THE MEDICAL .B.I.S. Investigation of Basic & Integrative Science
University of Miami
Miller School of Medicine VOLUME 6 SPRING 2018
Having received my own medical degree more than three decades ago, I am especially proud of the extraordinary accomplishments of our students at the Leonard M. Miller School of Medicine. As the University of Miami prepares them for careers in the medical sciences, they are making their own contributions to advance research and transform the future of medicine for everyone who needs care. I am honored to be included in this issue of the Medical I.B.I.S., and excited to see more of what the future holds for these bright minds.
From the President
We are rapidly realizing our vision for the future of the University of Miami – to become the hemispheric, excellent, relevant and exemplary university – thanks to the imagination and endeavors of our students. Connecting their curiosity and excitement across our schools and disciplines is extending the impact of our work to transform lives throughout our community and the world. Along with all of our distinguished faculty, I look forward to seeing and participating in the growing connections of our medical students with colleagues throughout the University. Those interactions, along with the research in this publication and all the research to come, will advance our ability to prevent, treat, and cure disease. I am continually inspired by the work of our students and grateful for their boundless dedication.
Julio Frenk, MD, PhD President, University of Miami
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It is my pleasure to present this issue of The Medical I.B.I.S., the University of Miami Miller School of Medicine student-produced research publication. This is the sixth annual edition and features outstanding research conducted by our medical students. The Medical I.B.I.S. is a wonderful example of the synergy occurring between our enthusiastic students and our equally committed and remarkable faculty. Furthermore, the priority that research plays at Miller School of Medicine is clearly reflected in this publication. The combination of intellectual curiosity on the part of our students, a highly diverse patient population and a terrific group of faculty creates an outstanding demonstration of the School’s commitment to transform lives through education, research and service. The research presented in these pages is remarkable and includes basic, translational and clinical investigation. As the Dean of the Miller School of Medicine, I am proud to see our students, just at the beginning of their research and clinical careers, starting to make contributions that will improve the care of the patients who entrust us with the privilege and responsibility to improve and maintain their health and wellbeing.
From the Dean
Our wonderful students clearly excel in research, as they do in clinical accomplishments, and their work will bring great value to our community in South Florida, the U.S., the Americas and the entire world.
Edward Abraham, MD Executive Vice President for Health Affairs CEO, UHealth Dean and Chief Academic Officer, Miller School of Medicine MEDICAL IBIS | VOL.6 | Spring 2018
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2018 Medical I.B.I.S. Staff Editor-In-Chief A. Mariquit Rosete Lu
Managing Editor Dylan Greif
Senior Editors Reshma Muppala Nikesh Doshi Tom Boyle Lily Zhang
Director of Layout Caiwei (Alison) Zheng
Layout Assistant, Photography Assistant Daisy Gonzalez
Director of Photography Nicole Lin
Publishing Editor Aarabhi Rajagopal
Publishing Assistant Editor Ahmed Yousef
Writers John Paul George Kolcun Brandon Rosen Catherine Zaw Lulu Wong Evgeniya (Jenny) Rakitina Jacqueline Baikovitz Sai Polineni Gautam Shrivastava Logan Stone Mackenzie Jones
Zhang, Lu, Greif, Muppala
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Selection Committee Chair David Feldman
Selection Committee Jeffrey Lowell Matt Field Ryan Gallo Olivia Gardner Jeff Wu
Section Editors Saradadevi Thanikachalam Amit Patel Afoma Umeano Santiago Montana Ladan Afifi Brooke Sarna
Investigation of Basic & Integrative Science
Faculty Advisor Emmanuel Thomas, MD, PhD Advisory Board Alex J. Mechaber, MD
Thanikachalam, Montana,Sarna, Umeano, Gardner
The Medical I.B.I.S. is published by the University of Miami Miller School of Medicine Student Government. We reserve the right to edit any submissions, solicited or unsolicted, for publication. This magazine is the work of University of Miami medical students, and the University of Miami is not responsible for its contents. Perspectives expressed by authors do not necessarily reflect the opinions of the University of Miami. We retain the right to reprint contributions, both text and graphics, in future issues as well as a non-exclusive right to reproduce these in electronic form.
Yousef, Zheng, Patel, Lin, Gonzalez The Medical I.B.I.S. welcomes comments and feedback. Please send questions and comments to medical.ibis@gmail.com.
Special Thanks to:
Student Government
Back Row: Shrivastava, Stone, Polineni, Rosen, Kolcun Front Row: Rakitina, Baikovitz, Jones, Wong MEDICAL IBIS | VOL.6 | Spring 2018
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Table Of Contents Alexander Bode
8-9
Characterizing Community Naloxone Programs and Opioid Overdose Trends in the United States
John Paul George Kolcun
10
Laser Thermal Ablation for Mesiotemporal Epilepsy: Analysis of Ablation Volumes and Trajectories
Kelsey Franklin, Madhu Parmar, Leah Hellerstein, Taylor Wurdeman
12-13
Improving Connection to Care for Patients at DOCS Health Fairs Through Access to Patient Navigators
Enmanuel Perez
14-15
Enhanced Astrocytic D-serine Underlies Synaptic Damage after Traumatic Brain Injury
Colette Shiu
16-17
Addressing Colorectal Cancer in South Florida Firefighters
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Ivonne Valentina Lollett
11
Comparing Central Corneal Epithelial, Stromal and Total Thickness in Primary Open Angle Glaucoma Patients and Non-glaucoma Patients
Adriana Wong
18-19
Transgender Men’s Experiences with and Perceptions of Gynecologic Care
Gabrielle Hodgins, Megan McSherry, and Eric Gibbs
20-21
The Debbie Project: A Service Learning Program Aimed at Reducing Bias Among Medical Students Toward Individuals with Intellectual and Developmental Disabilities
Brian Covello
22
Sai Polineni
23
Triple versus Single Contrast Multi-Detector Computed Tomography in the Setting of Penetrating Torso Trauma
Future Directions for ACA-related Research and its Impacts on Physician Researchers
Shaina Sedighim
Sze (Owen) Kiat Tan
24
Control of Glioma Invasion and Proliferation by Elucidating the Role of IncRNAs and EGF-TM7 Family Receptors
25
Serum Long Noncoding RNA HOTAIR as Novel Diagnostic and Prognostic Biomarker in Glioblastoma Multiforme
Maxwell Presser
26-27
Medical Facility Suicides: Using the National Violent Death Reporting System to Estimate Suicides in Medical Settings MEDICAL IBIS | VOL.6 | Spring 2018
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Photo by Mason Cajellas
I Opioid Overdose:
n the United States, the steadily rising opioid crisis has become a major public health concern. The CDC estimates that on average, 115 Americans die each day from an opioid overdose. A major factor contributing to this epidemic is the concurrent rise in prescription opioid use in the general population.
Trends and Community Naloxone Programs in the United States By Lulu Wong
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Doctors are prescribing more and more opioids to manage chronic pain in the United States, yet there has been limited to no reported improvement in the overall population pain burden. America's addiction to opioids is increasingly worrisome, especially in light of the recent spikes in both usage and overdose-related deaths. The opioid crisis impacts our entire country. Many people are personally affected by the opioid crisis, whether it is themselves or a friend, classmate, coworker, patient or family member suffering. That is what inspired Alex Bode, a third-year medical student, to pursue research studying the opioid crisis. Alex recognizes the severity of the issue since several of his high school classmates passed away due to opioid overdoses. Since starting medical school three years ago, he has researched and advocated for overdose protection programs in our country. In the summer of 2016, Miami-Dade County experienced an unusual spike in opioid-related cases and overdose fatalities. Toxicology reports from The Florida Poison Control documented traces of fentanyl found in heroin that was seized by law enforcement. Fentanyl is a powerful prescription opioid primarily used in the hospital setting, and is a thousand times stronger than heroin. At Jackson Memorial Hospital, healthcare providers were suspicious that fentanyl-laced heroin was responsible for the observed increase in overdose cases in their emergency department. Alex teamed up with several emergency medicine physicians at Jackson to perform a retrospective chart review.
As expected, there was a much higher rate of overdose cases cared for at Jackson in 2016. The study also uncovered something surprising. When looking at the use of reversal agent naloxone administered to patients experiencing overdose, the investigators found that there was a higher dose-per-case ratio. This suggested that the opioids being abused on the streets were of higher potency than ever before. This finding directly supported the theory that fentanyl-laced heroin was responsible for the increasingly worrisome overdose rate observed in Miami-Dade County. Alex then helped his mentors explore this issue on a national level. They contacted medical directors of emergency rooms, first responder companies, and public health departments to complete surveys evaluating the overdose rate and use of naloxone across the United States. Additionally, the team evaluated respondent cities for community naloxone programs. These programs have the main goal of getting naloxone to people faster by allowing bystanders, law enforcement, or paramedics to administer this potentially life-saving drug. Their survey had a response rate of over 60%. After reviewing overdose cases and naloxone usage over a period of 6 months, the inves-
tigators determined that there was, indeed, a rise in opioid overdose across the country. Some regions were hit much harder than others – Ohio and the Mississippi River Valleys reported the highest rates of opioid overdose. Not surprisingly, the regions with the highest rate of overdose correlated with increased prevalence of synthetic opioid analogs, such as fentanyl. Furthermore, these regions often lacked community programs for naloxone access, and if programs were present, they often had limited scope. This suggests that people have a harder time accessing naloxone in regions that need it the most. Alex and his mentors feel that it's important to advocate for community naloxone programs, especially in regions with high rates of overdose. Research shows that by allowing easier access to this important, life-saving drug, mortality rates due to opioid overdose decreases. They hope their data can help convince others about the importance of these programs too. For Alex, the opportunity to work in this study hit close to home. Raised in a small town in Illinois, Alex went to a rural high school with a class of only 150 people. Of these classmates, four had lost their lives due to a heroin overdose. He is grateful to be a part of something bigger and feels that his work can tangibly help
others at the heart of something that matters. At the moment, Alex is still working with his mentors to complete this study as he prepares to pursue a career in interventional radiology. Though emergency medicine may not be in the cards for Alex, he shares that he still very much looks up to his mentors from the study. Dr. Amado Baez, MD, MSc, MPH, FA AEM, FCCM is a young and enthusiastic doctor who has proven to be a great leader. "He's really energetic and always has a ton of projects going on," Alex said. "He's a go-getter type of personality, yet incredibly down-to-earth; definitely a career mentor and role model." Dr. Baez has since moved on to work in New York. However, the two still keep in touch and are planning to work together on this project in the future. Alex's research was presented at the American College of Emergency Physicians symposium this past November and the team has also submitted a manuscript for publication in the Western Journal of Emergency Medicine. In the future, they hope that their collaborations with John Hopkins can uncover new details regarding the current opioid epidemic, especially with the collection of more specific outcome measures for statistical analyses.
Alexander Bode Degree Program: MD 2019 Mentor: Amado Alejandro Baez, MD, MSc, MPH, FAAEM, FCCM Other Interests: Business Club DOCS Emergency Medicine Student Association Interventional Radiology Interest Group Radiologist Association of Young Scholars
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Laser thermal ablation for mesiotemporal epilepsy: analysis of ablation volumes and trajectories By Sai Polineni
"Not just saving lives, but improving quality of lives."
J
ohn Paul Kolcun, a third-year medical student, is part of that small group of students who come to medical school with a target specialty in mind and stuck with it. For him, that specialty is neurosurgery. As he himself put it, “one of the primary appeals of neurosurgery is the level of severity in the cases and the ability to influence functional outcomes.” His commitment to neurosurgery led him to begin shadowing in the operating room early into his first year of medical school. Through this experience of learning from and networking with professionals in the field, he was first introduced to the work of Dr. Jonathan Jagid, MD, an Associate Professor of Clinical Neurological Surgery at Miller.
For John Paul, the goal has always been “not just saving lives, but improving quality of lives”. Thus, the opportunity to work with researchers at Miller who are at the forefront of innovative, minimally invasive work has allowed him to explore his interests in functional neurosurgery and guide him towards his goal of becoming an academic neurosurgeon. He credits his mentors for affording him the opportunity to work on projects such as this. He advises underclassmen to manage their time wisely and take advantage of the many opportunities available at Miller to work alongside and learn from physicians at the cutting-edge of their fields.
John Paul became involved with neurosurgery research led by Dr. Jagid and Dr. Walter Jermakowicz, MD, PhD. For many suffering from intractable mesiotemporal epilepsy, the best available treatment has traditionally been an anterior temporal lobectomy. However, John Paul expresses there remains among patients a hesitancy to pursue a treatment that critics would describe as “scooping out part of the brain and hoping for the best”. His research compares of an alternative neurosurgical procedure: Laser thermal ablation. Laser thermal ablation is a new treatment option where, instead of removing the whole anterior temporal lobe, a laser heated wire is used to burn the “problem parts” of the brain causing the seizure. The procedure is less invasive and is intended to minimize the cognitive damage seen in anterior temporal lobectomies. The research team that John Paul worked with recently published a paper in Epilepsia titled “Laser thermal ablation for mesiotemporal epilepsy: analysis of ablation volumes and trajectories’ that aims to validate the efficacy of an alternative procedure with considerably reduced risks compared to invasive lobectomy.” The paper analyzes the volumes and trajectory of the burned areas of the brain and correlate these factors with clinical outcomes. The researchers found that burning the medial head of the hippocampus resulted in worse seizure-freedom outcomes, suggesting that, in mesiotemporal epilepsy, the medial head of the hippocampus may be involved in generating seizures.
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John Paul Kolcun Degree Program: MD 2019 Honors: Published in Epilepsia. PMID 28244590 Mentor: Jonathan Jagid, MD
Ivonne Valentina Lollett Degree Program: MD 2019 Honors: APSA Summer Research Symposium 2017 Mentor: Anat Galor, MD, MPH Other Interests: Teaching and tutoring, breeding betta fish Future Goals: Ophthalmology or Intermal Medicine, Clinical Research
Comparing central corneal epithelial, stromal and total thickness in primary open angle glaucoma patients and non-glaucoma patients By Brandon Rosen
P
rimary open-angle glaucoma (POAG) is the most prevalent form of glaucoma in the U.S. and is problematic for diagnosticians because of its idiopathic nature. A variety of risk factors that predispose individuals to POAG can be used to identify patients that should be closely monitored for symptoms. These risk factors include elevated intraocular pressure, old age, black ethnicity, and family history. Third-year medical student Ivonne Valentina Lollett is working with Dr. Anat Galor, MD, MPH, as well as resident Dr. Hatim Batawi, MD, of the Bascom Palmer Eye Institute and the Miami VA Medical Center in order to gain additional insight into other factors predisposing patients to glaucoma. The research team’s long-term objective is to better quantify risk. Despite
recent advances in the detection and treatment of glaucoma, glaucoma continues to be the most common cause of irreversible blindness globally. Characterized by progressive damage to the optic nerve, glaucoma poses a significant challenge for ophthalmologists due to its insidious onset and irreversibility. Although effective pharmacologic and surgical treatment options exist, early diagnosis before vision loss is difficult. Recent studies have revealed an association between central corneal thickness (CCT) and POAG susceptibility. Valentina is working to validate these findings in a clinical setting and determine which specific corneal layers are associated with POAG risk. Valentina conducted a retrospective case-control study of 112 patients at the Miami VA Medical Center that had optical coherence tomography (OCT) measurements of patient’s corneas and compared corneal thickness in patients with and without glaucoma. She found that glaucoma patients had significantly lower total thickness (CCT) and stromal thickness (ST) measurements than patients without glaucoma. In addition, she found that black patients had significantly lower CCT and ST measurements than white patients. Findings of the project suggest that the stroma is the corneal layer whose thickness is associated with glaucoma susceptibility and also provide a potential explanation for increased glaucoma susceptibility in black populations. Valentina hopes that these initial clinical observations can lead to future studies that will work to improve glaucoma risk assessment, allow earlier diagnosis and treatment initiation, and provide opportunities to develop individualized treatment options for glaucoma patients. Valentina is currently working with Dr. Galor on other research projects and hopes to make additional contributions to our understanding of corneal disease during her time at Miller. Valentina has thoroughly enjoyed her research experiences during medical school and believes it is important for physicians to conduct research and actively explore ways to improve the lives of their patients. She plans to make research an integral component of her medical career and looks forward to addressing her patients’ needs through innovation and discovery.
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Improving Connection to Care for Patients at DOCS Health Fairs Through Access to Patient By Gautam Shrivastava
I
magine seeing a patient in clinic and finding out they haven’t had medical care in a decade. You build a connection as you hear about their difficult past, but during the visit you discover some questionable laboratory values and potential chronic diseases. You explain what you’ve found and the need for further tests while watching the worry well up in their eyes. The patient assures you they will make the appropriate appointments. But life gets in the way and the patient is not able to make the appointment. They are “lost to follow-up,” a common outcome for patients struggling to navigate the complex terrain of annual clinics, referrals, and the high cost of insurance. Miller medical students participating in Department of Community Service (DOCS) health fairs have taken this issue to heart. The Patient Navigation Initiative (PNI) is a student-driven project aimed to improve patient follow-up. Originally developed as a Capstone project by third year MD/MPH students Leah Hellerstein and Taylor Wurdeman, PNI ran as a pilot project at the DOCS South Dade health fair in December 2016. Kelsey Franklin, a second year MD/MPH student, and Madhu Parmar, a second year MD student, are now spearheading the development of the PNI as members of the Research and Quality Improvement (RQI) team at DOCS. Working under the mentorship of Dr. Amar Deshpande, MD, and Dr. Erin Kobetz, PhD, MPH, the RQI team has successfully completed both a pilot study and a randomized controlled trial on the efficacy of PNI at DOCS health fairs in the past year. With this new research project, Kelsey and Madhu hope to introduce students to some of the barriers facing the patients they care for at the DOCS health fairs. Madhu’s interest in patient follow-up was
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sparked while studying abroad in Cape Town, South Africa. She volunteered at a student-run mobile health clinic that provided care to underserved townships across Cape Town, where she learned about longitudinal care in clinical medicine and the issue of patient access to medication. The experience also shed light on the realities of clinical work: Madhu saw first-hand that the problem with patient retention stemmed from non-medical aspects of patients’ lives, from unemployment to food insecurity. She felt that there needed to be a support system that extended beyond medicine and helped these patients stay connected to care.
in empathizing with patients, motivational interviewing, role-playing, and practical skills, such as using documentation systems.
Similarly, Kelsey spent three years volunteering in clinical research and worked as a Clinical Research Coordinator at a pediatric emergency department, focused on examining processes and quality improvement. Kelsey’s work in evaluating standard-of-care treatments for acute diabetic ketoacidosis and in challenging long-held paradigms with empirical evidence paved the way for her analytical role in examining the processes of DOCS in search of improvements.
“Patients really appreciate it too," Madhu says. One of her patients last year texted her praising the navigation program. She continues,
A month prior to the 2016 pilot study, a two-day patient navigation training was held for a team of medical and public health graduate students that involved exercises
The pilot project compared patients who underwent navigation to similar patients from previous fairs (who served as historical controls), with particular focus on 15 “increased risk” individuals, who were defined as having hypertension, a high fasting glucose, or other abnormal findings. Nearly half of the patients in the patient navigation group were connected to care, compared to none from previous historical controls, demonstrating a statistically significant difference in patient retention.
"Patients have such busy lives, so navigating healthcare is not always their top priority, and the system’s not that easy to navigate either.”
Madhu Parmar
Degree Program: MD 2020 Other Interests: DOCS RQI Leadership Future Goals: Internal Medicine, Family Medicine, Primary Care
Kelsey Franklin
Honors: Presented at the 2017 AAMC Conference Presented at the 2017 DOCS Community Health Leadership Conference
Degree Program: MD/MPH 2020 Other Interests: DOCS RQI Leadership Future Goals: Ob-Gyn, Family Medicine
Mentors: Dr. Amar Deshpande, MD Dr. Erin Kobetz, PhD, MPH
The successful pilot project was followed by a randomized controlled trial conducted at the DOCS Liberty City health fair in March 2017. In this trial, all high-risk patients were given navigators, and an additional 32 average risk patients were randomized for navigation. The findings after a three-month follow-up indicated that most of the patients attended their health appointment, had been counseled by their patient navigator, or had taken other beneficial actions such as getting a Jackson card, which allows them greater access to free healthcare services. The promising results led to the inclusion of PNI in future health fairs, and the
first official program was executed during the 2017 DOCS South Dade health fair.
PNI is a departure from the discontinuity that stems from annual fairs. She believes that
Working on this project has been fulfilling for both Kelsey and Madhu, especially since both hope to incorporate community initiatives in their medical practice. Kelsey wants a strong connection to the community she practices in and intends to place a special focus on social determinants of health and psychology. Madhu hopes to focus on functional medicine and to empower patients to take control of their own wellbeing through healthy lifestyle practices.
“this is a way for us to make a longer footprint in the community.�
Both Kelsey and Madhu have big plans for the future of the PNI, including making it a permanent part of DOCS health fairs. For Kelsey,
Kelsey presented the abstract for this project at the AAMC conference in November 2017 and received great feedback as she spread the word about patient navigation as a means to retain follow-up. Madhu feels that, in addition to achieving the mission of DOCS by improving long-term patient care, the PNI program will build invaluable life skills in communication and empathy for those helping patients.
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Photo by Jesse Orrico
"
Research revolves around one central idea: learning how to do research and learning how to think about different problems and how to attack those problems methodically in order to reach a conclusion unbiasedly.
"
Enhanced astrocytic d-serine underlies synaptic damage after traumatic brain injury By Logan Stone
T
raumatic brain injury (TBI) has been a focal point in neurological research, particularly its links to astrocyte reactivity. Currently, there is debate in the field concerning glial transmitters, which are released from glial cells such as astrocytes.
Enmanuel Perez
Degree Program: MD/PhD 2019
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It was initially understood that D-serine is released by astrocytes and that TBI could potentially alter this signaling pathway and contribute to synaptic dysfunction. However, Enmanuel Perez, a fourth year MD/PhD student, delved deeper into the literature and saw that there were two emerging ideas about the source of D-serine. While the first idea hypothesized that astrocytes were
serine racemase enzyme through a transgenic model, the increased D-serine levels that were initially detected in the sham treated controls were no longer observed. By eliminating the D-serine synthesizing enzyme specifically in astrocytes, no difference was detected when compared to the naive brain; however, an increase in D-serine was found following CCI injury. In essence, if this increased observance in D-serine levels could be inhibited following a CCI injury, synaptic damage associated with traumatic brain injury is minimized, leading to an overall better synaptic environment. One of the novel aspects of Enmanuel’s work is his usage of inducible, cell-specific transgenic mice. With these mice, a drug can be given to induce either the deletion or the over-expression of a target protein in a cell-specific manner. In fact, the perfect example of this is the focus of Enmanuel’s work in determining if D-serine levels are affected primarily by neurons or astrocytes and whether cellular expression changes after brain injury. His utilization of transgenic techniques ultimately helped establish a mechanism of action regarding D-serine by increasing or deleting the expression of serine racemase in both of these cell types. When asked what is his favorite part of the astrocytic D-serine project, Enmanuel replied, “In-vivo electrophysiology— this was something I pioneered at the lab. It’s pretty awesome because a lot of times when people do these studies, they do it in slices,” he explains. “What I was doing was I was recording from the mouse that was there, alive and anesthetized.”
the main contributors to D-serine release, the second camp diverged from the seminal studies of the 1990s and reported that D-serine was in fact primarily released and secreted by neurons. Born and raised in Puerto Rico, Enmanuel came here to Miami eight years ago when he was accepted to the MD/PhD program at the Miller School of Medicine. Enmanuel had found the perfect paradigm for his work. At the Liebl Lab, where Enmanuel works as a doctoral researcher, different electrophysiological techniques were employed in the naive hippocampus of mice to find that D-serine was indeed predominantly observed in the neuron-rich pyramidal cell and granule cell layers. Here, neurons express D-serine and the enzyme that makes it, serine racemase. But Enmanuel had another goal: to investigate whether elimination of serine racemase could prevent D-serine levels from increasing after TBIs, which has been linked to synaptic damage. He wondered if preventing this increase in D-serine could lead to an improved synaptic environment, with increased learning, memory, synaptic plasticity, and overall brain functioning during TBI recovery. To further investigate D-serine expression, Enmanuel utilized sham-treated mice in the naïve hippocampal state with no TBI present and compared them to mice with controlled critical impact (CCI) injuries to the brain. Having traced where D-serine is synthesized, his next step was to inhibit its expression in the mice with brain injuries. When Enmanuel took this step forward and knocked out the
Enmanuel’s work differed from prior research in that he did not need to artificially create an environment for the slices of hippocampus to survive long enough to record the data. Instead, he recorded from the mouse in the actual synaptic environment. Using stereotactic maps, Enmanuel was able to place recording electrodes on the mice and stimulate a path to the hippocampus in the pyramidal neurons. Enmanuel’s study design also featured double blinding to prevent bias. Enmanuel was blinded to the genotype and the injury groups were randomized to either sham-treated or CCI. Enmanuel concluded from his study that NMDA receptors need the co-agonist D-serine. He also found that after injury, the synaptic environment changes significantly. The Liebl lab revealed that during this change, there is a dichotomy between the neurons and astrocytes and that the NMDA receptors’ expression and function is altered. Moving forward, graduate students at the Liebl Lab are investigating further to see what regulates this increase or decrease in expression patterns by studying which molecules or pathways regulate serine racemase activity. “Enhanced astrocytic d-serine underlies synaptic damage after traumatic brain injury,” published in The Journal of Clinical Investigation, was funded by the NIH and is the culmination of his PhD work. He is the president of the Student Interest Group in Neurology (SIGN) and is a mentor to those interested in neurology and clinical research. “I always tell them research revolves around one central idea: learning how to do research and learning how to think about different problems and how to attack those problems methodically in order to reach a conclusion unbiasedly.”
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Addressing Colorectal Cancer in South Florida Firefighters By Jacqueline Baikovitz
Photo by Hermes Rivera
W
hat if your job could increase your risk of developing cancer? Firefighters work tirelessly to ensure the safety of their communities. In their line of duty, firefighters are exposed to carcinogens such as polycyclic aromatic hydrocarbons which are released from the burning of wood and plastics. The Firefighter Cancer Support Network reported in 2016 that 32% of active firefighters in South Florida have been diagnosed with cancer from 2008 to 2010, which is triple the cancer risk in comparison to the general population. Since her first year of medical school, third year MD/MPH student Colette Shiu has worked with the Firefighter Cancer Initiative because of her interest in community-based participatory research. Colette closely works with her mentor, Natasha Schaefer-Solle, PhD, RN, who runs the colorectal cancer firefighter screening project. She also works with Erin Kobetz, PhD, MPH, who is an Associate Professor of Medicine, Public Health Sciences and Obstetrics-Gynecology at the University of Miami Miller School of Medicine and is also the Director of the Jay Weiss Institute for Health Equity at the Sylvester Comprehensive Cancer Center. A group of South Florida firefighters reached out to Dr. Schaefer-Solle and Dr. Kobetz to determine ways to prevent diseases, including cancer, associated with occupational exposures.
A grant from the state of Florida created a partnership between South Florida firefighters and the University of Miami Miller School of Medicine to assess firefighters’ occupational hazards and establish programs to work on cancer prevention. Before embarking on the study, Colette led focus groups to determine how she can help firefighters in cancer prevention. She then began her project focusing on colorectal cancer screening. The American Cancer Society (ACS) reports that colon cancer is the second leading cause of cancer-related deaths in men and the third leading cause in women. Moreover, the National Institute for Occupational Safety and Health (NIOSH) reported in 2013 that firefighters have a 26% higher colorectal cancer mortality rate in comparison to the general population, demonstrating the need for colorectal cancer prevention in firefighters. While preventative screening has helped decrease the prevalence of colorectal cancer, mortality was over 50,000 people in 2017. Since colorectal cancer one is one the most diagnosed cancers among active firefighters in South Florida, Colette examined the feasibility of implementing colorectal screening at the workplaces of active firefighters in South Florida. Firefighters eligible for the study were between the ages of 40 and 65 years old and without previous colorectal cancer screening. The ACS recommends earlier colonoscopy for patients at high risk for developing colon cancer. For example, patients with a family history of colorectal cancer should undergo a colonoscopy at age 40 or 10 years before the youngest case of colorectal cancer in their immediate family, whichever comes first. The team distributed fecal immunochemical test (FIT) kits to the firefighters for use at home to collect stool samples. These stool samples were then sent to a laboratory. If the FIT results came back positive for blood in the stool, the researchers would refer the firefighters to gastroenterologists to schedule colonoscopies. The study is still ongoing, and Colette looks forward to reviewing the results of the colonoscopies. Colette presented her work at the American Public Health Association Conference in Atlanta, GA in November 2017, describing how the workplace colorectal cancer screening program increased rates of screening in the firefighter population. The study had a 62.5% completion rate for the FIT, which represents an improvement in screening adherence.
Colette Shiu Degree Program: MD/MPH 2019 Honors: Quantum Foundation 2017, American Public Health Association Conference 2017 Mentor: Erin Kobetz, PhD, MPH Other Interests: Laennec Academic Society, Christian Medical Association, Ob-Gyn Interest Group Future Goals: Ob-Gyn, Community-Based Research
Colette is continuing her research on cancer prevention in firefighters through her capstone project funded by the Quantum Foundation. The Quantum Foundation supports public health initiatives with the mission “to improve the health of Palm Beach County by supporting local health-related non-profits and entities to carry out projects and services in the community.” Colette's capstone project addresses an even narrower demographic: female firefighters. Because men make up the majority of firefighters, she is interested to see if there is a difference in cancer incidence between male and female firefighters. The upcoming capstone project is entitled “Understanding Retired Female Firefighters’ Perceptions of Cancer and Wellness.” Colette is interviewing groups of male and female firefighters to gain insight into the perceptions of retired firefighters regarding safety and health hazards, particularly on perceived cancer risk. She enjoys making a meaningful impact on a vulnerable population in the community, and is grateful that her MPH education is providing her the platform to directly improve community health.
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Transgender Men’s Experiences with and Perceptions of Gynecologic Care By Evgeniya (Jenny) Rakitina Photo by Peter Hershey
A
wareness of transgender identity has dramatically increased over the past few years. However, many healthcare professionals are still far from adequately understanding and addressing the health needs of transgender patients. Previous studies showed that gynecologists across the country report feeling uncomfortable and unprepared to care for transgender individuals. In broad terms, a transgender man is a person who was assigned female at birth but identifies as a man. A common misconception is that transgender men undergo gender affirmation surgery. This is not always true. According to the National Transgender Discrimination Survey (NTDS), only a small fraction of transgender men opt for surgery, which encompasses a number of invasive procedures at an often high financial expense. More commonly, transgender men retain their female genitalia while transitioning to a man’s identity through hormone replacement therapy, legal affirmation, and social transition. This means that these men are
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still in need of regular gynecologic care. The size of the transgender population in the U.S. is unclear, with many figures thought to be grossly underestimated. For this and numerous other reasons, meeting the health needs of transgender patients has proven difficult. Although the American College of Obstetricians and Gynecologists (ACOG) released a practice bulletin in 2011 stating that gynecologists should be prepared to care for transgender individuals, no transgender-specific guidelines were produced. This creates a huge gap separating providers from their transgender patients. Third-year MD/MPH student Adriana Wong has played a role in closing that literature gap. She works with a research team led by Dr. Lydia Fein, MD, an Ob-Gyn resident at Jackson. They work closely with Ob-Gyn Dr. Carlos Medina, MD as well as Dr. Christopher Salgado, MD, a plastic surgeon who specializes in gender affirmation surgery. Their collaborations identify the healthcare barriers transgender patients face.
Adriana evaluated transgender men’s experiences with and perception of gynecologic care and reproductive health care in Miami. Responses to the NTDS indicate that one in four transgender and gender nonconforming individuals are denied equal treatment in healthcare settings. Reports of discrimination include incidences of denial of care, verbal or physical harassment, and untrained providers. Gaining an understanding about the perceived value of gynecologic care as reported by transgender individuals was identified by Dr. Fein as the first step in assessing and improving the relationship between transgender men and access to healthcare. Adriana and her colleagues reached out to well-known and respected community leaders within the transgender community in Miami. They distributed anonymous web-based and paper surveys to self-identified transgender men in order to gather critical information regarding transgender men’s perceived needs in healthcare. Participants were asked to report how important they felt reproductive health-
care is for transgender men, including annual gynecologic care, routine cancer screening, STI testing, and general physical examination that includes pelvic examination. While it did not come as a surprise that many of them felt that routine cancer screenings and STI testing were very important, only 33% of participants actually attended annual visits. Over half of the respondents delayed gynecologic care due to gender identity concerns, specifically citing fear of mistreatment by uninformed providers as being the main reason for the avoidance of care. Many participants reported past experiences during which they were denied care for being transgender, shown a lack of respect, or felt judged from the providers. The data quickly began to show a recurring theme: there was a constant discrepancy between individuals’ perceived importance of health screenings and their actual use of healthcare services.
"A lot of people think of Ob-Gyn as healthcare for women only but truly it's for anyone who has female reproductive organs.
And it includes transgender men."
Perhaps among the most telling revelations is that the majority of study respondents were insured individuals, high-school or college graduates, and Caucasian. Historically these demographics have the best access to healthcare. Perceived stigma, fear of mistreatment, gender dysphoria - these barriers keep transgender men from accessing the care that they seek. Thus, transgender identity quickly began to emerge as a strong and independent factor preventing people from accessing care. Speaking to Adriana about her personal experience with this study, she emphasized the importance of proper, culturally-sensitive, trans-inclusive training for gynecologists. “A lot of gynecology offices are very feminine on the inside. Imagine being a transgender man sitting in this kind of setting waiting for a pap-smear and then having someone assume that you’re there for the sole purpose of accompanying a female partner when in fact you are the one who is seeking care”. Adriana stressed that there are many things providers can do in order to make their practices more inviting for this population of patients, as well as educating themselves on the transgender lifestyle in general. As a person who has always been interested in underserved communities and female health, Adriana came to the Miller School knowing that she wanted to be an Ob-Gyn. Growing up in Los Angeles she was exposed to the transgender population and saw the need for a more sensitive and inclusive environment for these individuals. “It’s interesting that a lot of people think of Ob-Gyn as healthcare for women only but truly it’s for anyone who has female reproductive organs. And it includes transgender men”, she states. Now that the study has concluded, she highlighted that gaining knowledge about the transgender population and the barriers to healthcare that they face definitely inspires her to be a more trans-inclusive provider in the future Despite all the limitations, the study produced meaningful and eye-opening results, shedding light on the apparent disconnect between the perceived importance and access to care by transgender men. This prompted Dr. Fein and Adriana to start another project involving the transgender community. Their current project involves focus groups in order to detail specific experiences that transgender men have had with gynecologists. These groups will explore mistreatment, judgement, and patient experiences with pregnancies, abortions, and contraception. The study promises to provide a comprehensive insight into the issues that transgender men face in their personal lives and give researchers a good understanding of best approaches to take in order to better serve their patients.
Adriana Wong Degree Program: MD/MPH 2019 Mentor: Lydia Fein, MD Other interests: Director of Patient Obstacles for Reproduction Health Advocates, President of Ob-Gyn Interest Group Future Goals: Aspires to pursue a career as an Ob-Gyn and specialize in gynecologic oncology
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The
Debbie Project:
A Service Learning Program Aimed at Reducing Bias Among Medical Students By Catherine Zaw
A
t first glance, the Debbie School situated in the Mailman Center for Child Development seems like any other early educational school. Look again and you’ll see just how special and unique it really is. The Debbie School provides an inclusive environment for children of all backgrounds and abilities with a focus on children with developmental disabilities or auditory impairment.
Clockwise from top: Gabrielle Hodgins, Eric Gibbs, Megan McSherry
program for medical students to volunteer with the Debbie School. During Gabby’s second year at UMMSM, she reached out to Megan McSherry and Eric Gibbs, both first years at the time. Together, the three worked to establish a volunteer program.
es,” Gabby explains. “We know physicians report not being comfortable treating patients with disabilities and how to interact appropriately with those with disabilities, so we decided to evaluate the effect volunteering might have on these biases.”
Needless to say, the Debbie Project was a success. The medical students expressed their enthusiasm and excitement, as well as the personal growth they felt after volunteering for a year in the Debbie School classrooms — so much that Gabby, Megan, and Eric were in-
The team decided to pilot a preliminary study to quantify any changes that may occur before and after volunteering with Debbie Project. Organized as a longitudinal assessment, they asked volunteers in their first cohort to take anonymous online surveys that assessed attitudes before and after at least 8 weeks of participation in the Debbie Project program. The survey utilized the Multidimensional Attitude Scale Toward Persons with Disabilities (MAS), a previously validated Likert-scale survey that consists of a written scenario pertaining to an individual in a wheelchair followed by 34 questions designed to assess the responder’s affect, behavior, and cognition.
The close proximity of the Debbie School with the Miller School of Medicine allows for a close partnership with the Debbie Project, a UMMSM student group that organizes a volunteer program at the Debbie School. Through the Debbie Project, medical students can volunteer to assist in classrooms, work one-onone with students, and serve as a friendly face to the many children, teachers, and administrators who enjoy the students’ weekly visits.
"It was so affirming to know that people care for these kids, and that if we do these studies, they will be valued.”
The idea for Debbie Project first began a little over two years ago. Gabby Hodgins, currently a fourth year UMMSM medical student, discovered that there was no
spired to try to quantify the impact that volunteering with children with disabilities had.
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“What came to mind was implicit bias-
In all, the team collected 19 paired pre- and post-program surveys — a 67 percent response rate from the total of 27 students that volunteered through Debbie Project. Even from baseline, the team identified differences between male and female-identifying
participants in the survey answers. Females reported higher levels of helplessness and guilt while male participants reported higher levels of fear. Those volunteers who had family members with disabilities reported significantly less stress and depression. By comparing participants’ attitudes pre-program and post-program, the study team found that after volunteering, student volunteers showed improvements in relaxation, serenity, pity, alertness, and desire to leave. In fact, there was no category measured in which attitudes worsened over the volunteer period. Even those volunteers who had family members with disabilities benefitted from volunteering with Debbie School, showing significant improvements across categories. The conclusions from their preliminary study were striking and affirmed the value of their program. The core finding from these data is that structured and longitudinal volunteering, such as that with the Debbie Project, could substantially improve medical student attitudes towards children with disabilities — regardless of prior experiences. Their research received high recognition
for a few conferences already, including first place at the Florida Chapter of American Academy of Pediatrics (FCAAP) conference and second place at the American Physician Scientist Research Symposium. “I think what was so unique about our study was that it was longitudinal,” Megan says. “There have been multiple studies that attempt to quantify changes in bias after just a few hours of working with those differently abled, like the Special Olympics. Our study, rather, is based on a yearlong transformative learning environment.” With such promising preliminary data, the Debbie Project team plans to move forward with their research, assessing if the benefits to volunteers from their time working with the Debbie Project lasts long into their medical training. Eventually, they hope to create a body of literature that supports incorporating service-learning programs into medical school curricula.
“This preliminary study was proof of concept,” Eric says, mentioning the limitation in their survey study that most of these improvements were self-reported by the volunteers. “We’re working on a larger IRB now with similar concepts but a slightly different structure of study. We want to add the Implicit Association Test this time around as well, and we hope that this will make our results more objective.” Above all, the three founders want to make sure the Debbie Project continues to provide medical students with the opportunity to volunteer with the passionate staff and to meet the adorable children of the Debbie School. “The thing that has been most touching is that everyone has been so supportive,” Gabby says. “We started this not knowing what was going to happen. From day one, we had more volunteers than we had space for. When the school found out about what we were doing, we got so much love. It was so affirming to know that people care for these kids, and that if we do these studies, they will be valued.”
Triple versus Single Contrast Multi-Detector Computed Tomography in the Setting of Penetrating Torso Trauma By John Paul Kolcun
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or trauma surgeons, the decision to operate is a key branch-point in patient care. Generally, any hemodynamically unstable patient with a penetrating injury to the abdomen is taken to the operating room. In patients with similar injuries but stable vital signs, however, further diagnostic imaging – in the form of computed tomography (CT) – is frequently indicated. Traditionally, this would be accomplished by single-contrast CT given IV, with radiopaque contrast material delivered to identify any internal injuries that require immediate surgical repair. In recent years, however, triple-contrast CT – given IV, orally, and rectally – has been studied increasingly as a higher-sensitivity test for internal injury. Brian Covello, a third-year medical student, recently analyzed the use of triple-contrast CT for hemodynamically stable patients with penetrating torso trauma. He conducted this study with Dr. Felipe Munera, a professor of radiology at the university. Brian retrospectively reviewed charts from Ryder Trauma Center for patients who had penetrating trauma to the torso and underwent CT imaging before surgery. In these patients, surgery either confirmed or did not confirm the presence of hollow organ injury. Furthermore, some of these images were single-contrast and some were triple-contrast. Brian worked with two radiologists who reviewed all of these images, record their findings, and rate their degree of confidence as to whether or not the patient had a hollow organ injury based on those images. Using surgical confirmation of actual injury as a standard, Brian was able to compare the sensitivity and predictive values of single- vs. triple-contrast CT for hollow organ injury. These findings showed conclusively that triple-contrast CT was a more specific tool to detect hollow organ damage. Therefore, this test can rule out internal injuries in these patients. Brian’s research holds implications beyond an improved detection strategy. Identifying patients without internal injuries prevents unnecessary exploratory surgeries and the associated morbidities to patients. “The next step,” Brian explained, “is to have more readers interpret our image sets, and to compare their findings. Inter-reader reliability is a major variable in assessing the validity of a new imaging tool. We have to make sure that the test works, no matter who reads the images.” Brian has been interested in acute care for many years, shadowing or volunteering in emergency departments since high school. “In college, I liked math and physics,” he said, “so when I decided to pursue medicine, radiology seemed like an obvious choice. It may sound cheesy, but I really love studying the technology we have available today.” He presented his preliminary findings to the American Society of Emergency Radiology at their national conference in Toronto in 2017. His career interests include diagnostic, vascular, and interventional radiology.
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Future Directions for ACA-related Research and its Impacts on Physician Researchers By Sai Polineni
I
n 2019, a lesser known but highly contentious program within the Patient Protection and Affordable Care Act (ACA) will be up for reauthorization in Congress: the Patient-Centered Outcomes Research Institute (PCORI). The decision to either continue or defund PCORI will influence the direction of studies and projects that medical students will undertake as future physician researchers. Many early proponents of the ACA hoped that PCORI would be able to fund and promote cost-effectiveness analyses that would reduce spending on unnecessary or inappropriate care. Currently, overtreatment constitutes up to one-third of American health care costs. However, amidst fears that PCORI would advance measures that influence “who”receives “what” care, Congress disallowed PCORI from using their findings to influence Medicare coverage and reimbursement. The ACA itself stipulates that PCORI “shall not develop or employ a dollars per quality adjusted life year [QALY] … as a threshold to establish what type of health care is cost effective or recommended.” As a result, PCORI research primarily compares the effectiveness of vari-
ous clinical options available to physicians without exploring the costs of these treatments. This leaves physicians and researchers in an interesting position. Defunding PCORI in 2019 would not only cut off a source of project funding, but would remove initiative for researchers to take on of a comparative effectiveness research. A decrease in these types of research projects may impact the quality and success of policy changes at the federal level. If, however, PCORI is reauthorized in 2019 and there are indications that the program will be strengthened, it may signal room for growth in this field. Supporters of PCORI reauthorization hope for an increase in financial and political support for this type of analysis. At its core, the debate around PCORI is the keystone debate around which the future of American healthcare may be framed. Given the recent consolidation amidst health care payers (insurers) and providers (physician and hospital groups) and the evolving opinions of the American public and physicians in favor of a single-payer healthcare system, it is possible that such a system will come to fruition at some point in the distant future. If
such a system were enacted, a national administrative body such as PCORI would be necessary to evaluate the many treatments and medications on the market and regulate prices via Medicare and other national programs. The debate hinges on how much power PCORI should be given to not only fund comparative- effectiveness research, but to also pursue cost-effectiveness research. Expanding PCORI’s role to weigh comparatively effective treatments against their cost per QALY would give the institute the ability to dictate the number or types of treatments provided at a state or federal level. Furthermore, it would signal a move towards a stronger federal body with heightened authority over health care costs and treatments. For those interested in health policy, Congress’s 2019 decision on PCORI may indirectly reveal where the current political community stands in relation to the single-payer system. Medical students should keep an eye around the PCORI reauthorization debate not only to monitor the direction of comparative effectiveness research, but also to better understand its implications for our future national health system structure and landscape.
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Control of Glioma Invasion and Proliferation by Elucidating the Role of IncRNAs and EGF-TM7 Family Receptors By John Paul Kolcun
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lioblastoma multiforme (GBM) remains a well-known yet challenging medical issue. GBM is the most common primary malignancy of the adult brain and, unfortunately, associated with the poorest survival: median survival after diagnosis ranges from 12-15 months, with 5-year survival rates as low as 3-5%. Standard therapy for these tumors begins with total or near-total surgical resection, with adjuvant chemotherapy and radiation therapy to follow. However, the recent and rapid advances over the past decade in genetic and immunologic sciences have not been lost to neuro-oncology. New, targeted therapies are currently under investigation for these lethal tumor. Shaina Sedighim, a second-year MD student, works in the laboratory of Dr. Michael Ivan, MD, MBS, a brain tumor specialist in the Department of Neurological Surgery. Her research aims to understand how subtle differences in long-noncoding RNA (IncRNA) expression between different types of glioma impact tumor development, progression, and clinical prognosis.
actual patient tumors are genetically altered to under express specific IncRNAs whose mutations have been implicated in GBM. Shaina describes that by following these manipulated cell lines with genetic analysis, the downstream effects of IncRNA variation can be elucidated. Learning more about these downstream effects helps to identify which particular IncRNA mutations contribute significantly to tumor development and progression. Shaina’s work was featured at the Department of Neurological Surgery’s annual Rosomoff Research Day. In the near future, Shaina hopes to extend her research to in vivo studies in rodent models. Using viral vectors, targeted IncRNA manipulation can be performed in mice, allowing Shaina and her team to measure the implication of these mutations on tumors in living animals using imaging studies, overall survival, and post-mortem immunohistochemi-
cal analysis to determine tumor invasion. Shaina is passionate about this work and its future clinical applications. “GBM remains one of the greatest threats in the cancer world. These IncRNAs represent novel targets for controlling the proliferation and invasion of GBM cells. Understanding and incorporating this biology into future clinical trials may lead to improvements in overall quality of life and survival for patients.” “The collaborative aspect of research,” continues Shaina, “is perhaps my favorite part.” In the Ivan lab, she worked closely with other groups in the University of Miami Lois Pope Life Center. This experience, with exposure to multiple role models of various disciplines, was a positive one. “They have shown me the importance of living a balanced life in medicine and science – these disciplines aren’t just jobs, but fulfilling lifestyles,” she said.
Shaina previously investigated immunologic therapies for brain tumors during her undergraduate studies and came to Miller already dedicated to neurosurgery and neuro-oncology research. She explains,
“To me, there is no puzzle more intellectually stimulating to tackle; there are no answers that are more meaningful than those that may potentially relieve the pain of an individual suffering from a life-threatening disease such as a brain tumor." In the Ivan Lab, glioma cell lines derived from
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Shaina Sedighim Degree Program: MD 2020 Mentor: Dr. Michael Ivan, MD Other Interests: Jewish Medical Students Association, Medical Students in Action, Clinical Research, Neurosurgery Interest Group, Immunologic Medicine Pathway, Anatomy TA
Serum Long Noncoding RNA HOTAIR as Novel Diagnostic and Prognostic Biomarker in Glioblastoma Multiforme By Brandon Rosen
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lioblastoma multiforme (GBM) is the most common primary brain tumor in adults. It is also the most malignant, and consequently, most lethal. Median survival time is approximately one year from diagnosis, and even with surgical resection and chemoradiation therapy, recurrence is virtually guaranteed. Although novel targeted therapies for GBM are being developed and tested clinically, effective assessment of tumor response on a molecular or cellular level poses a tremendous clinical challenge. Traditionally, GBM treatment efficacy is assessed in terms of patient survival, which provides little information concerning tumor response to therapy in real-time. Third-year medical student Sze Kiat Tan, who goes by Owen, is working with Dr. Nagi Ayad, PhD, Co-Director of the Miami Brain Tumor Initiative, to address this issue by developing a novel biomarker-based method to monitor the response of GBM to various therapies over time. Owen’s research project focuses on the Ayad lab’s previous observation that expression of some long noncoding RNA (lncRNA) are altered in GBM and appears to be involved in tumor proliferation. Owen developed a PCR-based serum assay to quantify expression of this biomarker in patients and found that it was significantly higher in GBM patients than in healthy individuals. The assay also displayed robust sensitivity and specificity (both > 85%), attesting to the validity of this as a GBM biomarker. Owen’s findings have the potential to dramatically alter the clin-
Sze (Owen) Kiat Tan Degree Program: MD 2019 Honors: AOA Research Fellowship, 3rd place poster at Florida Medical Association Annual Meeting in August 2017
ical management of GBM and improve patient quality-of-life. This biomarker assay only requires a blood draw from patients, and if optimized, could allow clinicians to avoid conducting invasive brain biopsies for traditional GBM staging. In doing so, clinicians may be able to more frequently assess GBM progression over the course of a patient’s disease, providing “real-time” insight into the status of the tumor and its response to treatment. Owen and Dr. Ayad recently obtained IRB approval for a clinical trial to more thoroughly evaluate the use of this lncRNA as a GBM biomarker. Owen plans to make translational research a focal point of his medical career, hoping to use his clinical observations to directly address patient needs in the lab. He has a strong interest in neurosurgery and plans to bring his skillset of patient-oriented science to the field. Owen says,
"As a doctor, you’re able to make a difference in someone’s life, but only through research can you make significant changes in medicine." MEDICAL IBIS | VOL.6 | Spring 2018
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Photo by Elijah O'Donell
Medical Facility Suicides:
Using the National Violent Death Reporting System to Estimate Suicides in Medical Settings By Mackenzie Jones
A
s a teenager, MD/MPH student Maxwell Presser first became interested in the subject of school shootings after reading "Give a Boy a Gun" , a book by Todd Strasser addressing on the Columbine High School massacre.
Years later, during his first summer at Miller taking public health classes, Maxwell continued to explore this interest by reading the book Private Guns, Public Health by Dr. David Hemenway, Ph.D. The book explains why gun violence should be treated as a public health problem, and inspired Maxwell to look for a way to combine his career in medicine with his evolving interest in gun violence.
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Realizing that research opportunities on gun violence are sparse due to limited funding, Maxwell sought more experience in the field by reaching out directly to the author of the book that had inspired him. To his delight, Dr. Hemenway was just beginning a project investigating violent suicides on medical facility campuses and invited Maxwell to his lab at the Harvard Injury Control Research Center to work on it. The study gave Maxwell the opportunity to combine his interests in preventable traumatic deaths with both medicine and public health. The goal of the project was to evaluate the National Violent Death Reporting System (NVDRS) as a surveillance system for medical facil-
ity suicides. The NVDRS is a surveillance system that contains data on violent deaths in 40 states, the District of Columbia, and Puerto Rico from multiple sources including state and local medical examiner, coroner, law enforcement, toxicology, and vital statistics records. Maxwell identified cases from 16 states in the NVDRS related to suicide, and then sorted them by location to narrow down the list to those that occurred in or on the grounds of a medical facility campus. Over the summer, he read thousands of cases to confirm the circumstances of death. In addition, he coded several variables based on short incident narratives. The details he looked at included the location within the medical facility where the suicide occurred and whether the suicide was completed by use of a firearm, by jumping from a building, by hanging, or by other means of self-inflicted injury.
policy and structural changes implemented to reduce such deaths. Working with Dr. Hemenway and other mentors on this project has taught Maxwell how to frame broad research questions and take small steps towards a greater goal. By working in the subject of violent deaths, he has seen how an increased awareness of gun violence has led to collaboration between unlikely partners, such as researchers, gun shop owners, and politicians. While gun violence continues to be a politicized issue, Maxwell is hopeful that people will be able to find common ground by focusing on injury prevention and the health of the public.
Scrutinizing detailed accounts of suicides from death certificates, coroner reports, and police reports over the course of the summer was a draining process. According to Maxwell, this effort was worthwhile because of the importance of accuracy in evaluating the value of the database as a surveillance tool. The results of the study revealed an estimated 0.050 annual medical facility suicides per 100,000 with an estimated 149-155 cases per year. Most cases involved patients and occurred in acute care hospitals, psychiatric hospitals, and nursing homes. Most of the victims were male and between the ages of 25-65 years old; hanging and firearms were the most common methods used. The project was successful in identifying the database as a strong and reliable tool for further research on the circumstances of violent deaths, particularly suicides within medical facilities. Although the number of suicides at medical facilities was lower than what was anticipated based on sparse data from older studies, Maxwell still recognizes the necessity for surveillance of these cases. He says,
“It is important to remember how problematic it is for a person to die of suicide in a medical facility, where patients and their families expect staff to take care of someone who is ill.” Such violent deaths tend to exhibit a ripple effect on the well-being of everyone involved in that person's life and care at the medical facility. It is not enough to examine the loss of life, but also the impact such an event would have on the well-being of others. An employee who may find the deceased patient, the physician who felt responsible for the patient’s safety, and the friends and family members dealing with the sudden loss of a loved one should all be taken into consideration. When assessing the unique and widespread impact of a person's violent death by suicide, even lower rates should be considered significant. Now that Maxwell's first project has established the surveillance potential, he aims to conduct more specific projects. He believes that the controlled environment of a medical facility creates an ideal setting for the implementation of suicide prevention efforts. Research investigating the causes of variable suicide rates in different types of medical facilities could inform
Maxwell Presser Degree Program: MD/MPH 2020 Honors: 3rd Place, Summer Research Symposium hosted by the UMMSM Chapter of the American Physician Scientist Association Mentors: David Hemenway, PhD and Cathy Barber, MPA Other interests: Trauma Surgery Interest Group, MD/MPH Ambassador for Class of 2021, Admissions Liaison for MD/MPH Program, Anatomy TA, and CrossFit Future Goals: Trauma Surgery, Advocacy, and Policy
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