Duke Research Blog

Following the people and events that make up the research community at Duke.

Category: Medicine Page 1 of 15

Understanding and Addressing Vaccine Hesitancy

In the midst of increasing outbreaks of vaccine-preventable disease, Duke global health researcher Lavanya Vasudevan (PhD, MPH, LPH) is investigating the reasons for vaccine hesitancy with focus on America and Tanzania.

Vaccine hesitancy refers to the refusal of or delay in accepting vaccinations, despite their availability. Vasudevan hopes to figure out what interventions will change the minds of target populations on such a heated topic.

She presented at Duke’s Global Health Institute on November 15th about her “big 5 research areas:” identification of sub-optimal vaccine uptake, contextualization of barriers to uptake, measuring parental concern, debunking misinformation, and developing and testing strategies aimed at addressing vaccine hesitancy.

Lavanya Vasudevan presenting at Duke’s Global Health Institute.

Globally, Vasudevan says that there are too many kids playing catch-up with their vaccines, meaning that even when children are getting vaccinated, the vaccinations they receive are not on time with the scheduled progression of immunizations, putting them at risk for contracting disease. Different countries measure vaccination coverage in different ways and on different timelines, which makes it harder to understand where sub-optimal vaccine uptake is happening. A better standard for assessing timeliness of vaccines is crucial. Vasudevan is working to confront this issue to gain better understanding of who and where hesitancy is coming from.

Identification of specific regions of vaccine hesitancy is crucial to navigating interventions, she added. Vasudevan wants to be able to pinpoint areas and understand the context-specific issues that vary across time, place, and vaccine type in order to be most effective.

She said that her work in Tanzania has provided insight to the problem of geographic accessibility and lack of proper supplies in the country, prompting delayed and missed vaccinations among 72% of children, according to self-reporting by their mothers. Tanzanian mothers expressed their frustrations during interviews. They frequently arrange to go to a clinic where vaccinations are offered on specific dates and travel long distances to get there. However, if there are not enough kids who come to be vaccinated, the facilities just won’t vaccinate those who did manage to show up for immunizations.  

Though the qualitative data gained through extensive interviewing and group discussions has been extremely useful and rich, Vasudevan says there is a need for quantitative tools that can rapidly screen for parent’s concerns when it comes to the vaccination of their children. Qualitative data is simply not informative on a large scale.

A review of pre-existing measures evaluated 159 studies, but the quantitative scales found were often complex and context-specific, as well as designed and validated for high-income settings. On this basis, Vasudevan and her larger research team decided to design a scale for use in Tanzania because of its specificity in addressing the contexts of the region. Tailored counseling is also being used to address the local concerns and issues.

Another parallel research project that Vasudevan is involved with aims to identify common vaccine myths, creating a taxonomy to tag these myths and developing and testing an intervention that will highlight and debunk misinformation found on the internet. The current end-goal for the work being done is a “vaccine fact-checker” that could be used on web browsers to identify the myths in vaccine-related information found online.

A common example of needles and vials containing immunization products (Creative Commons).

In closing, Vasudevan identified three main areas for developing and testing intervention strategies. She says these are behavioral nudges, educational strategies, and vaccination policy and legislation.

There is a need for parent-focused strategies that recognize parental concern for their child’s safety on all sides of the vaccination issue, she said. Stringent policies are likely to alienate hesitant parents rather than increasing vaccine uptake. This is why Vasudevan is so focused on understanding and contextualizing issues specific to hesitancy among parents. It seems that increase of vaccinations and improvement of immunization timeliness lies in hearing and reconciling with parental apprehensions and underlying root causes of these hesitations.

One area of focus that Vasudevan feels is underutilized is pre-natal care. Reduction of the divide between obstetrician/gynecologists (OBGYNs) and pediatric care may be a crucial component to educate parents and enrich their understanding about vaccinations following the birth of the child.

Beyond everything else, she said, building trust is essential; simply providing information to parents is not enough. It takes time and empathy to be enable parents to make healthy vaccination choices. Providing credible resources in a safe environment while tuning in to the causes of hesitancy may be the next step to the reduction of vaccine-preventable disease, a current top ten threat to global health.

Post by Cydney Livingston

Dreams of Reality: Performing Dementia

White Lecture Hall’s auditorium is a versatile space. It hosts classes, speakers, and student organizations. And this Wednesday, White 107 was an institution for the elderly, an elementary school classroom, a lake, and an old blue house.

On October 23, Duke welcomed solo artist Kali Quinn to the stage to perform her now 13-year-old, one-woman show, Vamping. Vamping is an artistic and humanistic rendition of dementia, inspired by Quinn’s personal experience with a grandmother who moved into an institution just as Quinn was leaving for college on the other side of the country. It tells the story of 91-year-old Eleanor Butler, who drifts in and out of old memories, joys, and regrets as she experiences dementia in an elderly care facility.

Eleanor undergoing a PET scan

Throughout the hour-long performance, the physicality of the stage remains constant. There is one actor, Quinn herself, accompanied by a few props: a projector, a wheelchair, a blanket, a voice recorder. Yet each of these, Quinn included, shapeshift constantly. Quinn plays not only Eleanor, but also a caregiver, a granddaughter, and Eleanor’s younger selves at different stages of life.

That’s what dementia is like, Quinn explains. It’s experiencing a hundred different things all at once. 

“I don’t know what’s dream and what’s awake,” says an elderly Eleanor as she returns from an old memory and just before she’s immersed into another one.

Vamping captures the existence of identity and personhood in diagnosis, according to Jessica Ruhle, Director of Education at the Nasher Museum of Art. While the story has no clear plot and no clear resolution, it flows in a way that is real and personal. At 91, Eleanor re-experiences her elementary school spelling bee, her 16-year-old flirtationship with the boy who would become her husband, the birth of her first child, her regret at not being a better wife and mother and grandmother, and so much more. She doesn’t particularly succeed in making sense of it all, but neither does she try. The resolution is simply an acceptance of life’s complexity.

A series of memories, materialized through pieces of film, are held over a 91-year-old Eleanor. This is the last scene of the performance.

Janelle Taylor, a medical anthropologist at the University of Toronto and one of the panelists following the performance, explained that this complexity is what differentiates pure medicine from an anthropological approach. “I do kind of the opposite of what medicine does,” she said. “Medicine makes sense of things by excluding possible causes and contexts. Anthropology seeks to bring it all together.”

The entanglement of all these different possible factors perhaps explains why Quinn’s performance also offers glimpses into the lives of caregivers, family members, and others who share in the experience of dementia. In many cases, a single diagnosis affects a far larger network than just the diagnosed patient.

And though that’s true in Vamping as well as the panelists’ experiences with dementia, they acknowledge that other stories of the same condition often go untold. “We’re very alike in our whiteness, our economic condition and ability to afford professional care,” said Ruhle, referring to herself and Quinn. After all, Eleanor experiences dementia within a care institution—which, according to Eleanor in the play itself, costs about $85,000 per year.

Taylor added that she was searching for more data on diagnosed persons who have no healthcare or no family. Unfortunately, there isn’t much existing research on such people, and the data are difficult to find. And adding onto that, there are many cases of dementia that are never formally diagnosed at all.

But even so, Quinn’s performance is important to share. Vamping doesn’t attempt to do the impossible by telling a universal narrative of aging and dementia; instead, it gives an immensely personal and humanistic story of one patient’s experience of life.

Even the cold realities play into its personal nature as well. As Eleanor exclaims at one point in the performance, more money is spent yearly on Viagra and breast implants than on Alzheimer’s. The implication is clear: there’s a need for more research, and there’s a need for more humanness.

By Irene Park

Meet the New Blogger: Meghna Datta

Hi! My name is Meghna Datta, and I’m a freshman. I’m from Madison, Wisconsin, so North Carolina weather has been quite the adjustment. Apart from the humidity, though, I’m so excited to be at Duke! I’m an aspiring pre-med student with absolutely no idea what I want to major in. And it’s funny that I’ve grown to love science as much as I do. Up until tenth grade, I was sure that I would never, ever work in STEM.

My first love was the humanities. As a child I was hooked on books (still am!) and went through four or five a week. In high school, I channeled my love for words into joining my school’s speech and debate team and throwing myself into English and history classes, until being forced to take AP Biology my sophomore year completely changed my trajectory.

Science had always bored me with its seemingly pointless intricacies. Why would I want to plod through tedious research when I could be covering a groundbreaking story or defending justice in a courtroom instead? But the lure of biology for me was in its societal impact. Through research, we’ve been able to cure previously incurable diseases and revolutionize treatment plans to affect quality of life.

Meghna Datta repping the Devils

In AP Bio, understanding the mechanisms of the human body seemed so powerful to me. Slowly, I began to entertain the notion of a career in medicine, one of many scientific fields that works to improve lives every day.

Now, the research going on at Duke doesn’t cease to amaze me. Specifically, I’m interested in science for social good. Be it sustainable engineering, global health, or data-driven solutions to problems, I love to see the ways in which science intersects with social issues. As I have learned, science does not need to be done in isolation behind pipettes. Science is exciting and indicative of society’s shared sense of humanity. At Duke, there’s no shortage of this environment.

As a blogger I’m so excited to see the inspiring ways that peers and faculty are working to solve problems. And because science isn’t a traditionally “showy” field, I am looking forward to shining the spotlight on people at Duke who tirelessly research behind the scenes to impact those at Duke and beyond. The research community at Duke has so much to celebrate, and through blogging I’m excited to do just that!

Designing Tomorrow, One Healthcare Innovation at a Time

Imagine a live, health-focused version Shark Tank open to the public: presentations from real health professionals, presenting real innovations they developed to address real health care issues. And yes, there are real money awards at stake.

It’s the 2019 Duke Health Innovation Jam.

At ten minutes ‘til show time, people gather in small groups clothed in suits, business attire, and white coats. They chat in low voices. The hum of comfortable conversation buzzes through the room. The sixth floor of the Trent Semans Center is quite the setting. Three sides of the room are encapsulated in glass and you can easily see an expansive view of both Duke’s West and Medical campuses, as well as luscious green trees comprising parts of Duke’s Forest. Naturally, there is a glorious view of the Chapel, basked in sunlight.

This light finds its way into the room to shine on various research posters at the back displayed on a few rows of mobile walls. Though a few strays meander through the stationary arrangements – stopping to look more closely at particular findings – most people make their way into the room and find a seat as the minutes dwindle away. The hum grows and there is a bit of anticipatory energy among those readying themselves to present.

At three minutes after 10, the program director of the Duke Institute for Health Innovation, Suresh Balu, takes position at the front of the room, standing before the small stage at center that is surrounded by lots of TV monitors. No seat in the room is a bad one. Balu indicates that it is time to begin and the hum immediately dissipates. He explains the general format of the event: six pitches total, five minutes to present, eight minutes to answer questions from investors, a show-of-hand interest from investors, and transition to the next pitch, followed by deliberation and presentation of awards.

After a round of thanks, introduction of the emcee – Duke’s Chief of Cardiology, Dr. Manesh Patel – the curtains opened – figuratively – on Duke’s fifth annual Innovation Jam.

Groups presented on the problems they were addressing, their proposed innovations, and how the innovations worked. There was also information about getting products into the market, varying economic analysis, next steps or detailed goals for the projection of the projects, and analysis of the investment they are currently seeking and for what purposes.

The first group pitched an idea about patient-centric blood draw and suggest a device to plug into existing peripheral draws to reduce the frequent poking and prodding that hospital patients often experience during their hospital stay when blood is needed for lab tests. Next up was a group who designed an intelligent microscope for automated pathology that has a programmable system and uses machine learning to automate pathological blood analysis that is currently highly time consuming. Third at bat was a group that made a UV light bag to clean surgical drain bags that frequently become colonized with bacteria and are quite frankly “nasty” – according to the presenter.

Batting cleanup was PILVAS – Peripherally Inserted Left Ventricular Vent Anticoagulation System – which is a device that would be accessory to VA ECMO support to reduce thromboembolism and stroke that are risks of ECMO. Fifth was the ReadyView and ReadyLift, a laparoscopic tool set that is much cheaper than current laparoscopic tools and methods, and because of its ability to be used with any USB compatible laptop, it would increase access to laparoscopic surgery in countries that have a high need for it. Last, but not least, was an innovation that is the first synthetic biometric osteochondral graft for knee cartilage repair that hopes to improve knee osteoarthritis surgical care as the first hydrogel with the same mechanical properties of cartilage.

Following a quick ten-minute break for investors to huddle around and discuss who should win the awards – $15,000 for Best Innovation and $15,000 for Best Presentation – the winners were announced. Drumroll, please.

ReadyView won Best Presentation and the synthetic osteochondral graft won Best Innovation. A pair of representatives from Microsoft were also in attendance – a first for the Innovation Jam – and awarded SalineAI, the group who designed the intelligent microscope with an independent award package.

Patel, the emcee, says we are in the midst of a fourth industrial revolution.

“What is the biggest cinema in the world?” Patel asked. “Netflix,” he says. Industries are reimagining themselves and healthcare is no exception.

What is the best healthcare system of the future going to look like? Of course, we really don’t know, but there are certainly people who are already doing more than just think about it.

Beyond Classroom Walls: Research as an Undergrad

“Science is slow,” says Duke undergraduate Jaan Nandwani. That’s one of the takeaways from her first experience with scientific research. For Nandwani, being part of a supportive lab makes it all worthwhile. But we’re getting ahead of ourselves. This statement needs context.

Nandwani, a prehealth sophomore, currently conducts research in the lab of neurologist Nicole Calakos, MD, PhD. The Calakos lab is focused on synaptic plasticity: changes that occur at the communication junctions between nerve cells in the brain. The lab researches how the brain responds to changes in experience. They also investigate the mechanistic mishaps that can occur with certain neurological conditions.

A neuron from a mouse brain. From Wikimedia Commons.

As a continuation of an 8-week summer research program she participated in earlier this year, Nandwani has been studying dystonia, a brain disorder that causes uncontrollable muscle contractions. She’s using western blot analysis to determine if the activity of a protein called eIF2α is dysregulated in the brain tissue of mice with dystonia-like symptoms, compared with their normal littermates. It is currently unclear if and when targeting the eIF2 signaling pathway can improve dystonia, as well as where in the brain “selective vulnerability” to the signaling occurs. If Nandwani is able to identify a specific region or time point “in which the pathway’s dysregulation is most predominant,” more effective drug therapy and pharmacological interventions can be used to treat the disorder. 

Outside of her particular project, Nandwani attends lab meetings, learning from and contributing to the greater Calakos lab community. Scientific work is highly collaborative and Nandwani’s experience is testament to that. Along with providing feedback to her own presentations in meetings and answering any questions she may have, Nandwani’s fellow labmates are always eager to discuss their projects with her, give her advice on her own work, and have helped her “develop a passion for what [she is] studying.” They’ve also helped her learn new and improved ways to conduct the western blot process that is so integral to her work. Though she admits it is tedious, Nandwani said that she enjoys being able to implement better techniques each time she conducts the procedure. She also says she is thankful to be surrounded by such a supportive lab environment.

It might seem hard to believe granted the scope and potential impacts of her work, but this is Nandwani’s first experience with research in a lab. She knew when coming to Duke that she wanted to get involved with research, but she says that her experience has surpassed any expectations she had – by far. Though she doesn’t necessarily foresee continuation of research in the form of a career and is more fascinated by clinical applications of scientific research, the experience cannot be replicated within a classroom setting. Beyond the technical skills that Nandwani has developed, she says that the important and valuable mentoring relationships she has gained simply couldn’t be obtained otherwise.

Duke undergraduate Jaan Nandwani doing research in the Calakos lab.

Nandwani hopes to continue in the Calakos lab for the remainder of her time at Duke – that’s two and a half more years. Though she will work on different projects, the quest to pose and answer scientific questions is endless – and as Nandwani said, science is slow. The scientific process of research takes dedication, curiosity, collaboration, failure, and a continued urge to grow. The scientific process of research takes time, and lots of it. Of course the results are “super exciting,” Nandwani says, but it is the experience of being part of such an amazing group of scholars and scientists that she values the most.

By Cydney Livingston

Vaping: Crisis or Lost Opportunity?

Wikimedia Commons

Whether you’re doing vape tricks for YouTube views or kicking yourself for not realizing that “USB” was actually your teenager’s Juul, you know vaping is all the rage right now. You probably also know that President Trump has called on the FDA to ban all flavored e-cigarettes to combat youth vaping. This comes in reaction to the mysterious lung illness that has affected 1,080 people to date. 18 of them have died.

At Duke Law School’s “Vaping: Crisis or Lost Opportunity” panel last Wednesday, three experts shared their views. 

Jed Rose, a professor of psychiatry and behavioral sciences and director of the Duke Center for Smoking Cessation, has worked in tobacco research since 1979, focusing on smoking cessation and helping pioneer the nicotine patch. Rose also directs Duke’s Center for Smoking Cessation.

According to Rose, e-cigarettes are more effective than traditional Nicotine Replacement Therapy (NRT). A recent study found that e-cigarettes were approximately twice as effective as the state-of-the-art NRT in getting smokers to quit combustible cigarettes (CCs). This makes sense because smokers are addicted to the action of puffing, so a smoking cessation tool that involves inhaling will be more successful than one that does not, like the patch.

Rose also took issue with the labeling of the current situation surrounding vaping as an “epidemic.” He called it a “crisis of exaggeration,” then contrasted the 18 deaths from vaping to the 450 annual deaths from Tylenol poisoning

Even in the “pessimistic scenario,” where e-cigarettes turn out to be far more harmful than expected, Rose said deaths are still averted by replacing cigarettes with e-cigarettes. 

The enemy, Rose argued, is “disease and death, not corporations”, like the infamous (and under-fire) Juul. 

James Davis, MD, an internal medicine physician and medical director for the Center for Smoking Cessation, works directly with patients who suffer from addiction. His research focuses on developing new drug treatments for smoking cessation. Davis also spearheads the Duke Smoke-Free Policy Initiative.

Davis began by calling for humility when using statistics regarding e-cigarette health impacts, as long-term data is obviously not yet available. 

Davis did present some known drawbacks of e-cigarettes, though, stating that e-cigarettes are similarly addictive compared to conventional cigarettes, and that a whopping 21% of high school students and 5% of middle school students use e-cigarettes. Davis also contended that “When you quit CCs with e-cigarettes, you are merely transferring your addiction to e-cigarettes. Eighty-two percent [of test subjects who used e-cigarettes for smoking cessation] were still using after a year.” 

However, according to Davis, there is a flipside. 

Similar to Rose, Davis looked to the “potential for harm reduction” — e-cigarettes’ morbidity is projected to be only 5-10% that of CCs. If the main priority is to get smokers off CC, Davis argues e-cigarettes are important: 30-35% of CC smokers say they would use an e-cigarette to quit smoking, where only 13% would use a nicotine patch. 

Furthermore, Davis questioned whether the mysterious lung disease is attributable to e-cigarettes themselves — a recent study found that 80% of a sample of afflicted subjects had used (often black-market) THC products as well.

Lauren Pacek, an assistant professor in psychiatry and behavioral sciences at Duke, examines smoking in the context of addiction and decision-making.

Pacek stated that flavored electronic nicotine delivery systems (ENDS) are important to youth: 61-95% of current youth ENDS users use flavored products, and 84% of young users say they would not use the products without flavors. So, banning flavored ENDS would ostensibly reduce young adults’ use, potentially keeping them off nicotine entirely.

However, Pacek pointed to the importance of flavors for adult users too: the ones that are purportedly using ENDS not for recreation or social status (as young people have been known to do), but for smoking cessation. Many former CC smokers report that flavored ENDS were important for their cessation. By banning flavored ENDS, the products look less appealing, and smokers are more likely to return to much more harmful cigarettes.  

So where do we go from here? 

Pacek did not take a concrete stance, but said her “take-home message” was that policymakers need to consider the impact of the ban on the non-target population, those earnest cigarette smokers looking to quit, or at least turn to a less harmful alternative. 

Rose also did not offer a way forward, but made clear that he does not support the FDA’s impending ban on flavored e-cigarettes and thinks the hysteria around vaping is mostly unfounded.

Davis did not suggest a course of action for the US, but as leader of Duke’s Smoke-Free Policy Initiative, he certainly suggested a course of action for Duke. The Initiative prohibits combustible forms of tobacco at Duke, but does not (yet) prohibit e-cigarettes. 

By Zella Hanson

Overdiagnosis and the Future of Cancer Medicine

For many years, the standard strategy for fighting against cancer has been to find it early with screening when the person is still healthy, then hit it with a merciless treatment regimen to make it go away.

But not all tumors will become life-threatening cancers. Many, in fact, would have caused no issues for the rest of the patients’ lives had they not been found by screening. These cases belong to the category of overdiagnosis, one of the chief complaints against population-level screening programs.

Scientists are reconsidering the way to treat tumors because the traditional hit-it-hard approach has often caused the cancer to seemingly go away, only to have a few cells survive and the entire tumor roar back later with resistance to previously effective medicine.

Dr. Marc Ryser, the professor who gave this meaty talk

In his May 23 talk to Duke Population Health, “Cancer Overdiagnosis: A Discourse on Population Health, Biologic Mechanism and Statistics,” Marc Ryser, an assistant professor at Duke’s Departments of Population Health Sciences and Mathematics, walked us through how parallel developments across different disciplines have been reshaping our cancer battle plan. He said the effort to understand the true prevalence of overdiagnosis is a point of focus in this shift.

Past to Future: the changing cancer battle plan
Credit: Marc Ryser, edit: Brian Du

Ryser started with the longstanding biological theory behind how tumors develop. Under the theory of clonal sweeps, a relatively linear progression of successive key mutations sweeps through the tumor, giving it increasing versatility until it is clinically diagnosed by a doctor as cancer.

Clonal sweeps model, each shade is a new clone that introduces a mutation credit: Sievers et al. 2016

With this as the underpinning model, the battle plan of screen early, treat hard (point A) makes sense because it would be better to break the chain of progression early rather than later when the disease is more developed and much more aggressive. So employing screening extensively across the population for the various types of cancer is the sure choice, right?

But the data at the population level for many different categories of cancers doesn’t support this view (point B). Excluding the cases of cervical cancer and colorectal cancer, which have benefited greatly from screening interventions, the incidence of advanced cases of breast cancer and other cancers have stayed at similar levels or actually continued to increase during the years of screening interventions. This has raised the question of when screening is truly the best option.

Scientists are thinking now in terms of a “benefit-harm balance” when mass-screening public health interventions are carried out. Overdiagnosis would pile up on the harms side, because it introduces unnecessary procedures that are associated with adverse effects.

Thinking this way would be a major adjustment, and it has brought with it major confusion.

Paralleling this recent development on the population level, new biological understanding of how tumors develop has also introduced confusion. Scientists have discovered that tumors are more heterogeneous than the clonal sweeps model would make it appear. Within one tumor, there may be many different subpopulations of cancer cells, of varying characteristics and dangerousness, competing and coexisting.

Additional research has since suggested a more complex, evolutionary and ecological based model known as the Big Bang-mutual evolution model. Instead of the “stepwise progression from normal to increasingly malignant cells with the acquisition of successive driver mutations, some cancers appear to evolve more like a Big Bang, where the malignant ability is already concentrated in the founder cell,” Ryser said.

As the first cell starts to replicate, its descendants evolve in parallel into different subpopulations expressing different characteristics. While more research has been published in favor of this model, some scientists remain skeptical.

Ryser’s research contributes to this ongoing discussion. In comparing the patterns by which mutations are present or absent in cancerous and benign tumors, he obtained results favoring the Big Bang-mutual evolution model. Rather than seeing a neat region of mutation within the tumor, which would align with the clonal sweeps model, he saw mutations dispersed throughout the tumor, like the spreading of newborn stars in the wake of the Big Bang.

How to think about mutations within a tumor
credit: NASA

The more-complicated Big Bang-mutual evolution model justifies an increasingly nuanced approach to cancer treatment that has been developing in the past few years. Known as precision medicine (point C), its goal is to provide the best treatment available to a person based on their unique set of characteristics: genetics, lifestyle, and environment. As cancer medicine evolves with this new paradigm, when to screen will remain a key question, as will the benefit-harm balance.

There’s another problem, though: Overdiagnosis is incredibly hard to quantify. In fact, it’s by nature not possible to directly measure it. That’s where another area of Ryser’s research seeks to find the answers. He is working to accurately model overdiagnosis to estimate its extent and impact.

Going forward, his research goal is to try to understand how to bring together different scales to best understand overdiagnosis. Considering it in the context of the multiscale developments he mentioned in his talk may be the key to better understand it.

Post by Brian Du

How the Flu Vaccine Fails

Influenza is ubiquitous. Every fall, we line up to get our flu shots with the hope that we will be protected from the virus that infects 10 to 20 percent of people worldwide each year. But some years, the vaccine is less effective than others.

Every year, CDC scientists engineer a new flu virus. By examining phylogenetic relationships, which are based on shared common ancestry and relatedness, researchers identify virus strains to target with a vaccine for the following flu season.

Sometimes, they do a good job predicting which strains will flourish in the upcoming flu season; other times, they pick wrong.

Pekosz’s work has identified why certain flu seasons saw less effective vaccines.

Andrew Pekosz, PhD, is a researcher at Johns Hopkins who examines why we fail to predict strains to target with vaccines. In particular, he examines years when the vaccine was ineffective and the viruses that were most prevalent to identify properties of these strains.

A virus consists of RNA enclosed in a membrane. Vaccines function by targeting membrane proteins that facilitate movement of the viral genome into host cells that it is infecting. For the flu virus, this protein is hemagglutinin (HA). An additional membrane protein called neuraminidase (NA) allows the virus to release itself from a cell it has infected and prevents it from returning to infected cells.  

The flu vaccine targets proteins on the membrane of the RNA virus. Image courtesy of scienceanimations.com.

Studying the viruses that flourished in the 2014-2015 and 2016-2017 flu seasons, Pekosz and his team have identified mutations to these surface proteins that allowed certain strains to evade the vaccine.

In the 2014-2015 season, a mutation in the HA receptor conferred an advantage to the virus, but only in the presence of the antibodies present in the vaccine. In the absence of these antibodies, this mutation was actually detrimental to the virus’s fitness. The strain was present in low numbers in the beginning of the flu season, but the selective pressure of the vaccine pushed it to become the dominant strain by the end.

The 2016-2017 flu season saw a similar pattern of mutation, but in the NA protein. The part of the virus membrane where the antibody binds, or the epitope, was covered in the mutated viral strain. Since the antibodies produced in response to the vaccine could not effectively identify the virus, the vaccine was ineffective for these mutated strains.

With the speed at which the flu virus evolves, and the fact that numerous strains can be active in any given flu season, engineering an effective vaccine is daunting. Pekosz’s findings on how these vaccines have previously failed will likely prove invaluable at combating such a persistent and common public health concern.

Post by undergraduate blogger Sarah Haurin
Post by undergraduate blogger Sarah Haurin


‘Death is a Social Construct’

Of the few universal human experiences, death remains the least understood. Whether we avoid its mention or can’t stop thinking about it, whether we are terrified or mystified by it, none of us know what death is really like. Turns out, neither do the experts who spend every day around it.

Nobody who sees this guy reports back, so we can only guess.

This was the overarching lesson of Dr. Robert Truog’s McGovern Lecture at Trent Semans Center for Health Education, titled “Defining Death: Persistent Problems and Possible Solutions.”

Dr. Truog is this year’s recipient of the McGovern Prize, an award honoring individuals who have made outstanding contributions to the art and  science of medicine. Truog is a professor of medical ethics, anesthesiology and pediatrics and director of the center for bioethics at Harvard Medical School. He is intimately familiar with death, not only through his research and writings, but through his work as a pediatric intensive care doctor at Boston Children’s Hospital. Truog is also the author of the current national guidelines for end-of-life care in the intensive care unit.

In short, Truog knows a lot about death. Yet certain questions about the end of life remain elusive even to him. In his talk, he spoke about the biological, sociological, and ethical challenges involved in drawing the boundary between life and death. While some of these challenges have been around for as long as humans have, certain ones are novel, brought on by technological advancements in medicine that allow us to prolong the functioning of vital organs, mainly the brain and the heart.

The “irreversible cessation of function” of these organs results in brain and cardiac death, respectively. When both occur together, the patient is declared biologically dead. When they don’t, such as when all brain function except for those that support the patient’s digestive system is lost, for instance, the patient can be legally alive without any hope of recovery of consciousness.

Robert Truog teaching (Harvard photo)

According to Truog, it is in these moments of life after the loss of almost every brain function that we realize “death is a social construct.” This claim likely sounds counterintuitive, if not entirely nonsensical, as dying is the moment we have the least control over our biology. What Dr. Truog means, however, is that as technology continues to mend failures of biology that would have once been fatal, our social and philosophical understanding of dying, what he calls “person death” will increasingly separate from the end of the body’s biological function.  

Biologically, death is the moment when homeostasis, the body’s internal state of equilibrium including body temperature, pH levels and fluid balance, fails and entropy prevails.

Personhood, however, is not mere homeostasis. Dr. Truog cited Robert Veatch, ethicist at Georgetown University, in defining person death as the “irreversible loss of that which is essentially significant to the nature of man.” For those patients who are kept alive by ventilators and who have no hope of regaining consciousness, that essentially significant nature appears to have been lost.

Nonetheless, for loved ones, signs like spontaneous breathing, which can occur in patients in persistent vegetative state, intuitively feel like signs of life. This intuitive sign of life is what made Jahi McMath’s parents refuse an Oakland California hospital’s declaration that their daughter was dead. A ventilator kept the 13-year-old breathing, even though she had been declared brain-dead. After much conflict, McMath’s parents moved her to a hospital in New Jersey, one of just two states where families can reject brain death if it does not align with their religious beliefs. In the end, McMath had two death certificates that were five years apart.


Muslim cemetery at sunset in Marrakech Morocco.
(Mohamed Boualam via Wikimedia commons)

The emotional toll of such an ordeal is immense, as the media outcry around McMath made more than clear. There are more concrete, quantifiable costs to extending biological function beyond the end of personhood: the U.S. is facing an organ shortage. As people are kept on life support for longer periods, it is going to become increasingly difficult for patients who desperately need organs to find donors.

In closing, Dr. Truog reminded us that “in the spectrum between alive and dead, we set the threshold… Death is not a binary state, but a complex social choice.” People will likely continue to disagree about where we should set the threshold, especially as technology develops.

However, if we want to have a thoughtful discussion that respects the rights, wishes, and values of patients, loved ones, and everybody else who will one day face death, we need to first agree that there is a choice to be made.

Guest Post by Deniz Ariturk, Science & Society graduate student

Zapping Your Brain Is Dope

Emerging technology has created a new doping technique for athletic performance that is, as of now, perfectly legal.

Coined “neuro-doping,” this method sends electric current through one’s brain to facilitate quicker learning, enhanced muscular strength, and improved coordination. Use of this electronic stimulus has taken off in the sports world as a replacement for other doping methods banned by the World Anti-Doping Agency (WADA). Because it’s relatively new, WADA has yet to establish rules around neuro-doping. Plus, it’s virtually undetectable. Naturally, a lot of athletes are taking advantage of it.

Image result for doping

One specific method of neuro-doping is known as Transcranial Direct-Current Stimulation (tDCS). It works by sending a non-invasive and painless electrical current through the brain for around three to 20 minutes, in order to excite the brain’s cortex, ultimately increasing neuroplasticity (Park). This can be done commercially via a headset like device for $200.

Image result for transcranial direct current stimulation headset
The Halo Sport

Weight lifters, sprinters, pitchers, and skiers are just some of many types of athletes who can benefit from tCDS. By practicing with these headphones on, new neural pathways are constructed to help their bodies achieve peak performance. Dr. Greg Appelbaum, director of Opti Lab and the Brain Stimulation Research Center, says it’s especially useful for athletes where technique and motor skills triumph — such as a sprinter getting out of the blocks or an Olympic ski jumper hanging in the air. Top-tier athletes are pushing that fine limit of what the human body can accomplish, but neuro-doping allows them to take it one step further.

Neuro-doping has other applications, too. Imagine insanely skilled Air Force pilots, surgeons with exceptionally nimble hands, or soldiers with perfect aim. tCDS is being used to make progress in things like Alzheimer’s and memory function because of its impact on cognitive functioning in the forms of increased attention span and memory. You could even learn the guitar faster.

In this sort of context, it’s a no brainer that neuro-doping should be taken advantage of. But how ethical is it in sports?

The precedent for WADA to ban a substance or technique has been based on meeting two of the following three criteria: (1) drugs or tools that likely enhance performance to secure a winning edge; (2) drugs or tools that place athletes’ health at risk; (3) any substances or techniques that ruin the “spirit-of-sport” (Park). Lots of research has shown tCDS is pretty legit. As for health risks, tCDS is still in the experimental stage, so not much can be said about its side effects. Ethically, it causes a lot of controversy.

Many issues come into play when thinking about allowing athletes to neuro-dope. Given its similarities with other popular drugs, tCDS could introduce unfair advantages. Furthermore, not everyone may have access to the technology, and not everyone may want to use it. However, it’s important to note that sports already have unfair advantages. Access to things like proper coaching and nutrition may not be a reality for everyone. Sports are just inherently competitive.

Back when baseball players doped, it was awesome to watch them crush balls out of the park. Reintroducing performance enhancement through tCDS could mean we start seeing mountain bikers launching insane air and world records being smattered. The human body could achieve newfound heights.

Are the benefits worth it? Does neuro-doping ruin the “spirit of the sport?” Regardless of these important questions, tCDS is a fascinating scientific discovery that could make a difference in this world. So, what do you think?

Will Sheehan
Post by Will Sheehan

Park, Cogent Social Sciences (2017), 3: 1360462
https://doi.org/10.1080/23311886.2017.1360462

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