Duke Research Blog

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

Category: Medicine (Page 1 of 12)

Long-Term Study Sees the Big Picture of Cannabis Use

Seventy percent of the United States population will have tried marijuana by the age of 30. As the debate on the legalization of the most commonly used illicit drug continues throughout the country, researchers like William Copeland, PhD, and Sherika Hill, PhD, from the Duke Department of Psychiatry and Behavioral Sciences are interested in patterns of marijuana use and abuse in the first 30 years of life.

Marijuana is the most commonly used illicit drug.

The Great Smoky Mountain Study set out in 1992 to observe which factors contributed to emotional and behavioral problems in children growing up in western North Carolina. The study included over 1,000 children, including nearly 400 living on the Cherokee reservation. In addition to its intended purpose, the data collected has proven invaluable to understanding how kids and young adults are forming their relationship with cannabis.

The Great Smoky Mountains Study collected extensive medical and behavioral research from 11 counties in western North Carolina.

Using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and patterns of daily use of the drug, Copeland and Hill found some unsurprising patterns: peak use of the drug is during young adulthood (ages 19-21), when kids are moving out of the home to college or to live alone.

But while most people adjust to this autonomy and eventually stop their usage of the drug, a small percentage of users (7%) keep using into their adulthood. Hill and Copeland have observed specific trends that apply both to this chronic user group as well as an even smaller percentage of users (4%) who begin using at a later stage in life than most people, termed the delayed-onset problematic users.

Looking at the demographics of the various types of users, Hill and Copeland found that males are twice as likely to engage in marijuana use to any extent than females. Of those who do use the drug, African Americans are five times more likely to be delayed-onset users, while Native Americans are twice as likely to decrease their use before it becomes problematic.

For both persistent and delayed-onset problematic users, family instability during childhood was 2-4 times more likely than in non-problematic users.

Persistent users were more likely to have endured anxiety throughout childhood, and delayed-onset users were more likely to have experienced some kind of trauma or maltreatment in childhood than other types of users.

The identification of these trends could prove a vital tool in predicting and preventing marijuana abuse, and the importance of this understanding is evidenced in the data collected that elucidates outcomes of marijuana use.

Looking at various measures of social and personal success, the team identified patterns with a resounding trend: recent use of marijuana is indicative of poorer outcomes. Physical health and financial or educational outcomes displayed the worst outcomes in chronic and delayed-onset users. Finally, criminal behavior was increased in every group that used; in other words, regardless of the extent of use, every group with use of marijuana fared worse than the group that abstained.

The results of Copeland and Hill’s work has important implications as legislators debate the legalization of marijuana. While understanding these patterns of use and their outcomes can provide useful insight on the current patterns of usage, decriminalization will certainly change the way marijuana is manufactured and consumed, and will thus also affect these patterns.
By Sarah Haurin

Opportunities at the Intersection of Technology and Healthcare

What’d you do this Halloween?

I attended a talk on the intersection of technology and healthcare by Dr. Erich Huang, who is an assistant professor of Biostatistics & Bioinformatics and Assistant Dean for Biomedical Informatics. He’s also the new co-director of Duke Forge, a health data science research group.

This was not a conventional Halloween activity by any means, but I felt lucky to be exposed to this impactful research surrounded by views of the Duke forest in fall in Penn Pavilion at IBM-Duke Day.

Erich Huang

Erich Huang, M.D., PhD. is the co-director of Duke Forge, our new health data effort.

Dr. Huang began his talk with a statistic: only six out of 53 landmark cancer biology research papers are reproducible. This fact was shocking (and maybe a little bit scary?), considering  that these papers serve as the foundation for saving cancer patients’ lives. Dr. Huang said that it’s time to raise standards for cancer research.

What is his proposed solution? Using data provenance, which is essentially a historical record of data and its origins, when dealing with important biomedical data.

He mentioned Duke Data Service (DukeDS), which is an information technology service that features data provenance for scientific workflows. With DukeDS, researchers are able to share data with approved team members across campus or across the world.

Next, Dr. Huang demonstrated the power of data science in healthcare by describing an example patient. Mr. Smith is 63 years old with a history of heart attacks and diabetes. He has been having trouble sleeping and his feet have been red and puffy. Mr. Smith meets the criteria for heart failure and appropriate interventions, such as a heart pump and blood thinners.

A problem that many patients at risk of heart failure face is forgetting to take their blood thinners. Using Pillsy, a company that makes smart pill bottles with automatic tracking, we could record Mr. Smith’s medication taking and record this information on the blockchain, or by storing blocks of information that are linked together so that each block points to an older version of that information. This type of technology might allow for the recalculation of dosage so that Mr. Smith could take the appropriate amount after a missed dose of a blood thinner.

These uses of data science, and specifically blockchain and data provenance, show great opportunity at the intersection of technology and healthcare. Having access to secure and traceable data can lead to research being more reproducible and therefore reliable.

At the end of his presentation, Dr. Huang suggested as much collaboration in research between IBM and Duke as possible, especially in his field. Seeing that the Research Triangle Park location of IBM is the largest IBM development site in the world and is conveniently located to one of the best research universities in the nation, his suggestion makes complete sense.

By Nina Cervantes        

Who Gets Sick and Why?

During his presentation as part of the Chautauqua lecture series, Duke sociologist Dr. Tyson Brown explained his research exploring the ways racial inequalities affect a person’s health later in life. His project mainly looks at the Baby Boomer generation, Americans born between 1946 and 1964.

With incredible increases in life expectancy, from 47 years in 1900 to 79 today, elderly people are beginning to form a larger percentage of the population. However among black people, the average life expectancy is three and a half years shorter.

“Many of you probably do not think that three and half years is a lot,” Brown said. “But imagine how much less time that is with your family and loved ones. In the end, I think all of us agree we want those extra three and a half years.”

Not only does the black population in America have shorter lives on average but they also tend to have sicker lives with higher blood pressures, greater chances of stroke, and higher probability of diabetes. In total, the number of deaths that would be prevented if African-American people had the same life expectancy as white people is 880,000 over a nine-year span. Now, the question Brown has challenged himself with is “Why does this discrepancy occur?”

Brown said he first concluded that health habits and behaviors do not create this life expectancy gap because white and black people have similar rates of smoking, drinking, and illegal drug use. He then decided to explore socioeconomic status. He discovered that as education increases, mortality decreases. And as income increases, self-rated health increases. He said that for every dollar a white person makes, a black person makes 59 cents.

This inequality in income points to the possible cause for the racial inequality in health, he said.  Additionally, in terms of wealth instead of income, a black person has 6 cents compared to the white person’s dollar. Possibly even more concerning than this inconsistency is the fact that it has gotten worse, not better, over time. Before the 2006 recession, blacks had 10-12 cents of wealth for every white person’s dollar.

Brown believes that this financial stress forms one of many stressors in black lives including chronic stressors, everyday discrimination, traumatic events, and neighborhood disorder which affect their health.

Over time, these stressors create something called physiological dysregulation, otherwise known as wear and tear, through repeated activation of  the stress response, he said. Recognition of the prevalence of these stressors in black lives has lead to Brown’s next focus on the extent of the effect of stressors on health. For his data, he uses the Health and Retirement Study and self-rated health (proven to predict mortality better than physician evaluations). For his methods, he employs structural equation modeling. Racial inequalities in socioeconomic resources, stressors and biomarkers of physiological dysregulation collectively explain 87% of the health gap with any number of causes capable of filling the remaining percentage.

Brown said his next steps include using longitudinal and macro-level data on structural inequality to understand how social inequalities “get under the skin” over a person’s lifetime. He suggests that the next steps for society, organizations, and the government to decrease this racial discrepancy rest in changing economic policy, increasing wages, guaranteeing work, and reducing residential segregation.

Post by Lydia Goff

Global Health Research from Zika to Economics

Brazil, Kenya and China: this week, the sixth annual Global Health Research Showcase proved that Global Health majors truly represent global interests.

This past summer, Duke PhD student Tulika Singh explored complementary diagnosis techniques for Zika virus pregnant women in Vitoria, Brazil. Zika is difficult to diagnose “because the PCR-based test can only tell if you’ve had Zika virus within about ten days of the infection,” Singh said. “That’s a big problem for enrolling pregnant women into our study on Zika transmission and maternal immunity.”

To combat this issue, Singh and her thesis advisor Sallie Permar trained collaborators to use the whole virion ELISA (WVE) laboratory technique which may reveal if an individual has been exposed to Zika. ELISA detects Zika through testing for the antibodies that most likely would have been produced during a Zika infection. Singh’s work allows the research team to better assess whether women have been exposed to Zika virus during pregnancy, and will ultimately guide Zika vaccine design. 

Master of Science in Global Health candidate Carissa Novak examined why some HPV positive women in Western Kenya are not seeking preventive measures against cervical cancer. All the women diagnosed with HPV were referred to the Country Hospital but only “33 to 42 percent actually sought treatment” leading to Novak’s main research question, “Why did so few women seek treatment?” To answer this question, she sent out quantitative questionnaires to 100 women and then followed up by interviewing 20 of them. She surveyed and interviewed both women who had and had not sought treatment. Her results showed that transportation and cost hinder treatment acquirement and that the women who did seek treatment were often directed to by a health worker or actively trying to prevent cervical cancer. Novak believes that increasing women’s trust and understanding of the health care system will assist in improving the percentage who seek treatment.

In Kunshan, China, Brian Grasso evaluated the development of Kunshan’s health system in relation to its economic development. “Kunshan is now China’s richest county-level city and it used to be a small farm town…My main take away was that economic growth has strengthened Kunshan’s health systems while also creating new health challenges,” Grasso said. What are some of these new health challenges? Some of them include air pollution, increased stress in manufacturing jobs and more car accidents. Grasso determines that other developing health systems should learn from Kunshan that without proper regulations poor health can result in the midst of progress.

Post by Lydia Goff

Creative Solutions to Brain Tumor Treatment

Survival rates for brain tumors have not improved since the 1960s; NIH Image Gallery.

Invasive brain tumors are among the hardest cancers to treat, and thus have some of the worst prognoses.

Dean of the Pratt School of Engineering, Ravi Bellamkonda, poses for his portrait inside and outside CIEMAS.

Displaying the survival rates for various brain tumors to the Genomic and Precision Medicine Forum on Thursday, Oct. 26, Duke professor Ravi Bellamkonda noted, “These numbers have not changed in any appreciable way since the 1960s.”

Bellakonda is the dean of the Pratt School of Engineering and a professor of biomedical engineering, but he is first a researcher. His biomedical engineering lab is working toward solutions to this problem of brain tumor treatment.

Unlike many other organs, which can sacrifice some tissue and remain functional, the brain does not perform the same way after removing the tumor. So a tumor without clearly defined boundaries is unsafe to remove without great risk to other parts of the patient’s brain, and in turn the patient’s quality of life.

Bellakonda hypothesized that brain tumors have characteristics that could be manipulated to treat these cancers. One key observation of brain tumors’ behavior is the tendency to form along white matter tracts. Put simply, tumors often spread by taking advantage of the brain’s existing structural pathways.

Bellakonda set out to build a device that would provide brain tumors a different path to follow, with the hope of drawing the tumor out of the brain where the cells could be killed.

The results were promising. Tests on rats and dogs with brain tumors showed that the device successfully guided out and killed tumor cells. Closer examination revealed that the cells killed were not cells that had multiplied as the tumor grew into the conduit, but were actually cells from the primary tumor.

The Bellamkonda lab’s device successfully guided and killed brain tumors in rats.

In addition to acting as a treatment device, Bellakonda’s device could be co-opted for other uses. Monitoring the process of deep brain tumors proves a difficult task for neurooncologists, and by bringing cells from deep within the tumor to the surface, this device could make biopsies significantly easier.

Although the device presents promising results, Bellakonda challenged his lab to take what they have learned from the device to develop a less invasive technique.

Another researcher in the Bellakonda lab, Tarun Saxena, engaged in research to utilize the body’s natural protection mechanisms to contain brain tumors. Creating scar tissue around tumors can trick the brain into treating the tumor as a wound, leading to immunological responses that effectively contain and suppress the tumor’s growth.

Visiting researcher Johnathan Lyon proposed utilizing electrical fields to lead a tumor to move away from certain brain regions. Moving tumors away from structures like the pons, which is vital for regulation of vital functions like breathing, could make formerly untreatable tumors resectable. Lyon’s 3D cultures using this technique displayed promising results.

Another Bellakonda lab researcher, Nalini Mehta, has been researching utilizing a surprising mechanism to deliver drugs to treat tumors throughout the brain: salmonella. Salmonella genetically engineered to not invade cells but to easily pass through the extracellular matrix of the brain have proven to be effective at delivering treatment throughout the brain.

While all of these therapies are not quite ready to be used to treat the masses, Bellakonda and his colleagues’ work presents reasonable hope of progress in the way brain tumors are treated.

By Sarah Haurin

Piloting Aviation Mental Healthcare

With more than 100,000 flights taking off per day, the safety of air travel is a far-reaching issue.

Air travel remains one of the safest forms of transportation, but are there things we can do to make it safer?

While air travel is by far the safest method of transportation — you are more likely to die from a car crash or even a shark attack than from an airplane crash — accidents do happen and can result in highly publicized fatalities.

Chris Kenedi is working with the ICAO to improve treatment of mentally ill pilots.

Auckland Hospital internist and psychiatrist Chris Kenedi, MD, MPH, is working with the International Civil Aviation Organization (ICAO) to improve safety of air travel by focusing on an issue that is usually only questioned in instances of tragedy: the mental health of pilots.

While screening procedures do currently exist, they are not enough for the extent of risk factors that are present in the pilot population.
Being a pilot is a high-stress job. It involves long hours, separation from family, and irregular sleep schedules, all of which can contribute to or exacerbate mental conditions.

Many pilots experiencing symptoms are unwilling to ask for help, because admitting mental illness can lead to a pilot’s license being revoked, which would not only affect financial circumstances but also be felt as a loss of identity.

Although data regarding aviation mental health is sparse, what is available suggests  mental health issues are among the greatest contributing factors to suicide and homicide-suicide incidents of plane accidents.

When Kenedi completed a systematic review of all data on the mental health of pilots and the current standard procedures, he found a deeply flawed system. Case studies of crashes caused by suicidal pilots showed that psychiatrists cleared them for flight even after episodes indicating a much deeper psychological imbalance.

One pilot who drove his car into a barrier, attempted to steal the car of a woman trying to help him, and slit his wrists so deeply that he required two years of rehabilitation before regaining all of his mobility, was diagnosed with a general anxiety disorder and cleared to fly without proper treatment.

In order to prevent further grave oversights, Kenedi suggests requiring the psychiatrist who assesses a pilot’s ability to fly to be separate from the treating psychiatrist. This separation prevents the assessing psychiatrist from having his or her judgement confounded by a relationship with the patient and thus becoming an advocate rather than an impartial assessor.

Kenedi said that alcohol and substance abuse treatments for pilots have been effective, however. Rather than relying on random drug and alcohol tests to disqualify impaired pilots, the system provides non-judgmental treatment and an opportunity to return to piloting.

Kenedi recommends a shift to treating mental illness in pilots in a similar way, so that individuals are not afraid to step forward and ask for help. Educating mental healthcare providers is also important, so that pilots are receiving the best care possible.

With proper resources and treatment, pilots with mental health concerns should be able to maintain their identity as pilots while gaining renewed resilience and support through the mental health system. This shift would hopefully help to prevent some of the small amount of air travel accidents that occur because of pilot issues.

By Sarah Haurin

 

Designing Drugs Aimed at a Different Part of Life’s Code

Individual RNA molecules fluoresce inside a breast cancer cell.

Individual RNA molecules fluoresce inside a breast cancer cell. Credit: Sunjong Kwon, Oregon Health & Science University, via Flickr.

Most drugs work by tinkering with the behavior of proteins. Like meddlesome coworkers, these molecules are designed to latch onto their target proteins and keep them from doing what they need to do.

If a protein is responsible for speeding up a reaction, the drug helps slow the reaction down. If a protein serves as a gatekeeper to a cell, regulating what gets in and what stays out, a drug changes how many molecules it lets through.

But proteins aren’t the only doers and shakers in our bodies. Scientists are finding that strings of RNA — known primarily for their role in shuttling genetic information from nucleus-bound DNA to the cell’s protein-manufacturing machinery — can also play a major role in regulating disease.

A portrait of Amanda Hargrove

Amanda Hargrove is an assistant professor of chemistry at Duke University.

“There has been what some people are calling an RNA revolution,” said Amanda Hargrove, assistant professor of chemistry at Duke. “In some diseases, non-coding RNAs, or RNAs that don’t turn into protein, seem to be the best predictors of disease, and even to be driving the disease.”

Hargrove and her team at Duke are working to design new types of drugs that target RNA rather than proteins. RNA-targeted drug molecules have the potential help treat diseases like prostate cancer and HIV, but finding them is no easy task. Most drugs have been designed to interfere with proteins, and just don’t have the same effects on RNA.

Part of the problem is that proteins and RNA have many fundamental differences, Hargrove said. While proteins are made of strings of twenty amino acids that can twist into myriad different shapes, RNA is made of strings of only four bases — adenine, guanine, cytosine and uracil.

“People have been screening drugs for different kinds of RNA for quite a while, and historically have not had a lot of success,” Hargrove said. “This begged the question, since RNA has such chemically different properties than proteins, is there something different about the small molecules that we need in order to target RNA?”

To find out, graduate student Brittany Morgan and research associate Jordan Forte combed the scientific literature to identify 104 small molecules that are known interact with specific types of RNA. They then analyzed 20 different properties of these molecules, and compared their properties to those of collections of drug molecules known to interact with proteins.

The team found significant differences in shape, atomic composition, and charge between the RNA-active molecules and the protein-active molecules. They plan to use the results to compile a collection of molecules, called a library, that are chosen to better “speak the language” of the RNA-active molecules. They hope this collection of molecules will be more likely to interact with RNA in therapeutically beneficial ways.

“We found that there are differences between the RNA-targeted molecules and the protein-targeted drugs, and some of them are pretty striking,” Hargrove said. “What that means is that we could start to enrich our screening libraries with these types of molecules, and make these types of molecules, to have better luck at targeting RNA.”

Discovery of Key Physicochemical, Structural, and Spatial Properties of RNA-Targeted Bioactive Ligands.” Brittany S. Morgan, Jordan E. Forte, Rebecca N. Culver, Yuqi Zhang and Amanda Hargrove. Angewandte Chemie, Sept. 18, 2017. DOI: 10.1002/anie.201707641

Kara J. Manke, PhDPost by Kara Manke

Rare Cancers and Precision Medicine in Southeast Asia

Data collected through genomics research is revolutionizing the way we treat cancer. But a large population of cancer patients are being denied the benefits of this research.

Patrick Tan MD, PhD is a professor of cancer and stem cell biology at Duke-NUS Medical School in Singapore.

In 2016, less than one percent of all the existing genomic data came from the 60% of the world population living outside of the US, Europe, and Japan. Furthermore, 70% of patients who die from cancer this year will come from Asia, Africa and Central and South America.

Patrick Tan, M.D., Ph.D., and the Duke-National University of Singapore (Duke-NUS) Medical School are key players in an effort to rectify this discrepancy, specifically as it exists in Southeast Asia.

In his talk, sponsored by the Duke Center for Applied Genomics and Precision Medicine, Tan focused specifically on his work in northeast Thailand with cholangiocarcinoma (CCA), or bile duct cancer.

Liver fluke

Liver flukes like this are parasites of fish that migrate to human hosts who eat the fish raw, leading to a form of bile duct cancer.

While CCA is rare in most of the world, it appears at 100 times the global rate in the region of Thailand where Tan and his colleagues work. Additionally, CCA in this region is of a separate and distinct nature.

CCA in this region is linked with a parasitic infection of the bile ducts called a liver fluke.  Residents of this area in Thailand have a diet consisting largely of raw fish, which can be infected by the liver fluke and transmitted to the person who eats the fish.

Because of the poverty in this area, encouraging people to avoid eating raw fish has proven ineffective. Furthermore, healthcare is not readily available, so by the time most patients are diagnosed, the disease has progressed into its later and deadly stage.

The life cycle of liver flukes. (Graphic U.S. Centers for Disease Control)

Tan’s genomic research has discovered certain factors at the gene level that make liver-fluke positive CCA different from other CCA. Thus genomic data specific to this population is vital to improve the outcomes of patients with CCA.

Duke-NUS Precision Medicine (PRISM) has partnered up with the National Heart Research Institute Singapore (NHRIS) in SPECTRA, a program designed to create a database of genomic data from the healthy Asian population. SPECTRA is sequencing the genomes of 5,000 healthy Asians in order to create a baseline to which they can compare the genomes of unhealthy individuals.

These and other programs are part of a larger effort to make precision medicine, or healthcare tailored to an individual based on factors like family history and genomic markers, accessible throughout southeast Asia.

By Sarah Haurin

 

Disaster Plans and the Mentally Ill

Houston, Miami, San Juan — Category 5 hurricanes, the most destructive storm systems, have made a record-breaking 6 landfalls this year. This represents a quarter of the total category 5 hurricane landfalls that the Atlantic has seen since 1851.

With statistics like these, disaster relief plans are becoming more important than ever. But do these plans do enough for marginalized groups, specifically the mentally ill?

Allan K. Chrisman, M.D., believes more can be done. As a career psychiatrist who has been deployed by the Red Cross in the aftermath of storms like Katrina and Matthew, Chrisman has seen and experienced the importance of including the mentally ill in disaster relief plans.

At his talk to physicians in Duke’s Hospital on Sept. 28, Chrisman, an emeritus  professor at Duke, highlighted specific aspects of disaster relief that are not doing enough for the one in four U.S. adults suffering from mental illness each year.

According to Chrisman, this part of the population is often less prepared for impending storms. When storms do hit, existing symptoms can be exacerbated, or new symptoms can appear.  Disruption of routine, inconsistency of taking medication and the overall stress that comes with emergencies all contribute to this exacerbation of mental illness.

While the Red Cross has an “everyone is welcome,” policy for their shelters, not being able to identify the needs of the mentally ill seeking sanctuary limits the organization’s ability to help. As a deployed psychiatrist, Chrisman worked with displaced mentally ill people to ensure they continued to get the care they needed even during the stress of a weather emergency.

One tool used by Chrisman and his colleagues to help these groups is the C-MIST framework. This system categorizes “functional-based needs” based on communication, maintaining health, independence, service and support, and transportation. It seeks to ensure not only that individuals are being given an option for a safe space in the wake of emergencies, but also that these spaces offer them the specific services they require.

Chrisman emphasized the need “to provide round-the-clock access to qualified mental health resources.”

He said that by following these inclusive protocols, disaster relief programs can do even more to protect the most vulnerable parts of the population.

By Sarah Haurin

Happy Patients, Healthy Lungs

Lung-shaped leaves

Evaluating a patient’s mental health before and after lung transplant surgery can help improve long-term outcomes. Source: tikyon, Flickr.

Diseases like Chronic Obstructive Pulmonary Disease (COPD) and Cystic Fibrosis (CF) are hard to treat. Lung transplant is important option for people who do not benefit from other treatments, and understanding the outcomes for these patients is crucial.

Patrick Smith, PhD, a clinical psychologist at Duke Hospital, shared his research into predictors for outcomes of lung transplant with a group of transplant physicians and surgeons at the Duke Hospital on Sept. 14.

“Patients receive transplants to live longer and to feel better,” Smith said.

Focus on the first goal has increased the median survival time after a lung transplant to six years. But Smith began his research because of an interest in the second goal.

An incredibly complex, long, and difficult procedure, transplants require extensive testing and therapies before a patient enters the operating room (OR). Among the pre-operative testing is a mental health assessment to determine if any psychological issues exist that could make recovery more difficult. Mental health issues can affect adherence, or a patient’s commitment to continuing the prescribed post-op medication after release from the hospital.

Smith’s research found that some of these tests can be incredibly useful at predicting outcomes not previously explored; patients who show cognitive impairments before surgery were found to be more likely to fall victim to delirium, a post-operative state of confusion and psychosis that has been linked to an increased risk of complications and death.

While acknowledging the usefulness of pre-operative testing, Smith also pointed out the inadequacy of this model. Failing to continue psychological assessments after the surgery and throughout the recovery means that doctors are missing important clues that could indicate how well patients will recover.

Through his research, Smith has found that the presence of depressive symptoms after transplant is actually a much more useful and accurate tool for predicting risk of mortality than symptoms exhibited before surgery.  

This point is strengthened by a previous study that found that successful treatment of depressive symptoms in liver transplant patients reduced the mortality rate of depressive patients to that of their non-depressive counterparts.

These results are promising for the possibility of improving transplant outcomes; by valuing and treating both pre-operative and post-operative signs of risk, doctors can improve the outcomes for their patients and ensure the limited supply of organs is being used in the best and most successful way possible.

Post by Sarah Haurin

 

 

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