Tracing the start of COVID-19 in GA

At a time when COVID-19 appears to be receding in much of Georgia, it’s worth revisiting the start of the pandemic in early 2020. Emory virologist Anne Piantadosi and colleagues have a paper in Viral Evolution on the earliest SARS-CoV-2 genetic sequences detected in Georgia. Analyzing relationships between those virus sequences and samples from other states and countries can give us an idea about where the first COVID-19 infections in Georgia came from. We can draw Read more

Reddit as window into opioid withdrawal strategies

Drug abuse researchers are using the social media site Reddit as a window into the experiences of people living with opioid addiction. Abeed Sarker in Emory's Department of Biomedical Informatics has a paper in Clinical Toxicology focusing on the phenomenon of “precipitated withdrawal,” in collaboration with emergency medicine specialists from Penn, Rutgers and Mt Sinai. Precipitated withdrawal is a more intense form of withdrawal that can occur when someone who was using opioids starts medication-assisted treatment Read more

CROI: HIV cure report and ongoing research

The big news out of CROI (Conference on Retroviruses and Opportunistic Infections) was a report of a third person being cured of HIV infection, this time using umbilical cord blood for a hematopoetic stem cell transplant. Emory’s Carlos del Rio gave a nice overview of the achievement for NPR this morning. As del Rio explains, the field of HIV cure research took off over the last decade after Timothy Brown, known as “the Berlin patient,” Read more

News

Malpractice insurance rates examined

A recent article published by Knowledge@Emory, an online business journal, presented the view of a leading Emory expert on health care reform regarding malpractice insurance rates. The article is titled “Will Medical Practices Survive Malpractice Insurance Rates?” and covers recent health care reform news including a discussion of medical malpractice insurance rates.

Excerpts from the article:

  • President Barack Obama’s planned overhaul of America’s healthcare system took a step forward October 13 when the powerful Senate Finance Committee voted 14 to 9 along party lines, except for Republican Senator Olympia Snowe, to move its healthcare bill along for broader consideration. While this vote is a positive sign in a debate that has raged on for years, it comes too late for many physicians in high-risk specialties who have made the difficult choice to either restrict their practice, relocate to friendlier states, or to shut down shop altogether because of galloping increases in malpractice and other liability insurance.
  • Kenneth E. Thorpe, PhD

    Kenneth E. Thorpe, PhD

  • Kenneth E. Thorpe, Robert W. Woodruff professor and chair of health policy and management at Emory’s Rollins School of Public Health, said, “In response to rising medical malpractice insurance rates, many physicians feel compelled to practice so-called defensive medicine, which may involve ordering extensive patient tests primarily to help defend their decisions in case the physician is later sued. Concern over malpractice insurance costs are also driving more specialists like obstetricians and gynecologists, and neurosurgeons, to restrict, sell or close their practices, leading to some question about whether or not there will be enough specialists available to meet the demand for their services.
  • Part of the challenge is that the standard rules of a business model don’t always apply to medical providers, according to Thorpe.
  • In a traditional business model, a larger organization can generally reduce many costs with economies of scale, but even if a doctor sells his or her practice to a larger group practice or a hospital, the insurance rates are still set by state commissioners,” he notes. “So even though a hospital practice may be substantially larger than a typical physician group practice, a hospital generally can’t exercise any more leverage when it comes to med-mal rates.”
  • Regulatory restrictions on the medical business model may limit the ability of medical practitioners to respond to liability insurance rates, but Thorpe says other approaches could put a dent in the costs.
  • “To begin with, more than 60 percent of med-mal claims go to identifying fault and administering the medical malpractice system leaving only 40 percent of the premium dollar paid to injured patients,” he says. At the same time 70 to in some states up to 90 percent of claims filed never receive any payment and are dismissed or dropped. “So it would likely be helpful if regulatory authorities or the courts can weed out the frivolous ones. Setting up specialized courts—similar to tax and other highly focused courts that already exist—might help to fast track the adjudication of these claims, which would cut down on administrative and other overhead costs. Will the proposed healthcare reforms address these issues? It remains to be seen if true reform can overcome the efforts of special interest groups that are trying to place their own interests above the public good.”
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Encouraging news on women and heart disease

A new study reported this week in the Archives of Internal Medicine delivers encouraging news that Americans are on the right track in the fight against heart disease among women.

The study reports that all women, especially those younger than 55, have recently experienced a greater increase than men in their chances of survival following a heart attack.

Study leader, Viola Vaccarino, MD, PhD, professor of medicine (cardiology), and director of the Emory Program in Cardiovascular Outcomes Research and Epidemiology, researched trends in the rate of in-hospital deaths following heart attack from June 1994, through Dec. 2006. Data were collected from 916,380 patients through the National Registry of Myocardial Infarction.

Between 1994 and 2006, in-hospital death rates decreased among all patients, but decreased more strikingly in women than in men. The decreased risk of death was largest in women younger than 55 years (a 52.9 percent reduction) and lowest in men of the same age (33.3 percent). The absolute reduction in the risk of death among patients younger than 55 was three times larger in women (2.7 percent) than men (0.9 percent).

Vaccarino and her colleagues say a large part (93 percent) of this sharper decrease in mortality of younger women compared with men in recent years is due to the improved risk profile of women compared with men at the time of the heart attack hospitalization, perhaps the result of better recognition and management of coronary heart disease and its risk factors in women before the acute heart event.

Whatever the reason, the improvement indicates that we are headed in the right direction, says Vaccarino. Increased and ongoing awareness to the prevention of cardiovascular risk factors—by healthy diet, regular physical activity and avoidance of smoke and smoking—is saving lives, she notes.

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Curiosity about health and a borderless world

Developing effective HIV prevention and intervention programs in the most affected communities is a challenge globally as well as locally. It’s also a challenge that Emory infectious disease specialist Carlos del Rio, MD, is addressing as newly appointed chair of the Rollins School of Public Health’s Hubert Department of Global Health.

Carlos del Rio, MD

Carlos del Rio, MD

Del Rio is uniquely equipped to address HIV prevention and intervention. As the former chief of medicine at Grady Memorial Hospital, Atlanta’s safety-net hospital, he witnessed firsthand patients affected by the disease. He says there ought to be incentives for people to stay healthy instead of barriers to staying healthy.

More daunting for del Rio is preventing disease on a global scale, much of which rests on changing unhealthy behaviors related to diet, exercise, smoking, and sex. He says we know very little about how to implement population-wide behavior change, and we need to learn more.

Del Rio says growing human capital to strengthen research capacity in resource-constrained countries is also key. Since 1998, the NIH/Fogarty International Center has funded the Emory AIDS Training and Research Program (AITRP) to build capacity in Armenia, the Republic of Georgia, Ethiopia, Mexico, Rwanda, Vietnam and Zambia. Led by del Rio, AITRP brings a select group of young scientists to Emory each year for advanced training. Emory faculty also train and mentor scientists in these countries.

The training program has opened avenues to improving health. In Ethiopia, del Rio helped expand HIV testing among the police force and bring antiretroviral therapy into the community for people living with HIV.

In the Republic of Georgia, the Emory AITRP and the Emory-Georgia Tuberculosis Research Training Program, another NIH/Fogarty program led by RSPH adjunct faculty member and Emory School of Medicine professor  Henry Blumberg, MD, has helped build research capacity in HIV, hepatitis, and tuberculosis research.

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Paris “Hands Over” to Atlanta for AIDS Vaccine 2010

Eric Hunter, PhD

Eric Hunter, PhD

As the AIDS Vaccine 2009 conference concluded today in Paris with more than 1,000 scientists in attendance, Eric Hunter, PhD, co-director of the Emory Center for AIDS Research (CFAR) and a Georgia Research Alliance Eminent Scholar, accepted the “hand over” for next year’s international conference in Atlanta.

The Emory CFAR will serve as local Atlanta host of AIDS Vaccine 2010, which takes place next Sept. 28 to Oct. 1, led by the Global HIV Vaccine Enterprise. The conference will bring scientists, community advocates, funders and policy makers from around the world to Atlanta to hear cutting edge scientific results, exchange new ideas, educate future leaders and engage a diverse group of scientists in the quest for an AIDS vaccine.

A number of Emory scientists were in attendance in Paris at AIDS Vaccine 2009. Hunter was interviewed by several news organizations, including the Lehrer News Hour and Science magazine, about the results of a recently concluded AIDS vaccine trial conducted by the United States and Thailand. The complete results of the trial were released at the meeting and also published online this week by the New England Journal of Medicine.

Hunter was among 22 scientists who initially had criticized the trial in a 2004 Science editorial. After seeing the full results and analysis of the trial this week, Hunter commented from the Paris meeting:

“The complete data from the trial indicate that it was modestly effective in preventing HIV-1 infection. However, it will likely be difficult to establish the mechanism by which the vaccine protected participants and additional studies will be needed. This positive result, though, gives a much needed boost to efforts aimed at developing an HIV-1 vaccine and takes the field from the position of perhaps an impossible goal to a possible goal.”

Hunter will chair AIDS Vaccine 2010 in Atlanta, along with co-chairs James Curran, MD, MPH, dean, Rollins School of Public Health; Carlos del Rio, MD, Hubert professor and chair of the Hubert Department of Global Health, Rollins School of Public Health; and Harriet Robinson, PhD, senior vice president of research and development, GeoVax and emeritus professor of microbiology and immunology, Yerkes National Primate Research Center, Emory University.

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Teens and crime: the Supreme Court to decide outcome

Emory’s Gregory Berns, MD, PhD, occasionally blogs for Psychology Today in a blog titled plus2sd.

Gregory Berns, MD, PhD

Gregory Berns, MD, Ph

Berns’ most recent blog taps his expertise on the use of brain-imaging technologies to understand human motivation and decision-making, as well as the biology of adolescent decision-making and the effects of peer pressure on risk attitudes.

In a blog called “My Immature Brain Made Me Do It?” he covers an upcoming case before the U.S. Supreme Court on life sentences for adolescents. Berns is Emory Distinguished Chair of Neuroeconomics and director of the Center for Neuropolicy, and a professor of Psychiatry and Behavioral Sciences, Emory University School of Medicine.

He writes: “On November 9th, 2009 the Supreme Court will hear arguments on whether the 8th amendment’s ban on cruel and unusual punishment prohibits courts from sentencing children to life without the possibility of parole for the commission of a non-homicide. The elephant in the room, and the thing that the Court has taken deliberate steps to leave out of its rulings in the past, is the human brain.

Numerous briefs have been submitted by mental health advocacy groups suggesting that the brain is not fully mature until the mid-20’s. But come November, the Court should once again ignore the growing drumbeat to blame the immature brain and leave neuroscience out of its decision.

But there are serious flaws with the “immature brain made me do it” argument. In fact, my group recently published a study calling this argument into question (PLoS One, 2009). All of the neuroscience findings cited in the briefs rely on a correlation of brain structure with either age or a measurement of cognitive function.

Correlation means that you take one measurement and see how it changes with some other measurement. While on average, these conclusions are statistically valid, there is too much variation from one person to another to draw conclusions about any one individual. But you won’t find individual variability mentioned in any of these briefs.”

To read more about Berns’ recent study findings, visit Emory’s Woodruff Health Sciences Center.

Or view a video:

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Why vaccine compliance matters

An outbreak of measles in the state of Washington last year sickened 19 children. Of those who fell ill, 18 had something in common—they were not vaccinated.

Saad Omer aims to increase vaccine compliance to prevent childhood diseases.

Saad Omer aims to increase vaccine compliance to prevent childhood diseases.

For Emory Rollins School of Public Health researcher Saad Omer, the Washington outbreak is a perfect example of the effect on an entire community when individuals are unimmunized. His research aims to shed light on ways to encourage increased vaccine compliance for adults and their children.

Omer says vaccine-preventable diseases such as measles, influenza, and pertussis often start among persons who forego vaccinations, spread rapidly within unvaccinated populations, and also spread to other subpopulations.

In a recent New England Journal of Medicine article, Omer and his colleagues reviewed evidence from several states showing that vaccine refusal due to nonmedical reasons puts children in communities with high rates of refusal at higher risk for infectious diseases such as measles and whooping cough.

Even children whose parents do not refuse vaccination are put at risk because “herd immunity” normally protects children who are too young to be vaccinated, who can’t be vaccinated for medical reasons, or whose immune systems do not respond sufficiently to vaccination.

Research findings indicate that everyone who lives in a community with a high proportion of unvaccinated individuals has an elevated risk of developing a vaccine-preventable disease.

Read more about Omer’s research on vaccine refusals in the fall 2009 issue of Public Health magazine.

Omer also discusses the importance of vaccinating against the H1N1 virus in an Oct. 16 article in The New York Times.

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Teaching students to be doctors: connections made

The Emory School of Medicine’s new curriculum was introduced in 2007 in order to create connections between faculty and students that last throughout the entire four years of medical school, “longitudinal” relationships much like those that should exist ideally between doctors and their patients.

Students practice providing exams

Students practice medical exams

Based on the kind of students who are attracted to Emory and on what they learn and model from their faculty mentors, these students are expected to grow not just in knowledge during their time at Emory, but also in compassion, curiosity, and commitment—and to use these traits wisely in serving their profession and community.

At the heart of the curriculum is a highly popular system of faculty advisers, each faculty mentor paired with eight or nine students.

These groupings are designated as “societies” named for historical medical luminaries—for example, Osler, Semmelweis, Lister, Harvey.

Faculty advisers who lead these societies in each class are chosen carefully, their salaries underwritten by the medical school so they can relinquish three half-days per week from their regular clinical and/or research duties to spend time with some or all of “their” students.

As the class of 2011 moves through the new curriculum, all now have completed the 18-month Foundations of Medicine phase, a whole-person approach section that combines clinical medicine and basic fundamentals of science, social sciences, humanities and public health.

This is not my father’s or mother’s medical school experience, students say. In the introduction-to-neuroscience module, for example, faculty share the classroom with a baseball player, who demonstrates and explains what a center fielder has to do to catch a fly ball or what a batter must consider before swinging at a ball leaving the pitcher’s hand at 95 mph.

Learn more about the curriculum in the 2009 Emory School of Medicine annual report, and more about the school in Emory Medicine. Read a message from Dean Thomas J. Lawley, MD.

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Children’s 1,000th pediatric transplant recognized

Emory University and Children’s Healthcare of Atlanta transplant surgeon Stuart Knechtle, MD, and his surgical team recently performed the 1,000th solid organ transplant on a Children’s patient. The milestone operation was performed on a child who received a liver through the Children’s Transplant Center.

Stuart Knechtle, MD

Stuart Knechtle, MD

Knechtle is chief of the Emory School of Medicine transplant division and professor of surgery, and surgical director of Children’s Liver Transplant Program. Children’s Liver Transplant program was founded in 1990 and has completed more than 300 liver transplants.

The liver transplant team is made up of many individuals who contribute to its success – liver transplant surgeons, transplant hepatologists (doctors with expertise in the treatment of the liver), and a team of gastroenterologists, anesthesiologists, pathologists, radiologists, mental health specialists, chaplains, nurses, social workers and pharmacists.

For more than 20 years, Emory and Children’s physicians have been at the forefront of pediatric transplant care, achieving several groundbreaking accomplishments, including:

  • Transplanted the world’s youngest (10 days old) and three smallest (2 to 4 pounds) liver transplant recipients
  • One of the first pediatric hospitals in the United States to perform three heart transplants in 24 hours
  • At the forefront of its field with ABO-incompatible liver and heart transplants
  • Performed more than 450 pediatric kidney transplants.
Children's kidney transplant recipient Quinn Roberts, age 8, poses with her donor Cheryl Thomas

Children’s kidney transplant recipient Quinn Roberts, age 8, with her donor Cheryl Thomas

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Congrats to the telomere/ribosome Nobelists

Congratulations to Elizabeth Blackburn, Carol Greider and Jack Szostak for the 2009 Nobel Prize in medicine. The award is for their work on telomeres, the protective caps on the ends of chromosomes that shorten with every cell division and need specialized enzymes to be replenished.

Greider, Blackburn and Szostak discovered telomerase, the enzyme that copies the ends of chromosomes using a special RNA template. Telomerase is turned off in most human cells, but cancer cells often must reactivate it so that they can keep dividing like crazy.

The discovery of telomerase has led to new leads for potential anticancer drugs. This is a good example of the impact basic research can have on medicine, since the prize-winners were not thinking about anticancer drugs in the 1980s when they were doing their work.

Telomeres are specialized protective structures at the ends of chromosomes

Telomeres are specialized protective structures at the ends of chromosomes

The telomere trio’s work relates to several lines of research at Emory.

Immunologist Cornelia Weyand and her colleagues have shown that the telomeres of T cells are abnormally shortened in patients with rheumatoid arthritis. In effect, their cells’ chromosomes are prematurely aged. This result provides some hints on how to treat autoimmune diseases.

If blood-forming stem cells can’t keep their telomeres in shape, they can’t continue to regenerate the blood. Pathologist Hinh Ly’s research has made a connection between genetic defects in telomere maintenance and bone marrow failure syndrome in human patients.

Geneticists Christa Martin and David Ledbetter have been probing the relationship between mutations or recombination in the regions of the chromosome adjacent to telomeres and developmental disorders such as autism and mental retardation.

The 2009 Nobel Prize in Chemistry, awarded to Venki Ramakrishnan, Tom Steitz and Ada Yonath, has an even stronger connection to Emory. Christine Dunham, part of a growing contingent of crystallographers here, worked on ribosome structure in Ramakrishnan’s lab at the MRC.

The ribosome is a machine that decodes mRNA and produces protein step by step

The ribosome is a machine that decodes mRNA and produces protein step by step

She is examining the molecular details of how antibiotics and viruses perturb ribosome function.

What the two Nobels have in common is that they both honor work on molecular machines containing RNA, connections to the ancient, shadowy “RNA world“.

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Preparing for H1N1

James Steinberg, MD

James Steinberg, MD

With the novel H1N1 virus gaining a foothold in the northern hemisphere, anxious doctors, researchers and members of the public are carefully watching its movement and behavior.

Even before WHO declared novel H1N1 a pandemic late last spring, Emory University had been readying for its arrival. James Steinberg, MD, chief medical officer at Emory University Hospital Midtown, has been at the forefront of that preparation.

“A few years ago a decision was made to fund a center for emergency preparedness and response,” says Steinberg. “Having CEPAR, headed by Dr. Alex Isakov, gave us a leg up on preparing for this pandemic. Concern about the avian flu a few years ago sparked a pandemic plan and an antiviral plan. Having those plans on board helped us hit the gate running with the swine flu.”

To listen to Steinberg’s own words about novel H1N1 and its effect on the current flu season, access Emory’s new Sound Science podcast.

An expert in infectious disease, Steinberg says three key factors go into the making of a pandemic. “A virus can cause a pandemic when it can cause significant disease, when it’s a new virus to which people don’t have any immunity, and when the virus has the capacity to spread from person to person,” Steinberg says. “The novel H1N1 virus appears to meet all three of these characteristics.”

Steinberg cautions that the word pandemic has a horrible connotation. “We think of the 1918 pandemic that killed 50 to 100 million people worldwide, more people than were killed during World War I itself,” says Steinberg. “But there are pandemics in which the bumps in mortality have been modest.”

The H1N1 virus spreads from person to person via large droplets, the ones that fall quickly onto surfaces. These viruses can be spread by being close to an infected person who is coughing or sneezing or by touching contaminated surfaces. That’s why hand washing reduces the chance of infection.

Thus far, the novel strain of H1N1 has been relatively mild. Most of those infected have recovered without hospitalization or medical care, but according to the CDC some groups are at higher risk and should be vaccinated first. These include pregnant women, people who live with or care for children younger than 6 months of age, healthcare and emergency medical services personnel, persons between the ages of 6 months and 24 years, and people ages 25 through 64 who have chronic health conditions.

Initial supplies of the nasal mist H1N1 vaccine are expected to be available this week, followed soon by the injectable vaccine. The regular seasonal flu vaccine will not provide protection against the novel H1N1 strain, so people will need both vaccines.

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