are administered, in order to build safer hospital settings.

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Stereotypes, Implicit Bias, and the Need for Being AntiRacist in Medicine Racism is a public health crisis in medicine. While individual doctors may not necessarily be racist, research shows that implicit stereotypes and biases affect how healthcare workers may respond to a patient, especially in crisis situations.

The Implicit Association Test (IAT) is the most commonly-used test for implicit biases among doctors, consisting of a computerized timed dual categorization task. This test is usually used to see how the test taker evaluates Black/White faces with “Good/ Bad” words to reveal the implicit assumptions they might make while under a time constraint.

In a study by Sabin and Greenwald (2012), researchers used the IAT to determine that doctors who claimed to have “warm feelings” towards both African and European Americans still could have implicit biases towards either group. These biases affected how they chose to treat patients, as doctors with more “pro-white” tendencies on the IAT were more

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likely to prescribe narcotic pain medication to a white patient after surgery, but not a Black patient.

This study demonstrates the need for doctors to not just condemn racism in medicine, but to be actively anti-racist. According to news reporter Eric Deggans, anti-racism means accepting racism as an undeniable part of American culture and history, working to educate oneself about it, and uplifting marginalized voices by supporting anti-racist organizations and outreach. In healthcare, anti-racism might mean that doctors need to make an active effort to become aware of their implicit biases because they can may unwittingly impact how doctors provide care.

Furthermore, stereotypes, biases, and racism affect not only the kind of care a patient is receiving, but also a patient’s attitude toward hospitals and medicine in general. Put simply, when a patient no longer perceives the hospital environment as being inclusive, they may be disinclined toward seeking help. This contributes to the wide healthcare disparities in the U.S. for certain groups—such as women, POC, immigrants, and LGBTQ+ individuals, especially

those that are transgender, who may feel discriminated against or that their “concerns are not being heard” by their healthcare providers.

As shown in the Sabin and Greenwald (2012) study, pain medication is particularly an area of medicine that is plagued by implicit bias and racism. For example, research shows that Black and Hispanic patients are less likely to receive prescription pain medications for the same conditions than white patients are.

Pain stereotypes extend to gender as well. Female patients with chronic pain consistently report feeling “mistrusted” and “not taken seriously” by doctors, perhaps due to stereotypes of women being “hysterical” and exaggerating their emotions.

Women also report their appearance being brought up frequently as a reason they do not receive adequate care, such as by providers saying, “You don’t look ill.” or “You’re too young [to have chronic pain]!”

It is worth noting that on the flip side, men are stereotyped as “brave” and “masculine”, meaning that male patients are less likely to reach out to doctors for help

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managing their chronic pain or to follow their doctor’s treatment advice due to the fear of being seen as feminine or weak.

Thus, the promotion of inclusive (anti-racist and anti-stereotyping) practices by doctors serves to increase both the quality of a patient’s care and the patient’s positive attitudes towards their provider and treatment.

A Seat at the Table for Everyone When reading about the studies and examples above, many people’s initial instinct is to ask, “So what? How can we solve this dilemma?” And inevitably, the solution proposed is to hire more diverse doctors from different backgrounds.

Improving diversity in the hospital and the clinic is indisputably the best first step. After all, diversity is the first step toward inclusivity. However, hiring more diverse doctors will not fully neutralize systemic problems that have been present for decades.

Nor is it fair to put the burden of “fixing the system” on doctors from minority or underrepresented backgrounds in medicine.

Think back to the dinner party example. Inviting more guests to the table might increase inclusivity, but what about the guests who have already been sitting down?

All healthcare workers must make the effort to be more inclusive together, whether through training existing doctors to be more culturally sensitive, utilizing strategies that help doctors acknowledge and become aware of their implicit biases, or promoting bias-reduction at the institutional level.

These are not problems that can be fixed overnight, but larger systemic issues that will require a careful overhaul of research, policies, ideas, and training. By promoting self-reflection and active efforts against stereotypes and biases, we stand to create a more diverse hospital setting where everyone has a seat at the table, doctors and patients alike.

Chapman, Elizabeth N., Anna Kaatz, and Molly Carnes. “Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities.” Journal of General Internal Medicine 28, no. 11 (2013): 1504–10. https:// doi.org/10.1007/s11606-013-2441-1.

Deggans, Eric. “'Not Racist' Is Not Enough: Putting In The Work To Be Anti-Racist.”

NPR. NPR, August 25, 2020. https://www.npr. org/2020/08/24/905515398/not-racist-is-notenough-putting-in-the-work-to-be-anti-racist.

Ebede, Tobechi, and Art Papier. “Disparities in Dermatology Educational Resources.” Journal of the American Academy of Dermatology 55, no. 4 (2006): 687–90. https://doi.org/10.1016/j. jaad.2005.10.068.

Eneanya, Nwamaka Denise, Wei Yang, and Peter Philip Reese. “Reconsidering the Consequences of Using Race to Estimate Kidney Function.”

Jama 322, no. 2 (2019): 113. https://doi. org/10.1001/jama.2019.5774.

Kolata, Gina. “Many Medical Decision Tools Disadvantage Black Patients.” The New York Times. The New York Times, June 17, 2020. https://www.nytimes.com/2020/06/17/health/ many-medical-decision-tools-disadvantageblack-patients.html.

Macapagal, Kathryn, Ramona Bhatia, and George J. Greene. “Differences in Healthcare Access, Use, and Experiences Within a Community Sample of Racially Diverse Lesbian, Gay, Bisexual, Transgender, and Questioning Emerging Adults.” LGBT Health 3, no. 6 (2016): 434–42. https://doi.org/10.1089/lgbt.2015.0124.

Prichep, Deena. “Diagnostic Gaps: Skin Comes In Many Shades And So Do Rashes.” NPR. NPR, November 4, 2019. https://www.npr.org/ sections/health-shots/2019/11/04/774910915/ diagnostic-gaps-skin-comes-in-many-shadesand-so-do-rashes.

Sabin, Janice A., and Anthony G. Greenwald.

“The Influence of Implicit Bias on Treatment Recommendations for 4 Common Pediatric Conditions: Pain, Urinary Tract Infection, Attention Deficit Hyperactivity Disorder, and Asthma.” American Journal of Public Health 102, no. 5 (2012): 988–95. https://doi. org/10.2105/ajph.2011.300621.

Samulowitz, Anke, Ida Gremyr, Erik Eriksson, and Gunnel Hensing. “‘Brave Men’ and ‘Emotional Women’: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain.”

Pain Research and Management 2018 (2018): 1–14. https://doi.org/10.1155/2018/6358624.

Zestcott, Colin A., Irene V. Blair, and Jeff Stone.

“Examining the Presence, Consequences, and Reduction of Implicit Bias in Health Care: A Narrative Review.” Group Processes & Intergroup Relations 19, no. 4 (2016): 528–42. https://doi.org/10.1177/1368430216642029.

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LET THE SILENT EPIDEMIC BE HEARD NOBEL PRIZE WINNERS BRING LIGHT TO HEPATITIS C By

Ashley Chen Maha Khan

A silent epidemic is sweeping the nation. Discovered in 1989, hepatitis C struggles to gain the recognition it needs. For victims like Rick Starr, contraction of the disease occurred well before its discovery. Starr is one of the 75% of individuals infected who developed chronic hepatitis C because his body could not clear the virus on its own. It was only through a mandatory blood test for his job that he was diagnosed with hepatitis C. Due to social stigma surrounding the disease, he waited 7 years before seeking treatment. During those years, he experienced no obvious side effects: clinical diagnosis of hepatitis C is frequently missed because it is often asymptomatic. The Centers for Disease Control and Prevention (CDC) estimates that 3.5 million people are living with hepatitis C, and at least 50% of people living with hepatitis C do not know they are infected.

This lack of awareness presents a serious issue as the rate of new hepatitis C cases is 4 times as high as they were 10 years ago among people ages 30-39 (Figure 1). By awarding the 2020 Nobel Prize in Physiology

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and Medicine to virologists Harvey J. Alter, Michael Houghton, and Charles M. Rice for their discovery of hepatitis C, there is hope for a revival of research in and greater understanding of the virus.

Hepatitis is an inflammation of the liver. It is usually spread through contaminated blood. The virus can cause abdominal pain, fatigue, jaundice, liver failure, and in some cases death.

In 1967, the hepatitis B virus (HBV) was identified

by Baruch Blumberg. At this time, Alter was working at a blood bank at the United States National Institutes of Health. Blood could be screened to ensure that people would not get HBV from a transfusion; however, patients were still developing hepatitis. The blood-borne agent causing the disease was not being screened out by the tests developed for hepatitis A and B. This prompted Alter to study the transmission of hepatitis caused by blood transfusions in the 1970s.

Alter and his colleagues showed that a third, bloodborne viral pathogen could transmit the disease to chimpanzees.

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As Alter found evidence for non-A, non-B hepatitis, Houghton was working at Chiron Corporation with his colleagues to identify the virus based on genetic material from infected chimpanzees. Spending the late 1980s isolating the genetic sequence of the virus, they collected DNA fragments from an infected chimpanzee and matched fragments of the unknown virus with those from patients with hepatitis until they were able to find a match. They discovered that it was a new kind of RNA virus of the Flaviviridae family, which includes viruses that cause dengue, Zika, West Nile, and yellow fever, and named it the hepatitis C virus (HCV) in a 1989 paper. Building on Alter and Houghton’s work, Rice led a team based at Washington University to study the hepatitis C genome and show that this new virus could, in fact, cause hepatitis. His team used genetic-engineering techniques to characterize a portion of the genome responsible for viral replication and showed that when the new RNA variant of HCV reached the liver unimpeded, it would cause hepatitis. Work by Alter, Houghton, and Rice fit together to make great strides in explaining most blood-borne hepatitis cases, which was not feasible with the prior identification of hepatitis A and B viruses. Alter’s speculation of a

new hepatitis virus led to Houghton’s discovery of the virus and Rice’s confirmation of its role in causing liver disease.

The WHO estimates that 71 million people worldwide are chronically infected with HCV with approximately 400,000 annual deaths, mostly from cirrhosis and liver cancer. More individuals die from hepatitis C than all of the 60 reported infectious diseases combined. Treatment is critical as nearly 320,000 deaths can be prevented by testing and referring infected persons to care and treatment.

The standard therapy of pegylated interferon-alpha and ribavirin has its limitations. Thus, creating an HCV vaccine is ideal. Efforts to develop a vaccine began more than 30 years ago. Since then, researchers have studied over 20 potential vaccines in animals.

However, there are limited animal models of hepatitis C infection as well as ethical and cost concerns.

Hepatitis A and B currently have vaccines, but HCV presents a challenge as it is highly variable among strains. HCV occurs in at least six genetically distinct forms. Different HCV genotypes are distributed unevenly in different parts of the world (Figure 2).

A global vaccine would have to protect against all of these variants of the virus.

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Because of the virologists’ discovery of hepatitis C, the disease can now be cured for the first time, raising hopes of eradicating it. Nonetheless, further research is needed to tackle this prevalent disease and improve global health. A vaccine is needed to control the virus.

One of the Nobel Prize laureates, Houghton, is now working on a vaccine against HCV. Unfortunately, research initiatives in the virus have slowed due to decreased funding and willingness to commit to such a long-term project. In the face of COVID-19, however, virology and viruses are finding a place in the public eye. The prize will hopefully contribute to the attention and spur investment in a possible vaccine. By reviving enthusiasm in treatment and shedding light on the silent epidemic, a better understanding of viruses can be uncovered, saving millions of lives.

"A Hepatitis C Success Story". 2020. Gastrointestinal Society. https://badgut.org/ information-centre/a-z-digestive-topics/a-hepatitis-c-success-story/.

Caffrey, Mary. 2020. "Discovery Of Hepatitis C Virus Brings Nobel Prize".

AJMC. https://www.ajmc.com/view/discovery-of-hepatitis-c-virus-bringsnobel-prize.

Callaway, Ewen, and Heidi Ledford. 2020. "Virologists Who Discovered Hepatitis C Win Medicine Nobel". Nature. https://www.nature. com/articles/d41586-020-02763-x#:~:text=Blood%2Dborne%20 pathogen&text=Houghton%2C%20then%20working%20at%20 Chiron,named%20it%20hepatitis%20C%20virus.

Chambers, Thomas J., Chang S. Hahn, Ricardo Galler, and Charles M. Rice.

1990. "Flavivirus Genome Organization, Expression, And Replication".

Annual Review Of Microbiology 44 (1): 649-688. doi:10.1146/annurev. mi.44.100190.003245.

Guidelines For The Care And Treatment Of Persons Diagnosed With Chronic Hepatitis C Virus Infection. 2018. Geneva: World Health Organization.

"Hepatitis". 2016. Medlineplus. https://medlineplus.gov/hepatitis.html.

Hepatitis C, A Silent Epidemic. 2020. Ebook. Centers for Disease Control and Prevention. https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/ Hepatitis-C-A-Silent-Epidemic-Infographic.pdf.

Highleyman, Liz. 2020. "New Hepatitis C Cases Tripled Over The Past Decade".

Hep. https://www.hepmag.com/article/new-hepatitis-c-cases-tripled-pastdecade.

Manns, M P, H Wedemeyer, and M Cornberg. 2006. "Treating Viral Hepatitis C: Efficacy, Side Effects, And Complications". Gut 55 (9): 1350-1359. doi:10.1136/gut.2005.076646.

Rizza, Stacey. 2020. "Why Isn't There A Hepatitis C Vaccine?". Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/hepatitis-c/expertanswers/hepatitis-c-vaccine/faq-20110002.

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RESEARCH

GOOGLE'S DEEP DIVE INTO HEALTHCARE USING AI By

Chloe Palumbo Esther Beck

Alan Turing’s 1950 paper, Computer Machinery and Intelligence, introduced a simple yet novel question: Can machines think? His answer came in the form of the Turing Test, which sought to determine whether a computer could reliably pass as a human when prompted with a series of questions. Turing’s work set the precedent for artificial intelligence by bringing the question of whether machines can exhibit human intelligence to the fore.

But what exactly is artificial intelligence? For many, the term “artificial intelligence” conjures up images of machines taking over the world in some sci-fi apocalypse. Despite all the buzz about artificial intelligence in the past decade, most people still only have a vague understanding of what exactly artificial intelligence is and the role it plays in modern society. At the most rudimentary level, artificial intelligence is the act of replicating human intelligence in computer systems.

Whether it be through speech-recognition or decision making, artificial intelligence has made profound leaps in industries as wide-ranging as automobiles and healthcare.

One such advance came in 2008 after Google launched their Google Health project, marking the commencement of their venture into the healthcare industry. Originally designed to allow Google users to centralize their health records, the Google Health project has shifted its focus in recent years to artificial

intelligence research.

One predominant focus of the Google Health project is Acute Kidney Injury (AKI) prevention. At a staggering 13.3 million cases worldwide per year, AKIs pose a significant global health threat by causing kidney failure in as less as two days due to the accumulation of waste products in the blood. If diagnosed early enough, experts believe that up to 30% of AKIs are treatable, but early detection systems have plenty of room for improvement. The DeepMind team at Google Health seized this opportunity to initiate a research project that employs artificial intelligence in order to predict AKIs as quickly as 48 hours before they strike. To do this, they’re testing a neural network that processes electronic health records at certain time steps and outputs the probability of AKI development within the next 48 hours. Any probability above a certain threshold indicates a positive result and will notify clinicians as soon as possible.

Additionally, the model provides a measure of uncertainty with each prediction that allows clinicians to distinguish between more and less ambiguous cases.

The artificial intelligence technology is so accurate, in fact, that it correctly detected AKI in 90% of patients with conditions that became so severe they required dialysis.

In addition to acute kidney injuries, Google Health’s artificial intelligence technology has ventured

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into oncology, tackling lung cancer diagnosis using advances in 3D volumetric modeling. Rather than having radiologists sift through hundreds of 2D images per single CT scan, which is both time-consuming and often prone to errors, Google Health’s artificial intelligence technology uses a patient’s current CT scan as well as any previous scans to generate an overall malignancy prediction and to identify subtle malignant tissues. So far, the results have been very promising, with artificial intelligence technology performing at the same proficiency, if not better, as U.S. board-certified radiologists. In fact, an additional 5% of cancer cases were detected using artificial intelligence technology.

Google Health artificial intelligence technology has also ventured into blindness detection caused by diabetic retinopathy. Diabetic retinopathy induces lesions towards the posterior of the retina and poses a risk to 415 million diabetics worldwide. Luckily, with early diagnosis and consistent screening, such occurrences can be prevented. What’s most widely used by ophthalmologists is optical coherence tomography (OCT), a detailed 3D image of the back of the eye, to diagnose eye diseases. However, OCT images require lengthy expert analysis for them to be accurate. The sheer quantity of scans alone in hospitals worldwide creates delays between the scan and treatment that

can cost a patient their eyesight. Google Health’s artificial intelligence model was constructed in a stepwise fashion. Firstly, the model was equipped with anonymous pre-labeled retina images by over 50 ophthalmologists which were rated on a scale from 1 to 5, depending on the quantity and severity of diabetic retinopathy signs present. These pre-labeled images were then inputted into an image recognition algorithm so that the model could identify certain features indicative of diabetic retinopathy, including nerve tissue damage, swelling, and hemorrhaging.

After the model was trained on a large enough data set, it could then be transferred to a device, termed the Automated Retinal Disease Assessment (ARDA) in which retina images are accepted as inputs and analyzed for signs of diabetic retinopathy. After detection, the program informs physicians which patients are in need of treatment and corroborates its decision with specific features that provide insight into how it came to its decision, as well providing the percent confidence in its recommendation. In recent trials, Google Health’s artificial intelligence technology could detect eye diseases in a matter of seconds.

Promising results in a lab is one thing, but whether that can translate into a clinical environment is another. One of the first instances of ARDA’s implementation in a clinical setting was in Thailand, where

Modeling framework for Google’s artificial intelligence lung cancer detection technology.

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RESEARCH

a total of 4.5 million diabetics were screened by only 200 retinal specialists. After its incorporation, nurses claimed that although it sped up the process significantly, ARDA would often return no result at all. Part of this phenomenon can be explained by the fact that during the training process only the highest quality scans were used in an attempt to guarantee higher accuracy. While that worked in early trials, when it came to ARDA’s application in a clinical setting, scans that were not up to its quality standards were rejected.

In fact, a staggering 20% of scans were rejected due to low quality. If artificial intelligence technologies are ever to be successfully incorporated in real-world clinical settings, more rigorous processes need to be implemented to ensure that scans ranging in quality can be analyzed for successful diagnosis.

There is no doubt that artificial intelligence holds immense potential for changing the healthcare industry as we know it. Promising results serve as a testament to the incredible power of computer systems in detecting and diagnosing diseases, thereby reducing time delays and potentially making the difference between life and death. However, rigorous trials must be conducted before it can gain regulatory approval. Translating encouraging laboratory results to a clinical setting is a pertinent requirement before artificial intelligence can truly become a fixture of the healthcare industry.

“A Major Milestone for the Treatment of Eye Disease.” Deepmind. Accessed November 13, 2020. https://deepmind.com/blog/article/moorfields-majormilestone.

“Acute Kidney Injury.” International Society of Nephrology, August 25, 2020. https://www.theisn.org/commitment-to-kidney-health/focus-areas/acutekidney-injury/.

“Applying Deep Learning to Metastatic Breast Cancer Detection.” Google AI Blog, October 12, 2018. https://ai.googleblog.com/2018/10/applying-deeplearning-to-metastatic.html.

“Diagnosing Diabetic Retinopathy with Machine Learning.” Google. Accessed November 13, 2020. https://about.google/stories/seeingpotential/.

“Google Health.” Wikipedia. Wikimedia Foundation, November 12, 2020. https://en.wikipedia.org/wiki/Google_Health.

Heaven, Will Douglas. “Google's Medical AI Was Super Accurate in a Lab. Real Life Was a Different Story.” MIT Technology Review. MIT Technology Review, April 27, 2020. https://www.technologyreview. com/2020/04/27/1000658/google-medical-ai-accurate-lab-real-life-cliniccovid-diabetes-retina-disease/.

Shravya Shetty, M.S. “A Promising Step Forward for Predicting Lung Cancer.”

Google. Google, May 20, 2019. https://blog.google/technology/health/ lung-cancer-prediction/.

Shravya Shetty, M.S. “Using AI to Improve Breast Cancer Screening.” Google.

Google, January 1, 2020. https://blog.google/technology/health/improvingbreast-cancer-screening/.

Tomašev, Nenad. “A Clinically Applicable Approach to Continuous Prediction of Future Acute Kidney Injury.” Nature News. Nature Publishing Group, July 31, 2019. https://www.nature.com/articles/s41586-019-1390-1.

Turing test. (2020, October 29). Retrieved November 13, 2020, from https:// en.wikipedia.org/wiki/Turing_test “Using AI to Give Doctors a 48-Hour Head Start on Life-Threatening Illness.”

Deepmind. Accessed November 13, 2020. https://deepmind.com/blog/ article/predicting-patient-deterioration.

“What Is Artificial Intelligence? How Does AI Work?: Built In.” What is Artificial Intelligence? How Does AI Work? | Built In. Accessed November 13, 2020. https://builtin.com/artificial-intelligence.

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COVID-19 AND THE "FAT" PARADOX MERITS OF THE KETOGENIC DIET IN A COVID-19-STRICKEN WORLD By

Jack Osborn Helen Wei

Introduction Ketogenic diet is a high-fat, low carbohydrate diet used primarily as a quick weight loss regimen. By restricting carbohydrate intake, the body switches its primary fuel source from glucose to ketones, organic molecules synthesized by the liver to deliver clean, long-lasting, and abundant energy. While there is still much to be uncovered about the effect of the diet transiently on the body, there are many significant and well-understood long-term implications, including the lowering of inflammatory markers associated with diseases such cancer, diabetes, and obesity.

The ketogenic diet can be therefore viewed as a preventative measure to reduce chronic inflammation associated with a host of inflammatory diseases. SARS (Severe Acute Respiratory Syndrome), an inflammatory respiratory illness caused by a coronavirus, is responsible for hijacking its host genome and inducing a cytokine storm in the body. SARS-CoV-2, for example, has been shown to prevent gene activation of interferons, proteins released by

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infected cells that signal to nearby cells to activate their own genes to slow further viral replication.

Without interferon activation, viruses such as coronavirus are capable of unchecked replication and runaway inflammation that impedes the immune system, promoting a dangerous inflammatory response.

Within a matter of days, COVID-19 swept up society into a state of paranoia and fear, igniting concerns surrounding the short term and long-term implications on our health. As more information emerged regarding its mechanism of transmission, who is most at risk, and who presents the biggest risk of transmission, scientists developed a key understanding of why at-risk individuals are hit the hardest, and how we can best respond to COVID-19 positive individuals through treatment.

Key Demographics and Risk Factors for COVID-19 While it is currently well-understood that COVID-19 has detrimental short-term conse-

quences on the body, there is still much to be uncovered regarding its long-term deleterious implications, from cognitive impairment to cardiovascular disease, to exacerbation of existing socioeconomic inequalities. We observed a common theme amongst hospital admission trends: people of color and those of a low socioeconomic status seemed to be hit the hardest, highlighting social inequity associated with disease and access to healthcare.

Initial studies suggested that younger individuals were generally less prone to developing severe symptoms potentiated by high levels of inflammation, with the majority of severe cases belonging to immunocompromised people, such as the elderly population and those with preexisting conditions. So, while it is easy to think of young people as being relatively immune to the disease, they represent the most dangerous demographic, potentially unknowingly transmitting the disease to the most immunocompromised and susceptible individuals.

In addition to understanding how COVID-19 acutely affects

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an infected individual, analyzing the impact of the virus on longterm health outcomes can serve as a valuable tool to embrace healthy living habits. A study from the University of Washington and Stanford University School of Medicine displayed a strong inverse relationship between smoking and COVID-19 mortality rates across forty countries.

However, mortality variation across countries was determined to be too great to be accounted for by the consequences of smoking, attributing various confounding variables to the observed protection that smoking supposedly provided. In fact, ensuing studies showed that the high levels of inflammatory markers associated with long-term smoking not only caused smokers to be more susceptible to severe COVID-19 symptoms, but also left them with further lung scarring and damaged systemic organ tissue. With so much to be learned about COVID19 as it pertains to chronic health outcomes, it becomes increasingly more critical to understand how the virus ravages the body even following recovery, ulti-

mately highlighting the need to adopt anti-inflammatory and disease-warding lifestyles.

Inflammation and Metabolic Disease In a study analyzing the impact of the ketogenic diet on adipose (fat) tissue inflammation, mice fed a high fat and low carbohydrate diet displayed increased VAT γδ T cell expression, reduced pro-inflammatory macrophages associated with metabolic dysregulation, and a “protective gene expression signature”, suggesting that the diet not only boosted metabolism and decreased adipose tissue volume, but also conferred a protective effect on the mice.

By seemingly altering immune function, the diet had a profound impact on the health of the mice, albeit brief. These results show that in addition to enhancing fat metabolism, the diet can directly modulate immune mechanisms, leaving much to be uncovered about its implications on metabolic disease, and other concurrent proinflammatory diseases.

The Interaction Between the Ketogenic Diet and the Comorbidity of Disease Anti-inflammatory diets such as the ketogenic diet are vital to staving off deadly proinflammatory disease. While the ketogenic diet is yet to be completely elucidated in the context of its comorbidity with a host of inflammatory diseases, it has a direct impact on the inflammasome, a multiprotein complex that detects stressors and pathogens and activates proinflammatory cytokines to fight off pathogens. In a mice study, the most prominent ketone present in our blood, beta-hydroxybutyrate, was shown to prevent the inflammasome from activating, in turn inhibiting an activation cascade that would otherwise exacerbate inflammation (Figure 1). Additionally, the diet greatly increased goblet cell production, critical to successfully mounting an immune response against pathogens, and reduced myeloid cells that typically mount a massive proinflammatory immune response. Furthermore,

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the ketogenic diet had implications on the level of the genome: through RNA sequencing analyzing γδ T cells, the ketogenic diet was shown to increase anti-inflammatory gene expression. By boosting mitochondrial efficiency of γδ T cells, a class of T cells with a distinctive T cell receptor most prevalent in the gut mucosa, the body is primed and more efficient

employment of the ketogenic diet in coronavirus-stricken patients holds promising results. While it is currently difficult to compare the results seen in mice to those of COVID-19 patients, several studies have been undertaken to analyze the symptoms and progress of the disease in the context of the ketogenic diet.

Figure 1. The potential pathway by which the ketogenic diet modulates inflammasome activity: ketones such as BHB inhibit Drp-1 recruitment, thereby diminishing inflammation and boosting the brain’s recovery capacity to ischemic damage.

Interview with a Mount Sinai Neurosurgeon I spoke to a neurosurgeon at Mount Sinai in New York City to discuss what factors helped him decide to utilize the diet. The physician, who was placed in the COVID-19 ward at his hospital when NYC was the epicenter of the virus, mandated that his patients on ventilators be put on a strict low carbohydrate regimen.

As an individual aware of the

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at responding to and mounting an attack against pathogens and subsequently reducing the systemic inflammatory load.

Likewise, the coronavirus has been shown to impact immunocompromised individuals and people with preexisting conditions.

Seeing as the ketogenic diet has profound chronic impacts at both the gene and metabolic levels,

therapeutic benefits of the diet, it was an easy, evidence-driven choice for him. “We put a couple of patients on an old form of tube feed called PulmoCare (a relatively high-fat, low carbohydrate form of tube feed). When it became clear that what was killing them was a massive inflammatory surge, we knew what direction we should be taking the care.” Despite not evaluating these patients’ health outcomes, he emphasized the value of mitigating a cytokine storm prompted by COVID-19.

Ever since then, he discussed the health outcomes he saw first-hand as a result of anti-inflammatory measures taken. “People aren’t dying at the rate they were towards the beginning of the year, the reason primarily being both a low-carbohydrate diet and steroid administration. As a result, that inflammatory surge is happening a lot less. The overall mortality rate is far lower than it was in February and March.” Despite not evaluating these patients’ health outcomes and their recovery capacity, his

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decision to employ a carbohydrate restrictive tube feed on intubated COVID-19 patients was a testament to the therapeutic and widespread value of implementing the ketogenic diet, both in practice and as a preventative measure.

Adaptation While this diet presents benefits including reduced low-grade chronic inflammation associated with a host of proinflammatory diseases, weight loss, boosted mental clarity, etc., many individuals have cited negative outcomes, including initial irritability and low sustainability in the long-term.

In addition to having to adapt to the new coronavirus era, people would be forced to adapt to the new challenges and experiences that the ketogenic diet brings.

“When people are in a stressful environment, they tend to not go to the unfamiliar. It’s a little hard to get people to think out of the box in crisis mode”, said the physician I spoke to. However, a study from UCSF shows that even slight restriction, not just complete ketosis, can positively affect the gut microbiome, so some of the effects of the diet can be conferred quite quickly. This

evidence explains that even in a short duration of employing the ketogenic diet, some of its anti-inflammatory benefits can be reaped quickly, eliminating any adaption or commitment to the diet that people would otherwise find to be unsustainable. While restrictive ketogenic diets can be employed to severely ill coronavirus patients who present otherwise few options for treatment, the data show that some of the conferred benefits are obtained rapidly and have a lasting impact on patient outcomes.

Understanding the comorbidity of disease with the coronavirus has remained an elucidating point for future treatment. In understanding how the ketogenic diet has improved COVID-19 patient outcomes, we create the opportunity to not only better understand the mechanisms by which COVID-19 spreads and is transmitted, but also to shed light on potential therapeutic approaches to other proinflammatory diseases, and how we can take preventative measures to mitigate risk of these diseases. Despite the broader positive implications of ketogenic diet employment, there is still more to learn about the coronavirus. With so much currently unclear, further studies are warranted to analyze

the comorbidity of coronavirus and inflammatory diseases.

Anand, Paras. “Faculty Opinions Recommendation of Ketogenic Diet Improves Brain Ischemic Tolerance and Inhibits NLRP3 Inflammasome Activation by Preventing Drp1-Mediated Mitochondrial Fission and Endoplasmic Reticulum Stress.” Faculty Opinions – PostPublication Peer Review of the Biomedical Literature, 2019. https://doi.org/10.341 0/f.732878128.793559831.

Chowdhry, Kavya. “Has COVID-19 Highlighted Social Injustice Built into Our Cities?” The Centre for Evidence-Based Medicine. University of Oxford, October 7, 2020. https://www.cebm.net/2020/10/ has-covid-19-highlighted-social-injusticebuilt-into-our-cities/.

Dutta, Sanchari Sinha. "Keto diet could be beneficial for elderly COVID-19 patients".

News-Medical. https://www.news-medical.net/ news/20200914/Keto-diet-could-be-beneficialfor-elderly-COVID-19-patients.aspx. (accessed November 1, 2020).

Robertson, Sally. "An inverse relationship between smoking and COVID-19". News-Medical. https://www.news-medical.net/news/20200615/ An-inverse-relationship-between-smokingand-COVID-19.aspx. (accessed November 12, 2020).

Schnell, Patrick. Photograph. New York, March 30, 2020. Mount Sinai Brooklyn.

Stubbs, B.J., and J.C. Newman. “Ketogenic Diet and Adipose Tissue Inflammation—a Simple Story?

Fat Chance!” Nature Metabolism 2 (January 20, 2020): 3–4. https://doi.org/https://doi. org/10.1038/s42255-019-0164-2.

Weiler, Nicholas. “Ketogenic Diets Alter Gut Microbiome in Humans, Mice.” Ketogenic Diets Alter Gut Microbiome in Humans, Mice | UC San Francisco. University of California San Francisco, May 13, 2020. https://www.ucsf.edu/ news/2020/05/417466/ketogenic-diets-altergut-microbiome-humans-mice.

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TREATING AN INVISIBLE CONDITION TREATMENT AND THERAPY OPTIONS AFTER AN ASD DIAGNOSIS By

Sarah Kim Rachel Zhang

What is Autism Spectrum Disorder?

Contrary to popular belief, autism spectrum disorder (ASD) is not a single disorder, but rather a diverse set of several neurodevelopmental disorders characterized by symptoms such as hypersensitivity to certain stimuli, delays in cognitive or social skill development, and difficulties with verbal or nonverbal communication.

In order to make a diagnosis, health professionals must first observe specific delays in a child’s development. However, there are a multitude of other behaviors which may be indicative of autism; in fact, not everyone with autism spectrum disorder possesses

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characteristic traits of autism to the same degree. Due to the variability in behavior observed across different people with ASD, it can sometimes take months or years for someone to obtain a proper diagnosis. Considering this difficulty, it becomes critical to comprehend the various aspects of ASD including symptoms, diagnosis, treatment options, and available healthcare specialists.

Types of Diagnostic Tools & The Process of Getting a Diagnosis The American Academy of Pediatrics (AAP) recommends that a child receive developmental

and behavioral screening during regular visits to their pediatrician or primary care physician at 9, 18, and 30 months old. In addition, the AAP also recommends that children receive specific screening for ASD at 12 and 24 months old, as well as additional screening if a child is at higher risk or exhibits behavior symptomatic of ASD. Arriving at a general diagnosis relies on two steps. First, a preliminary screening is conducted to determine if a more thorough evaluation for autism may be necessary. The screening also identifies other conditions which may be present. If the screening results in a need for further examination, the individual will be referred to a developmental specialist for a

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more comprehensive diagnostic evaluation.

The absence of a consistently accurate medical test or a distinctive physical marker makes it much more difficult to identify ASD. In order to improve the diagnosis process, medical practitioners have developed several assessments to definitively diagnose ASD and gauge its severity.

The Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) is a checklist for early detection of ASD among children between 16 and 30 months, asking yes/no questions.

Examples of these questions might include if the child in question becomes upset by everyday noises or responds when their name is called. The Autism Diagnostic Observation Schedule–Generic (ADOS-G) is a structured interview with directed activities. The Autism Diagnostic Interview–Revised (ADI-R) is a semi-structured interview with the child’s parents.

The Childhood Autism Rating Scale (CARS) uses a 15-point system to evaluate a child’s listening response, verbal communication, relationship with others, and ability to adapt to change. All of these exams are conducted by trained specialists.

It is important that ASD is identified as soon as possible.

The earlier ASD is diagnosed, the sooner treatment can begin, and the sooner the individual will benefit from this treatment in the long run. Most ASD diagnoses occur between the ages of 2 and 3 years old, when delays in reaching certain social, communicative, and developmental milestones become most apparent. While it is also possible to be screened for autism as an adult, most diagnostic tests are designed for children, and it can be particularly difficult to diagnose ASD at an older age. This is further complicated by adults who have developed strategies to compensate for their condition or have learned to mask their symptoms in order to struggle less with social acceptance and interaction. Adult evaluations for autism rely heavily on direct observation and discussions with the specialist concerning their difficulties with sensory issues, social situations, and restricted interests or compulsive repeated behaviors such as self-stimulation, or “stimming”.

If a person’s early development did not have any features suggestive of autism, but they began struggling with social withdrawal and related

issues in their teens or adulthood, this suggests a cognitive or mental health issue other than ASD.

Treatment and Therapy Because autism manifests itself in unique ways depending on the person, there are many different options for therapy available. In fact, it is recommended that several different types of therapy are part of an autistic person’s treatment and care.

Physical therapy can help autistic individuals practice their gross and fine motor skills. Deficits in coordination, lack of posture control, and other issues with mobility, strength, and body awareness can be treated by physical therapists. Physical activities that involve sports, gymnastics, and other games can help people with ASD take part in a more specialized physical education program. These activities also help children develop play skills, which can then be applied to situations involving social interaction with peers.

Speech therapy can help autistic children improve their verbal communication. Often, the goals of speech therapy are to improve one’s

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conversational skills, creativity with language, and understanding of words outside of a learned context. Jaw-strengthening exercises done with a speech therapist can help improve enunciation and singing short songs or reading aloud together can help a child become more confident and comfortable with spoken language.

For autistic individuals who are non-verbal, alternative methods of communication are available.

Many learn to use sign language, while others use electronic “talking” devices or picture boards to help convey their thoughts.

Applied behavioral analysis (ABA) is a method of treatment which consists of one-on-one time spent with a clinician delivering a personalized regimen of behavioral training targeted towards a certain goal, such as learning to greet a friend or write a name.

This approach involves breaking down large tasks into smaller steps, rewarding the completion of each incremental task along the way.

ABA is the most frequently

Occupational therapy can help children with autism gain more body awareness and stronger motor skills.

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chosen option for ASD treatment. However, in recent years, controversy has arisen surrounding this therapy method.

The Autistic Self Advocacy Network (ASAN) contends that ABA is based on a cruel premise of trying to make people with autism pass as neurotypical instead of offering support to help autistic individuals live a happy, healthy, and a self-determined life.

In its early stages, ABA therapists would hit, shout at, or electrically shock patients when they exhibited “abnormal” behavior: that is, behavior that is overtly “autistic”, such as stimming or other socially inappropriate behaviors. Despite the severity of this program, it seemed like a better choice to most parents than institutionalizing them, and in fact, autistic children following this regimen tended to show higher likelihoods to spontaneously socialize and use language. However, it’s difficult to determine how applicable ABA is. A child might learn something with a therapist when there is an incentive to do so but choose not to apply the skill in a different social setting. A child might know when to look a therapist in the eye, especially with prompts and a reward, but still not understand the etiquette of eye contact in a social situation.

Nowadays, other variations of behavioral treatment are in development, such as pivotal response training (PRT) and the Early Start Denver Model (ESDM). Both are inspired by ABA but sidestep the more controversial aspects of it in favor of a more neurodiverse-inclusive approach. Instead of ABA’s one-skill-at-a-time approach, pivotal response training is playbased, initiated by the child, and targets multiple “pivotal” areas of a

child’s development at once. ESDM involves a trained therapist using play routines to help toddlers and young children to learn new skills across many domains, such as singing a song while playing with a toy in order to encourage the child to vocalize.

Occupational therapy is also a useful treatment method for many people with autism. In this context, the term “occupation,” refers to meaningful and purposeful activity.

An occupational therapy session involves direct client contact in a one-on-one or small group situation. “Occupational therapy has always emphasized what is meaningful to the individual,” details Liz Maruyama, OTR (Occupational Therapist Registered). “Each of our patients have their own unique qualities, even with the same diagnosis. Occupational therapists specifically design their sessions to recognize the patient’s preferences and to minimize barriers to their participation. We focus on the adaptation and resilience of the individual, rather than going by the book on treating their diagnosis.”

Activities completed in an occupational therapy session depends on the client’s goals for the day. If a client is struggling with hand-eye coordination, handwriting exercises or coloring activities can help with those fine motor skills. If a child needs help with body awareness or coordination, an occupational therapist might organize activities that exaggerate muscular feedback to the brain, such as resistive climbing or completing an obstacle course.

Like speech therapists, occupational therapists can help clients with social awareness through cooperative games that encourage communication and help the client practice anticipating social interac-

CLINIC tion. Ultimately, while the therapist is the professional in charge of these therapy sessions, the client is just as involved, if not more so, in the decision-making of the session plan.

Healthcare Professions and Specializations Which Deal with Autism & Other Neurodevelopmental Disorders Because many different types of therapy exist to help autistic people, it follows that many different types of professionals have experience with treating ASD. Examples of healthcare specialists who tend to work with autistic individuals include neurologists, child psychologists, psychiatrists, neuropsychologists, developmental pediatricians, and speech-language pathologists (SLP). Physical therapists, occupational therapists, and behavioral therapists also often work with people with ASD. Therapy for autistic and neurodivergent individuals tends to be very hands-on and reliant on social interaction, and lockdown brought on by the COVID-19 pandemic drastically impacted the way many therapists and specialists conducted their sessions. Christine Jurjovec, OTR/L (Occupational Therapist Registered/Licensed), is a pediatric occupational therapist who manages The Balanced Kid, a therapy clinic with locations in Westmont and Naperville.

Jurjovec has had to adapt her practice in light of the lockdown by offering teletherapy sessions.

“We offered teletherapy to kids who were able to handle it, but for others it was very difficult to

adapt a remote session to their needs,” said Jurjovec. “Some of our clients are non-verbal or require greater support than can be offered remotely. However, I and the other therapists checked in often with their family and gave them options for support at home.”

Jurjovec also traveled to her clients’ backyards or local playgrounds to do socially distanced in-person sessions. “I actually ended up turning the trunk of my car into a portable clinic,” she described. “I’d carry my therapy equipment in the back to bring them out during an outdoor session. The kids would bring their own toys as well, so I was able to engage them with activities like kicking their soccer ball to each other six feet apart.” Jurjovec continued, “Overall, I think the outdoor experience for these kids was a great change of pace. I had to get creative with the environment around us in our sessions, but given the circumstances, they showed a lot of promise in their progress.”

The Balanced Kid reopened in-clinic services in June. In accordance with current COVID19 policy, their waiting rooms are currently closed, and they have implemented a curbside dropoff and pick-up system for their clients. In-clinic sessions at The Balanced Kid tend to be play-based and relationship-based. With physically engaging equipment such as suspended swings and crash pads, children can stimulate their visual, auditory, and tactile sensory systems. In this multisensory environment, each child can participate in beneficial activities designed to improve their sensory processing.

Final Points ASD is a condition that manifests itself in many different ways.

The specific symptoms as well as the severity of the condition inform the type of treatment which yields the most benefit to a person diagnosed with ASD. As such, a treatment program involving a number of different therapies must be designed with the specific individual’s needs in mind. Whatever diagnosis and support a neurodivergent individual receives, the end goal should inherently be a happy and healthy adult life, unbound

by ASD in a manner that is as autonomous and self-sufficient as possible.

To learn more about occupational therapy and/or The Balanced Kid, please visit www.thebalancedkid.com/contact.

Devita-Raeburn, Elizabeth. “The Controversy Over Autism’s Most Common Therapy.” Spectrum.

Last modified August 10, 2016. https:// www.spectrumnews.org/features/deep-dive/ controversy-autisms-common-therapy/ “The Diagnostic Process.” Operation Autism.

Last accessed November 3, 2020. https:// operationautism.org/autism-101/ the-diagnostic-process/ Hye Ran Park et al. “A Short Review on the Current Understanding of Autism Spectrum Disorders.”

PubChem. Last modified February 25, 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4766109/ Patricelli, Kathryn. “Introduction to Autism Spectrum Disorder.” Gulf Bend Center.

Last modified August 5, 2016. https:// www.gulfbend.org/poc/view_doc. php?type=doc&id=8763&cn=20 “Physical Therapy Guide to Autism Spectrum Disorder.” ChoosePT. Last modified October 23, 2019. https://www.choosept.com/ symptomsconditionsdetail/physical-therapyguide-to-autism-spectrum-disorder "Screening and Diagnosis of Autism Spectrum Disorder.” Centers for Disease Control and Prevention. Last modified March 13, 2020. https://www.cdc.gov/ncbddd/autism/screening. html “Signs of Autism in Adults.” NHS. Last modified April 22, 2019. https://www.nhs.uk/conditions/ autism/signs/adults/

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COVID-19 UNDER THE SEA By

David Yao Sophia Carino

It has been seven months since the coronavirus crossed the line in our lives from being a mere news notification to manifesting itself, for the fortunate, in the form of quarantine. With so much time that has gone by, many of us have found ways to adapt to our newly brought-on circumstances. For some, a drive to work became a walk to a computer, meetups with friends turned into Google Meets, and trips to the grocery store “cyberized� to online shopping.

Surveys conducted by the US Census Bureau quantify the extent to which these impacts have in the U.S. From September 30th to October 12th, 37.5% of the 250 million adult respondents reported that a portion or the entirety of their job turned into telework.

Similarly, around 35.1 and 52 percent of respondents reported reducing their number of trips to stores and public transportation use, respectively.

On the surface, these statistics show relatively substantial progress to climate sustainability compared to past years. The partial revitalization of the economy, in conjunction with reduced transportation, gives hope that a working economy and climate concerns are not mutually exclusive. However, the impact of the global pandemic transcends deeper than just the surface.

The data suggests more people have thought twice about taking trips and utilizing public transportation than before COVID-19, but beneath this environmental solace lies our natural drift towards

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the pre-COVID-19 environment. Take, for example, the reduction in public transportation usage. A study conducted by a Vanderbilt University professor, Dan Work, shows how the discontinuation of public transportation services could lead to increased traffic congestion in major cities such as Chicago, New York, Boston, San Francisco, etc. With the inevitable switch from pooling passengers in one vehicle to using individual vehicles, traffic in these cities is predicted to substantially escalate- increasing the number of vehicles and the amount of emission per vehicle. In fact, models by Glen Peters et al. add we will most likely see an increase in gas emissions during 2021 despite the 2020 reduction.

Needless to say, COVID-19 has influenced atmospheric chemistry; yet, another overlooked facet of the pandemic is its impact below sea level.

Before COVID-19, a long-term concern for oceans was acidification. In ocean acidification, atmospheric molecules, the most notable being carbon dioxide, are absorbed into the ocean, react with water, and reduce carbonate concentrations, all while increasing the pH of the environment. Experiments have shown this process alters marine ecosystems to the point where even predator-prey relationships change. The news of smaller nitrogen dioxide concentrations and less carbon dioxide emissions post-COVID-19 have led experts in the field to believe oceans are recovering.

Unfortunately, this change was not brought about

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by environmental policy and the gradual return of pre-COVID economic emissions has not been taken into consideration.

In addition to ocean acidification, there is also the issue of plastic pollution. By the year 2050, the weight of plastic pollution will be greater than that of all the fish in the Earth’s oceans. Unfortunately, this area of sustainability has not been improved nor brought to the same level of attention as other topics in the political sphere. The oversupply and recent price drop of oil directly lead to cheaper plastic production. The price of manufacturing new plastic products is then economically favorable compared to the profit-margins of recycling, which facilitates greater plastic production. In terms of recycling, no policy measures have been taken to mitigate the production of plastic; in fact, stay-at-home orders have led to more organic and inorganic waste generation overall.

In municipalities with previously low recycling rates, the convenience and demand for waste products continue to promote low recycling rates. The city of Chicago published a report showing consistently low rates of recycling. Since 2016, Chicago has yet to recycle more than ten percent of recyclable products with each year descending. The amount of recyclable material accumulated up until October of this year has almost equaled that of the quantity measured during the previous year. Medical waste generation has also seen a significant spike.

Roughly 129 and 65 billion masks and gloves, respectively, are used a month, none of which are recycled. Should this rate be maintained, this year will end with ~30% more waste compared to 2019, a pronounced detriment to an already astonishing rate for the oceans.

Case studies on plastic pollution in coastal regions of Europe have shown detrimental effects to coasts and are both literally and figuratively downstream consequences of the surge in plastic demand and usage. Based on drone imagery, it was shown on the Catalan coast that the open sea received plastic pollution from coastal waters. To better understand the problem, five Mediterranean countries participated in a study involving plastic particles floating around their shores. Ninety percent of all litter in these studies was plastic products. The study recognized a multi-disciplinary approach between multiple countries that provides more ground for effective legislation.

On the other hand, coronavirus has also left some bodies of water unperturbed. Legislation regulating maritime travel and the beaches in coastal areas of the Veneto region has been the silver lining for these regions. When these regulatory orders are inevitably uplifted, it is likely a resurgence, and possibly an increase from pre-COVID-19, of human intervention will occur. Almost all ecological improvements that coastal regions have seen depend on COVID-

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19-based orders. It is these laws and the temporary diminish in pollution in coastal regions that further procrastinate consistent efforts towards coastal conservation.

As desirable as it sounds to return to a pre-COVID-19 world, it is safe to assume the relatively promising environmental improvements that have emerged during this time of global hardship will be undone. The pandemic we live in today is almost nothing but disastrous compared to the circumstances of 2019. But excluding conservationist discussions from our coronavirus discourse will only reflect our passive attitude to sustainability needs before the pandemic. These times give every individual an obligation to reflect upon the ways we may contribute to more sustainable practices or increase awareness.

The very fact that such cases of pollution occur in our recession is evidence of our natural gravitation towards an environmentally perturbing society.

The National Oceanic and Atmospheric Administration provides undergraduates with a list of opportunities to get involved. Sign up for the UChicago career advancement to receive updates on sustainability opportunities.

Adyel, Tanveer M. “Accumulation of Plastic Waste during COVID-19.” Science.

American Association for the Advancement of Science, September 11, 2020. https://science.sciencemag.org/content/369/6509/1314.full.

“Air Pollution in a Post-COVID-19 World.” ESA. Accessed November 14, 2020. https://www.esa.int/Applications/Observing_the_Earth/Copernicus/ Sentinel-5P/Air_pollution_in_a_post-COVID-19_world.

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Barcelo, D., and Y. Pico. “Case Studies of Macro- and Microplastics Pollution in Coastal Waters and Rivers: Is There a Solution With New Removal Technologies and Policy Actions?” Case Studies in Chemical and Environmental Engineering. Elsevier, June 24, 2020. https://www. sciencedirect.com/science/article/pii/S2666016420300177.

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“Impacts of Ocean Acidification on Marine Seafood.” Trends in Ecology & Evolution. Elsevier Current Trends, November 2, 2012. https://www. sciencedirect.com/science/article/pii/S0169534712002625.

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“The Effects of COVID-19 Induced Lockdown Measures on Maritime Settings of a Coastal Region.” Science of The Total Environment. Elsevier, June 11, 2020. https://www.sciencedirect.com/science/article/pii/ S0048969720336445.

Gonçalves, Gil, Umberto Andriolo, Luís Pinto, and Filipa Bessa. “Mapping Marine Litter Using UAS on a Beach-Dune System: a Multidisciplinary Approach.” Science of The Total Environment. Elsevier, November 25, 2019. https://www.sciencedirect.com/science/article/pii/ S0048969719357377.

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A CRISIS WITHIN A CRISIS THE OPIOD EPIDEMIC AND THE COVID-19 PANDEMIC By

Sanjana Rao Anna Argulian

The COVID-19 pandemic has devastated the United States, killing approximately 225,000 people over the last 10 months. However, over the two decades before COVID-19 reached American shores, a more insidious epidemic has been ravaging the country. In 2018, it was estimated that 128 people died of an opioid overdose every day, leading to an overall total of 450,000 opioid related overdoses from 1999 to 2018. Among those who survived, chronic opioid abuse has been shown to inflict critical damage to their pulmonary and respiratory health, placing them at high risk of developing severe symptoms should they contract COVID-19. Moreover, many such individuals are already at risk from a socioeconomic standpoint, as a large majority are either homeless or incarcerated. The opioid crisis in the USA has not disappeared under the onslaught of COVID-19. On the contrary, affected individuals are now more vulnerable than ever.

Opioids refer to a class of drugs that bind to opioid receptors, blocking pain signals from the brain and stimulating the release of dopamine, resulting in feelings of euphoria. Users find themselves craving the drug, as it strongly reinforces the wish to repeat the experience. Commonly abused opioids include Hydrocodone (VicodinÂŽ), Oxycodone, Fentanyl, Morphine, Codeine, and Heroin, some of which are prescribed as pain medication. Substance Use Disor-

der (SUD), or more specifically, Opioid Use Disorder (OUD), is highly prevalent in the United States, with an estimated 2 million suffering from it and more than 10 million people misusing or abusing opioids.

OUD has been associated with a long list of adverse effects, including chronic kidney, liver, and lung diseases, as well as cardiovascular diseases, type 2 diabetes, obesity, and cancer. Chronic opioid misuse is associated with disordered breathing, which can result in hypoxia, or low oxygen levels in the brain.

Similarly, studies show that up to 10% of patients who take opioids over long periods develop hypoxemia, which is an oxyhemoglobin saturation of lower than 90%. Low oxygen levels can lead to permanent brain damage and can severely damage the workings of several organs, including the lungs and heart. A recent study among Medicare patients suffering from arthritis that compared the effects of opioid prescriptions with NSAIDs and COX-2 inhibitors found that opioid therapy was correlated with a 77% increased risk of cardiovascular events. COVID-19 has been demonstrated to have (according to data from the Chinese Center for Disease Control and Prevention) a fatality rate of triple the normal fatality rate in patients with chronic respiratory disease. Further data from the CDC indicates that patients with comorbidities are at a higher risk of hospitalization with COVID-19, as well as fatal complications. Moreover,

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various opioids, especially fentanyl and morphine, have been shown to have immunosuppressive properties—as they behave like cytokines, modulating immune responses by binding to the Ο-opioid receptor on immune cells. Thus, a great percentage of the population is potentially at a higher risk of developing more severe symptoms of COVID-19. It is important to note that the COVID-19/opioid epidemic overlap cuts both ways. As opioid use often results in slow breathing and lower oxygen levels, compromised lung function due to COVID-19 could potentially increase the risk of a fatal overdose even among those who use opioids in a purely therapeutic manner.

These populations are not only vulnerable from a scientific standpoint. Several indirect factors, such as housing instability and stress can increase their risk of contracting both OUD and COVID-19, and as many as 35 million people may face eviction this October as a result of the economic and housing crises that accompanied the rise of COVID-19. Disturbance of the financial stability of families can often serve as a trigger for a downward spiral that both increases the risk of developing a substance use disorder as well as relapse. A large percentage of those suffering from OUD are already either homeless or incarcerated,

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both of which increase their likelihood of catching COVID-19 as they lack access to personal protective equipment, sanitation, and social distanced shelters.

Demographics play a role as well in determining the likelihood of COVID-19 complications. A study published in September 2020 demonstrated that African American individuals with substance use disorders, specifically OUD, have significantly adverse outcomes as compared with Caucasian (both healthy and with OUD) individuals, in terms of fatality and hospitalization. Moreover, 60% of those with OUD declared incomes equal to or below 200% of the federal poverty level in 2017, leading to another socioeconomic concern that plagues this population: access to insurance. An estimated 18% of the 2 million middle-aged adults with OUD lack insurance. This provides a large roadblock in the efforts to contain both crises as multiple studies have shown that individuals without health coverage are unlikely to seek treatments recommended to them. This suggests that those who are uninsured and suffering from OUD and COVID are unlikely to get the treatment that they most likely require.

Preventing relapse and facilitating healthy recovery were essential components of the fight against

CURRENT EVENTS

the opioid crisis before COVID-19. However, as mentioned previously, the stress and instability sparked by the pandemic has increased the likelihood of relapses. Unfortunately, COVID-19 has severely impacted the efficacy and logistics of rehabilitation programs in various ways. Firstly, rehabilitation programs rely on objective methods of assessment such as breathalyzer and urine tests to measure a patient’s progress and to serve as a deterrent against relapse. As these tests involve contact with bodily fluids and in-person collection, they increase the likelihood of spreading COVID-19 resulting in their discontinuation by multiple rehabilitation centers for the time being. Other challenges that rehabilitation centers face include the obstacles posed by social distancing measures which hinder efforts to foster a stress-free communal environment. Virtual programming has its own complications, and in-person and socially distanced events lack the supportive atmosphere of pre-COVID rehabilitation procedures, which often involved hugs and physical support.

Visitors and even their family members have been limited or barred entirely from numerous facilities, increasing the isolation of patients and impairing their recoveries. In the event of an overdose, social distancing decreases the likelihood of the individual being found and treated, increasing the probability that the overdose results in a fatality. Naloxone, a drug that reverses the effects of an opioid overdose, is also less likely to be administered as it is commonly administered via the nose, which would put bystanders at risk of contracting the virus. In addition, due to FDA regulations, most treatments for OUD must be picked up in person, increasing individuals’ risk of catching COVID-19.

A large percentage of our population is in a highly vulnerable state, at the crossroads of multiple crises.

The solution to this problem requires a multi-pronged approach, from improving sanitation and infrastructure for the homeless to ensuring at-risk individuals receive the medications and treatment they need.

Policy must be implemented to save the millions of people who are on the edges of or are directly in the center of the opioid epidemic and have the threat of COVID-19 looming over their heads.

Baldini, Angee et al. “A Review of Potential Adverse Effects of Long-Term Opioid Therapy: A Practitioner's Guide.” The primary care companion for CNS disorders vol. 14,3 (2012): PCC.11m01326. doi:10.4088/ PCC.11m01326 "Patients’ Frequently Asked Questions | Drug Overdose | CDC Injury Center".

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Mcamericas.Org. https://mcamericas.org/uploads/content/COIVD-19/ The%20COVID-19%20Pandemic_%20Practice%20And%20Policy%20 Considerations%20For%20Patients%20With%20Opio.pdf.

"Opioid Data Analysis And Resources | Drug Overdose | CDC Injury Center".

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"Coronavirus (COVID-19)". 2020. Samhsa.Gov. https://www.samhsa.gov/ coronavirus.

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2020. National Alliance To End Homelessness. https://endhomelessness. org/coronavirus-and-homelessness/.

"Millions Of Americans May Not Be Able To Pay Rent In October". 2020.

Cnbc.Com. https://www.cnbc.com/2020/10/02/millions-of-americansmay-not-be-able-to-pay-rent-in-october.html.

"Key Facts About Uninsured Adults With Opioid Use Disorder". 2020. KFF. https://www.kff.org/uninsured/issue-brief/key-facts-about-uninsuredadults-with-opioid-use-disorder/.

Vallejo, Ricardo et al. “Opioid therapy and immunosuppression: a review.”

American journal of therapeutics vol. 11,5 (2004): 354-65. doi:10.1097/01. mjt.0000132250.95650.85 Forman, Ethan. 2020. "Coronavirus Concerns Shift Addiction Support Online". The Salem News. https://www.salemnews.com/news/local_news/ coronavirus-concerns-shift-addiction-support-online/article_eb60a9336dc7-50eb-8c02-b1ec9500ef0c.html.

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ulse p THE PRE-MEDICAL STUDENTS’ ASSOCIATION the university of chicago FACEBOOK /uchicagopmsa WEBSITE pmsa.uchicago.edu