Editorial

Peter T. Zacharia, MD

The term game changer was originally used to describe a decisive play in a sports match. A 50-yard pass play setting up a touchdown for the eventual win during a low-scoring gridiron contest is one such example. An eighth inning, tie-breaking home run in a baseball game is another. Both would be lauded as game changers during postgame commentary on a Sunday evening sports analysis show. Important developments outside the world of sports which profoundly alter expected outcomes are also regarded as game changers. Progress in scientific fields, and especially medicine, can often be compared to an 18-play scoring drive in football, with the information gained from the work of successive researchers and spanning decades resulting in game-changing advances. Historic examples of this include the work of several individuals during the late 19th and early 20th centuries culminating in the identification and purification of insulin for treatment of diabetes mellitus. Other game changers in medicine have been the result of astute observations by scientists and physicians whose curiosity led to development of life-improving substances and technologies. Alexander Fleming’s observation, the death of staphylococcal cultures surrounding an area of fungal contamination of a bacterial culture, had the makings of a game-changing observation, although it was not immediately recognized at the time. It would take years before the importance and life-saving significance of his observation, which eventually led to the isolation and production of penicillin, would be realized. During World War II, Sir Harold Ridley, a British ophthalmologist, provided care for members of the Royal Air Force whose cockpit canopies shattered sending fragments of acrylic plastic into their eyes. His observation that these fragments failed to incite an inflammatory reaction inspired him to develop the first intraocular lenses for use in cataract surgery obviating the need for thick postoperative aphakic spectacles, mercifully changing the game and quality of life for millions of cataract patients during subsequent decades

In this issue we examine several of the more recent game changing ideas in medicine and how they have extended and enhanced the lives of patients.

In an article entitled, “The Remarkable Journey from Desiccated Scabs to Genomic Vaccines,” Anthony Esposito, MD; and George Abraham, MD; impart the fascinating story of vaccine development beginning with the use of desiccated scabs in the practice of variolation in ancient China, jumping in time nearly 28 centuries to Edward Jenner’s work with cowpox in England, and weaving in the stories of Pasteur and others whose work led to development of other vaccines in the late 19th and early 20th centuries. They trace the path to the most recent vaccination technology using mRNA in the COVID-19 vaccine and dispelling myths and fears of mRNA integration within human DNA after injection. Along the way they also remind us of the origin of the political opposition to vaccines and compulsory vaccination in late 19th century England and the United States as well as the parallels to vaccine resistance in the news today.

In their article, “Amplify Your Practice With Point of Care Polymerase Chain Reaction Testing;” Craig Lilly, MD; and Nathaniel Hafer, PhD.; deliver an efficient summary explaining briefly the mechanism of PCR and discussing its use in various clinical applications as well as advances in technology. These advances have even allowed this tool to evolve into point of care PCR, helpful during the COVD-19 pandemic, no longer requiring the use of a central laboratory for analysis of specimens. Supplementing their article is a concise and informative table listing the utility of this powerful technology which allows identification of specific organisms causing infectious disease, selection of antimicrobials to combat the infection, and monitoring the response to treatment. Additional applications discussed for this versatile, gamechanging weapon include diagnosis of genetic disease, selection of therapy in oncology and monitoring for organ transplant rejection.

Teri Kleinberg, MD, a Worcester ophthalmologist discusses teprotumumab, a monoclonal antibody against the insulin-like growth factor I receptor which has been a game changer in the treatment of thyroid eye disease, which results in proptosis and can cause visual symptoms including double vison and loss of vision. She describes older techniques to treat thyroid eye disease prior to development of teprotumumab including lubrication, steroids, radiation and surgery. Dr. Kleinberg goes on to discuss the effectiveness of teprotumumab as determined in the multicenter OPTIC Trial, where a revolutionary treatment in reversing the proptosis and related symptoms which result from the disease were evaluated. Finally, she touches upon the sad truth which is the astronomical cost of this therapy and the limitations those fees put on its use.

Nancy Sidhom, MSN, ANP-BC, CDCES describes the game-changing role of continuous glucose monitoring in managing blood sugar levels in the treatment of diabetes mellitus and discusses advantages over fingerstick testing of blood sugar levels and the role CGM plays in educating a patient in the management of the disease. She reviews and compares three of the available CGM sensor devices and discusses studies showing the effectiveness of these devices in improving and facilitating diabetes management in patients.

Anna K. Morin, PharmD, in her article, “Herpes Zoster Vaccine: A Breakthrough in Preventing Shingles,” reminds us of the symptoms and clinical characteristics including sequelae of Herpes zoster, commonly known as shingles, which can be a devastating and very uncomfortable reactivation of the varicella zoster virus occurring more often with advancing age. She discusses the replacement of the older and less effective zoster vaccine live or Zostavax vaccine with the newer and much more protective recombinant zoster vaccine branded as Shingrix. She lists the recommendations of the Advisory Committee on Immunization Practices regarding who should get the vaccine, as well as contraindications in her article on a disease which threatens us all.

Tina Shiang, MD, writes an article on informatics and the future of radiology. She discusses artificial intelligence algorithms developed and cleared by the U.S. Food and Drug Administration for clinical use in interpreting radiological images, but offers the opinion that AI is unlikely to replace human radiologists any time soon. Dr. Shiang encourages other radiologists to learn about and explore the field of informatics and utilization of AI to augment a radiologist’s interpretations of images for the purpose of improving patient care.

Charlotte Walmsley, a fourth-year medical student at University of Massachusetts T.S. Chan School of Medicine , gives us a student perspective on recent cancer advances after having worked at the Massachusetts General Hospital Cancer Center prior to starting medical school. She discusses the paradigm shift from the 20th-century surgery followed by chemotherapy to 21st-century treatments, which include targeted therapy and immunotherapy for cancer as well as more recently developed chimeric antigen receptor therapy, or CAR-T. She completes her article with encouraging data on the treatment of pediatric patients with leukemia and rare cancers exemplified by anaplastic thyroid cancer.

In addition to these articles discussing game changers in medicine, our society curator, Dale Magee, MD, gives us a brief history of medical education in the United States with a discussion of the first women to earn medical degrees and 19th-century educational institutions intended to train female physicians. Federic Baker, MD, FAAFP, laments the missed opportunities and unfulfilled promises of electronic medical records software, citing poor software designs and workflows. He blames dysfunctional EMR programs as a factor in physician burnout and advocates for policymakers to hold EMR vendors and third-party payors accountable for EMR shortcomings. Peter Martin, Esq., in his column “Legal Consult” gives us an update on a recent Massachusetts Supreme Judicial Court decision regarding whether MassHealth is subject to a statute of limitations when it attempts to recoup overpayments for services rendered by a health care entity. Reassuringly, the answer is that there is a six-year limitation.

We hope you enjoy and learn from the articles in this issue, and that you continue to read Worcester Medicine which focuses on a different theme each issue. Previous issues exploring topics affecting the medical community and the general public are available on our website: www.wdms.org/publications.

Peter Zacharia is an ophthalmologist in private practice in Worcester who has been on the editorial board of Worcester Medicine for several years.