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

Category: Medicine Page 2 of 20

Poetry and Pedagogy: The Push for Humanities Education in Medicine

“If language shapes inequitable systems, then their disruption relies in part on our ability to effectively wield language in subversive ways”

Dr. Irène Mathieu, MD
Dr. Mathieu reading from her award-winning 2017 book orogeny 

Buried within a smattering of bullet points and data nuggets, these evocative words flashed across the slide deck of Dr. Irène Mathieu, MD. As Assistant Professor of Pediatrics at the University of Virginia School of Medicine and an award-winning poet, Mathieu thinks medical students could benefit from a stronger background in the humanities. Over the course of her guest lecture, “Playing Between the Lines: Poetry by a Pediatrician,” Mathieu dropped many such pieces of wisdom linking the study of language, and more broadly the humanities, with the practice of medicine. She shared this wisdom through a variety of methods, including original poetry, anecdotes from her life, and the latest research into the field of narrative medicine. The lecture was organized by the Trent Center for Bioethics, Humanities, and History of Medicine and hosted by Dr. Sneha Mantri, MD, MS, Assistant Professor of Neurology at Duke University School of Medicine.

Published in 2016 and co-authored by Dr. Charon, “The Principles and Practice of Narrative Medicine” is considered as one of the influential works in the field. 

The field of narrative medicine, hardly twenty years old, can trace its roots to Columbia University, when a group of physicians and scholars, spearheaded by Dr. Rita Charon, MD, PhD, sought to change the discourse surrounding traditional medical training. Emphasizing various humanities-based approaches, narrative medicine seeks to increase the propensity of physicians to perceive strife, uncertainty, and complexity in the pursuit of caring for complex illnesses. In her discussion, Mathieu cited multiple studies that detail the positive impact of an exposure to the humanities on the empathy, wisdom, tolerance for ambiguity, and resistance to burnout in medical students. More recent studies have shown that narrative medicine experimental training programs have similar impacts.

Like many of her contemporaries, Mathieu sees the utility in narrative medicine to impact not only the personal lives of physicians, but also the systems in which they interact. By approaching treatment through the lens of narrative medicine, she believes that physicians can better reimagine health systems into more equitable entities. In her pursuit of greater health equity, Mathieu identified two concepts that every physician should strive to possess: structural competency and critical consciousness. Structural competency, a term coined by her colleagues in an influential 2014 paper, proposes a model of patient engagement that goes beyond the realm of cultural awareness and further into understanding upstream, systemic issues such as zoning laws, food delivery systems, and health insurance. Critical consciousness, the ability to recognize the inherent contradictions and inequities within society, complements the structural competency framework. By consistently engaging in critical reading and reasoning, future physicians will be better able to reflect on the “power, privilege, and the inequities embedded within social relationships”.

While Mathieu recognized the power of narrative medicine, she also acknowledged how poetry has never had its proper place within the prose-heavy field. In her eyes, however, incorporating poetry into narrative medicine frameworks makes a lot of sense. For one, it allows a deeper level of vulnerability and dynamicity that literary fiction and theory cannot provide. More practically, however, poetry tends to err on the shorter side of literature (Mathieu calls them “multisensory micro-stories”), offering a less time-consuming alternative for busy medical students and residents.

For most of Mathieu’s life, her passion for poetry and medicine developed on parallel tracks. It wasn’t until her undergraduate years that she began to think of poetry more externally and started to seek out opportunities for publication. Around the same time, through her work in various global health initiatives, she witnessed the power words and policy can possess over the healthcare needs of entire populations. She identified a need for a humanities education, replete with poetry and theory and fiction, as critical to increasing equity within the healthcare system. When Mathieu assumed her latest role at UVA, on the eve of publishing her third poetry collection, the critically acclaimed Grand Marronage, she was given the opportunity to integrate her poetry within the university medical curriculum. Today, Mathieu has a secondary appointment as Assistant Director of the Program in Health Humanities at UVA’s Center for Health Humanities and Ethics. The parallel pathways of her life had converged.

As Mathieu revealed during her presentation, much of her poetry has little to do with her daily medical practice. Rather, she views poetry more along the lines of an escape. This escape takes the form of a critical reflection, by connecting the quotidian with themes of family and love, excess and presence. Mathieu’s poetry has the rare ability to walk readers through her complete narrative process, from the barest of sensory details to the ambiguities of emotion.

Perhaps there is no more fitting an ending to this article than an invitation to join Mathieu’s narrative world. After all, no amount of prose can substitute for a real poem. Below is a particularly striking excerpt of Mathieu’s artistry from the first stanza of her poem, “the forest fire of family trees”:

the problem is we don't know
that many ways of doing things
for instance, neither of us can
fry an egg without public radio
chattering in our ears, & there
are worse blueprints for a home,
like what my grandfather taught
my uncle. we think we know
people until we see the way
they eat a banana, totally unlike
how we peel and devour the fruit,
only instead of eating a banana
it's something way bigger,
like loving another person.
Post by Vibhav Nandagiri, Class of 2025

What are Healthcare Researchers Doing to Address Health Equity?

“Community engagement” and “health disparities” are some of the most trending terms in healthcare right now, but what are people actually doing about them? On Wednesday, February 2, panelists in healthcare sat down as part of Duke’s Research Week to talk about ways in which they and their organizations were actively addressing health disparities by focusing on communities. (View the session)

Dr. L. Ebony Boulware, professor at the Duke University School of Medicine and director of the Duke Clinical and Translational Science Institute, set the stage by defining health equity for the vast number of us that might only have read about it in a mission statement or an article but weren’t exactly sure how it was conceptualized. To work towards health equity, she said, means that “everyone has an opportunity to attain their full health potential regardless of any socially defined circumstance.” These circumstances could range from poverty to structural racism, but the main theme was that community engagement is a key player as we think about how best to achieve equity.

Slide taken from Dr. L. Ebony Boulware’s presentation.

COVID-19 is a great example of why health equity matters, as we ponder whether the pandemic could have turned out any different if more people had access to vaccines, personal protective equipment, and the capacity to socially distance. Dr. Michael Cohen-Wolkowiez, a professor of Pediatrics at the Duke University School of Medicine, and Dr. Giselle Corbie-Smith, a professor at the UNC School of Medicine gave a pertinent example of their work addressing the health disparity on our minds right now– access to COVID-19 testing – and the RADx program out of the NIH that is funding work to address this problem.

But even before COVID-19, attaining health equity was a tough goal to address for virtually every country in the world. Health equity isn’t just a nicety, it affects how long we are alive. And while progress in terms of life expectancy differences is improving, much work remains to be done to close the myriad gaps that remain. Dr. Tyson Brown, associate professor of Sociology at Duke, highlighted his research into structural racism to stress the fact that structural racism is toxic for population health and disproportionately affects people of color.

Slide taken from Dr. Tyson Brown’s presentation.

Dr. Schenita Davis Randolph, a registered nurse and professor at the Duke School of Nursing, zoomed in a little to highlight what true community engagement looks like. As part of her lab’s research to improve uptake of pre-exposure prophylaxis (PrEP) treatment to address HIV in Black women, they designed an intervention for beauty salons, known to be trusted venues for health promotion in the Black female community. But “how do we use community engagement so it’s not just a checkmark?” This, among other pressing challenges to community engagement in addressing health disparities, is what Dr. Keisha Bentley-Edwards, developmental psychologist and professor at the Duke University School of Medicine, talked about.

As the panel discussion came to a close, a key message emerged. As Dr. Davis remarked, both disparities and the communities that are hurt by them are complex, and so until we take a multi-faceted approach to understanding them, we continue to grasp for the ultimate goal of health equity.

But while these disparities are complex, they are certainly not unsolvable. Dr. Corbie-Smith emphasized that “we have a clear understanding of of how health disparities work.” All that’s left to do is solve them, and Dr. Bentley-Edwards highlights this move from awareness to solutions as a challenge to achieving health equity. Perhaps most significantly, though, it’s important to move from inertia to action. While there are seemingly thousands of ways in which communities in the U.S and around the world face barriers to health access, it’s important to do something – however small. As Dr. Bentley-Edwards concluded, by everyone working within their sphere of influence to close the health equity gap, that sphere becomes bigger and bigger and the gap becomes smaller and smaller.   

LowCostomy: the Low-Cost Colostomy Bag for Africa

It’s common for a Pratt engineering student like me to be surrounded by incredible individuals who work hard on their revolutionary projects. I am always in awe when I speak to my peers about their designs and processes.

So, I couldn’t help but talk to sophomore Joanna Peng about her project: LowCostomy.

Rising from the EGR101 class during her freshman year, the project is about building  a low-cost colostomy bag — a device that collects excrement outside the patient after they’ve had their colon removed in surgery. Her device is intended for use in under-resourced Sub-Saharan Africa.

“The rates in colorectal cancer are rising in Africa, making this a global health issue,” Peng says. “This is a project to promote health care equality.”

The solution? Multiple plastic bags with recycled cloth and water bottles attached, and a beeswax buffer.

“We had to meet two criteria: it had to be low cost; our max being five cents. And the second criteria was that it had to be environmentally friendly. We decided to make this bag out of recycled materials,” Peng says. 

Prototype of the LowCostomy bag

For now, the team’s device has succeeded in all of their testing phases. From using their professor’s dog feces for odor testing, to running around Duke with the device wrapped around them for stability testing, the team now look forward to improving their device and testing procedures.

“We are now looking into clinical testing with the beeswax buffer to see whether or not it truly is comfortable and doesn’t cause other health problems,” Peng explains.

Poster with details of the team’s testing and procedures

Peng’s group have worked long hours on their design, which didn’t go unnoticed by the National Institutes of Health (NIH). Out of the five prizes they give to university students to continue their research, the NIH awarded Peng and her peers a $15,000 prize for cancer device building. She is planning to use the money on clinical testing to take a step closer to their goal of bringing their device to Africa.

Peng shows an example of the beeswax port buffer (above). The design team of Amy Guan, Alanna Manfredini, Joanna Peng, and Darienne Rogers (L-R).

“All of us are still fiercely passionate about this project, so I’m excited,” Peng says. “There have been very few teams that have gotten this far, so we are in this no-man’s land where we are on our own.”

She and her team continue with their research in their EGR102 class, working diligently so that their ideas can become a reality and help those in need.

Post by Camila Cordero, Class of 2025

Junior Alec Morlote Pursues a Love for Biology Via Fruit Flies

As Alec Morlote emphasizes, he’s a Biology major because “I’m really interested in it. I’d definitely be a Biology major whether I was pre-med or not.”

Morlote, a Trinity junior from northern New Jersey, works in the lab of Dr. Pelin Volkan studying the neurobiology of fruit flies. Why fruit flies, of all things? Well, Morlote initially signed up for a research fellowship program during the summer following his freshman year.

Of course, in March of that year, COVID-19 happened, so Morlote ended up postponing his work to this past summer. He got paired with the Volkan lab because he didn’t want to work in an area of research that was very familiar to him.

“I wanted to use research as an opportunity to learn something completely new,” he said. The neurobiology of fruit flies hit the nail on the head.

Alec Morlote

The Volkan Lab is a cell biology and neurobiology lab that studies how social behavior, specifically courting, is affected by stimuli, using fruit flies as a model organism. Morlote’s specific project has to do with olfactory stimuli – the things flies smell. In flies, as he explained, one gene is responsible for courtship behavior in male flies. If you take out the olfactory receptor of the fly, however, that gene won’t be active.

Morlote is interested in seeing how the olfactory receptor is critical to the expression of this gene.

To do this, he has been working on imaging the antennae of flies – work he describes as “cool, but tedious.” It’s incredibly detailed work to pick apart the antenna off of such a tiny creature.  Once isolated, neurotransmitters in the antenna that have been tagged with green fluorescent protein (GFP) light up, thus showing the expression pattern of all cells expressing the neurotransmitter.

Humans clearly don’t have as simplistic a courtship behavior as fruit flies, but the simplicity of the fruit fly makes it an incredibly valuable organism for studying neurobiology. All discoveries in humans initially started with some sort of watered-down version of the human anatomy, whether mice or in this case, fruit flies. Discoveries into the neurobiology and neuroplasticity of fruit flies just might yield significant discoveries into the neurobiology and neuroplasticity of the human brain.

When asked about his favorite and least favorite parts about his research, Morlote laughed.

“I don’t like doing work for three months and getting no results at all,” he remarked in reference to the initial work he started on this summer – but alas, such is the nature of scientific research. But he adds that the best part of research is getting results, any at all. And even no results can mean something.

Morlote’s poster from his summer research

Research was a way for Morlote to narrow his post-graduation plans. He knows now that he wants to pursue an MD, or possibly an MD/PhD. But initially, research was a way for him to see whether this was the path for him at all. When asked why he chose to be pre-med, Morlote said that “it just seemed like the most practical way to apply a love for science.” Biology is the science that he loves the most, and so being pre-med seemed like a no-brainer.

It’s also a family business. Both of Morlote’s parents are doctors, so medicine “is not unfamiliar territory to me.” Being Latin American, both his parents have worked extensively with Latin communities in New Jersey, which is work he hopes to emulate in the future.

Whether or not benchwork stays a part of his life, Morlote knows that he wants his career to involve research somehow. The way he sees it, “you’re doing the bare minimum if you’re just a doctor but you’re not trying to better medicine in some way.” 

Contributing to research just might become his way.

Post by Meghna Datta, Class of 2023

The Most Important 26 Hours of My First Term at Duke

As any first-year will tell you, the scramble for joining new clubs can be a daunting one. As the dust settled from the Involvement Fair, I looked at the fistful of flyers overflowing from my desk. One of these flyers stood out to me in particular: Student Collaborative on Health Policy (SCOHP). The program, backed by the Duke Margolis Center for Health Policy, seeks to educate, serve, and research within the Duke and Durham community regarding the social, economic, and political determinants of health care.

The Four Committees of SCOHP

Intrigued, I ventured to the Social Sciences building the following Sunday afternoon for their inaugural GBM. The event was lively, filled with a dizzying number of avenues for involvement. One such avenue that was the SCOHP-organized Health Policy Case Competition, advertised as a two-day team sprint to develop and pitch solutions to a pressing health care problem. The prizes were handsome: $1,000 for 1st place, $500 for 2nd place, and $250 for 3rd place, courtesy of the Margolis Center and RTI International. Furthermore, participants would be given access to mentors and industry leaders with vast experience in the area of public health.

Six teams, each consisting of three to five members, participated in the case-writing festivities. On Friday, September 10 at 5:00 PM, the case document was released. Our task: to develop a five-year plan aimed at increasing the screening for human papillomavirus (HPV) in either Malawi, South Africa, or Eswatini via a novel imaging technology known as microbeads. A considerably complex task given the vast number of social, institutional, and political barriers lying between the new technology and the women who needed it the most, not to mention the potential for HPV developing into cervical cancer if left undetected and untreated.

The Case Competition Title Document

Our team, Team J, assumed the role of a local NGO partnering with the Eswatini government. The preliminary hours of the competition were spent sifting through a sea of research. We read reviews of tissue imaging technology, feasibility studies on drug distribution networks, and mathematical projections of healthcare costs. At once invigorating and ceaselessly frustrating, the process of developing a comprehensive solution required significant mental and physical rearrangement. The nine hours following the release of the case were spent in a variety of popular campus study spots, from Bostock to Rubenstein Library, The Coffeehouse to dorm common rooms. In the early morning hours, our plan had finally begun to take shape.

A meager five hours of rest separated Day One of the competition from Day Two. After a night of brainstorming and research, we were left with three hours to finalize our five-minute proposals before a hard 12:00 PM deadline. As the deadline approached, we changed into our best attire from the clavicle up (the marvels of Zoom) and sat down. For the next hour and change, ideas flowed thickly and quickly; eager and persuasive tones emanating from our screens, tense silence as the judges moved into breakout rooms for deliberation.

The top three teams, Team J included, were selected for a final presentation round. The guidelines for this round: strengthen the argument, lengthen the presentation. We were in the final stretch. What followed was two hours of remarkably focused work, the likes of which I had never experienced in a team setting. As we sat down for the deciding presentation of the competition, I felt an immense sense of pride, not only in our solution, but also in our twenty-six hour transformations from perplexed receivers to confident presenters. This confidence and breadth of knowledge was visible in all three teams over the course of their fifteen-minute presentations and subsequent five-minute Q&A’s.

Team J’s Final Round Presentation Over Zoom

As the clock struck 7:00 PM on Saturday, September 11, the judges had submitted their verdict, at which point the teams turned towards the screen with rapt attention. The SCOHP organizers began reading the final standings. In what was described as an extremely close decision for the judges, Team J ended up winning first place. Battling the equally powerful forces of disbelief and sleep deprivation, we let out a collective breath. It was all over.

At the time of the competition, I had yet to complete a month at Duke. I didn’t know it then, but those twenty-six hours would end up being some of the most impactful in my first semester. The competition offered an entirely different approach to learning, one that was grounded in interdisciplinary inquiry and effective collaboration. And to think–it all started with a flyer buried underneath many other flyers.

Post by Vibhav Nandagiri, Class of 2025

Science Behind the Scenes: Get To Know a Zebrafish Lab Technician

It’s 7:30 a.m. on a Sunday morning, and Mark McDonough is making a very familiar journey through a very unfamiliar mode. With the light rain pelting down on his gelled hair, he’s walking the 2-mile trek from East Campus to West Campus. The C1 doesn’t run until 8:30 a.m. on weekends, and his job is simply too important to wait for Duke-provided transportation.

Since his third week as a freshman, Mark has held the position of Lab Technician at the Duke University School of Medicine Zebrafish Core Facilities. Through the job, which he earned via the university’s work-study program, Mark has had the opportunity to make his college experience more affordable while completing the behind-the-scenes work that keeps the university’s labs running.

Upon arriving at work every morning, Mark spends anywhere from thirty minutes to an hour cleaning the filters on the fish tanks, after which he removes feces and inserts food. These three tasks are just a microcosm of his duties as a lab technician, but without them, a majority of his assigned fish would die before their biological characteristics could be fully measured.

As a freshman, Mark McDonough (pictured) has had the opportunity to work in a lab that does cutting-edge research.

Mark’s day-to-day responsibilities are similar to those of many lab technicians. Hundreds of Duke’s affiliated research labs make use of living subjects and biological specimens which must be sheltered, fed, and closely monitored. Without the presence of lab technicians, studies involving these subjects could lead to inconsequential or misleading results.

Mark’s supervisor, Z-Core Facilities Manager Karina Olivieri, fully understands the importance of the three lab technicians in her five zebrafish facilities. Says Olivieri, technicians ensure the “health of the fish and quality of their water so that researchers can collect measurements and make valuable insights.” As the demand for zebrafish grows on Duke’s campus, she expects the number of lab technician roles to grow as well. This trend will likely not be unique to Duke.

The zebrafish’s see-through embryo, rapid life cycle, and well-documented genome make it a “model organism” for biological experiments.

Nationwide, demand for lab technicians has accelerated in many of the largest research corporations and academic institutions. According to the Foundation for Biomedical Research, almost every U.S. drug must pass through animal testing in order to reach FDA approval, meaning that larger amounts of living specimens must be preserved as the pharmaceutical industry grows. The rising presence of these experimental subjects may be why the Bureau of Labor Statistics reports that lab technician roles are increasing at a rate of 11%, which beats the national average for STEM occupations.

Though lab technicians don’t present work at prestigious conferences or see their names printed at the top of cutting-edge research articles, their work is pivotal for ensuring that innovative research can be conducted at Duke and beyond. So in the unlikely event that you recognize a passing stranger as a lab technician, make sure to thank them for their service to the Duke community. They keep the university’s vibrant research scene – and its fish – thriving.

Post by Shariar Vaez-Ghaemi, class of 2025

Nobel Laureate Dr. Jennifer Doudna and Groundbreaking Applications of CRISPR

In 2011, Dr. Jennifer Doudna began studying an enzyme called Cas9. Little did she know, in 2020 she would go on to win the Nobel Prize in Chemistry along with Emmanuelle Charpentier for discovering the powerful gene-editing tool, CRISPR-Cas9. Today, Doudna is a decorated researcher, the Li Ka Shing Chancellors Chair, a Professor in the Department of Chemistry and Molecular as well as Cell Biology at the University of California Berkeley, and the founder of the Innovative Genomics Institute.

Doudna was also this year’s speaker for the MEDx Distinguished Lecture in October where she delivered presented on “CRISPR: Rewriting DNA and the Future of Humanity.”

“CRISPR is a system that originated in bacteria as an adaptive immune system” Doudna explained.

Dr. Jennifer Doudna holding the Nobel Prize in Chemistry

When bacterial cells are infected by viruses those viruses inject their genetic material into the cell. This discovery, a couple decades ago, was the first indication that there may be ways to apply bacteria’s ability to acquire genetic information from viruses.

CRISPR itself was discovered in 1987 and stands for “Clustered Regularly Interspaced Short Palindromic Repeats.” Doudna was initially studying RNA when she discovered Cas-9, a bacterial RNA-guided endonuclease and one of the enzymes produced by the CRISPR system. In 2012, Doudna and her colleagues found that Cas9 used base pairing to locate and splice target DNAs when combined with a guide RNA.

Essentially, they designed guide RNA to target specific cells. If those cells had a CRISPR system encoded in their genome, the cell is able to make an RNA copy of the CRISPR locus. Those RNA molecules are then processed into units that each include a sequence derived from a virus and then assemble with proteins. This RNA protein then looks for DNA sequences that match the sequence in the RNA guide. Once a match occurs, Cas9 is able to bind to and cut the DNA, leading to the destruction of the viral genome. The cutting of DNA then triggers DNA repair allowing gene editing to occur.

“This system has been harnessed as a technology for genome editing because of the ability of these proteins, these CRISPR Cas-p proteins, to be programmed by RNA molecules to cut any desired DNA sequence,” Doudna said.

Jennifer Doudna holding a Model of CRISPR-cas9

While continuing to conduct research, Doudna has also been focused on applying CRISPR in agriculture and medicine. For agriculture, researchers are looking to make changes to the genomes of plants in order to improve drought resistance and crop protection. 

CRISPR-cas9 is also being applied in many clinical settings. In fact, when the COVID-19 pandemic hit, Doudna along with several colleagues organized a five-lab consortium including the labs of Dan Fletcher, Patrick Hsu, Melanie Ott, and David Savage. The focus was on developing the Cas13 system to detect COVID-19. Cas13 is a class of proteins, that are RNA guided, RNA targeting, CRISPR enzymes. This research was initially done by one of Doudna’s former graduate students, Alexandra East-Seletsky. They discovered that if the reporter RNA is is paired with enzymes that have a quenched fluorophore pair on the ends, when the target is activated, the reporter is cleaved and a fluorescent signal is released. 

One study out of the Melanie Ott group demonstrated that Cas13 can be used to detect viral RNA. They are hoping to apply this as a point-of-care diagnostic by using a detector as well as a microfluidic chip which would allow for the conduction of these chemical reactions in much smaller volumes that can then be read out by a laser. Currently, the detection limit is similar to what one can get with a PCR reaction however it is significantly easier to run.

Graphical Abstract of Cas13 Research by the Melanie Ott lab

“And this is again, not fantasy, we’ve actually had just fabricated devices that will be sitting on a benchtop, and are able to use fabricated chips that will allow us to run the Cas13 chemistry with either nasal swab samples or saliva samples for detection of the virus,” Doudna added.

Another exciting development is the use of genome editing in somatic cells. This involves making changes in the cells of an individual as opposed to the germline. One example is sickle cell disease which is caused by a single base pair defect in a gene. Soon, clinicians will be able to target and correct this defect at the source of the mutation alleviating people from this devastating illness. Currently, there are multiple ongoing clinical trials including one at the Innovative Genomics Institute run by Doudna. In fact, one patient, Victoria Gray, has already been treated for her sickle cell disease using CRISPR.

Victoria Gray being treated for Sickle Cell Anemia
Meredith Rizzo/NPR

“The results of these trials are incredibly exciting and encouraging to all of us in the field, with the knowledge that this technology is being deployed to have a positive impact on patient’s lives,” Doudna said.

 Another important advancement was made last summer involving the use of CRISPR-based therapy to treat ATR, a rare genetic disease that primarily affects the liver. This is also the first time CRISPR molecules will be delivered in vivo.

In just 10 years CRISPR-cas9 has gone from an exciting discovery to being applied in several medical and agricultural settings. 

“This powerful technology enables scientists to change DNA with precision only dreamed of a few years ago,” said MEDx director Geoffrey Ginsburg, a Professor of Medicine at Duke. “Labs worldwide have redirected the course of research programs to incorporate this new tool, creating a CRISPR revolution with huge implications across biology and medicine.”

Examples of further CRISPR-Cas9 research can also be found in the Charles Gersbach lab here at Duke. 

By Anna Gotskind, Class of 2022

When the gut’s internal ecosystem goes awry, could an ancient if gross-sounding treatment make it right?

Lemur researchers make a case for fecal transplants to reduce the side effects of antibiotics. Photo by David Haring, Duke Lemur Center.

Dr. Cathy Williams knew something wasn’t right. The veterinarian had felt off for weeks after her 2014 trip to Madagascar.

At first she just felt bloated and uncomfortable and wasn’t interested in eating much. But eventually she developed a fever and chills that sent her to the emergency room.

When tested, doctors found that what she had wasn’t just a stomach bug. She was suffering from an infection of Clostridium difficile, a germ that causes severe diarrhea and abdominal pain and can quickly become life-threatening if not treated promptly.

“It was horrible,” Williams said.

The condition is often triggered when antibiotics disrupt the normal balance of bacteria that inhabit the gut, allowing “bad” bacteria such as C. difficile to multiply unchecked and wreak havoc on the intestines.

To get her infection under control, Williams asked her doctors if they could try an approach she and other veterinarians had used for decades to treat lemurs with digestive problems at the Duke Lemur Center. The procedure, known as a fecal microbiota transplant, involves taking stool from a healthy donor and administering it to the patient to add back “good” microbes and reset the gut.

At the time it was considered too experimental for clinical use in human cases like Williams’. She was prescribed the standard treatment and was sent home from the hospital, though she wouldn’t feel well enough to go back to work for another month. But now new research in lemurs is confirming what Williams and others long suspected: that this ancient if gross-sounding treatment can help an off-kilter gut microbiome get back to normal.

In a recent study in the journal Animal Microbiome, a research team led by Duke professor Christine Drea, former PhD student Sally Bornbusch and colleagues looked at the gut microbiomes of 11 healthy ring-tailed lemurs over a four-month period after receiving a seven-day course of the broad-spectrum antibiotic amoxicillin.

The lemurs were split into two experimental groups. One was a wait-and-see group, with continued follow-up but no further treatment after the antibiotics. The other group was given a slurry of their own feces, collected prior to antibiotic treatment and then mixed with saline and fed back to the same animal after their course of antibiotics was over.

“It sounds crazy,” Williams said. But she has used a similar procedure since the 1990s to treat illnesses in Coquerel’s sifaka lemurs, whose infants are known to eat their mother’s poop during weaning — presumably to get the microbes they’ll need to transition to solid food.

A baby Coquerel’s sifaka tries some of her first solid foods. Photo by David Haring.

Drea, Bornbusch and team used genetic sequencing techniques to track changes in the lemurs’ gut microbiome before, during and after treatment.

As expected, even a single course of antibiotics caused the numbers of microbes in their guts to plunge compared with controls, briefly wiping out species diversity in both experimental groups before returning to baseline.

“Antibiotics had dramatic effects, even in healthy animals,” Drea said.

But in terms of which types of bacteria bounced back and when, the patterns of recovery in the two groups were different. Lemurs that received the “poop soup” treatment started to stabilize and return to their pre-antibiotic microbiome within about two weeks. In contrast, the bacterial composition in the wait-and-see group continued to fluctuate, and still hadn’t quite returned to normal even after four months of observation.

This kind of therapy isn’t new. Reports of using fecal transplants to treat people suffering from food poisoning or diarrhea date back as far as fourth century China. The evidence for its effectiveness in captive settings has Bornbusch advocating for freezing stool at Smithsonian’s National Zoo, where she is now a postdoctoral fellow.

“If we can bank feces from animals when they’re healthy, that can be a huge benefit down the road,” Bornbusch said. “It can help the animals get better, faster.”

And now if any of her lemur patients were to get sick with C. difficile like she did, Williams said, “I would absolutely go with a fecal microbiota transplant.”

“People are put off by it,” Drea said, “But the disgust for this approach might actually have been holding up a fairly cheap and useful cure.”

Ring-tailed lemurs at the Duke Lemur Center in North Carolina. Photo by David Haring, Duke Lemur Center

This research was supported by the National Science Foundation (BCS 1749465), the Duke Lemur Center Director’s Fund, and the Duke Microbiome Center.

CITATION: “Antibiotics and Fecal Transfaunation Differentially Affect Microbiota Recovery, Associations, and Antibiotic Resistance in Lemur Guts,” Sally L. Bornbusch, Rachel L. Harris, Nicholas M. Grebe, Kimberly Roche, Kristin Dimac-Stohl, Christine M. Drea. Animal Microbiome, Oct. 1, 2021. DOI: 10.1186/s42523-021-00126-z.

By Robin Ann Smith

Duke has 38 of the World’s Most Highly-Cited Scientists

Peak achievement in the sciences isn’t measured by stopwatches or goals scored, it goes by citations – the number of times other scientists have referenced your findings in their own academic papers. A high number of citations is an indication that a particular work was influential in moving the field forward.

Nobel laureate Bob Lefkowitz made the list in two categories this year.

And the peak of this peak is the annual “Highly Cited Researchers” list produced each year by the folks at Clarivate, who run the Institute for Scientific Information. The names on this list are drawn from publications that rank in the top 1% by citations for field and publication year in the Web of Science™ citation index – the most-cited of the cited.

Duke has 38 names on the highly cited list this year — including Bob Lefkowitz twice because he’s just that good — and two colleagues at the Duke NUS Medical School in Singapore. In all, the 2021 list includes 6,602 researchers from more than 70 countries.

The ISI says that US scientists are a little less than 40 percent of the highly cited list this year – and dropping. Chinese researchers are gaining, having nearly doubled their presence on the roster in the last four years.

“The headline story is one of sizeable gains for Mainland China and a decline for the United States, particularly when you look at the trends over the last four years,” said a statement from David Pendlebury, Senior Citation Analyst at the Institute for Scientific Information. “(This reflects) a transformational rebalancing of scientific and scholarly contributions at the top level through the globalization of the research enterprise.”

Without further ado, let’s see who our champions are!

Biology and Biochemistry

Charles A. Gersbach

Robert J. Lefkowitz

Clinical Medicine

Pamela S. Douglas

Christopher Bull Granger

Adrian F. Hernandez

Manesh R.Patel

Eric D. Peterson

Cross-Field

Richard Becker

Antonio Bertoletti (NUS)

Yiran Chen

Stefano Curtarolo

Derek J. Hausenloy (NUS)

Ru-Rong Ji

Jie Liu

Jason W. Locasale

David B. Mitzi

Christopher B. Newgard

Ram Oren

David R. Smith

Heather M. Stapleton

Avner Vengosh

Mark R. Wiesner

Environment and Ecology

Emily S. Bernhardt

Geosciences

Drew T. Shindell

Immunology

Edward A. Miao

Microbiology

Barton F. Haynes

Neuroscience and Behavior

Quinn T. Ostrom

Pharmacology and Toxicology

Robert J. Lefkowitz

Plant and Animal Science

Xinnian Dong

Sheng Yang He

Philip N. Benfey

Psychiatry and Psychology

Avshalom Caspi

E. Jane Costello

Honalee Harrington

Renate M. Houts

Terrie E. Moffitt

Social Sciences

Michael J. Pencina

Bryce B. Reeve

John W. Williams

Post by Karl Bates

How is Universal Healthcare Like the Waterboarding Debate?

The Duke Medical Ethics Journal (DMEJ) is an undergraduate publication started in Spring of 2020 that examines conversations around universal patient-doctor responsibility. In other words, they’re training the next generation of healthcare providers to ask big questions and make informed decisions. So, we owe them a huge thank-you in advance. 

On Sunday, October 24th, DMEJ hosted Dr. Gopal Sreenivasan to speak with current members. The event was open to the public as part of the club’s mission to promote ethical practices across all fields. Dr. Sreenivasan is a moral philosopher, but he is also a professor of medicine at Duke Medical School. His position as the “Crown Professor of Ethics at the Trent Center for Bioethics, Humanities & History of Medicine,” is part of an initiative to connect societal arts and sciences aspects of Duke University to the Medical School. 

Dr. Gopal Sreenivasan

“Today, I want to talk to you all about the human right to health,” he opened. 

Sreenivasan’s talk was focused on the question of how individual countries can provide healthcare or insure health.  “One division within the human right to health is the division between health and healthcare,” he clarified. “Another is the difference between a regular right and a human right.” 

As a philosopher, Sreenivasan took the issue of access to health and placed it on a universal scale. He addressed the social determinants of health (callback time!) as part of the solution, alongside more direct-but-still-indirect healthcare actions like vaccinations. His conclusion? We are ultimately moving away from the narrative that we have a right to healthcare and towards the narrative that we have a human right to health

“You have a right to health, but that does not necessarily mean you are going to be healthy. There are still factors that affect this which are under no one’s control. It doesn’t mean that if you don’t live to be 80 or 85 that your right has been violated. But you’re still entitled to a broader range of things than just health.”

To help illustrate this for my fellow visual learners, I’ve made a fun little visual aid. 

Sreenivasan laid out a verbal map to demonstrate the confusion policy makers face about addressing the wellbeing of their constituents. If you believe healthcare is a right, you believe the government has a different role to play than if you believe health is a right. You may expect less of them in terms of handling indirect factors like social determinants and vaccines. If you believe healthcare is a human right, you expect all governments to provide healthcare access universally. This is different from Sreenivasan’s preferred view: health is a human right. All people are entitled to all aspects of their health being addressed all the time in every way in every place. 

The word human in “human right” indicates universality the same way removing the care from “healthcare” does; they both broaden the scope. 

After that lovely philosophical grammatical discussion (Do colorless green ideas sleep furiously?) as our foundation, Sreenivasan moved on to a challenging analogy: waterboarding

“It does not belong to the nature of a right that everyone has to have it. But it does seem to belong to the nature of a human right that everyone has to have it. Take the human right to not be tortured, for example.”

Your moral view may differ on whether or not it is a human right not to be tortured. You may think the right should apply to all people, or no people, or only some people. But you also may think that the right should apply to only certain aspects of torture; maybe you think that specifically waterboarding doesn’t count.

(The debate around whether or not waterboarding counts as torture and whether or not it is prohibited under human rights legislation is one that has been around for a long time. Torture has been banned by multiple American presidents in multiple environments, but the language around waterboarding in particular is highly controversial. You can read more about the debate here.)

“It’s not that some people have a human right not to be tortured which protects them from waterboarding, and other people have a human right not to be tortured but it is somehow lesser and does not protect them from waterboarding. You can’t pick and choose the content based on the person for whom the right belongs.”

So, how is the waterboarding debate like universal healthcare?

For one, it’s a matter of exclusion. It’s a matter of moral philosophy. It’s a matter of definition. 

The question of whether there should be universal healthcare goes far beyond the question of whether healthcare is a right. 

How do we improve access? Who is at fault for rising drug prices? How is America’s healthcare system different than other countries? These questions must start with questions of definition. Who is our target audience? Who is included? Who is excluded? What is included? What is excluded? 

“It seems intuitive that human rights are all or nothing.” Sreenivasan explained. “Either everyone has them or no one has them. But then you must say that their content also has to be the same.”

Post by Olivia Ares, Class 2025

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