July 24, 2020, NIH Record, Vol. LXXII, No. 15

July 24, 2020 Vol. LXXII, No. 15

Exposure and Effects,” the final installment in the Office of Dietary Supplements 2019- 2020 Seminar Series. MIXED MEDIA MESSAGES Media frequently broadcast health information that, to Joe and Jane Public, Do Conflicts in Health seems at odds, Nagler said, describing the Communication Shake Your examples above. “In our experience, the Confidence? conflict and controversy often co-occur, but they don’t always,” she said. “It’s possible BY CARLA GARNETT to have information that is in conflict, but Should I eat fish for better heart health or where there is not necessarily heated dispute worry more about the mercury it contains? or disagreements.” How about alcoholic beverages—is a glass An associate professor in the of red wine good for me or not? When Dr. Rebekah Nagler of the University of Hubbard School of Journalism and Mass should I start having regular mammo- Minnesota discussed conflicting health Communication at the University of grams—at age 40, 45, 50? And should I go messages at a recent ODS seminar. Minnesota, Nagler has conducted research annually or every 2 years? PHOTO: UNIVERSITY OF MINNESOTA on public health messaging for more than No doubt most of us have confronted a decade. Her work has been supported health headlines that presented us with To offer insights on how the public by NCI as well as the Office of Research conflicting options. What, if any, effect receives and processes such mixed on Women’s Health via its Building did the conflict have on your confidence messages, NIH grantee Dr. Rebekah Nagler Interdisciplinary Research Careers in in science or medicine? How did media presented “Conflicting and Controversial Women’s Health program. reports factor into your decision? Health Information in the Media: Content, SEE NAGLER, PAGE 4

Harris Reflects on Decades of Research into Rare Disorder BY DANA TALESNIK

Severe developmental neuropsychiatric disorders cause patients and their families relentless suffering. Treatment of symptoms may provide short bursts Richard Fagerlin of relief but CIT-developed devices deployed to Covid-19 do little to GIVE IT TO GET IT improve the frontlines. See story, p. 12. patient’s Fagerlin Discusses Economics ALSO THIS ISSUE quality of life. and Value of Trust Briefs...... 2 Determined BY RICH MCMANUS to improve Medical History Matters in Era of Big Data. . .3 outcomes for Back when people used to work in offices Who Is NINR’s New Director? ...... 5 these intracta- and reported to bosses and interacted with ble conditions, coworkers—a state that, it is said, will come HHS Deputy Secretary Hargan Returns to investigators again—trust was a key component in moving NIH, Donates Again to Blood Bank...... 7 have persevered; things forward. Digest...... 9 their longtime Speaking, virtually, on the topic of trust Milestones...... 10 Dr. James C. Harris research is at a time when it is hard to come by amid SEE HARRIS, PAGE 6 SEE FAGERLIN, PAGE 8 CIT Produces Tools for Covid Fight. . . . . 12 BRIEFS

Fitness Challenge Welcomes NIH’ers Put on your bell-bottoms, grab your favorite cassettes and pack the Polaroid for a fun-filled, nostalgic journey to some of America’s most popular out-of-the-way places. NIH is participating in Coast to Coast, a fun and invigorating fitness and walking challenge available to all employees. It is sponsored by Kaiser Permanente. The challenge started July 21 and runs through Aug. 31. You will be whisked away on a virtual shore-to-shore tour. Coast to Coast will take you across this great land of ours, stopping at amazing attractions with postcard-perfect vintage and modern images, plus “bet-you-didn’t-know” descriptions. Each day you’ll visit a new attraction, earning points and “road signs” as you record exercise minutes or steps. To make this challenge even easier, you can link your own personal tracking device (Fitbit, Garman, etc.) with the Coast to Coast website or mobile app. Your step count will automatically update daily to “During this pandemic period, I have gone back to drawing,” said Sahar Rais-Danai, deputy chief grants help you keep pace with the competition and keep management officer at NIAMS. “Although my artwork might have taken a dark turn, I think this conveys track of your personal goals. an important message. It’s definitely getting framed and put up in the bathroom.” Speaking of competition, you won’t be alone on We’ve Seen Your Pets—Now Show Us Your Projects your Coast to Coast journey. You will be “compet- ing” with other NIH employees in a race to earn the In the same spirit as the recent NIH Record photo series on pets who got us through our teleworking most points. You can also choose to team up with travails, we are now soliciting photos of projects you may have undertaken during the pandemic period, 3 or 4 other coworkers for a friendly and exciting and of which you are proud. team competition, even if you’re social distancing. Did you complete a piece of furniture, build a guitar, master the baking of sourdough bread or concoct Get ready to move toward a healthier you—register homemade ginger beer? Did you take up painting, learn bonsai or become a bike mechanic? at https://fedsgetfitmas.coasttocoastwellness. Here’s the challenge: Send us a photo (high-resolution color digital image) that visually captures your com/#/welcome. achievement and a caption of 30 or fewer words. Feel free to include yourself in the image. We will accept submissions through Friday, Aug. 7. Email us at [email protected] or [email protected]. Food Drive Now at Halfway Point We are now halfway through this year’s Feds Feed Families Campaign. As of June 30, NIH reported donating 140,201 pounds of food. On June 25, NIH hosted a “Virtual Food Drive” event. Katherine Donnelly, nutrition education specialist from the Capital Area Food Bank, provided an overview of the extent of food insecurity in our region and described which populations are particularly impacted. She explained how local organizations are meeting needs during this uniquely challenging time. At the end of the webinar, Tim Tosten, associate director for program and employee services at the Office of Research Services, provided information on how NIH staff can help fight hunger through the Feds Feed Dr. Peter Kilmarx (l), FIC deputy director, Families Campaign. drills holes in a log to inoculate with shiitake mushroom spore dowels at home in Bethesda For more information on the campaign, visit in April. The mushrooms will grow in 6-12 https://www.ors.od.nih.gov/FedsFeedFamilies/ months. The masks (above) were made by his Pages/default.aspx. If you have any questions wife, Nichaphat Kilmarx, for their family and about the effort, contact FedsFeedFamiliesNIH@ friends. nih.gov.

2 • NIH RECORD • JULY 24, 2020 While these technologies might help limit spread Medical History Matters of the virus, Radin said it’s important to think about their implications, given the history of big in Era of Big Data data. How, for example, will private companies or BY ERIC BOCK governments use mobility data in the present and future? Scientists involved in machine learning often don’t know the origins of the “Sometimes even the best of intentions are datasets they use to write and test algo- upended by the momentum of the technological rithms, including where the Pima Indians systems that people find themselves in,” Radin Diabetes Database (PIDD) came from, concluded. explained Dr. Joanna Radin at a recent virtual NLM history talk. “The history of the PIDD makes political and economic subjectivity visible in ways that are of enormous consequence to practitioners and participants in medical and machine learning,” said Radin, associate professor of the history of medicine and history at Yale University. Machine learning is a sub-discipline of Dr. Joanna Radin (above and below) lectures virtually to an NIH audience on Big Data. artificial intelligence that dates to the 1950s. Radin explained: “It focuses primarily on algorithms capable of learning longitudinal study of diabetes. Estimates suggest or adapting their parameters based on a set of that 90 percent of the reservation enrolled in the observed data without having been programmed study. NIH researchers later worked with computer to do so.” scientists to digitize long-term patient data. ON THE COVER: Coronavirus spike protein In 1987, Dr. David Aha and several graduate “Medical information collected has been regarded structure. Coronaviruses are enveloped viruses students at the University of California, Irvine, built as a valuable resource for improving general knowl- responsible for 30 percent of mild respiratory an archive of datasets called the UC Irvine Machine edge about the disease,” she said. infections and atypical deadly pneumonia in humans Learning Repository. It offered programmers the worldwide. These pneumonia include those caused by infections with SARS-CoV and MERS-CoV. The ability to download large, well-validated datasets In the 1990s, Aha, who had been collecting data coronavirus spike glycoprotein mediates virus entry needed to test algorithms. for the repository, had completed a postdoctoral fellowship at Johns Hopkins. It was around this into cells and represents an important therapeutic time that a researcher from the Applied Physics target. The illustration shows a viral membrane decorated with spike glycoproteins; highlighted Laboratory, located near Johns Hopkins, came into in red is a potential neutralization site, which is a possession of the dataset. protein sequence that might be used as a target for “What surprises me is that we get from a situation vaccines to combat coronaviruses. where we’re using data collected from indigenous IMAGE: DAVID VEESLER, UNIVERSITY OF WASHINGTON people for diabetes research and, by 2006, the dataset became so standard that it’s being used The NIH Record to teach people how to use R, a popular statistical Since 1949, the NIH Record has been published software package,” Radin said. “Such uses are biweekly by the Editorial Operations Branch, purely about teaching people about how to use Office of Communications and Public Liaison, data.” National Institutes of Health, Department of Health and Human Services. For editorial policies, email A few years ago, she spoke to an expert in machine editor or phone (301) 496-2125. learning who was writing an algorithm for New Editor: Rich McManus York City’s electricity provider to predict where [email protected] One of the oldest files in the repository was the fires might spark in the underground power grid PIDD. It became a standard for testing data-mining and trigger an explosion of manhole covers. To Associate Editor: Carla Garnett [email protected] algorithms in predicting diabetic status. What made test and optimize the algorithm, the expert fed the PIDD so valuable is that programmers knew it it several complex, widely available data sets, Staff Writers: reliably predicted when people get diabetes. including the PIDD. Eric Bock • [email protected] Dana Talesnik • [email protected] The Pima, who refer to themselves as Akimel The story of how participants in an NIH research Subscribe via email: Follow: O’odham, which translates to “River People,” are study on diabetes and how their data was used [email protected] http://nihrecord.nih.gov/ an indigenous community. Most of the community to refine an algorithm that would predict where a Facebook “f” Logo CMYK / .eps Facebook “f” Logo CMYK / .eps lives on the Gila River Indian Reservation located in manhole cover would erupt “is exemplary of the The NIH Record Arizona. In the early 1960s, the institute now known history of big data,” Radin said. is recyclable as as NIDDK began conducting an epidemiological mixed paper. study of arthritis among the community. The Today, the use of patient data from all kinds of researchers quickly learned that the inhabitants communities is part of the public health response had one of the highest recorded rates of diabetes. to Covid-19 outbreaks around the world. Officials are using contact-tracing mobile apps to identify By 1965, Radin said, every resident older than 5 in people who might have been exposed to the virus. the study area had been asked to participate in a

NIH RECORD • JULY 24, 2020 • 3 Nagler  CONTINUED FROM PAGE 1 “This is just the very nature of scientific discovery and “Researchers, clinicians, we’re pretty well-equipped to negotiate this...My concern we’re seeing that play out in the covid context right now. As has always been about the public and the research—as knowledge—advances, there is going to be that public’s ability to reconcile seemingly sort of two-steps-forward/one-step-back approach. And we conflicting information,” she explained. She defined conflicts in health infor- can wind up with situations where there are mation in a few ways, including “messages legitimately opposing effects.” that are providing information about the ~DR. REBEKAH NAGLER same behavior, resulting in two distinct outcomes.”  Several factors can account for the disputes, Nagler explained. Distinct study empirical evidence linking media exposure mention of conflict and controversy is design or variations in measurement are two to the reported outcomes. She and colleagues there? How much attention was paid to examples. “Early cohort studies pointed to set out to provide data on how people are risks and benefits, on balance?” potential benefits of antioxidants and certain exposed to messages and whether behavior Researchers were able to connect some individual vitamins, but in the later, random- changes as a result. subsequent actions to respondents’ exposure ized control trials, results “didn’t hold up. One key finding: Conflicting nutrition to warring medical messages, particularly in That’s another place where there could seem messages delivered by television were per- a study about mammography screening. to be a shift in findings… ceived differently than messages in print But, specific behavior changes aside, why “This is just the very nature of scientific media. TV was associated with greater does it matter whether people take note of a discovery,” she said, “and we’re seeing that confusion and, in turn, more distrust in couple of conflicting health stories? What’s play out in the covid context right now. As dietary recommendations. Researchers the real harm? research—as knowledge—advances, there is also saw some evidence of reduced health Nagler worries about what she termed the going to be that sort of two-steps-forward/ behaviors linked to the confusion people “carryover or spillover” result. She described one-step-back approach. And we can wind up felt, with markedly lower levels of fruit and a worst case “cumulative, across-topic, with situations where there are legitimately vegetable consumption, for example. across-source meta effect” on someone opposing effects.” Nagler’s group also looked at messages exposed to volumes of conflicting or contro- Generally, she noted, public under- involving e-cigarettes, the HPV vaccine versial media content over time. standing of scientific research is limited, a as well as guidelines for mammography “It could ultimately systematically fact that the National Science Foundation and screening for prostate cancer. The undermine their trust in science at large, but has been documenting for years. A large researchers considered accuracy of the specifically in public health recommenda- percentage of Americans don’t know what media reports as well. Many 2009 broad- tions,” she said. scientific study is. casts of mammography guidelines, for As an example, she referred to a 2014 “We’re seeing a lot of these gaps play out instance, contained mistakes or erroneous study in which people who were exposed now with Covid-19, with limited research reporting. to conflicting reports about wine, fish and literacy among the public and variations in Timing of the research could prove coffee were shown to be less inclined to eat people’s understanding of risk,” Nagler said. significant too, Nagler found. Debates fruits and vegetables, which have never been In addition, she noted, “news coverage surrounding the Affordable Care Act in dispute as healthy. historically has omitted a lot of the meth- coincided with media events about shifts in In the Q&A period, an attendee asked odological and contextual information that cancer screening recommendations from about the potential impact of health people would need to make sense of these major professional findings and understand why there could be organizations. shifts and seemingly inconsistent results.” “So what we So the media sends mixed messages and did—through the public might be confused. Would people’s systematically behavior reflect this? analyzing media Over the years, “there were a lot of content—was ask assumptions of adverse media effects—this to what extent did belief that the media was disseminating all discourse around of this conflicting information and it was the controversy having all sorts of deleterious effects,” said evolve?” Nagler Nagler, who took issue with the assump- explained. “How Dr. Abby Ershow (l) of the Office of Dietary Supplements introduces Nagler, who has been looking at how health messages are received by the public. tions, mainly because she couldn’t find any much explicit

4 • NIH RECORD • JULY 24, 2020 STARTS THIS FALL Zenk Selected as Next NINR Director On July 1, NIH director Dr. Francis Collins announced that he selected Dr. Shannon Zenk as the next director of the National Institute of Nursing Research. A registered nurse and leading nurse researcher, Zenk is currently nursing collegiate professor in the department of population health nursing science at the University of Illinois at Chicago (UIC) College of Nursing and a fellow at the UIC Institute for Health Research and Policy. She is expected to begin her new role as NINR director in early fall. “Dr. Zenk’s diverse and original research experience paired with her expertise as a nurse educator make her an ideal choice to lead NIH’s efforts in nursing science,” said Collins. As NINR director, Zenk will oversee NINR’s science that seeks to improve Nagler worries about a “carryover or spillover” the lives of individuals and families result. She said a worst case “cumulative, across-topic, across-source meta effect” on living with illness and to develop per- someone exposed to volumes of conflicting or sonalized strategies to maximize health controversial media content over time...“could and well-being at all stages of life and ultimately systematically undermine their trust in science at large, but specifically in public across diverse populations and settings. health recommendations.” Zenk’s research focuses on social inequities and health with a goal messages delivered via Twitter, Facebook of identifying effective, multi-level and other social media platforms. approaches to improve health and elim- “What’s unique about social media, of inate racial/ethnic and socioeconomic course, is the ability to share and dissemi- health disparities. Her research portfolio also includes nate,” Nagler responded. “And a lot of the Dr. Shannon Zenk NIH-supported work into urban food concern is about misinformation…How PHOTO: UNIVERSITY OF ILLINOIS AT CHICAGO quickly and easily we could share informa- environments, community health tion is super problematic right now.” solutions and veterans’ health. What about getting messages directly Through pioneering research on the built environment and food deserts, Zenk from the horse’s mouth, so to speak? Would and her colleagues helped bring national attention to the problem of inadequate surveying scientists with health-related access to healthful foods in low-income and black neighborhoods. questions and sharing results with the Zenk was elected as a fellow of the American Academy of Nursing in 2013 and was public help solve some of the contradictions inducted into the International Nurse Researchers Hall of Fame in 2019. She has spent presented by media? time as a visiting scholar in Rwanda and Australia. “I don’t know if it would necessarily solve She earned her bachelor’s in nursing, magna cum laude, from Illinois Wesleyan the problem, but it might at least help get University; her master’s degrees in public health nursing and community health an upstream factor where you know who is sciences from UIC; and her doctorate in health behavior and health education from the doing the actual message creation and devel- University of Michigan. opment,” Nagler concluded. “To what extent Upon Zenk’s arrival at NIH, current NINR acting director Dr. Tara Schwetz will do scientists feel that it is their responsibility continue in her role as NIH associate deputy director. to help communicate their results? I think the move towards open communication and public engagement in the last couple years is really positive. Journalists often struggle to get researchers to call them back to serve as sources and help talk things through for the public. I would like to think that could be a potential solution or part of a solution.”

NIH RECORD • JULY 24, 2020 • 5 Harris said Harris. “These children CONTINUED FROM PAGE 1 are particularly sensitive to attention to their disruptive bringing us closer to better treatments. behavior.” One such investigator, Dr. James Not all LNS patients C. Harris, director, Developmental injure themselves. Classic Neuropsychiatry Clinic and professor at cases with less than 1 Johns Hopkins University, has devoted percent HGprt enzyme more than 30 years to studying neurogenetic present with self-injury, syndromes, particularly Lesch-Nyhan but there are variants. syndrome (LNS), in which patients are prone Patients who have 3-5 to self-injury. percent enzyme tend to Harris, who spoke at a June 3 virtual have dystonia and other Clinical Center Grand Rounds, showed neurological symptoms graphic images of patients’ self-mutilation: but don’t self-injure. Other a missing finger and lip disfigurement patients who have closer from self-biting and an eye injury from Harris speaks virtually to an NIH audience at Grand Rounds. to 20 percent enzyme also self-hitting. These patients had classic LNS, a don’t self-injure; they tend genetic disorder also characterized by other [Nyhan’s] description set us off to try to to have some motor clumsiness and mild to aggressive behaviors, dystonic movement understand what those deficits were.” no dystonia. All of them have hyperuricemia, disorder and intellectual disability. Over the years, Harris and his colleagues’ but treating it has no effect on the self-injury. This rare syndrome, first described in NIH-funded research has delved into the “Overall, the variants contribute a great 1964 by Dr. Michael Lesch, then a medical spectrum of HGprt enzyme deficiency, deal because they allow us to look at an student, and his mentor Dr. William Nyhan, measuring metabolites and studying the extended phenotype,” said Harris. “[LNS stems from a deficiency of an enzyme that, 3 underlying neurobiology. Their numerous variants also allow us] to carry out cognitive years later, NIH’s Dr. Jay Seegmiller would studies sought to gauge motor, cognitive, and behavioral measures across the full • • • spectrum, keeping in mind that self-injury is one symptom that’s apparent only in classic “It was an interesting idea that a behavior could designate a cases with essentially no enzyme.” newly described genetic metabolic syndrome, and [Nyhan’s] In a recent study with 17 LNS patients compared with healthy subjects, Harris and description set us off to try to understand what colleagues found discrepancies in white those deficits were.” matter, areas deep in the brain teeming with

~DR. JAMES C. HARRIS nerve fibers and encased in a protective myelin sheath that affects motor, sensory • • • and cognitive function. “I think this is particularly interesting identify as HGprt. The less enzyme present, linguistic and social abnormalities in LNS because no one has looked carefully at white the more severe the patient’s symptoms. patients. He continues to use the latest The amount of HGprt deficiency is based imaging technologies to analyze brain on the type of mutation—there are hundreds structure and chemistry, looking at pathways of possible ones—of a single X-linked gene. from genes to self-injury. That gene, HPRT1, was first sequenced in the In classic LNS cases, patients often wear 1980s, around the time Harris came on the arm restraints to protect against self-injury, scene to study LNS. though some can communicate when they Nyhan had described LNS as involving feel safe enough to loosen them. Harris told structural deficits in the central nervous the story of a young boy named John who system with the characteristic behavioral told his caregivers when he felt safe enough phenotype of self-injurious behavior. to have his restraints released. On one Further research would reveal the syndrome occasion, Harris said, while a caregiver was is an X-linked metabolic disorder: the transferring John from bed to his wheel- Dr. Maryland Pao, clinical director, NIMH enzyme deficiency causes hyperuricemia— chair, his hand inadvertently hit his caregiver Intramural Research Program, introduces Harris, whom she met as a medical student excess uric acid in the blood. in the face. at Johns Hopkins. “He and his wife Cathy “It was an interesting idea that a behavior “The caregiver continued as if nothing DeAngelis became my academic parents and could designate a newly described genetic had happened because if he responded, he’d shepherded my early career at Hopkins, for which I am eternally grateful,” she said. metabolic syndrome,” said Harris, “and reinforce the behavior and it would persist,”

6 • NIH RECORD • JULY 24, 2020 matter in LNS before,” said Harris. Using diffusion tensor imaging, they are finding markedly less white matter in the brains of LNS patients, and the white matter is abnormal. “Strikingly, the classic Lesch-Nyhan cases are consistently lower in their cognitive capacity on [verbal learning and recognition] tests than the variants and both are quite different from the normal controls,” he said. Over the years, treatments for LNS have included symptom management, protective equipment along with psychiatric, occupational and speech therapy interventions. Among the pharmacotherapy options, researchers continue to focus on dopamine (D1) receptor antagonists, which may show benefit in treating dystonia and self-injury, said Harris. A recent, promising clinical trial using HHS Deputy the D1 drug ecopipam produced significantly Hargan Returns to less frequent and severe self-injury but the trial was canceled due to side effects, said Give Blood Harris, noting that doses may need tweaking On July 1, HHS Deputy in subsequent studies if the drug can again be Secretary Eric Hargan made available for further study. and his chief of staff Will “We’re hoping this type of work can be Brady donated blood continued,” said Harris, “because the D1 in support of Clinical antagonist is the only drug treatment we’ve Center patients. This is seen that’s actually been demonstrated to a continuing effort by have an effect in a controlled study.” Hargan to bring attention Another promising treatment, partic- to the importance of ularly in children with LNS, is a metabolic blood donation during precursor using the dietary supplement the Covid-19 pandemic. S-adenosyl-methionine (SAMe). Harris He wants to highlight is encouraged by the neurobehavioral that donating blood improvement in SAMe trials, adding that the is safe and encourage treatment remains a work in progress that heathy individuals to requires refinement. Benefit is reported in help with blood, platelet approximately 30 percent of adult cases. and convalescent plasma As Harris and colleagues fine-tune donations. At top are their understanding of the neurobiological (from l) Dr. Kamille West, pathways of LNS, another approach— chief of the department targeted deep-brain stimulation—has helped of transfusion medicine’s improve, and in some cases eliminated, blood services section; self-injurious behavior. He showed a video Hal Wilkins, donor clip of a patient self-biting, spitting up food resources supervisor; and hitting his caretaker at baseline. Later, Hargan; Brady; and after deep-brain stimulation, the patient is Kathy Robinson, donor calm, amicably interacting with others, with resources specialist. At right center, Hargan is taken care of by Ahmed Cham; Brady no sign of self-injury. (bottom) is seen to by Beisha “Belle” Zhu. Hargan had visited the NIH Blood Bank on Mar. Building on decades of research, 24, joined by his wife, to donate blood and make a video on the importance of new studies renew hope of finding more blood donation. effective, sustainable treatments for LNS and other developmental neuropsychiatric PHOTOS: CHIA-CHI CHARLIE CHANG conditions.

NIH RECORD • JULY 24, 2020 • 7 but it’s true. These negotiate obstacles, often by accruing trust are heavy, scary, due to having extended it to others in the difficult times, but past. historic times, too. Fagerlin says workplace culture is “the Mostly these are sum of what you permit and what you revealing times. promote.” The best cultures emphasize the We show more of latter, which tends to be more positive than a who we are under set of strictures and thou-shalt-nots. pressure. Pressure Two lies work against a culture of trust, makes us more of he said: Trust is earned over time, and trust who we already takes a lifetime to earn, but only a second were.” to lose. With our beliefs Throw away the scorecard, urged “You are the most trusted people on the planet,” Fagerlin told NIH’ers. and principles put Fagerlin. When mistrust emerges between daily to the test, two parties, both often think they’ve gone Fagerlin suggests halfway to meet the other. “It’s the first step Fagerlin examining the polar- past halfway that impresses me the most,” CONTINUED FROM PAGE 1 ities and tensions he said. they reveal. “Trust isn’t what you earn, it’s some- societal unrest and a pandemic, Richard For example, we all want a boss who is thing you give. If you don’t give it, you’ll Fagerlin, founder and president of Peak clear. But we also want flexibility. never get it.” Solutions, gave the third talk in the Deputy “There’s a tension between those two Fagerlin isn’t calling for blind trust or Director for Management Seminar Series values,” said Fagerlin. “Each one is the ignorance; there are people who will take on June 4. downside of the other.” advantage of you, but the percentage is small, Although his talk was scheduled long But just as breathing requires both and the gains of trusting far outweigh the before trust was elevated to a crucial national inhaling and exhaling—unless you want occasional downside, he argued. concern—Do we trust the police? Do we trust vaccines?—Fagerlin acknowledged the weight of the moment. w w w “The times we’re in right now make trust more important than ever before,” he said. “Trust isn’t what you earn, it’s something you give. “This presentation is absolutely just in time.” If you don’t give it, you’ll never get it.” For the last 20 years, the Edelman public ~RICHARD FAGERLIN relations firm has compiled a Global Trust Report, said Fagerlin. In 2020, its focus is w w w competence and ethics. “No organizations were found both competent and ethical in 2020,” he said. to suffocate—there needs to be a balance Trust is a stool with three legs, he posited: “Trust is at an all-time low in the systems between the two. integrity, competence and compassion. they examined.” Another example: Flattening the curve by “Integrity is more than honesty,” he But the three most trusted occupations staying home vs. killing the economy. explained. “It comes from the same word as in America this year are doctor, scientist and “The point of tension isn’t deciding integer, or whole number. It’s a wholeness, a national health official. what’s right or wrong, but in admitting what consistency of self.” “That’s powerful,” said Fagerlin, “because the factors are—safety is paramount in this Competency, he said, is the ability to every one of you fits. You are the most instance—and learning to manage them,” acquire knowledge, but more crucially, “to trusted people on the planet. You have been Fagerlin suggests. “The goal is not to solve a be able to broker that knowledge to other placed in the highest position, which has problem, but to manage tensions.” people.” never been the case in the history of time… This often involves abandoning the Compassion, he admitted, “is the most The whole world’s eyes are upon you.” either/or mindset and welcoming both/and, difficult. It requires a pure understanding of But it’s easy to slip when, given any set he said. There is an upside to tension, and the where people are coming from. You’ve got to of circumstances—say, the importance of best leaders know better than to resolve all of be able to rejoice when people are rejoicing wearing masks in public—30-40 percent of it. Respect, empathy and an open mind are a and grieve when they are grieving. the public will interpret the same set of facts leader’s best allies in tight situations. “If you have all three of these characteris- totally differently. Leaders, by the way, are not necessarily tics, you have trust.” “These are unprecedented times,” said the experts, or the most senior people. Interestingly, whichever of the stool legs Fagerlin. “We’re all tired of hearing about it, Rather they are problem-solvers who can is most important to you is likely to be the

8 • NIH RECORD • JULY 24, 2020 DIGEST

one you most unfairly judge others by, he said. Long-Acting Injectable Form of HIV “We tend to overvalue what’s important Prevention Outperforms Daily Pill to us,” Fagerlin noted. “Remember, you can A pre-exposure prophylaxis (PrEP) regimen containing an inhale too much and end up out of balance.” investigational long-acting form of the HIV drug cabote- He concluded with three suggestions for gravir injected once every 8 weeks was more effective than getting past the halfway point in building a daily oral Truvada at preventing HIV acquisition among relationship of trust. cisgender men who have sex with men and transgender • “Everyone needs CPA,” he declared: I women who have sex with men in a clinical trial sponsored by NIH. cause…I participate…I allow. “This is the coat A long-acting form of cabotegravir of arms of our various cultures. We need to While both methods were highly effective for HIV prevention injected was more effective than daily oral Truvada. take ownership.” in the study population, the final data analysis indicated that cabotegravir had a superior protective effect. Findings from • Always assume positive intent. “I judge the study, called HPTN 083, were to be discussed during the 23rd International AIDS Conference. myself on my intentions. But I judge others on their actions…Take the risk to assume a The only currently licensed PrEP medications—daily oral pills containing the HIV drugs tenofovir and emtricitabine—are highly effective at preventing HIV when taken as prescribed. However, taking a pill positive intention.” daily can be challenging. A long-acting form of PrEP could offer a less frequent, more discreet option • Be offensive, or willing to offend others. that may be more desirable for some people. HPTN 083 and an ongoing companion study called HPTN Fagerlin admits that feelings of offense are at 084, which is evaluating long-acting injectable cabotegravir for HIV prevention in cisgender women in an all-time high and cautioned against being sub-Saharan Africa, are sponsored by NIAID. a bully. He emphasized “candor with care” In May 2020, a review of HPTN 083 data indicated a high level of efficacy for long-acting injectable in order to be real, authentic and vulnerable. cabotegravir among cisgender men and transgender women who have sex with men. The current “As the saying goes, wounds from a brother results are based on a more extensive analysis of interim data from 4,566 study participants. are better than a kiss from an enemy.” Overall, the rate of HIV acquisition in the participants was low. Among the 52 participants who acquired He touted the model of servant leader- HIV, 13 were in the study group who received the cabotegravir-based PrEP regimen plus placebo daily ship: “Lift up others so they can be great. oral tablets, and 39 were in the group who received daily oral Truvada plus placebo injections. Detailed Do the right thing. Ask every day, ‘What’s analysis of these data indicated that the superior efficacy of cabotegravir was statistically significant. needed from me right now?’” Both products were safe and generally well-tolerated. Participants in the cabotegravir group were more And have the humility to forgive others likely to experience fever and pain or tenderness at the injection site compared to those in the Truvada when things go awry. “Choose courage group, who received placebo injections. Those in the Truvada group were more likely to report nausea. over comfort in taking the first step toward Complexity of Tooth Enamel Revealed at Atomic Level reconciliation.” During a brief Q&A moderated by NIH Scientists used a combination of advanced microscopy and chemical detection techniques to uncover the structural makeup of human tooth enamel at unprecedented atomic resolution, revealing lattice deputy director for management Dr. Alfred patterns and unexpected irregularities. The findings could lead to a better understanding of how tooth Johnson—who issued Fagerlin a standing decay develops and might be prevented. The research was supported invitation to visit NIH once travel restric- by NIDCR and findings appeared in Nature. tions abate—Fagerlin acknowledged that “This work provides much more detailed information about the atomic some employees must cope with malignant makeup of enamel than we previously knew,” said Dr. Jason Wan, a narcissism in bosses. program officer at NIDCR. “These findings can broaden our thinking “Don’t let people live rent-free in your and approach to strengthening teeth against mechanical forces, as brain,” he counseled. “Don’t let them take well as repairing damage due to erosion and decay.” more energy than they deserve.” He also Enamel is made up of Your teeth are remarkably resilient, despite enduring the stress and pointed out that sometimes “there are tightly bunched, oblong strain of biting, chewing and eating for a lifetime. Enamel—the hardest crystals that are about necessary endings.” substance in the human body—is largely responsible for this endur- 1,000 times smaller in ance. Its high mineral content gives it strength. Enamel forms the Two final nuggets: clear expectations width than a human hair. outer covering of teeth and helps prevent tooth decay, or caries. coupled with immediate and regular IMAGE: KAREN DEROCHER, feedback are the most motivating factors in NORTHWESTERN UNIVERSITY To survey enamel at the tiniest scales, researchers use microscopy methods such as scanning transmission electron microscopy (STEM), the workplace. And when change comes, only which directs a beam of electrons through a material to map its atomic makeup. three people like it—if they’re in charge, if they implement it, or if they benefit by it. STEM studies have shown that at the nanoscale, enamel comprises tightly bunched oblong crystals that are about 1,000 times smaller in width than a human hair. These tiny crystallites are made mostly of “It sucks for everyone else!” he said. a calcium- and phosphate-based mineral called hydroxylapatite. STEM studies coupled with chemical The full lecture is available at https:// detection techniques had hinted at the presence of much smaller amounts of other chemical elements, videocast.nih.gov/watch=35467. but enamel’s vulnerability to damage from high-energy electron beams prevented a more thorough analysis at the necessary level of resolution. “Human enamel is much more chemically complex than we thought,” said co-first author Dr. Paul Smeets, a research associate at Northwestern University. The findings could lead to new approaches to toughen enamel and prevent or reverse cavity formation.

NIH RECORD • JULY 24, 2020 • 9 MILESTONES

NINDS’s Kehne Retires After 35 characterized novel CRF-1 receptor antagonists for As medical director, he established operational the treatment of depression, anxiety and stress-re- priorities for OMS and developed, implemented Years in Neuroscience lated disorders, helping to successfully secure a and adjusted work-related medical and counseling BY SHANNON E. GARNETT multi-year collaboration with a large pharmaceuti- services to meet the evolving needs of the NIH cal company. workforce. For 35 years, Dr. John Kehne, a program director in NINDS’s Division of Translational Research, has Upon leaving Neurogen, Kehne became an Schmitt is responsible for establishing the first built a career in neuroscience—primarily focused independent consultant working with biotech com- postexposure chemoprophylaxis program for HIV-1 on discovery and development of new drugs for panies to advance compounds through discovery exposures in the nation. He also developed the first treating central and development. standardized approach for evaluating and treating nervous system (CNS) workers for potential exposures to B virus. Other disorders. He officially In 2012, he joined the NINDS Division of career highlights include designing the medical retired on June 30. Translational Research (DTR) as a scientific project portion of the NIH biological surety program and manager and acting director of the Anticonvulsant revamping OMS operations to provide support for “I have had a very Screening Program (now ETSP)—a preclinical the NIH community during the Covid-19 pandemic. satisfying career in platform for identifying potential new drug treat- neuroscience, and feel ments for epilepsy. He later became a DTR program Upon retirement, Schmitt plans to travel nationally very gratified that at director with interests in preclinical pharmacology, and internationally (when the pandemic subsides), NINDS I have helped animal models and preclinical neurotherapeutic spend time with grandkids and extended family position the Epilepsy development, and head of ETSP. and complete a long list of woodworking projects Therapy Screening and consulting. He says he will miss “patient-care Program [ETSP] “I was particularly excited by the specific challenge responsibilities, daily interactions with the amazing for further success, posed to me of taking a longstanding, highly OMS and NIH staff, an incredible variety of clinical helped build a new successful preclinical epilepsy screening program and administrative challenges, and being involved screening program to the next level to address critical unmet medical in supporting the NIH mission.” for finding non-ad- Dr. John Kehne needs in epilepsy,” said Kehne. dicting analgesics and Most recently, he contributed to the conception and NHLBI’s Hewitt Mourned recruited great teams to maximize future success,” development of a new NINDS preclinical program said Kehne. “I won’t leave neuroscience, but I have Keith Hewitt, former head of the information ser- for identifying non-addicting analgesic alternatives vices section at the National Heart, Lung and Blood what seems like several lifetimes of interests and to opiates, as part of the NIH Helping to End activities I would like to pursue.” Institute, died of Addiction Long-term (HEAL) Initiative to address natural causes at Raised by parents who valued broad-based the nation’s opioid crisis. According to Kehne, ETSP his home in Sao education and stressed the importance of science served as a prototype for this new program. Jose do Calcado, to their 9 children, Kehne developed an early In retirement, Kehne plans to pursue his many Brazil. He was 80 appreciation for science and had a particular fond- hobbies and interests including several outdoor years old. ness for astronomy. In fact, he might have pursued activities such as gardening, hiking and canoeing, a career in astronomy if Amherst College had not Hewitt began his as well as woodworking, music and rekindling his federal career established the first neuroscience undergraduate passion for astronomy. program in the United States during his sophomore as a Peace year. After taking a “fascinating” psychopharma- “Throughout my career, I have been fortunate to Corps volunteer cology course, Kehne became one of the nation’s be a member of many talented teams that have in Brazil after first undergraduate neuroscience majors. tackled immensely challenging problems,” he said. graduating from “To quote Michael Jordan, ‘Talent wins games, but the University “Bottom line, I still loved astronomy but, to quote teamwork and intelligence win championships.’ So, of Wisconsin in the poet Robert Frost, it would be the ‘road not I truly thank all of those team members with whom 1964. He met taken’ as neuroscience and psychopharmacology I have had the privilege of working and I applaud and married would form my career’s trajectory,” Kehne said. my NINDS colleagues for the tremendous progress his wife Ketta in Brazil. Upon Keith Hewitt He earned his bachelor of arts degree in neurosci- made in advancing an array of new translational programs to facilitate therapy development.” returning to the ence from Amherst in 1976 and pursued doctoral U.S., he was named chief of the Education Branch training in psychology with an emphasis in psycho- OMS Chief in the Peace Corps/Action Office of Volunteer pharmacology at the University of Massachusetts, Placement. earning his Ph.D. in 1983. Kehne completed a Schmitt postdoctoral fellowship in biological psychiatry in Retires He then worked with the National Institute on 1985 at Yale University School of Medicine, which Alcohol Abuse and Alcoholism for several years, led to an associate research scientist position. Dr. James Schmitt where he directed youth programs. He organized retired on June the first National Conference on Alcohol and Youth Kehne later became a discovery scientist in 30 after 38 years at Notre Dame University. With students and the pharmacology department at Merrell Dow working with NIH. faculty/staff from colleges around the U.S., the Pharmaceuticals in Cincinnati. While there, he For 31 years, he conference was the first to identify and evaluate provided in vivo pharmacology support for a wide has served as programs designed to reduce alcohol abuse variety of projects that targeted various psychiatric medical director of among college students. The program manual he and neurological disorders. the Occupational wrote based on conference deliberations, Beer Is a In 1996, Kehne joined Neurogen—a CNS Medical Service Four-Letter Word, was used on college campuses biotech company in Branford, Conn.—where he Dr. James Schmitt (OMS). Other posi- for several years. advanced to the level of executive director of tions he has held include staff physician and senior staff physician In 1985, he joined NHLBI, where he initiated exten- pharmacology. At Neurogen, he also served as the sive collaborations with state health departments. biology co-leader of a team that identified and in OMS.

10 • NIH RECORD • JULY 24, 2020 His groundwork resulted in annual conferences at the Cardiovascular Research with state health department officials responsible Institute at the University of for cardiovascular risk reduction. Hewitt worked California, San Francisco. He and closely with the members of NHLBI’s National his family then moved to Ohio, High Blood Pressure Education Program, National where he was a senior research Cholesterol Education Program and National fellow and clinical investigator at Asthma Education Program to develop risk-reduc- the Cleveland Clinic. tion education programs. After leaving NHLBI, he Jerry returned to NHLBI in continued to work with NIH, helping to establish 1965 to help lead its extramural NICHD’s National Maternal and Child Health programs and eventually became Education program. its director of extramural affairs. Hewitt’s colleagues found that working with His accomplishments advancing him was plain fun. Whether planning a national NHLBI’s extramural programs conference or coordinating community outreach were recognized when NIH strategies, he infused energy and purpose into named him DRG director in 1986. what others may have seen as an impossible When Jerry retired in 1995, project schedule, driven perhaps by his rigorous he was a rear admiral and training for the marathons he ran in the U.S. and assistant surgeon general in abroad. Over the years, he worked with hundreds Dr. Marie Röder Green and Dr. Jerome “Jerry” Green should be the PHS, conferred by Surgeon of people at NIH and state health departments remembered as a scientific power couple. General C. Everett Koop. He and, remarkably, he kept in touch with most of also garnered multiple awards them. His instincts were the perfect fit for his role Institute of Pathology in Washington, D.C. Marie in his career, including the Assistant Secretary for of promoting and diffusing NIH science: welcome eventually returned to NIAMS under a fellowship Health’s Award for Exceptional Achievement “for friends, build coalitions, grow the network, improve in its Laboratory of Biochemistry and Metabolism. outstanding leadership in effecting changes in NIH public health. She later moved to NCI, where she primarily extramural program activities.” Hewitt is survived by his wife Ketta and sons studied breast cancer in its Laboratory of Molecular Jerry and Marie both came from families that Frederico and Erik who live in Brazil, and his Carcinogenesis. Marie then joined NHLBI in 1988, gratefully found homes in the U.S. after fleeing per- daughter Yedda, who lives in Virginia. after a couple of years away from NIH. secution in Europe. As a result, “they were very big Former DRG Director and NIH According to their daughter, Karen Green, they social justice people,” said Karen. “They gave to a encouraged each other in nightly discussions of lot of causes like the Southern Poverty Law Center Scientist Wife Remembered science and work at the dinner table. Some of and the ACLU, and Doctors Without Borders.” BY DON LUCKETT those discussions likely focused on Marie’s effort to advance research on carcinogens in cosmetics The concern Jerry had for others radiated into his A remarkable couple who devoted most of their and to get the FDA to act after she discovered work life. “He raised the bar in DRG,” said Barbara lives to public service and health at NIH recently that a stain called Stanzel could detect possible Williams, his former secretary and long-time friend. passed away. At age 91, they both succumbed to Covid-19. Dr. Jerome “Jerry” Green died on Apr. 26 and Dr. Marie Röder Green died on May 10. But Jerry and Marie should be remembered as a • • • scientific power couple. Both Greens came from families that gratefully found homes Jerry retired as director of the Division of Research Grants (now the Center for Scientific Review) in in the U.S. after fleeing persecution in Europe. As a result, 1995, after 40 years of service at DRG, NHLBI and Jerry and Marie “were very big social justice people.” in the Commissioned Corps. Marie retired as an NHLBI program officer after many years of federal • • • service. Thousands of scientists across the country still carcinogens in lipstick. Finally, after she published a “He brought a whole new level of respect for benefit from Jerry’s efforts to advance NIH extra- study in 1980—“Mutagenicity of Some Lipsticks and everyone who worked there…and he gave me the mural research programs. Their Dyes”—in the Journal of the National Cancer confidence and tools to succeed when I moved to While at DRG, he championed the First Institute and other researchers weighed in, the FDA the NIH Executive Secretariat.” Independent Research Support and Transition banned the use of Orange No. 17 dye in cosmetics The admiration he earned also endured. Anne (FIRST) award, which supports newly independent 3 years later. Stroh, a former DRG and NHLBI human resources investigators, and the Method to Extend Research Jerry and Marie’s love affair with each other and specialist, explained: “After he retired, several of In Time (MERIT) award, which provides long-term science began when they met in freshman biology us routinely had lunch with Dr. Green…This contin- support to investigators who demonstrate remark- class at Brooklyn College. After Marie earned a ued in more recent years with visits with him and able ability and productivity. master’s in zoology at the University of Wisconsin, his wife.” Stroh treasured these conversations, Marie was a trailblazer at a time when few females she married Jerry and joined him at Albany Medical which sparkled with humor and intelligence even worked at the bench. In 1956, she joined an School, where he earned his M.D. and she earned in later years. intramural lab at what is now NIAMS. After she and her Ph.D. in pathology. Condolences and remembrances would be appreci- Jerry started their family in California, she returned In 1955, Jerry joined what is now NHLBI and the ated via [email protected]. to the bench at what is now Case Western Reserve Commissioned Corps, which sent him to the San University in Cleveland. Francisco PHS Hospital for his residency. While Moving back to D.C., she joined the Armed Forces there, he also served as a special research fellow

NIH RECORD • JULY 24, 2020 • 11 CIT Produces Ear Savers, Nasal home. This revealed a problem they had not Swabs for NIH’ers previously considered: BY SARAH FICHTER, ROBERT WAXMAN the hook configuration of the original design could As the Covid-19 global pandemic continues, testing get caught in long hair. The ear saver device is shown at left; at right is the 3-D printed swab. and protection for health care workers and support To help prevent this issue, staff remain critical in responding to the crisis. To the team developed a new support these efforts, the Center for Information To give Children’s staff the opportunity to physi- design with an alternate hook shape and a long cally handle the swabs and become familiar with Technology’s signal processing and instrumentation rectangular back. They called the new design the section (SPIS)—a central NIH bioengineering the design, the SPIS team printed several dozen Tsunami Ear Saver, named after the shape of the swabs and asked the hospital’s laboratory pathol- resource that provides custom engineering solu- strap hooks. The straps are available in two config- tions and in-house fabrication for NIH Intramural ogy and sample collection staff to examine them urations to accommodate different head sizes. This Research Program projects—turned their experi- and provide feedback on how the swabs’ physical design allows the strap to conform with the back of properties might affect their work with patients. ence in rapid prototyping, novel instrumentation the head and eliminates pressure points while the design and software development toward devising hook design reduces the chance of hair tangles. SPIS was specifically concerned about the safety tools and equipment that could help. and durability of the 3-D-printed materials. To Robert Reff, a nurse at the Clinical Center who Two results of their creative work are the design assess whether the material might be brittle and usually works 12-hour shifts, was an early adopter prone to breaking, the evaluation included per- and production of ear savers that help alleviate dis- of the Tsunami Ear Saver and quickly became a fan. comfort from wearing disposable face masks and forming mechanical testing to determine conditions “The ear savers work great for me because I no under which the swabs might break. This involves in-house production and evaluation of 3-D-printed longer have any ear pain after wearing masks for nasal swabs to use for Covid-19 testing. twisting and bending the swabs well beyond what extended periods of time,” he says. “The ear saver would happen in actual patient use to identify works great with the combination of the KN95 any weak points. Children’s laboratory personnel Face Mask Ear Savers [mask] and the cloth mask on top because they are were also concerned about possible interactions Ear savers may not seem like important equipment, both held by the ear saver. Before, they both would between testing reagents and the 3-D-printed but they can make a difference in comfort and sometimes slide off my ear because two masks materials that could affect virological analysis safety for health care workers. Clinical Center around my ears created a lot of pressure and bent results. Each organization that prints the swabs is staff—in particular nurses working 8-hour shifts or my ears forward and made the masks slide off.” encouraged to perform its own evaluations, and longer—are required to wear surgical or disposable Reff is not alone, as several groups of Clinical SPIS is coordinating with other stakeholders during face masks throughout their shifts for protection. Center nurses are interested in the Tsunami Ear the testing process. Friction from mask straps can cause irritation and Saver and have even asked for different versions of even abrasions to ears when worn for long periods To be ready for a possible resurgence of the the design. SPIS hopes their device will also prove virus this winter, SPIS worked with staff from the over consecutive days, which can make nurses’ useful for other NIH employees when they begin to already difficult work more challenging. To provide Children’s National Hospital biomedical engineering return to physical workspaces and are required to team and the Walter Reed National Military Medical more comfort and safety to medical staff, the SPIS wear masks. team created ear saver straps designed to relieve Center’s 3-D Medical Applications Center on painful chafing and irritation from prolonged wear evaluating the swabs and manufacturing require- of disposable face masks. 3-D-Printed Nasal Swabs ments, to help develop the required regulatory Testing is key to gathering data that informs and process controls, documentation and safety SPIS set out to design a reusable, quickly produced responses to the pandemic, and testing can only testing needed for consistent and safe production and cost-effective ear saver device that could be done with the appropriate equipment. To of the swabs. If rapid production of swabs becomes be cleaned with common supplies. While the help find solutions to covid-related problems like necessary in the future to alleviate shortages, the most common ear saver designs include features localized shortages of certain medical supplies, ongoing collaborative preparations will facilitate that require fabrication using widely available the SPIS team started a general knowledge-shar- NIH swab production. 3-D-printing technologies, the team focused on ing exchange with its long-time intramural and designs that could be laser-cut from acrylic sheets. Confronted by this pandemic, the CIT SPIS team extramural collaborators. developed practical solutions for frontline health This approach offered several advantages: bulk Aware that Children’s National Hospital in care workers by expanding its collaborative work acrylic sheet costs less than 3-D printer materials; Washington, D.C., was concerned about a possible and quickly reorienting its members’ engineering using this material means the ear saver can be shortage of nasal swabs for testing, the team shared knowledge and experience toward the new more easily disinfected; and laser cutting offers a the design of a 3-D-printable nasopharyngeal swab problems posed by Covid-19. much faster production rate than 3-D printing. developed by the University of South Florida in “The team’s flexibility and creativity in approach- The SPIS team chose a two-dimensional design collaboration with Formlabs and Northwell Health. ing our community’s needs is just one of many that included multiple hooks for size adjustment. Because Children’s was not equipped to print the examples of the larger NIH Intramural Research When testing the available acrylic to find some- swab in its own labs, the SPIS team offered to work Program’s rapid response to this pandemic,” said thing that could conform to the back of the head with them in evaluating these new 3-D-printable Dr. Andy Baxevanis, CIT’s acting scientific director without being uncomfortable or too brittle and swabs for potential use at the hospital. and director of computational biology for the IRP. prone to breaking, the team discovered that acrylic A thorough evaluation and approval of the swabs “NIH’s approach of fostering interdisciplinary, left over from a previous IRP scientific collabora- by hospital staff was especially important because cross-IC technology groups such as the SPIS tion performed the best due to its thickness. The 3-D-printed swabs are distinctly different in size, team allows the IRP to quickly address emerging material was flexible enough to improve comfort shape, flexibility and texture from the normal FDA- global health challenges through many different significantly but still durable enough to withstand approved swabs commonly used. This can be a approaches. You never know what solution, big or the tension of mask straps. concern for patient comfort, especially in children, small, the minds at NIH might think of next, once given the challenge.” Due to the limited on-site staff available to help and the fact that 3-D-printed swabs look markedly evaluate the fit and comfort of the ear saver, an different from normal ones can deter medical staff SPIS engineer asked his wife to try the device at and patients from using them.

12 • NIH RECORD • JULY 24, 2020