UChicago PULSE Issue 3.2: Winter 2017

PULSE PULSE TRUMP VOLUME 3.2, WINTER 2017

VOLUME 3.2, WINTER 2017

CARE Expected Changes in Healthcare

from the editor-in-chief

Dear reader, Another year, another issue of PULSE! This quarter, we focused on healthcare, from domestic to international to the disparities in between.

Particularly, with the political changes at the beginning of this winter quarter including the inauguration of a new president, we highlighted the expected trajectories of healthcare in our own country and the socioeconomic effects that the future might hold.

The winter issue also presents a series of critical reviews including an introduction to new biotechnology, devices that hold the potential to change healthcare and medical practice. In more detail, we explore the case of HIV treatment using the Medici drug delivery system as well as how the FDA historically approached the virus and related blood donation policies in place today. In addition, we take a look at maternal health worldwide in pregnancy, obesity and its influences, and the curious case of the literal broken heart.

Each day reveals new changes, new curiosities, new news about health, research, policy, and an overwhelming multitude of developments in a coursing river of current events. PULSE aims to calm the river to a stream, and with luck, bring some of the interesting gems to your attention. We hope you enjoy!

With regards, Irena Feng

editors Irena Hsu Madeline Kim Jihana Mendu Abhijit Ramaprasad Victor Suarez Esther Wang

writers Swathi Balaji David Gao Hannah Jacobs-El Kalina Kalyan Nikita Mehta Medha Reddy Fatima Sattar Michelle Siros Scott Wu

production Julia Chael Purujit Chatterjee (cover design) Jihana Mendu Yolanda Yu

other contributors Kaplan Test Prep The Princeton Review

pulse - winter 2017

CONTENTS WINTER NEWS 2 KAPLAN MCAT QUESTIONS 5 ESSENTIAL TIPS FOR YOUR 6

MED SCHOOL INTERVIEW

a feature from The Princeton Review BANNING BLOOD: THE FDA’S LASTING RESPONSE

TO THE HIV EPIDEMIC

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EXPECTED CHANGES IN HEALTHCARE UNDER 10

A TRUMP PRESIDENCY (cover story)

A look into changes in Medicaid eligibility, state healthcare funding,

and health savings accounts THE MEDICI DRUG DELIVERY SYSTEM 16 KAPLAN MCAT ANSWERS 19 OBESITY: A PREVENTABLE PROBLEM 20 GLOBAL HEALTHCARE SYSTEMS 22 A LIGHTNING STRIKE: ECLAMPSIA 25 SMALL GREAT THINGS: HEALTH DISPARITIES 28 MEDICAL TECHNOLOGICAL INNOVATIONS 34 HEALING A BROKEN HEART: TAKOTSUBO 38

table of contents || 1

WINTER NEWS Hydrogel wound sealant simplifies trauma treatment Hospital readmission rates decrease with ACA penalties Hormone that plays a role in fetal development may help protect the ovaries from chemo damage C. albicans yeast avoids polyQ aggregation and toxicity in unidentified mystery mechanism Using zinc chelation to regenerate injured optic nerves Review finds it unlikely that MRIs have genotoxic effects Socioecology of sexual/reproductive health care use among young urban minority males determines barriers Delayed adjuvant chemotherapy after lung cancer surgery still effective and associated with higher survival than surgery alone Ultrasensitive local anesthesia triggered by light Real-time measurements of drugs in bloodstream using electrochemical aptamer-based sensors Use of progesterone associated with improved pregnancy success in women with recurrent pregnancy loss Promotion of natural tooth repair by using GSK-3 inhibitors to boost tooth stem cells’ ability to produce dentin (to repair holes) Dual role of Nav1.7 protein identified in pain promotion AND relief Calcium levels in heart’s arteries help personalize blood pressure treatment strategies for pre-hypertension Alcohol boosts activity of Agrp neurons, which are required for alcohol-induced overeating Epilepsy drug from fish model shows promise in trial Amygdalar activity independently and robustly predicted cardiovascular disease events Prevention of dietary-fat-fueled ketogenesis attenuates BRAF V600E tumor growth Bacteria found to form potentially infective prions fMRI method/analysis developed to highlight abnormal patterns of brain activity that point to higher risk for longterm, post-concussive symptoms Caffeine may counter age-related inflammation Epigenetic changes rather than DNA changes partially responsible for metastasis in pancreatic cancer Increased painkiller tolerance prevented by co-treatment with drug that blocks peripheral binding of painkillers Industry funding influences patient advocacy organizations, raising concerns regarding conflicts of interest Electronic control of gene expression and cell behaviour in Escherichia coli through redox signalling Ultrasound pulses activate release of drugs from nanoparticles to tweak brain activity Loosened blood pressure guidelines recommending people aged 60+ get systolic BP under 150 Viruses sense chemical signals left behind by their forebears so they can decide whether to kill or just to infect their hosts Tyrosine kinase blocking collagen IV-derived peptide to treat age-related macular degeneration Soft robotic sleeve supports heart function Inflammation of microglia can convert astrocytes into A1 reactive types that kill other brain cells Wide differences in cardiovascular mortality rates/causes among 3 major Hispanic ethnic groups, current method of grouping them together masks wide variation, skews data Testing pediatric brain tumor tissue for genetic abnormalities is clinically feasible, can guide treatment.

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Population-based payment model improves quality of care for low-income patients.

An alternative payment model of healthcare improved quality of care, lowered cost, and narrowed gaps in quality of care for low-income patients. The program, called the Blue Cross Blue Shield of Massachusetts’ Alternative Quality Contract (AQC), is a population-based payment model that pays a lump sum for all aspects of a person’s care rather than following a pay-per-service healthcare system. While quality improved for all members enrolled in the AQC, enrollees in areas with lower socioeconomic status experienced a greater improvement in quality of care than similar enrollees in areas with higher socioeconomic status, while still spending approximately equal amounts. Differences in improvements were observed in adult preventive care, pediatric care, and chronic disease management. Narrowing of health disparities suggests such a payment model can encourage providers to focus on providing improved quality of care for more disadvantaged populations.

Implanted microdevice locally delivers low doses of drug when activated by external magnet.

Biocompatible hydrogels were used to design a device roughly 1 centimeter wide such that it could contain various moving parts to precisely control intermittent movement. The microdevice used the unique mechanical properties of hydrogels to deliver drugs and be controlled after implantation without a sustained power supply.

The hydrogel components cover a wide range of properties and provide functions such as valves, rotors, pumps, and drug delivery mechanisms depending on structure and design. Tests in a mouse model of osteosarcoma using a cancer drug revealed that use of the device over 10 days inhibited tumor growth showed higher treatment efficacy and lower toxicity than higher systemic doses of the drug. The device was implanted under the skin and could be wirelessly controlled through magnetic actuation to trigger release of drug payloads from reservoirs.

Updated “Common Rule” modifies federal regulation of human subjects and biospecimens.

For the first time since 2005, the federal government revised its “Common Rule,” regulations that govern federally funded research involving humans. Originally in a draft proposal for revisions to the Common Rule, research involving biospecimens (such as blood, tissue, or other samples) would require consent from the donor regardless of the presence of identifying information (as opposed to only required for biospecimens that have identifiable private information); however, this revision was ultimately left out in the updated Common Rule after facing significant opposition. Other updates to the Common Rule modified the consent requirement for specimens from biobanks rather than directly from participants, added to informed consent disclosure requirements, and redefined “identifiable biospecimen” and determined how frequently such a definition needs to be updated. The updated Common Rule changes up the human subjects research oversight system and will affect the privacy debate surrounding human research regulations.

New gene therapy process uses novel mechanism to deliver mRNA into cells for protein synthesis.

The use of small neutral molecules to transport mRNA into the cells is an improvement from previous methods using positively charged transport molecules since the small neutral molecules can easily biodegrade and release the mRNA to lead to protein synthesis. The new therapy uses charge-altering releasable transporters (CARTs) that can change from the positively charged molecules to small neutral molecules, transporting the negatively charged mRNA across the cell membrane, transforming to release the

mRNA afterwards. This transformation occurs via intramolecular rearrangements that lead to changes in physical properties. This gene therapy mechanism holds particular potential in vaccination, using mRNA’s temporary effects to initiate immune responses then biodegrade to eliminate foreign materials. This delivery of mRNA to other tissues can also broadly affect protein replacement therapy and genome editing, advancing multiple areas of research as well as clinical practice.

Genome-wide screen identifies genes essential for HIV infection but not for cellular survival.

Host proteins make important nonviral targets for therapies since they are generally essential for HIV entry, replication, and transmission. Using a genome-wide CRISPR-based screen, five host factors were identified to be required for HIV infection but, when removed, nonessential for cellular proliferation and viability. Three of these host factors had not been identified in earlier studies using different screening methods. These include proteins for HIV entry, binding, and cell-to-cell transmission. These HIV host dependency factors are important because they are required for productive infection but not for cellular viability, indicating that removing them does not affect cell survival but still halts HIV infection in its tracks. As a result, these factors are ideal targets for therapeutic interventions. Additionally, the focus on host dependency factors for infection can be extrapolated to other viral infections as well.

Scalp cooling can reduce chemotherapy-induced hair loss in some breast cancer patients.

For women undergoing chemotherapy for early-stage breast cancer, the use of a scalp cooling system via external caps (silicone, which gets cooled, and neoprene for insulation) led a lower risk of hair loss at 4 weeks after treatment. Three quality-of-life measurements (out of five) also showed benefit for the women who received scalp cooling, including feelings of physical attractiveness which subsequently influenced self-esteem and sense of well-being. The majority of the study’s patients retained more than half of their hair after completing their chemotherapy regimen, indicating that scalp cooling prior, during, and after each chemotherapy cycle can help breast cancer patients retain hair. It’s theorized that cooling works by reducing hair follicle cell division, making cells less susceptible to the damaging effects of chemotherapy.

Yemen launches mass polio vaccination program in conjunction with the WHO and UNICEF. Due to concerns about the potential reappearance of polio in Yemen, a major polio vaccination campaign has been launched in the face of the threat of polio virus importation. The campaign aims to immunize 5 million children under the age of 5, with specific focus on high-risk families such as uprooted families and refugees due to the civil war and looming famine. Nearby countries Syria and Iraq saw polio outbreaks in the past few years, indicating that the shaky health system and threat of famine could easily lead to the reappearance of polio in Yemen as well. Concerns about immunization remain due to the severe acute malnourishment and diarrhea that could afflict such high-risk children, since the polio vaccine would be rapidly flushed out rather than taking effect.

Such preventive measures will hopefully stand against outbreaks in the face of disrupted health systems and other risk factors.

WHO releases list of world’s highest priority needs for new antibiotics.

The WHO released a list of the highest priorities for new antibiotics, with the intent to spur the pharmaceutical industry into action.

Due to growing antibiotic resistance, treatment options grow slim and the WHO declared that it did not believe market force would be enough for timely development of new drugs. Three major categories of bacterial threats were defined: critical, high, and medium, with 12 bacterial threats separated into those categories. Threats were categorized based on level of drug resistance, mortality rates, frequency of infection outside of hospitals, and burdens placed on health care systems. Critical pathogens cause severe infection and high mortality in hospital patients, costing lives and health care resources. High-priority pathogens cause large number of infections in otherwise healthy people; medium-priority pathogens show a trend of increasing resistance to available drugs.

Systemic immunity required for cancer immunotherapy Different variants of ApoE protein confer different Alzheimer’s risks by differentially producing amounts of A-beta (toxic to nerve cells) TET2 mutations in blood cells promote heart disease by stimulating thickening of fatty plaques in arteries Tau protein tangles in entorhinal cortex affects spatial memory in older mice, leads to altered neuronal activity vCJD (mad cow disease, caused by infection with BSE) identified in patient with unexpected genetic makeup Highly drug-resistant tuberculosis spreads in South Africa Immunotherapy/checkpoint inhibitors less effective against tumors with abnormal # of chromosomes Two consecutive nights with less than six hours of sleep are associated with decreases in performance which last for a period of six days Hysterectomy-corrected cervical cancer mortality rates reveal a larger racial disparity in the United States Serum microRNAs may serve as biomarkers for MS Cellular senescence promotes adverse effects of chemotherapy and cancer relapse; removing senescent cells alleviates symptoms Complementary gasotransmitters CO, H2S in sleep apnea Giant cell arteritis (autoimmune disease) results from deficiency of PD-1 immune checkpoint Targeting Parkinson’s-linked protein could neutralize 2 of the disease’s causes Updated the guidelines for diagnosing cystic fibrosis 14 novel genes that may underlie the risk of developing undiagnosed developmental disorders are reported Gene-edited CAR T cells successfully treat 2 cases of B-cell acute lymphoblastic leukaemia as last resort Rat-grown mouse pancreases help reverse diabetes in mice Antisense oligonucleotides (RNA) targeting tau gene reduces tau tangles, reduces other pathological symptoms New brain mapping technique reveals circuitry of Parkinson’s disease tremors Interspecies chimerism attempted with mammalian pluripotent stem cells Suppressing the activity of overlapping memory trace interrupts linkage without damaging original memories Distinct sets of genetic defects in a neuronal protein lead either to infantile epilepsy or to autism spectrum disorders Mysterious cluster of amnesia cases, possibly tied to opioids Loss of small mitochondrial protein in mice results in premature hearing loss involving the inner ear Case-control study associates acute toxic encephalopathy with lychee consumption in outbreak in Muzaffarpur, India Retrospective study finds association between specific autoimmune diseases and subsequent dementia Hospital admissions for cardiovascular diseases decline on days with major snowfalls compared to days with no snowfall, but they jump by 23% two days later Air pollution may double dementia risk in older women Specific differences in the brains of those who attempt suicide or not (specifically those with bipolar disorder) Vitamin B12 deficiency associated with risk of preterm birth New gene-delivery therapy restores partial hearing, balance in deaf mice New HIV infections in gay men drop by a third in England Metabolite made by many tumours increases their vulnerability to a class of drug Substantial number of Medicare beneficiaries die soon after discharge from emergency departments Gradual environmental change is an ally to viral pathogens Atrial fibrillation hospitalizations rise as mortality rates decline

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(NEWS, CONTINUED) Novel genetic defect prevents brain tumor cells from repairing damaged DNA Melanoma cell and a white blood cell can fuse to form a hybrid with the ability to metastasize Breast cancer treatment more likely to cause job loss in women with low income level, partially influenced by race Male hormone blockers increase survival rate in recurring prostate cancer when coupled with radiation Neural circuit identified in pain-stress system responsible for increase and decrease in pain caused by stimuli FDA permits marketing of first newborn screening system for detection of four, rare metabolic disorders Older Medicare patients admitted to hospital in the US treated by international graduates had lower mortality New blood test that detects pancreatic cancer in early stages Ingestible device powered by biocompatible galvanic cell battery that draws energy from stomach acid Injection could lower cholesterol by changing DNA Antimicrobial peptides found in blood of Komodo dragons Cheap biochip for cell manipulation and diagnosis developed microfluidics, electronics, and inkjet technology California bill proposed to repeal HIV-specific penalties such that transmitting any infectious/communicable disease would be misdemeanor (not felony) Red blood cells exposed to low oxygen levels acclimatize faster to repeat of low-oxygen conditions Intravas injection of hydrogel provided long-term, reliable contraception in rhesus monkeys as vasectomy alternative Phase I/II clinical trials find ketogenic diet potentially safe and effective for treatment of epilepsy Smoking correlated to increased coffee consumption Physician preference main determining factor in prescription of insomnia medication Key malaria metabolite in blood attracts more mosquitos Subpopulation of beta cells resist attack in type 1 diabetes Genome-wide association study of autism spectrum disorders suggests that related genetic variants may be positively selected during human evolution due to link with intellectual achievement Multimodal laser-based angioscopy developed for structural, chemical, and biological imaging of atherosclerosis Two new drug therapies for TB could simplify and generalize treatment Taking less drug with low-fat breakfast as effective as 4x that amount of drug on an empty stomach — save cost, efficiency Zika virus can persist in bodily fluids for extended time CDC reports 18% drop in new HIV infections over six years Unnecessary shocks from implanted defibrillators cause cascade of healthcare use regardless of reason US patent office rules that Broad Institute’s CRISPR patents are distinct from University of California’s patents, affecting genome editing and biotech industry Sociodemographic disparities in chronic pain show that poorer, less educated people are more likely to experience severe ongoing pain Commonly used TB test predicts whether infected children will develop disease, need early intervention Drug-specific “cardiac safety index” developed using heart cells from human induced pluripotent SCs for early screening for drug toxicity Men similarly susceptible to paternal depression similar to postpartum depression women who’ve just given birth Patients more likely to suffer post-surgery complications when treated by surgeons associated with more complaints related to disrespect and dismissiveness

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Vitamin D supplements prevent respiratory tract infections Two genetic loci associated with acute kidney injury New psoriasis drug approved by FDA Fasting-mimicking diet reduced markers/risk factors for aging and age-related diseases Physicians’ opioid prescribing patterns linked to patient’s risk for long-term drug use Two genes identified as targets that can convert adult pancreatic islet alpha cells into insulin-producing beta cells MRI, algorithm developed able to predict autism in toddlers Caloric restriction without malnutrition extended lifespan and health of rhesus monkeys Tanzania’s government stops 40 privately-run health centers from providing AIDS-related services Sequenced genome of giant single-celled organism with remarkable regenerative abilities Intracortical brain-computer interface much faster with typing for patients with paralysis Exercise appears as lifestyle factor most important to reducing risk of death from breast cancer relapse Diminished neural responses to anticipated rewards may increase vulnerability to future problematic drug use, shows promise for future methods to predict drug abuse Cesium reversibly suppresses cell proliferation by inhibiting cellular metabolism Proliferation of progenitors of sensory hair cells can be used for regeneration of hair cells and treatment for hearing loss Human skin commensal bacteria produce antimicrobials that reduce Staph aureus and are deficient in atopic dermatitis Retrospective study of patient data disproves reverse association of non-melanoma skin cancer and dementia Human trial for malaria vaccine achieves 100% protection against infection for at least 10 weeks FDA approves marketing of test to identify organisms that cause bloodstream infections and provide antibiotic sensitivity results Distinct populations of non-cancerous cells interact with pancreatic tumors in different ways, diversity explaining treatment variability Wave of polio-like paralysis starting in early 2014 potentially attributed to Enterovirus D68 as demonstrated by mouse model CDC reports 2.5 time increase in fatal drug overdoses from 1999 to 2015 in the United States Antiviral treatment combining two cancer drugs targets host cells rather than viral enzymes, successfully inhibiting both dengue and Ebola virus infections despite major differences FDA approves new adjuvant drug forcarcinoid syndrome diarrhea that cannot be controlled by somatostatin analog therapy alone High-fat, low-carb ketogenic diet alleviates gout’s joint swelling, tissue damage, and systemic inflammation in rat model Intermittent explosive disorder associated with significantly increased risk of substance abuse American Cancer Institute finds overall decrease in colorectal cancer incidence but rise in cases among young adults Tanning devices significantly contributes to illness and premature mortality from melanoma and other skin cancers Reported surge in human cases of bird flu H7N9 New method uses inductive heating of magnetic nanoparticles to improve tissue cryopreservation and rewarming Ketamine (“special K”) provides rapid robust relief to severe depression, questions of dosage and duration remain Innovative use of tilapia fish skin in Brazil as bandages for burns due to high collagen content, moisture, tension, and availability FDA approves first treatment for overproduction of urine during the night, Noctiva, as nasal spray

Kaplan MCAT QUESTIONS QUESTION 1 While on the phone, a friend says: “A good friend would let me borrow the bike.” This friend is using which impression management strategy?

A. Managing appearances B. Alter-casting C. Ingratiation D. Self-disclosure

QUESTION 2 When an electron collides with a positron (a particle with identical mass and a positive charge), the two particles are converted completely into energy; this is called an annihilation reaction. Positron Emission Tomography (PET) is an imaging technique that introduces positrons into a patient’s body and detects the location of annihilation reactions. Which of the following is true immediately before the annihilation reaction?

I. There is no electric field at the point halfway between the positron and the electron.

II. The system is an electric dipole.

III. The particles move toward each other at a constant acceleration.

A. I only B. II only C. II and III only D. I, II, and III

QUESTION 3 What role does peptidyl transferase play in protein synthesis?

A. It transports the initiator aminoacyl-tRNA complex.

B. It helps the ribosome to advance three nucleotides along the mRNA in the 5’ to 3’ direction.

C. It holds the proteins in its tertiary structure.

D. It catalyzes the formation of a peptide bond.

See page 19 for answers!

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THE PRINCETON REVIEW’S 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-onone 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.

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1. Be Prepared

2. Take Your Time

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

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. This includes 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.

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 — essential in a good doctor.

Here are some sample medical school interview questions to help you prepare!

For more, go to princetonreview.com/med-school-advice • Why did you choose your undergraduate major?

• What are you greatest strengths and weaknesses?

• What qualities do you look for in a physician? Can you provide an example of a physician who embodies any of these ideals? How do they do this?

• What do you believe to be some of the most pressing health issues today?

Why? • What books/film/media come to mind as being important to your sciences/non-sciences education?

• What kinds of medical schools are you applying to and why?

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

3. Ask Great Questions

4. First Impressions Matter

5. After the Interview

The best interview is a dialogue with considerable give and take.

Approach the interview as a conversation 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.

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. Carry your documents in a portfolio. Make eye contact and use a firm handshake. Smile and be positive. In a group setting, 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.

Don’t forget to send a thankyou 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.

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BANNING BLOOD: THE FDA’S LASTING RESPONSE TO THE HIV EPIDEMIC Author: Michelle Siros Editor: Madeline Kim

In June 2016,

49 people were killed and another 53 were injured in a vicious attack on a nightclub popular within the gay community in Orlando, Florida. The mass carnage resulted in an immense and urgent need for blood donations. Gay and bisexual men lined up to give blood, but they were prohibited from donating if they had engaged in sexual activity with another man in the past year. Many people questioned why these willing donors were turned away, but the Food and Drug Administration (FDA) had only one response: HIV. In 1985, when the HIV epidemic was at its peak in the U.S., the FDA put recommendations for blood donation practices in place in order to limit risks of transmitting HIV. Since gay men had the highest rates of HIV infections out of any other demographic at that time, before HIV was fully understood, they were banned from donating any blood products. The term “MSM,” meaning men who have sex with men, was coined in order to indefinitely prohibit all sexually active gay men from donating blood. The regulation also included women who had

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been sexually engaged with a MSM, as well as transgender people who were categorized as MSM. The FDA has amended the rule numerous times, to the point where gay men are now allowed to donate blood one year from their last man-man sexual encounter. This policy, though heavily revised, still reportedly stands for its original purpose, to curb HIV transmittance in blood transfusions. However, with the development of intense screening procedures for testing donated blood, and the fact that FDA already mandates thorough screening and testing of blood samples from all donors, this distinct restriction seems not only unnecessary, but also indicative of continued prejudice against gay men.

With modern hiv

testing available, it is easier than ever to screen for HIV. In fact, donated blood goes through testing for over a dozen different antigens, infections, and viruses. One major test in particular, known as the Nucleic Acid Test (NAT), is run on virtually all donated blood in the U.S. It was developed in the early 2000s and has been improved upon multiple times since, such that it is now the main method used to screen blood donations for HIV.

The red cross

recently reported a shortage in blood donations, so much so that elective surgeries were cancelled temporarily in major cities, until further blood drive efforts could raise the stocks of the blood banks. The Red Cross also reports that increases in donations annually are at about 3%, but with the increase in number and complexity of major surgeries like transplants, the demand for blood grows annually by 6%, outpacing donation efforts two-fold.

With all of the available tests, and the continued enforcement of blood donation screenings, why is the ban on MSM donations still in place at all? Given the immense need for blood donations and the growing demand, it would seem logical for the FDA and other regulatory institutions to broaden categories of people eligible for blood donation. However, the FDA, among other top medical sources, still enforce a one-year deferral from the last homosexual encounter for any blood donations from MSM, or from others engaged sexually with MSM. Furthermore, the FDA’s sole argument in defense of the law is that they want to curb the transfer of HIV through blood transfusion.

However, according to a report from the National Institutes of

Health, since NAT screening was introduced, the risk of HIV infection through blood transfusion has been reduced to about 1 in 2 million blood units. In recent times, the testing blood donations go through is so rigorous that blood banks can tell with near certainty if blood is HIV infected, even it was only infected in the past ten days. Therefore, it seems likely that a correlation between blood testing improvements and the decrease in HIV positive blood transfusions can be drawn.

The FDA itself reports that the testing efficacy has become so high recently such that the ban is more of a precaution. Plus, the FDA records that in the last two decades HIV has not been transmitted through blood because of the screenings.

“

The solution

to this stigmatization of gay and bisexual men seems simple: lift the ban and continue to screen the donated blood so that only blood from healthy donors is used in transfusions. However, this seems less likely than ever in the current landscape of American politics. The commissioner of the FDA is appointed by the President of the United States and confirmed by the senate, both of which were recently turned majorly socially conservative in the 2016 election. In the current scheme of appointments and government changes, the outlook for a socially progressive head of the FDA is grim.

So far, all advocacy for MSM blood drives have been stopped at the blood banks. Blood banks run by organizations like the

This distinct restriction seems not only unnecessary, but also indicative of continued prejudice against gay men.”

Therefore,

it would seem that the regulation stems from stigma against homosexual males. This prejudice dates back to a time when gay men were stereotyped as more polygamous than heterosexual men.

This is relevant because since the initial ban, the perception of gay monogamy has increased in tandem with acceptance of gays in society. In addition, with the legalization of gay marriage recently, it is easier for gay men to engage in long-term monogamous relationships. It seems unreasonable that after having been tested along with their partner, men who have one healthy, uninfected sexual partner should still be banned from donating.

American Red Cross and American Blood Banks are obligated to follow the FDA’s ban. When organizers of MSM blood drives reached out to the American Red Cross, American Blood Banks, and American Blood Centers, they were told that the organizations agreed the rule was “outdated” and “needed to change” but the FDA policy was the law. When meeting with FDA representatives, protesters of the bans reported they were told that “too much testing needed to happen to ensure MSM blood didn’t pose an additional risk,” essentially repeating the same concerns they have had since the beginning of their ban.

Rates of HIV are still the high-

est among gay men, and while the risks of transfer through blood would seem to be higher in response to this increased HIV prevalence in the community of gay men, this does not take into account the accuracy of the screens and tests that all donated blood undergoes (and the fact that sexuality does not have an effect on susceptibility to HIV).

Since the tests for HIV have become so well developed and effective, the policies against gay men donating blood are obsolete.

Especially now, with the need for donated blood extremely high, the current rule only serves to perpetuate a long-standing prejudice against homosexuality.

Candidate, Li Zhou MPA, and R.T. Winston Berkman JD/MPA Candidate. “Ban the Ban: A Scientific and Cultural Analysis of the FDA’s Ban on Blood Donations from Men Who Have Sex with Men.” Columbia Medical Review. Center for Research and Digital Scholarship, Columbia University, 06 Jan. 2015. Web. 25 Feb. 2017.

Center for Biologics Evaluation and Research.

“Questions about Blood — Revised Recommendations for Reducing the Risk of Human Immunodeficiency Virus Transmission by Blood and Blood Products — Questions and Answers.” US Food and Drug Administration Home Page. Center for Biologics Evaluation and Research, n.d. Web. 25 Feb. 2017.

“Donation FAQs.” American Red Cross. N.p., n.d.

Web. 25 Feb. 2017.

Fox, Maggie. “As Promised, FDA To Lift Ban on Gay Blood Donation.” NBCNews.com.

NBCUniversal News Group, 12 May 2015.

Web. 25 Feb. 2017.

Howard, Jacqueline. “FDA to Re-evaluate Controversial Gay Blood Ban.” CNN. Cable News Network, 28 July 2016. Web. 25 Feb. 2017.

McKenzie, Sheena. “Gay Men Outraged over Ban on Blood Donation.” CNN. Cable News Network, 14 June 2016. Web. 25 Feb. 2017.

National Institutes of Health. U.S. Department of Health and Human Services, n.d. Web. 25 Feb. 2017.

The Times Editorial Board. “End the Outdated, Unscientific Restrictions on Gay Blood Donors.” Los Angeles Times. Los Angeles Times, 1 Dec. 2016. Web. 25 Feb. 2017.

Walkley, A.J. “Fighting the FDA’s Antiquated Policy on Blood Donation.” The Huffington Post. TheHuffingtonPost.com, 17 July 2013.

Web. 25 Feb. 2017.

Zabarenko, Deborah. “The Nation Has a Major Blood Shortage.” ABC News. ABC News Network, 19 Sept. 2016. Web. 25 Feb. 2017.

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EXPECTED CHANGES IN HEALTHCARE UNDER A TRUMP PRESIDENCY A look into changes in Medicaid eligibility, state healthcare funding, and health savings accounts

Author: David Gao Editor: Abhijit Ramaprasad

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Image taken by Gage Skidmore October 29, 2016 at a campaign rally in Phoenix, AZ Distrubted under Creative Commons

Healthcare will inevitably change under President Donald Trump. While his administration has not yet enacted major reform (as of this writing, February 25, 2017), theories abound as to how healthcare will change. Some significant changes are elucidated below:

REPEAL OF MEDICAID EXPANSIONS background The proposed repeals target the 2014 expansions put into action by the Affordable Care Act (ACA). “Expanding� meant eligibility for Medicaid, based on income levels, would increase. For example, a household of four with parents making up to 138% of the federal poverty line (FPL), currently $33,000 per year, would be eligible to sign up for Medicaid. Prior to expansions, eligibility would be at or below 100% of the FPL ($22,050 in 2009) in 17 states and at or below 50% of the FPL ($11,025 in 2009) in another 17 states. In 2012, the Supreme Court ruled that states, not the federal government, could decide whether or not to expand their Medicaid program; if they did, the federal government would cover 100% of the cost of newly eligible adults for the first three years, whereas states not expanding would not receive such funding for new Medicaid enrollees. The 32 states (plus the District of Columbia) that expanded Medicaid today have an average uninsured population of 8.6%, while the 19 states that declined to expand Medicaid have an average uninsured population of 11.9%, a number sure to increase should Trump proceed with his campaign plans to repeal expansions.

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possible effects •

Demand for healthcare is empirically modeled as a downward-sloping curve in the price-quantity space; that is, as price of healthcare increases, quantity demanded decreases.

Since the repeal of Medicaid expansions will make stricter eligibility criteria and make it more expensive for uninsured individuals to use healthcare, a lower quantity of healthcare will be demanded.

•

Repealing the Medicaid expansions will also cause the number of insured individuals in states that previously expanded Medicaid to decrease, increasing the overall number of uninsured within that state. When this uninsured population seeks care, they will be imposing a heavy cost on themselves due to the lack of insurance. On the other hand, since such individuals understand the high cost of being uninsured, losing their insurance would cause them to further decrease the rate in which they seek healthcare services, further decreasing their health and welfare.

•

By decreasing the incidence in which they seek preventive healthcare services, this uninsured population will inevitably cost hospitals a tremendous amount during acute, catastrophic cases of medical care. Hospitals are required by law to treat patients entering their facilities who are facing severe, life-threatening conditions, regardless of the patient’s ability to pay. Hospitals would therefore be directly affected; hospitals currently spend 30 billion dollars per year on uncompensated care, which would only increase as the supply of uninsured individuals increases. Therefore, as hospitals raise their service costs to offset treatment costs, a heavy negative externality (the unintended side-effects of a policy) will be imposed on the insured population when they also seek treatment.

•

The increase in hospital costs would impose a heavy externality on the insured population in other ways as well. Due to rising hospital costs, whenever a hospital treats an insured individual, that individual’s insurance company would be paying more than they would have under the current ACA. Insurance premiums would increase to offset the increased costs. The net result of repealing the Medicaid expansions therefore would cause insurance premium costs to outweigh savings gained by insurance coverage, or in other words, would cause insurance to become even more actuarially unfair and partial.

•

Of course, other externalities would occur as a result of the repeal of Medicaid expansions, such as an increase in the incidence of communicable diseases, as well as job lock (when individuals do not freely leave their jobs for better compensated ones) because of workers’ refusal to switch jobs for fear of losing insurance.

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IMPLEMENTATION OF THE CASSIDY-COLLINS BILL background Two senators, Bill Cassidy (Louisiana, R) and Susan Collins (Maine, R) have proposed a bill to repeal the current entitlement, means-tested, and federally funded Medicaid program and replace it with a block grant system. Federal funding for states that chose to expand Medicaid would be decreased to 95% of the funding they would have received, while states that chose not to expand would not receive any funding. To states that chose to expand Medicaid under the current ACA system, the block grants will serve as a federal spending cut. The Cassidy-Collins Plan, through the use of block grants, offers states 95 percent of the federal subsidies which they would have received. (This five percent decrease would translate to approximately 46 billion dollars from 2014 through 2022, well over half of the $73 billion states are expected to spend.)

Proponents of the grant say this decreased federal funding trades off with more personalized, increased state insurance.

possible effects •

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States that chose to expand Medicaid or not would suffer unsustainable funding. The block grant as it is proposed would be indexed to inflation, which rises more slowly than healthcare costs. States that chose not to expand Medicaid would receive stagnant grants, which would not account for increases in population and medical costs. These states would raise taxes and reduce funding to other departments, such as education and transportation.

•

This “flexibility” would likely manifest in a health policy question of “how do we pay” due to the drastic cuts in federal spending. A likely answer is via a reduction in state spending on health. In exchange for the decreased federal funding, states may choose to reduce Medicaid benefits, make stricter enrollment requirements, and increase premiums; an estimated 14 to 21 million are estimated to lose their coverage by 2026 (on top of the individuals who would lose their coverage from the Medicaid expansion repeal). State legislators would, rather than enact health policy based on increasing the overall health access, enact policy based on fiscal and budgetary factors. Moreover, with the decreased federal funding, states would need to choose which diseases and disorders would be more heavily reimbursed. Although the US has empirically emphasized equity in health amongst those who can afford insurance, equity would be reduced not only between individuals who can and cannot afford insurance, but also amongst individuals able to afford insurance and who suffer from different medical conditions.

IMPLEMENTATION OF HEALTH-SAVINGS ACCOUNTS (HSAS) background Health savings accounts are medical savings accounts available to individuals with high deductibles, which take the form of tax savings on income taxes. President Trump has proposed expanding the use of HSAs as tax breaks for health insurance consumers.

possible effect Wealthier individuals will inevitably benefit more from the implementation of HSAs, as they will be better shielded from federal taxes. For individuals who pay little to no income tax, such an account does not save them money, and furthermore, imposes a high cost in a non-refundable deductible.

REFERENCES FPL data taken from: http://familiesusa.org/product/federal-poverty-guidelines FPL data taken from: http://obamacarefacts.com/obamacares-medicaid-expansion/ Bill-Cassidy plan details from: https://www.nytimes.com/interactive/2017/01/24/us/politics/obamacare-alternative-plan.html

http://www.cassidy.senate.gov/imo/media/doc/One%20Pager%20(1.20.17)%20(002).pdf Hospitals spend $30 billion on uncompensated care: http://www.nber.org/bah/2008no1/w13758.html State and federal spending numbers were calculated via data obtained from: http://www.cbpp.org/research/federal-government-will-pick-up-nearly-allcosts-of-health-reforms-medicaid-expansion; the estimated federal share of Medicaid expansion is $931 billion between 2014 - 2022, and the states’ share $73 billion. Therefore, 95% of $931 billion translates to a loss in funding of $46.55 billion over the course of nine years.

Medicaid expansion image — Taken from: http://kff.org/medicaid/issue-brief/what-coverage-and-financing-at-risk-under-repeal-of-aca-medicaidexpansion/ Medicaid cuts image — Taken from: http://www.cbpp.org/medicaid-cuts-would-grow-over-time-under-house-budget-committee-block-grant

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THE MEDICI DRUG DELIVERY SYSTEM Deep in the

industrial center of Hayward, California is a device originally developed to treat Type II Diabe-

According to a 2016 study by the Joint United Nations Programme on HIV/AIDS (UNAIDS), over 2.1 million individuals became infected with HIV in 2015, amounting to a total of over 36.7 million people living with the disease by the end of the year.

tes that may also revolutionize and win the war against HIV/ AIDS. HIV, or human immunodeficiency virus, is a pathogen that attacks white blood cells in the immune system and can lead to AIDS, or acquired immunodeficiency syndrome. As the HIV epidemic persists within regions such as Sub-Saharan Africa, the most striking aspect of HIV is its rapid and rampant growth.

One frightening explanation for the continued spread of the virus is incognizance; the aforementioned study reports that only 60% currently afflicted by HIV are aware of their status.

This lack of awareness is usually due to inadequate education and access to testing and treatment.

However, Intarcia Therapeutics, an innovative biopharmaceutical company with its main manufac-

Author: Scott Wu Editor: Madeline Kim

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turing facility based in Hayward, California, has created a device that aims to combat the spread and toll of HIV: the Medici Drug Delivery System.

Enter the Bill and Melinda Gates Foundation, a charitable organization started by the philanthropic couple with an enduring concern for the wellbeing of underprivileged peoples.

With the goal of preventing the spread of HIV — specifically in Sub-Saharan Africa — the Gates Foundation has invested $140 million in research and development at Intarcia Therapeutics. According to Dr. Doris Zane, Intarcia Senior Director of Preclinical Development, “the Gates Foundation will take a $50 million equity stake in the company and provide as much as $90 million more in grants, earmarked to certain research milestones toward the development of the Medici Drug Delivery System.”

In an increasingly

competitive biopharmaceutical market, specifically in California’s Bay Area, Intarcia Therapeutics’ Inc. Medici Drug Delivery System has distinguished itself as a leader in subcutaneous drug delivery. The Medici System is a matchstick-sized metal

pump placed under the skin that provides a continuous flow of medication. Within the tiny Medici device is a straightforward yet effective operation of drug delivery. On one end of the cylindrical pump, extracellular water from the human body enters the pump and diffuses through a semipermeable membrane. Once through the membrane, the fluid enters an osmotic engine, where it is allowed to expand and drive a piston at a regulated rate. Using the energy from the piston, the prescribed drug can be steadily

released at the other end of the pump. For the Gates Foundation and Intarcia, the drug of choice for HIV prevention is likely to be in the class of drugs that work by pre-exposure prophylaxis (PrEP). HIV PrEP drugs are newly developed drugs used for individuals who are at significant risk of contracting HIV from other infected people, and can reduce the risk of infection by up to 92% when taken regularly. In clinical trials across the globe, the drug is credited with substantially decreasing HIV infection rates in both heterosexual and homosexual communities, as well as among intravenous drug users affected by the disease. PrEP drugs represent one of the few approved pharmaceutical methods of HIV prevention that can rival established methods like contraception and abstinence. One of the few drawbacks of PrEP drugs are that they must be taken orally every day to be effective; however, its

pairing with the Medici System presents an advantageous solution. Using the Medici System, high concentrations of PrEP drugs can be dispensed regularly at small amounts, which would circumvent any inconveniences associated with oral intake. This form of dosage is especially beneficial for lower income communities that may lack access to safe drinking water. In an interview with the Wall Street Journal, Andrew Farnum, Director of Program Related Investments at the Gates Foundation, said that “[while] Medici would likely find a market in the U.S. and other wealthy countries...the ultimate goal is developing an HIV prophylaxis device that will save lives in the developing world.”

The implementation

of the device is remarkably simple, which Dr. Doris Zane presents as highly beneficial: “compared to other drug delivery systems which may be more invasive, the Medici System can be placed under the skin by a trained healthcare professional in an in-office procedure that only takes a few minutes.” An additional benefit to this minimally invasive procedure is that it only needs to be performed or

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“

repeated once a year. Although miniscule compared to other pumps on the market, the Medici System can deliver a year’s supply of medication.

Initially, the intended medication was exenatide, a peptide agonist used to activate a glucagon receptor effective in treating Type II Diabetes. Dr. Zane notes that “the challenge the company faced was to come up with a formulation of exenatide that would remain stable at body temperature for at least a year and that was potent enough to be effective at the micro doses delivered by the pump.” Fortunately, Intarcia’s Development group in Hayward, California succeeded in formulating a viable version of the drug, which permitted the company to file an application with the United States Food and Drug Administration in January, 2017 that would allow the Medici System to be marketed.

Intarcia’s innovation and the Gates Foundation’s generosity may have an enormous impact on

The Medici System pump paired with PrEP drugs will become readily available to affected communities around the world.”

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the future of HIV/AIDS prevention. Should the program prove successful, the Medici System pump paired with PrEP drugs will become readily available to affected communities around the world. For many Sub-Saharan African communities, the potential halt of the disease that has wreaked havoc since the 1960s offers new, affordable hope.

For the Gates Foundation, this altruistic investment represents another chance to blunt the effects of disease and increase the quality of life in impoverished areas. For the Medici System, the possibilities do not stop with HIV prevention or even Type II Diabetes treatment, but may extend far into other realms of disease.

“Gates Foundation to Invest Up to $140 Million in HIV Prevention Device.” AIDS.UA. Wall Street Journal, 30 Dec. 2016. Web. 11 Feb. 2017. <http://www.aids.ua/enews/ gates-foundation-to-invest-up-to-140million-in-hiv-prevention-device-11939. html>.

“Global HIV Statistics Fact Sheet November 2016.” UNAIDS. United Nations, Dec. 2016.

Web. 20 Feb. 2017. <http://www.unaids.org/ en/resources/fact-sheet>.

“Pipeline & Technology: The Medici Drug Delivery System.” Intarcia Therapeutics, Inc. Intarcia Therapeutics, Inc. Web. 10 Feb. 2017. <http://www.intarcia.com/pipelinetechnology/>.

Kaplan MCAT

ANSWERS & EXPLANATIONS QUESTION 1 B, Imposing a role on another person (in this case, “good friend”) is the hallmark of altercasting. This example is also the opposite of ingratiation, choice (C), because the implication behind the statement is that one is a “bad friend” if he or she does not lend the bike; ingratiation is the use of flattery or conformity to win over someone else.

QUESTION 2 B, Item II is correct because an electric dipole always exists between two identical charges of opposite magnitude. Item I is incorrect because there is always an electric field at every point in an electric dipole; though the potential may be equal to zero at certain points, the field can always be calculated. Item III is incorrect because the electrostatic force (and, consequently, the acceleration) increases as the distance between the particles decreases. Therefore, choice (B) is the correct answer.

QUESTION 3 D, Peptidyl transferase is an enzyme that catalyzes the formation of a peptide bond between the incoming amino acid in the A site and the growing polypeptide chain in the P site. Initiation and elongation factors help transport charged tRNA molecules into the ribosome and advance the ribosome down the mRNA transcript, as in choices (A) and (B). Chaperones maintain a protein’s three-dimensional shape as it is formed, as in choice (C).

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

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OBESITY A PREVENTABLE PROBLEM Author: Kalina Kalyan Editor: Victor Suarez Obesity affects over 35% of adults and 17% of children and adolescents in the United States. The presence of obesity, particularly in the United States, has increased dramatically in recent years and is three times higher than one generation ago.

Although obesity is not classified by the Center for Disease Control (CDC) as a “preventable cause of death,” obesity often leads to a number of life-threatening health issues including Type 2 Diabetes and cardiovascular disease. The health concerns that come with obesity are relatively simple to understand and are well researched. Additionally, obesity is preventable and if eradicated, many deaths could be prevented.

This can be accomplished through advancements in how members of society are educated

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and through the implementation of healthier food options. Yet, it is also critical to help those already affected by obesity and provide the support they need to make a positive change in their lives.

Following a healthy lifestyle is crucial for the prevention of obesity. The problem is the unequal access to the resources needed to follow a healthy lifestyle. Adult and child obesity trend in areas of poverty inside and outside the United States.

This is due to a number of reasons. Primary reasons include lack of proper example, lower levels of education, and limited availability of fresh foods at affordable prices. In the case where people do have access to the resources that enable a healthy lifestyle, it is critical that those who are obese take individual (personal) responsibility and utilize these resources. However, it is also important at a socie-

tal level to support individuals who may struggle with making healthy lifestyle choices through making physical activities more available, such as through the implementation of more programs that promote active lifestyles. These programs may include activities such as swim classes, “boot camp” classes, and even yoga. In addition, it is critical that access to healthier dietary choices occurs and is accessible to everyone, especially the poor. Lastly, food and nutrition courses for students, particularly those in high school, should be implemented and required. The food industry must also work to reduce fat, sugar, and salt content in foods as well as ensuring that nutritious options are available and affordable for all customers.

While the implementation of these suggestions will help reduce obesity, it is essential to help those who are already considered

IMAGE: fat cells obese.

In considering obesity, it is important to recognize its societal aspects and the stigma that surrounds it, as these play a critical role in the lack of desire to ask for help from the perspective of someone afflicted with obesity.

A person may gain weight for a number of reasons other than simply lack of education or access to healthier options. Some overeat due to stress, loss of a family member or friend, or pre-existing health conditions. It is important to possess a certain level of empathy regarding the topic of obesity because the social consequences of being obese are serious and often extremely pervasive. Those who are obese are often subject to bias and stigma. It is not uncommon for society to immediately place harsh and demeaning labels on those who are obese. The stigma that surrounds obesity poses a number of issues, particularly for those who try and seek help — obese children and adolescents are often subject to bullying which has an immense impact on a child’s development as it can lead to depression, anxiety, and social isolation. The same holds for obese adults. Obese adults also face discrimination in various forms from their employers as well as colleagues.

This stigma often prompts those who struggle with their weight to avoid seeking help, as they may be afraid of negative and potentially offensive reactions from health care professionals. This may also cause obese patients to avoid obtaining medical care because of negative experiences, which is extremely alarming from a healthcare perspective. Without the reduction of the stigma that surrounds obesity, obesity will remain an issue that continues to persist in society.

“

that does not discriminate against those who struggle with obesity, but rather encourages a healthy lifestyle in order to alleviate that struggle. It is also important for healthcare professionals to provide adequate support for those who are obese, particularly by ensuring they provide the same quality of care and level of respect to each patient regardless. The prevention of obesity is just as important as its treatment and thus, the implementation of healthy lifestyle resources — both

It is important to possess a certain level of empathy regarding the topic of obesity because the social consequences of being obese are serious and often extremely pervasive.”

It is critical that society works towards providing a supportive environment for those impacted by obesity, as it is an issue that will only be resolved through the initiative of each individual. No one can force a person to lose weight. It must be the desire of someone affected by obesity to take responsibility to seek out help and to make healthy lifestyle choices. Thus, it is important that society provides an environment

material and social — is key in reducing obesity and creating a healthier society.

“Obesity, Bias, and Stigmatization.” Obesity, Bias, and Stigmatization — The Obesity Society.

N.p., n.d. Web. 24 Feb. 2017.

National Institutes of Health. U.S. Department of Health and Human Services, n.d. Web. 24 Feb. 2017.

“Obesity and Overweight.” World Health Organization. World Health Organization, n.d. Web. 24 Feb. 2017.

“Overweight & Obesity.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 17 Nov. 2016. Web. 24 Feb. 2017.

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GLOBAL HEALTHCARE SYSTEMS: WHY DISEASE RESPONSE MEASURES ARE INEFFECTIVE Author: Nikita Mehta Editor: Abhijit Ramaprasad

The development

of medicine over the past century has resulted in vaccines, antibiotics, and drugs that can prevent and treat previously incurable illnesses. Increased accessibility to routine vaccinations has prevented tetanus, measles, and typhoid fever, while reduced mortality rates have contributed significantly to global health security [3]. Unfortunately, the emergence of effective healthcare systems has been largely restricted to specific regions in the world. The healthcare divide between developed and underdeveloped countries is staggering.

Low education rates, limited access to technology, a lack of both medical professionals and of funding for drug research and development, underfunded and overcrowded hospitals, protracted dissemination of public health information, and unaffordable medical services have plagued underdeveloped countries. As a result, less economically developed countries are unable to provide their citizens with robust healthcare

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programs. The weak international response to recent disease epidemics has also reduced the effect of 21st century improvements and discoveries inmedicine. Why are global health systems so internally fragile?

The failure of

modern medicine in treating disease in less developed countries is perhaps most clear in the case of Ebola. On August 17th, 2014, a Liberian clinic in the capital, Monrovia, was attacked and plundered by armed residents [7]. The consequences were devastating.

Patients carrying the Ebola Virus Disease (EVD), a communicable hemorrhagic fever, absconded the clinic [7, 8]. Unsterilized, disease-ridden medical instruments were stolen [7]. This was not an isolated incident. Multiple groups attacked clinics in a coordinated effort to resist foreign intervention by hindering the disease eradication process. In the months preceding the attack in Monrovia, a Doctors Without

Borders clinic in Guinea was evacuated after a similar attack [2]. With a 50% mortality rate and no evidence of airborne transmission, EVD should be relatively easy to contain with germane body substance isolation procedures and adequate personal protective equipment [4, 8]. The initial few Ebola cases could have been controlled with rehydration and symptom-specific treatments if caught early [1].Why did this happen?

Not only are

literacy rates overwhelmingly low in countries where Ebola is most prevalent, but the dissemination of public health information is both slow and ineffective [1].

Ebola awareness only started to increase months after the first documented cases, when a wellknown physician from Sierra Leone died of the disease [1].

Access to the internet, television, and radio is limited in the more rural areas, which results in a communication bias where a large part of the population is excluded from awareness

campaigns [1]. Furthermore, diseases with visible symptoms are heavily stigmatized, especially if they are previously unheard of. The late outreach heightened fear of both the disease and of the foreign aid workers who were attempting to control its spread.

Another issue is

related to the lack of funding. In some of the countries affected by Ebola, the government spends less than $100 a year, per person, on healthcare [1]. This is coupled with a shortage of healthcare workers and facilities to treat and quarantine patients suffering

from the disease. When Ebola cases were suspected, they were neither reported nor treated immediately [1]. Instead, these suspected cases quickly turned into documented cases [9, Figure 1]. Limited funding and resources contributed significantly to the spread of Ebola across Western Africa.

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At the

international level, governments were slow in responding to the outbreaks of Ebola [1]. The World Health Organization, a branch of the United Nations responsible for controlling and eradicating disease and working with governments to implement strong healthcare systems, was still suffering from the global financial crisis [5]. The WHO was both understaffed and underfunded, and was forced to slash almost a quarter of their budget for 20132014 [5]. Dr. Marie-Paule Kieny, an assistant director of the WHO said, with regards to Ebola, that “there’s no doubt that we’ve not been as quick and powerful as we might have been” [5]. The CDC only activated their Emergency Operations Center five months after the first suspected cases of Ebola [9, Figure 2]. By the time that the international community decided to play an active role in disease control measures, it was too late.

The fragility of

healthcare systems in Sierra Leone, Guinea, Liberia, and other countries affected severely by the epidemic is an issue that contributed significantly to the Ebola response. Wars and shortages have plagued Western Africa for the last few decades and many governments in this region are not equipped to handle a disease for which there is no cure, vaccination, or standardized treatment [1]. It wasn’t just our interconnected global health systems that fell apart during the epidemic — the already unsteady healthcare systems in Western Africa crumbled to the ground, and the inequality between the developed and underdeveloped world was made horrifyingly apparent.

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“

There’s no doubt that we’ve not been as quick and powerful as we might have been.”

The problem of

infectious disease is not restricted to underdeveloped countries — globalization has drastically increased the rate of disease transmission, while decreasing the possibility of early containment. Since the Ebola and Zika epidemics, new protocols for early detection, accurate reporting, and the deployment of equipped health workers have been developed by the Global Health Security Agenda (GHSA), a disease control network composed of almost fifty nations and various international organizations. Dr. Margaret Chan, the director of the WHO, emphasized the importance of building stronger connections with communities in less economically developed countries during the Commonwealth Health Ministers Meeting in 2016 [6]. Chan argued that “a lack of trust was a big barrier to successful control during the recent [Ebola] epidemic” [6]. The ministers discussed better training for frontline health workers to ensure that the first responders in any emergency are better able to control, contain, and treat disease while “ensuring patient safety” [6]. The development and execution of novel policy frameworks, in conjunction with ased collaboration between governments will hopefully prevent similar outbreaks in the future.

However, bringing effective healthcare systems to the developing world will take a global effort. Only when all countries are equipped with the necessary resources to combat curable

illnesses and prevent the spread of transmittable diseases, will we be one step closer to achieving universal health security.

[1] Belluz, Julia. “Seven reasons the Ebola epidemic is still raging.” Vox. Vox, 04 Sept.

2014. Web. [2] CBC News. “Ebola Clinic in Guinea Evacuated After Attack.” CBC/Radio Canada, 05 Apr. 2014. Web. [3] Centers for Disease Control and Prevention.

“Basic TB Facts.” N.p., 20 Mar. 2016. Web. [4] Centers for Disease Control and PreventionCenters for Disease Control and Prevention. “Review of Human-to-Human Transmission of Ebola Virus.” N.p., 01 Oct. 2015. Web. [5] Fink, Sherri. “Cuts at WHO Hurt Response to Ebola Crisis. NY Times, 2014. Web. [6] Henley, Will. “Governments Focus on Boosting Health Security in Response to Emerging Threats”. The Commonwealth, 2016. Web. [7] Moore, John. “Report: Armed Men Attack Liberia Ebola Clinic, Freeing Patients”. CBS News, 2014. Web. [8] World Health Organization. “Ebola Virus Disease”. WHO, 2016. Web. [9 and Figures] Dahl, et al. CDC’s Response to the 2014-2016 Ebola Epidemic — Guinea, Liberia, and Sierra Leone. MMWR Suppl 2016;65(Suppl-3):12-20.

A LIGHTNING STRIKE

eclampsia in pregnancy Author: Fatima Sattar Editor: Irena Hsu Eight hundred thirty a day.

Two point eight million within 28 days. The former refers to maternal deaths; the latter to newborn deaths. As coined by Doctors without Borders and unknown to many, “the avoidable crisis” is a maternal health issue faced by many women around the world — primarily those in underdeveloped regions such as Africa and South/East Asia. As a point of comparison, 2,500 maternal deaths occurred in Europe while 527,000 occurred in developing regions in the year 2000. In other terms, for every one woman that suffered in Europe, 200 women suffered in less developed countries. While this disparity is huge, it is not surprising given the lack of resources, education, sterile birthing environments, and clinics, which are among some of the factors that play into the maternal health crisis. The term “avoidable crisis” is what most caught my attention about this issue. That’s not a common term used to describe health situations,

especially those within underdeveloped countries.

Unlike some of the other more well-known, pressing diseases such as diabetes or AIDS that lead to chronic illness, maternal health related deaths take place within just minutes, hours, or at most a few days after birth.

Such a short time frame of risk is exactly what gives this crisis its name. Intervention during this critical period is the literal difference between life and death for these 527,000 women. While there can be many complications during this period, the top three destructive occurrences are severe bleeding after childbirth, infections during the birthing process, and a deadly condition known as eclampsia, which this article will primarily focus on.

Dr. Sarosh Rana, associate professor of obstetrics/ gynecology, Section Chief of Maternal-Fetal Medicine, and faculty at the Center for Global Health among others, is what you would call an expert on

preeclampsia, a precursor to eclampsia. With her warm smile and inviting demeanor, Dr. Rana could hardly hide her passion for the subject. “When I was in medical school [in India], all I remember seeing were cases of eclampsia. These women would come in and would just be seizing. It was terrible because some would come in unconscious and we couldn’t figure out how to induce their labor and we didn’t have many operating rooms,” Rana said when asked how she became interested in field.

The infamous condition, preeclampsia, is a complication to pregnancy that primarily results in high blood pressure, which can be deadly during labor. To date, the causes of preeclampsia are primarily unknown. What is known now is that all women develop new blood vessels to supply blood to the fetus during pregnancy.

Women with preeclampsia don’t develop these blood vessels properly. A surprising factor

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is that women who have never even had blood pressure issues seem to develop this disease. A segment of Rana’s research aims to detect preeclampsia in individuals using certain biomarker.

When a woman shows symptoms of preeclampsia, one of the best responses is to induce labor because never identified or left untreated, preeclampsia can develop into eclampsia. Eclampsia is characterized by seizures during pregnancy and transpires when blood vessels in the brain are affected as a result of the preeclampsia. Eclampsia explains the seizures that Dr. Rana was seeing in her early patients.

Interestingly enough, the condition gets its name from the Greek word for lighting. With no other way to describe the seizures that seemed to occur during pregnancy, the Ancient Greeks termed the condition as sudden bursts of lightning strikes.

Preeclampsia is not a condition that is unique to women in these underdeveloped regions, although Rana does say that African-American populations have a higher percentage of women that are prone to this condition.

Regardless, it’s a universal condition that can affect all women. So what is setting women in areas like Europe and the United States apart from the rest of the world?

“It boils down to resources,” Rana says.

In America, the standard perinatal care is very different from those women in Africa or Southeast Asia. The average American woman visits the doctor about twenty times before she goes into delivery. At each of these check-ups, an ultrasound is taken and progress of the mother

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and baby is monitored. Most importantly to preeclampsia, the mother’s blood pressure is taken. While this blood pressure can arise due to previous cases of blood pressure in the mother and environmental factors such as diet, most of these women develop high blood pressure only during their pregnancies. Any sign of high blood pressure and the doctor immediately flags the case. The mother is warned and all necessary cautionary steps are taken to ensure that the case never develops into eclampsia.

Dr. Rana conducts some of her research at the Hôpital Albert Schweitser hospital in Haiti. Unlike women in America, Haitian women are almost never seen before the time of delivery, so preeclampsia is never detected. “The only treatment for preeclampsia is the

delivery,” Rana says. Even if a Haitian woman were tested for preeclampsia at 28 weeks and her labor was induced, the likelihood of her baby surviving is slim to none without equipment such as incubation units, monitoring equipment, and staff. With the resources found in developed regions hospital’s, delivery at 28 weeks may be a possibility.

Regardless of these occasional appointments, Rana says that the most critical time period is during the actual delivery.

“I think it’s the recognition of complications that this patient is potentially really sick or can get sick that is key.” Once this realization has been made, the right decisions can be carried out. A typical delivery scene at the HAS hospital is a room with six beds and a handful of nurses. Rates of infection are high as even

standard sanitary techniques are hard to implement. Rana talks of nurses who don’t even have access to gloves during delivery and rely on simply washing their hands between deliveries. These conditions are at least something for those who come to the hospital — even less is known about all those who deliver at home.

Sadly enough, one doesn’t even have to look as far as Haiti to see the effects of preeclampsia on low-income individuals.

Even within the surrounding community around the University of Chicago, women are denied access to clinics when they don’t have health insurance.

If they are experiencing slight symptoms that don’t warrant admittance to the hospital, they still don’t have access to clinics that can appropriately diagnose them. Especially with the current political climate and its effects on health care, more individuals are at risk to being denied appointments. Without these regular check-ups, preeclampsia is never detected and symptoms are only seen at the time of delivery when more often than not, it’s too late.

However, maternal mortality is not as bleak of a topic as it once was. WHO reported that maternal health mortality has dropped by 44% in the last 20 years.

Countries like Bhutan, Cambodia, Mongolia, and Rwanda have reduced their number of maternal deaths by ¾. By 2030, WHO aims for less than 70 deaths for every 100,000 live births — a goal that’s possible through the efforts and research by people like Dr. Rana.

The reason why the maternal health crisis, though severe, is also so avoidable is because there

are known solutions to many of the complication that arise during childbirth. In general, access to antenatal care, skilled personnel during childbirth, and some monitoring after childbirth can greatly reduce the risk. In the example of severe bleeding, drugs like oxytocin have been shown to alleviate the symptoms.

The rate of infection significantly decreases with better hygiene and eclampsia could be avoided with the detection of preeclampsia. Some of the steps that WHO has taken to tackle the maternal health crisis are finding adequate research are funding research to find low-budget solutions, providing governments with the education and resources to monitor the issue within their own states, and training health professional workers to become more skilled in dealing with childbirth and the complications that can arise.

Truly as befitting of its name, the “avoidable crisis” is exactly that. There are currently known methods of treatment, a rare feat that can’t be said of other diseases like HIV/AIDS; the process of eradicating the risks involved with childbirth lies solely on the collective effort of individuals to raise awareness for this tragic occurrence and work to make sure all women have the same access to care. As WHO has already shown, there is more than one way to move forward and a lot of progress is being made to conquer the maternal health crisis. With new research and cost-effective resources, WHO’s goals are definitely within reach.

Lee Macon and Marijane Leonard. (2015, November 30). Eclampsia. Retrieved February 24, 2017, from http://www. healthline.com/health/eclampsia#Treatment6 Maternal death: The avoidable crisis. (2013, November 15). Retrieved February 24, 2017, from http://www.msf.ca/en/article/maternaldeath-avoidable-crisis Maternal Mortality. (2016, November). Retrieved February 24, 2017, from http://www.who.int/ mediacentre/factsheets/fs348/en/ Preeclampsia. Retrieved February 24, 2017, from http://www.mayoclinic.org/diseasesconditions/preeclampsia/basics/definition/ con-20031644 Rogo, K., Oucho, J., & Mwalali, P. (2006). Disease and Mortality in Sub-Saharan Africa (2nd ed.). Retrieved March 2, 2017, from https:// www.ncbi.nlm.nih.gov/books/NBK2288/ Saving mothers' lives. Retrieved February 24, 2017, from http://www.who.int/ reproductivehealth/publications/monitoring/ infographic/en/ World Health Organization. Saving Mothers' Lives [Digital image]. Retrieved March 2, 2017.

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SMALL GREAT THINGS Author: Swathi Balaji Editor: Irena Hsu

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AN EXPLORATION OF HEALTH DISPARITIES

“Did you ever think our misfortune is directly related to your good fortune?

How often do you remind yourself how lucky you are that you own your own house, because you were able to build up equity through generations in a way families of color can’t?

How often do you open your mouth at work and think how awesome it is that no one’s thinking you’re speaking for everyone with the same skin color you have?

How hard is it for you to find a greeting card for your baby’s birthday with a picture of a child that has the same skin color as her?

Here you are on your high horse…patting yourself on the back for being an advocate for a poor, struggling black woman like me…but you’re part of the reason I was down on the ground to begin with.”

These are the very real and deeply rooted sentiments regarding white privilege expressed by Ruth, a black nurse with over twenty years of experience in labor and delivery. She is on trial for a crime she did not commit — murder. Targeted as the scapegoat by a white supremacist father who accuses her of killing his newborn son, Ruth cannot help but wonder where she went wrong; she was the only black nurse on the floor and was specifically told by her supervisor not to touch the baby to respect the patient’s wishes. Yet, as the only nurse present when the baby goes into cardiac distress, what else was she to do but fall back on her training as a medical professional?

Ruth is the protagonist in Jodi Picoult’s highly acclaimed and recently published novel Small Great Things, which explores racism, privilege, and power in modern-day America by following the mindsets of a black nurse fighting discrimination, a white supremacist who lost his son, and a lawyer fighting for Ruth’s case, unaware of her own white privilege. While reading the novel, I could not imagine why a healthcare provider would be stopped from administering care for the sake of purported patient rights — simply due to his or her skin color. To my surprise, Ruth’s story is actually based on a real event where an African American nurse in Flint, Michigan was prevented from administering care to an infant on the premise of her skin color.

Thankfully unlike the case in Picoult’s novel, the real incident had a happier ending as the nurse was not the only black nurse on the floor, and several

African American personnel successfully sued the hospital for discrimination. Despite the satisfactory results, however, this unique case brings up many questions. What role do racial inequities play in healthcare, on both the provider side and the patient side? How do disparities affect medicine?

Racism in medicine is a lot more prevalent and complicated than we would like to think it is — the issue isn’t black and white. Satel and Klick (2004) would argue that racism in the health care system is exaggerated and that it is more important to look at patients on a case-by-case basis, considering patient preferences, insurance, and doctor’s treatment decisions as reasons that minority patients might not receive the same quality of care. For Satel and Klick, access to care, quality of care, and health literacy are more important factors which affect health disparities; “when access to care is excellent…and patient characteristics are relatively homogeneous — such as in military health care systems — there are negligible racial disparities in care.” What if these factors are not so homogeneous? Access to care can be limited primarily because of discrimination and subsequent disparities arising from transportation barriers, food deserts, and implicit biases from the provider side. Thus, racism might not be blown out of proportion and may, in fact, be underplayed in medicine.

discrimination against patients Often, the request for a new provider might not stem from prejudice but from cultural or religious

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preferences. For instance, a Muslim woman may want a female physician because of her religious beliefs, and this is perfectly justified — unfortunately, it is not always accommodated. Dr. Aasim Padela, an emergency medicine physician and health services researcher at the University of Chicago, reports that about 50% of Muslim women delay their care because of their inability to find a female provider. A Muslim woman had reached out to him, stating the following: “I went to the doctor and I was wearing a hijab and they assumed I didn’t speak English and they wouldn’t let me choose a female doctor.”

It is unclear why providers would make such assumptions — is it due to an unconscious bias or an unwillingness to make accommodations? Either is possible. Medical schools and other professional schools incorporate cultural sensitivity into their curricula to make sure that providers are aware of patient preferences and cultural motivations, but the issue has yet to subside. Medical students should not simply learn about these issues in a classroom setting; unless they study cases and practice their cultural sensitivity skills with pseudo-patients (other students, faculty, or volunteers from the community), the issue simply will not be addressed to the extent that it deserves to be.

To pinpoint how and why such assumptions are made, it is imperative to research minority groups and assess why they have a limited quality of care.

Dr. Padela highlights how “health care disparities are researched across race, ethnicity, against rural and non-rural residential status and even among people of alternate sexual orientations” but not across religion — why is this factor trivialized or ignored as an influence on healthcare disparities?

He additionally states that Muslims as a minority group are not seen as a primary focus for research in disparities because of how people cannot make an immediate connection between religion and limited access to health, how many in the Muslim population are not tied to any pioneering research that would shed more light on their disparities, and how unconscious bias in providers may prompt dismissal of the Muslim population as a “fringe group.”

The National Institutes of Health (NIH) reports in its Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC) that, of the money given to health research by the National Institutes of Health, 2% of the funding (2.9 billion dollars) goes towards health disparities research.

However, it is unclear what disparities research encompasses, since it is such a broad research topic.

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Healthcare disparities research is atypical in that it “assigns project funding according to populations tracked by gender or ethnicity”; since the databases used to track gender and ethnicity are complex, they are not currently compatible with the RCDC system. This implies that the specific disparities research subcategories remain hidden and are not transparent to Congress or to the public. According to Dr. David Williams, a professor of public health at the Harvard School of Public Health, blacks have higher death rates than whites in about 12 of the most common diseases, including heart disease, cancer and stroke. Latina women suffer more from cervical cancer because they are less likely to get regular screenings unless they experience symptoms (Paz and Massey 2016). When minority groups are clearly more susceptible to diseases for a plethora of reasons, it does not make sense for the research subcategories to not be specified. Without increased transparency in funding allocation, the NIH will not be able to adequately address the growing importance of health disparities research targeted at specific ethnic populations.

Minority groups have different social determinants of health. Some common barriers for Latinas include “fear of results, embarrassment of being touched, access to health care, and language issues as reasons for not obtaining regular screenings.”

Environmental factors also create barriers due to how residential location, hazards, and pollutants can play roles in exacerbating diseases, such as hypertension in Chinese Americans. For illegal immigrants, these determinants are compounded by the fear of seeking medical care, lack of health insurance, and poor quality of care due to inability to afford better care. Without proper research

factoring in a wide range of parameters, such as socioeconomic status, family structure, race, and religion, it is difficult to hone in on why disparities arise, especially when contexts vary on a case-bycase basis.

racism towards providers Dr. Sachin Jain, a professor of medicine at Stanford, was once told by a furious patient to “go back to India.” As an American-born and raised citizen, Dr. Jain was very disturbed by the patient’s reaction and was disappointed that his colleagues “minimized what had happened,” much like how Ruth’s coworker in Picoult’s novel minimized the gravity of the supervisor’s discriminatory action towards Ruth. This repetitive, dismissive behavior undermines the value of minority caregivers; more than the patient’s ignorance and racist remarks, it shocked me that Dr. Jain’s well-educated colleagues could not recognize the injustice that was lying in front of them like an open book. It simply is not acceptable for minority providers to be mistreated or discriminated by patients but it happens anyway because healthcare organizations often emphasize equal treatment for patients, but not the flipside.

When 15% of pediatric residents at Stanford report that they have experienced prejudice from patients and their families, it is evident that discrimination has not been addressed enough in medical schools or in healthcare companies.

Although medical schools have incorporated cultural competency lessons to ensure that providers can treat patients in a non-discriminatory manner, they do not seem to put nearly as much effort in addressing how healthcare providers should respond in the heat of the moment when a patient attacks the provider’s ethnicity or origin.

The American Medical Association (AMA) should directly address discrimination against doctors by patients in its Code of Medical Ethics; however, for now, the code does recommend that physicians “terminate the patient-physician relationship with a patient who uses derogatory language or acts in a prejudicial manner only if the patient will not modify the conduct.” The AMA makes it seem as if the physician could simply walk out of the room, but it may not even be possible to so easily terminate a patient-physician relationship. Ending a doctor-patient relationship is not feasible when considering complications that could arise from coverage and insurance for the patient, the caregiver’s salary (which depends on how many patients are seen), and the ultimate goal to treat the patient.

If a patient is in need of acute care or has a severe

emergency, it is very impractical to suddenly find a new physician, simply because the patient could not “modify the conduct.” Thus, the AMA should specify how to get around financial and logistical barriers and specify the procedures for how to terminate the doctor-patient relationship in such extreme circumstances.

Paul-Emile et al. (2016) offers a solution to dealing with racist patients through the consideration of five factors: “the patient’s medical condition, his or her decision-making capacity, options for responding to the request, reasons for the request, and effect on the physician.” According to Paul-Emile, physician reassignment should depend on the severity of these factors and should not compromise quality of care for the patient or employment rights for the healthcare provider. But in the case that the healthcare provider must endure discrimination and abuse from the patient side to ensure the purported quality of care, this solution too has its own loopholes. Consequently, healthcare organizations must follow a case-by-case module in order to manage racism directed at providers, but the question still remains whether the racism itself can be limited in patients.

our very own south side In 2014, many South Side residents protested against the University of Chicago due to its lack of a Level 1 Trauma Center, which they felt was imperative for equal access to care, especially amidst the gun violence. Their threat was “No trauma center, no Obama library.” These cries first arose in 2010 when Damian Turner, a charismatic youth advocate and aspiring musician, was gunned down in a drive-by shooting — just four blocks from the university hospital. Due to the lack of a trauma center, he was driven all the way to Northwestern,

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where he passed away just ninety minutes after he had been shot. His mother stated in remorse, “My sweet baby could still be alive today if the U. of C. had a trauma center. It’s just down the street.”

Last year, the university decided to allocate resources to support such a trauma center, which will be opened in 2018. The hospital did not have the financial resources to take this on in 2014 but it is now receptive to the wishes of many in the South Side community, especially those in low-income areas. In addition, through its Get Care Initiative, the University of Chicago Medicine has opened or

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will soon implement Level 1 trauma services, an adult cancer center, two more floors of the Center for Care and Discovery, centers for advanced care in Orland Park and the South Loop, a cancer care center in Mary Hospital, and a merger with Ingalls Memorial Hospital and its five outpatient centers.

This will dramatically improve quality of care for many patients in need of adult trauma care, cancer treatment, and emergency services, which is a step closer to reducing inequities for patients by reducing transportation barriers and increasing their access to healthcare.

It would be wrong to suggest that racism overshadows all disparities in healthcare, but it is certainly the elephant in the room. Jodi Picoult addresses her book on white privilege and racial inequities to blacks and whites in her Author’s Note.

What about other minorities? How should we look at the picture?

The University Community Service Center (UCSC) and Center for Asian Health Equity are just two of the many organizations on our campus that address this dilemma. The UCSC recently held a conference exploring the institutional and cultural reasons for discrimination, addressing how any

why it is ingrained in Chicago institutions and what we can do to change it; through such conferences, we learn to inspect our own privileges and biases, understanding how we fit into the institution as minority groups. The UCSC and Center for Asian Health Equity also offer us many opportunities to become involved with social justice, housing and development, civic engagement, health policy, and other prominent issues that affect the South Side community.

Thus, for those of us who fall under the shades in between, what matters is that we too are involved in our communities. Racism and prejudice are not synonymous, especially in a healthcare setting. It is up to all of us to be aware of our privileges and disadvantages and work to shed light on inequities as we engage in small great things.

Health and Human Services, n.d. Web. 01 Mar. 2017.

Fortino, Ellyn. "South Side Residents To University Of Chicago: No Trauma Center, No Obama Presidential Library." Progress Illinois. Progress Illinois, n.d. Web. 06 Feb. 2017.

Glanton, Dahleen, and Lolly Bowean. "In About-face, U. of C. Medicine to Build Adult Trauma Center on Hyde Park Campus." Chicago Tribune.

Chicago Tribune, 18 Feb. 2016. Web. 06 Feb. 2017.

Heher, Ashley. "UChicago Researcher Documents Dramatic Shortcomings Tracking American Muslim Health Disparities." Science Life. Science Life, 6 Apr. 2015. Web. 06 Feb. 2017.

Howard, Jacqueline. "Racism in Medicine: An 'open Secret'." CNN. Cable News Network, 26 Oct. 2016. Web. 06 Feb. 2017.

Paul-Emile, Kimani, Alexander K. Smith, Bernard Lo, and Alicia Fernandez.

"Dealing with Racist Patients — NEJM." New England Journal of Medicine. New England Journal of Medicine, 25 Feb. 2016. Web. 06 Feb. 2017.

Paz, Karen, and Kelly P. Massey. "Health Disparity among Latina Women: Comparison with Non-Latina Women." Clinical Medicine Insights.

Women's Health. Libertas Academica, 2016. Web. 01 Mar. 2017.

Picoult, Jodi. Small Great Things. New York: Ballantine, 2016. Print.

Satel, Sally, and Jonathan Klick. "The Problem of Racism in the Health Care System Is Exaggerated." Race Relations. Ed. James D. Torr. San Diego: Greenhaven Press, 2005. Opposing Viewpoints. Rpt. from "Don't Despair over Disparities." Weekly Standard 9 (1 Mar. 2004). Opposing Viewpoints in Context. Web. 6 Feb. 2017.

“If I cannot do great things, I can do small things in a great way.” – Dr. Martin Luther King Jr.

Terry, Don. "A Death Sparks a Demand for Care." The New York Times. The New York Times, 02 Oct. 2010. Web. 06 Feb. 2017.

Chen, Mei-Lan, and Jie Hu. "Health Disparities in Chinese Americans with Hypertension: A review." Health Disparities in Chinese Americans with Hypertension: A review. ScienceDirect, n.d. Web. 01 Mar. 2017.

Figure 2. http://chicagotonight.wttw.com/sites/default/files/field/image/r_ UChicagoMed_1_Edit.jpg. Source: Chicagotonight.com

"Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC)." National Institutes of Health. U.S. Department of

Figure 1. http://familiesusa.org/sites/default/files/product-images/ HealthDisparitiesthumbnail_0.png. Source: Familiesusa.org

Figure 3. http://www.bestmedicaldegrees.com/wp-content/uploads/2016/01/ RacialDisparitiesHealthCare.jpg. Sources: medicareadvocacy.org, archive.ahrq.gov, commonwealthfund.org, kff.org, hbr.org

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MEDICAL TECHNOLOGICAL INNOVATIONS THE DEVICES THAT WILL CHANGE HEALTHCARE Author: Hannah Jacobs-El Editor: Jihana Mendu Medical advancements are important in continuing to protect and treat patients both inside and outside of the hospital setting. With 2017 in full swing, there are many new improvements that have great potential in aiding and better treating patients. Many of these advances are noticeably more technological, as the current generation of both patients and doctors are becoming more accustomed to the use of present-day technology. These new devices and programs could be the next step in treating patients more efficiently and precisely in turn lowering health risks, shortening hospital stays, decreasing the costs of health care, and establishing an overall higher standard of living and care.

I. Mobile Stroke Unit The Mobile Stroke Unit is used to shorten the time between the onset of stroke-like symptoms and the delivery of thrombolytic (clot-busting) drugs. These thrombolytic drugs must be administered within three hours of the onset of symptoms in order to be effective, so time is essential when it comes to their efficacy(1). The Mobile Stroke Unit is similar to an ambulance in that it transfers patients to the hospital rapidly in order to receive care. These specific units, however, contain specialized staff, such as a paramedic, a critical care nurse, a CT technologist and an EMS driver. The unit is also equipped with special equipment, such as a portable CT scanner that images a patientâ&#x20AC;&#x2122;s brain, a mobile lab that tests blood samples, and medications in order to diagnose and treat strokes promptly. The CT scans and blood information are wirelessly transmitted to clinic neuroradiologists at the nearest Primary Stroke Center, where they decipher the type of stroke the patient is experiencing (ischemic, caused

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by a blood clot; or hemorrhagic, caused by a ruptured blood vessel). The test will also alert the onsite team as to what type of stroke has occurred so that they may administer appropriate treatment accordingly. If the stroke is ischemic, they can initiate intravenous (IV) tissue plasminogen activator, which works more effectively when provided immediately, to attempt to break up the clot; with hemorrhagic stroke cases, a patientâ&#x20AC;&#x2122;s blood and brain pressure are controlled and drugs that counteract blood thinners are administered as the patient is quickly taken to the nearest hospital in order to receive surgical treatment.

The Mobile Stroke Unit is easily contacted if 9-1-1 is called, as the dispatcher will contact the staff directly if they determine the person is experiencing a stroke. If hospitals can reach patients faster and administer these tests and medications on the scene, both short and long-term positive outcomes are much more probable.

II. SpaceOAR Prostate cancer is the second most common cancer in men globally; about one man in every 7 will be diagnosed with prostate cancer, with 161,360 new cases and 26,730 deaths estimated for 2017 (2). A considerable number of these men undergo internal radiation therapy, or brachytherapy, for the treatment of localized prostate cancer due to its lower risk of impotence and urinary incontinence compared to external-beam radiation therapy (EBRT) and surgical procedures (3). Both forms of radiation therapy (brachytherapy and EBRT), however, have considerable side effects such as rectal bleeding, painful urination and bowel movements, urinary and rectal leakage, sexual dysfunction, secondary cancers in the region of radiation, in addition to chances of impotence and incontinence.

SpaceOAR (Spacing Organs at Risk) Hydrogel is a rectal protection device for prostate cancer radiation therapy patients (4). This apparatus is used in conjunction with radiation treatments and reduces rectal injury and side effects in men receiving prostate cancer radiation therapy. SpaceOAR acts as a spacer and pushes the rectum away from the prostate, decreasing rectal injury during radiation therapy. Although this small distance may seem trivial, it pushes the rectum, the organ

at risk, out of the high-dose radiation region and prevents the cells from being damaged along with prostate cancer cells. This hydrogel spacer is injected into the male in a minimally invasive procedure and is generally not noticeable or uncomfortable for the patients. The device can stay in place for up to three months during radiation treatment; after this time it is absorbed and leaves the body via urine. The device is considered safe as it is similar to other products currently being used in brain surgery, cardiology and ophthalmology.

An experiment run at the University of Heidelberg found that the rectal dose reduction with SpaceOAR was about 60% greater compared to the rectal dose without the hydrogel. Hydrogel application had a 38% rate of acute grade 1 gastrointestinal (GI) toxicity (mild diarrhea, mild cramping, slight rectal discharge or bleeding), which is about the same as that without the SpaceOAR. However, there were no reported Grade 2 or higher GI toxicities, and a 24% rate of acute grade 2 or greater genitourinary (GU) toxicities (generalized telangiectasia, intermittent macroscopic hematuria), compared to 3-8% grade 2 or higher GI toxicities and 56% acute grade 2 GU toxicity without the SpaceOAR.

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III. Advances in Prosthetics The concept of prosthetics is not new in the medical world; the use of such contraptions goes back to the discovery of prosthetic big toes in Ancient Egypt. The prosthetics being designed today, however, are considerably more advanced and effective. One such example is the Defense Advanced Research Projects Agency’s (DARPA) prosthetic limb advancements.

DARPA’s limbs were originally created to assist wounded military soldiers with amputations in returning to active duty and improving their quality of life; now, however, they are also intended for non-military patients with medical amputations, spinal cord injuries and neurological diseases (5).

One such prosthetic is the “Modular Prosthetic Limb,” which was tested in 2016 on Johnny Matheny, a man who lost his lower left arm to cancer eight years prior. This prosthetic was developed by the Applied Physics Laboratory (APL) at Johns Hopkins and was designed for full neural integration. In other words, it can not only receive signals from the human brain, but also enable two-way transmission, transmitting signals to and from the brain. The device works by detecting when pressure is being applied to any of the fingers and converts these sensations into electric signals that are carried to the brain, which then provides patterns of stimulation to sensory neurons.

The device senses not only pressure, but also temperature and texture. DARPA conducted a

similar study with the Modular Prosthetic Limb on a paralyzed man, Nathan Copeland, and succeeded in helping him feel touch directly in the brain through a neural interface system connected to the prosthetic arm (6).

The Modular Prosthetic Arm has an exceptional range of motion compared to past prosthetics and can engage in most activities, although some hand gestures or movements are still difficult to produce, especially for more novice users. The prosthetic is applied with surgical procedures such as osseointegration, which connects prosthetic devices directly to the bone of the upper arm.

Both the Modular Prosthetic Limb and the prosthetic design at APL use a closed circuit that merges synthetic and biological wires.

The company is currently working on a product, called the “Myo band” that will allow for fine-tuning the sensory implants and advancing them so that patients can perform actions simultaneously, rather than sequentially. The main challenge with creating these DARPA prosthetics is constructing an interface that is directly compatible with a patient’s own nervous system and making the connection fast enough to interpret his or her movement intent accurately without interruptions. This two-way communication has the potential to allow those who are paralyzed or have amputated limbs to engage with others and the world in a way that was not previously possible.

DARPA Modular Prosthetic Limb

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IV. 3D Printing of Biomaterials Organ transplants are a difficult process even today; there are many limitations as to who can donate and receive organs, and there are a finite number of donors, especially compared to the number of patients who are in need of transplants. Thanks to 3D printing, these all may become problems of the past. Organovo is a company that engages in 3D bioprinting, specifically of the liver. They successfully 3D-printed liver tissues in 2014 and are currently on track to print functional liver parts for human transplantation (this advancement is especially notable since the most commonly transplanted organ is the liver) . These transplants have been shown to be fully functional and stable for up to 28 days, and provide a predictive liver toxicity marker assessment that

will warn a physician if there are any complications in the liver.

As of now, Organovo has not received clearance for the liver tissue, although it is predicted that it will be assessed by the FDA within the next two years. Pre-clinical trials have shown that the 3D bioprinted liver tissue function successfully in mice, and in-vivo experiments have detected function of the liver tissue through the presence of three proteins in lab miceâ&#x20AC;&#x2122;s blood after implant surgery . The company is also researching the production of 3D printed human kidney tissue. With these pre-clinical successes, we hope to see further advancements in the following years as the use of 3D organs becomes a more common procedure in the medical world.

The devices and programs mentioned are only a few of the advancements to come in the following months and years. Healthcare is improving at an exponential rate, and patients are experiencing a higher quality of care both inside and outside of the United States. With these developments, it is likely that health issues that are critical today will be easily preventable and treatable in the near future.

1. "Mobile Stroke Treatment Unit." Cleveland Clinic. Cleveland Clinic, n.d.

Web. 28 Feb. 2017. <http://my.clevelandclinic.org/health/articles/mobilestroke-unit>.

2. "Key Statistics for Prostate Cancer." American Cancer Society. American Cancer Society, n.d. Web. 28 Feb. 2017. <https://www.cancer.org/cancer/ prostate-cancer/about/key-statistics.html>.

3. Uhl, Matthias, Gencay Hatiboglu, and Klaus Herfarth. "Effect of a Prostaterectum Hydrogel Spacer on Reducing Acute Radiation Proctitis: A Single Center Experience." University of Heidelberg (n.d.): n. pag. Web. 28 Feb. 2017. <http://www.spaceoar.com/assets/WhitePaper_Effect_prostaterectum_hydrogel_spacer_092811.pdf>.

4. (Image from here) "What Is SpaceOAR Hydrogel?" SpaceOAR System Rectum-Sparing Prostate RadioTherapy | Augmenix. N.p., n.d. Web. 01 Mar. 2017. <http://www.spaceoar.com/what-is-spaceoar/>.

5. Stone, Maddie. "DARPA's Mind-Controlled Arm Will Make You Wish You Were a Cyborg." Gizmodo. Gizmodo, 12 May 2016. Web. 01 Mar. 2017.

6. "Defense Advanced Research Projects Agency." Defense Advanced Research Projects Agency. DARPA, 2016. Web. 01 Mar. 2017. <http://www.darpa. mil/news-events/2016-10-13>.

7. (Image from here) "DARPA Achieves Goal of Restoring Sensation." The O&P EDGE. Oandp, 15 Sept. 2015. Web. 01 Mar. 2017. <http://www. oandp.com/articles/NEWS_2015-09-15_01.asp>.

8. "ExViveâ&#x201E;˘ Human Liver Tissue Performance." Organovo. N.p., n.d. Web. 01 Mar. 2017. <http://organovo.com/tissues-services/exvive3d-human-tissuemodels-services-research/exvive3d-liver-tissue-performance/>.

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HEALING A BROKEN HEART takotsubo

(stress-induced) cardiomyopathy

Author: Medha Reddy Editor: Esther Wang The recent death of Debbie Reynolds, who passed away just one day after her daughter Carrie Fisher, highlights a relatively new diagnosis among physicians: stress induced cardiomyopathy, or broken heart syndrome.

The symptoms of broken heart syndrome often seem akin to experiencing a heart attack, requiring physicians to run a series of diagnostic tests to distinguish between the two.

Although broken heart syndrome fundamentally differs from heart attacks in its cause and short term effects, there is one similarity between the disorders: both can be deadly if not appropriately addressed. These newly discovered consequences of grief have introduced a more dangerous element that exceeds its previously known physiological manifestations.

In broken heart syndrome, a portion of the heart enlarges as a result of a sudden stress, and A, Angiogram of normal left ventricle in systole shows contraction of all myocardial segments.

B, Angiogram of left ventricle with takotsubo defect shows contraction of the base with akinesis of the apex.

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hence, pumps inefficiently. This is in contrast to the remainder of the heart, which either continues to function normally or contracts with slightly more force. X-rays have revealed that the abnormally functioning part of the heart begins to “balloon outwards,” making the area above it seem contrastingly small. Hence, x-rays reveal a jug shape, similar to “tako tsubo,” or an octopus trap; this is why broken heart syndrome is frequently referred to as takotsubo cardiomyopathy.1 Thus, this distinct shape visually illuminates the difference between broken heart syndrome and a heart attack. Other diagnostic tactics follow from the different causes of each disorder.

While both present similar signs and symptoms such as chest pain and shortness of breath, heart attacks are caused by narrowing of the arteries from fatty tissue accumulation, which increase the likelihood of an artery of the

heart being blocked by a blood clot.1 On the contrary, broken heart syndrome is not resultant from arterial blockage, but the excessive presence of stress hormones. This key difference allows medical practitioners to determine the appropriate diagnosis through blood tests (which check for the presence of certain enzymes associated with heart damage), electroencephalograms, electrocardiograms, or echocardiograms. Unfortunately, as broken heart syndrome is stress-induced, these advancements in testing present cannot be used for the purposes of early detection.

The “stress” that induces broken heart syndrome can be defined as anything the body perceives as abnormal. This varies from person to person, and could potentially range from emotional news, either good or bad,1 to physical complaints such as dehydration.4 To help the body

cope with this stress, certain hormones, including adrenaline, are released. While the effects of adrenaline on the heart remain unclear, it is believed that it either causes the arteries of the heart to constrict3 or causes the heart cells to stop functioning by binding with them and allowing calcium to enter.4 Regardless of this uncertainty, the chain of effects of stress upon the heart is clear – stress causes the release of a significant amount of adrenaline, which strains the heart.

Although adrenaline has been isolated as the primary cause of broken heart syndrome, its

“

low blood pressure, shock, and potentially life-threatening heart rhythm abnormalities”.4 Patients are prescribed heart medication, often including angiotensin-converting enzyme inhibitors, beta blockers, or diuretics, to reduce the likelihood of subsequent episodes and activity of the heart.

Because it is not associated with blocked arteries, strategies and surgical interventions normally utilized with heart attacks, including balloon angioplasty and stent placement, are deemed ineffective.3 Although broken heart syndrome may induce potential

stress, individuals with a history of neurological conditions and psychiatric disorders are considered to be at a higher risk.1 While much has been uncovered about the causes, effects, and appropriate treatments for broken heart syndrome, much remains unknown. Studies on why certain quantitative realities of the disorder are true have the potential to lead to new treatment strategies and further research questions in both cardiology and endocrinology. In many respects, this highlights the truth that broken hearts literally heal on their own.

Broken heart syndrome can be deadly if not appropriately addressed."

several roles within the body complicate this rule. In rare cases, it has been observed that broken heart syndrome may be induced by drugs that induce the formation of stress hormones, including Epinephrine, Duloxetine, Venlafaxine, and Levothyroxine.3 Further, while the general belief is that stress is what induces broken heart syndrome, this belief has been isolated to cases that involve sudden and unexpected stress. The implication is that the chronic stress many experience in their daily lives, which still causes long-term exposure to adrenaline, does not present as a risk factor.4 While the effects of broken heart syndrome conventionally correct themselves in a short time span after the incident, the brief failure of the heart muscle is still drastic, and requires an appropriate course of treatment. As the ailment reduces the strength of heart muscle, complications may include “congestive heart failure,

complications, its effects are more likely to be short-term with appropriate medical intervention.

Such complications are relatively rare, and the likelihood is further reduced by the observed recurrence rate in patients. In patient follow-up monitoring, Johns Hopkins University Hospital has found that in a five-year span, none of the patients who had presented with broken heart syndrome were readmitted for the disorder.4 The same study had found that the patients were overwhelmingly women, a finding further confirmed by other literature sources. Peculiarly, a majority of the patient population were post-menopausal women, a distinction that has yet to attain a scientific basis.4 While most patients were encompassed by this description, patients from either sex of a wide range of age categories have been found with broken heart syndrome. Since the disorder is dependent on individuals varying tolerance levels of

[1] Is Broken Heart Syndrome Real? (n.d.).

Retrieved February 04, 2017, from http:// www.heart.org/HEARTORG/Conditions/ More/Cardiomyopathy/Is-Broken-HeartSyndrome-Real_UCM_448547_Article.jsp#.

WIwZTbGZMdU [2] Publications, H. H. (n.d.). Takotsubo cardiomyopathy (broken-heart syndrome).

Retrieved February 04, 2017, from http:// www.health.harvard.edu/heart-health/ takotsubo-cardiomyopathy-broken-heartsyndrome [3] Mayo Clinic Staff Print. (2016, November 05).

Broken heart syndrome. Retrieved February 04, 2017, from http://www.mayoclinic.org/ diseases-conditions/broken-heart-syndrome/ home/ovc-20264165 [4] Gaede, S. (n.d.). Frequently Asked Questions about Broken Heart Syndrome. Retrieved February 04, 2017, from http://www. hopkinsmedicine.org/asc/faqs.html Figure 1: Derrick, Dawn. “Figure 1.” The “Broken Heart Syndrome”: Understanding Takotsubo Cardiomyopathy. Retrieved March 08, 2017, from http://ccn.aacnjournals.org/ content/29/1/49.full

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