FLU IS COMING REDUCING HARM from ALARMS P39 P20 MALE BREAST CANCER P42 Travel Well Contents

Emory Health

WINTERDigest 2019

contagion

CRASH INTO ME p30 TAMING THE HUNGER NERVE p36 FLU IS COMING REDUCING HARM FROM ALARMS p39 p20 MALE BREAST CANCER p42 travel well contents

16 Go Fish Unlike a human heart, a zebrafish heart heals rapidly if injured and soon returns to nearly normal shape and pumping ability. What can we learn from regenerating fish hearts? A lot, it turns out.

Flu is Coming 20 Infectious disease experts have had plenty to worry about in the past several decades, including AIDS, SARS, Ebola, and Zika. But one disease scares them above all others: influenza. 20 travel well

PHOTO SHUTTERSTOCK

Crash Into Me 30 Driver behavior, from speeding to distraction, causes most auto accidents. What can be done to reduce the risk? An Emory/Grady effort aims to find out.

30 contents MUST SEE TV

The Emory Brain Health Center and Georgia Public Broadcasting (GPB) are partnering on a news magazine that airs Mondays at 8 p.m., hosted by Emory’s Jaye Watson.

Emory Health 36 Digest Jonathan Lewin Exec VP for Health Affairs, Exec Director of the Woodruff Health Sciences Center, and President, CEO, and Board Chair of Emory Healthcare

Mary Loftus Editor

Peta Westmaas Art Director

Pam Auchmutey, Martha McKenzie Associate Editors Jack Kearse Director of 15 42 Photography Janet Christenbury, Eric Dunlap, Quinn Eastman, Gary Goettling, Taming the Reducing Harm from Rachel Hershenberg, Melva “Hunger Nerve” 36 Alarms 39 Robertson, David Weiss Contributing Interventional radiologist The cacophany of an Writers Carol Pinto Production Manager ICU David Prologo believes ’s monitors isn’t good Jarrett Epps Advertising Manager freezing the nerve that for anyone, from patients Wendy Darling Web Specialist sends hunger signals to to staff. So this critical Karon Schindler Exec Director, the brain may help people care team did something Editorial, Communications Vince Dollard Associate VP, lose weight. about it. Communications

the well and more Emory Health Digest is published twice a year for patients, Social Feed 4 Patient POV 42 donors, friends, faculty, and staff Kudos and tweets from Eric Dunlap saw his of the Woodruff Health Sciences 10 Center. © 2019 Emory University around the Woodruff beloved grandmother “Patients can Health Sciences Center. succumb to breast cancer Emory University is an equal opportunity/ and his mother survive it. equal access/affirmative action wind up taking The Well 5 employer fully committed to achieving But he never thought he a diverse workforce, and complies Sleep better. Order in with all applicable federal and Georgia enormous amounts was at risk. state laws, regulations, and executive the OR. Political clout. orders regarding nondiscrimination and affirmative action in its programs and of medication Hazards of hot soup. Spin Policy Wise 44 activities. Emory University does not discriminate on the basis of race, color, cycle. Medication psycho- Antibiotic resistance may religion, ethnic or national origin, gender, and that can be a genetic information, age, disability, sexual sis. Heart disease. No to be the greatest medical orientation, gender identity, gender expression, or veteran’s status. Inquiries pretty dark road mosquitoes. Help for pea- challenge of our time, should be directed to the Office of Equity and Inclusion, 201 Dowman Drive, nut allergies. Scrubbing says David Weiss, of Administration Bldg, Atlanta, GA 30322. to follow.” Telephone: 404-727-9867 (V) | 404-712- veggies. Kidney voucher. the Emory Antibiotic 2049 (TDD).

Regenerating fish hearts. Resistance Center. 18-EVPHA-EVPHA-0453 travel well

MUST SEE TV

Emory senior Afam Maduka was part of a team that joined Emory ethnobotanist Cassandra Quave to collect plants at the Joseph W. Jones Ecological Research Center at Ichuaway. The plants will be tested for medicinal purposes. “It’s like being a kid again,” Maduka says. “You never know what you’re going to discover.”

Don’t miss the full story at emry.link/planthunters

WINTERWINTER 2019 2018 3 to our readers

sphere

Jon Lewin @JonLewinMD • 8 Dec So glad that @EmoryRadiology is at the forefront of our @emoryhealthcare system-wide Lean journey, #EmPower. It will be great for our patients, first and foremost, for our faculty and staff, & for responsible stewardship of our resources! Thx for taking the lead on our roll-out!

Winship Cancer Institute of Emory University @WinshipAtEmory 28 Dec Jonathan Lewin, executive VP for health affairs, executive The Emory Proton Therapy Center, the first and only facility of its kind in Georgia, officially director of the Woodruff Health Sciences Center, and opened its doors in Midtown Atlanta with a president, CEO, and board chair of Emory Healthcare. VIP ribbon-cutting ceremony. #protontherapy

What drives us? The desire to move forward. Emory University investigators received $734 million ($686 million of this total was awarded to Woodruff Health Sciences Center researchers) in exter- Wnal research funding last year, an increase of 17 percent from the previous year. This funding doesn’t sit dormant. It serves as a cat- Jon Lewin @JonLewinMD • 3 Dec Proud to join Dr. Raymond Schinazi (and alyst, producing lifesaving treatments and innovations Dr. Lucky Jain) at the French Residence to and transforming the way we prevent, detect, and treat honor @drugbuster21 for receiving the Legion of Honor of France with the rank of Knight for disease. The recently inaugurated “synergy awards” his incredible contributions. @emoryhealthsci support cross-disciplinary projects among faculty at @EmoryPediatrics are proud to have our very our schools of medicine, nursing, and public health, own Chevalier! Yerkes National Primate Research Center, Emory Col- lege of Arts and Sciences, and more. Projects include developing biomarkers for neurodegenerative disorders (medicine/public health), improving imaging for stroke patients (medicine/Yerkes), and exploring how shift- work impacts the microbiome (nursing/medicine). This issue of Emory Health Digest highlights research as well, from Emory doctors at Grady inves- Emory Health Sci @emoryhealthsci • 3 Jan tigating ways to make driving safer, to immunologists Almost every week Brenda Baker, assistant working on a universal flu vaccine, to a radiologist aim- professor @EmoryNursing, travels to a state-run prison in SE Atlanta, where she volunteers as part ing to combat obesity by freezing the “hunger nerve.” of the Motherhood Beyond Bars program. http:// Some call it a research pipeline. I like to think of it ow.ly/pdYS50jYG1o #prison #womenshealth as a research river, ever flowing, with untapped power and unlimited potential.

Be well, Jon Lewin [email protected]

4 EMORY HEALTH DIGEST be well the well

The Power of Self-Care Routines Starting with Sleep It’s important to build healthy habits and stick to them. Adhering to self-care routines can reduce stress, anxiety, and depression. Often, if you add or resume one healthy habit, it will trigger others. To that end, let’s look at sleep.

Routines you can set a clock by External cues in the environment signal to your body that it is time to wake up or time to sleep. Are you a lark (an early riser) or an owl (a night person)? Consider this when building your sleep routine. A habit of going to sleep at the same time every night increases Winding down time the chances you’ll be able to roll out of Create a buffer zone between waking bed when the alarm goes off. Con- and sleeping. Take 45 minutes to an sistent sleep patterns influence daily hour to give your mind and body secretion of cortisol and melatonin, permission to slow down. If you can’t Excerpt from Acti- which promote healthy levels of energy, turn your mind off, get your thoughts vating Happiness: A alertness, and appetite. It’s best to have out by writing them down, telling Jump-Start Guide to set sleeping and waking times even on them to someone, or recording them Overcoming Low Mo- the weekend, plus or minus an hour. If onto your phone. Use external cues tivation, Depression, you need to, work your sleep time back like putting on pajamas, brushing or Just Feeling Stuck, in 15-minute intervals. Eight hours isn’t teeth, listening to music, doing by clinical psychologist a magic number—go with what works relaxation exercises, or reading. Once Rachel Hershenberg, for you. you’re in bed, take slow, diaphrag- Emory assistant profes- matic breaths for a few minutes; sor of psychiatry and Creating a sleep sanctuary imagine the sights, sounds, and behavioral sciences. Make your bedroom a personal sanc- smells of a peaceful place all around tuary. Aim for the right temperature, you. The more you wind down in the a comfortable mattress, pillows stuffed same way, tucked in at the same time, just right, a heavy blanket, and low or the easier it will be for your body no light. An eye mask, ear plugs, and to fall asleep when you turn off the white noise machine may help. lights and close your eyes. EHD

WINTER 2019 5 think well

Order in the OR: Gender matters

Researchers led by Emory primatologist Frans de Waal found that medical teams working in operating rooms (ORs) follow patterns of cooperation and conflict similar to those of non-human primates. In the study, researchers observed and recorded all social interactions in three ORs during 200 surgical procedures. Previous studies of behavior in health care teams have mostly relied on questionnaires rather than records of actual behavior. Researchers found that: • conflicts were directed mostly down the hierarchy between members several ranks apart • cooperation and conflict in theOR varied by gender, with less cooperation when the OR team included more male members • less conflict and more cooperation existed if the attending surgeon’s gender (male or female) differed from that of the majority of the team. “We used the techniques and concepts of evolutionary biology to understand how humans interact in the operating room,” says de Waal, director of the Living Links Center at Emory’s Yerkes National Primate Research Center. “Our findings show that theOR is a microcosm of typical primate social tendencies.” Indeed, primates in general jostle for position more within their own Research published in gender group. Proceedings of the “Based on what we know about other species as well as human anthropol- National Academy of ogy, rivalries and conflict are more typical within than between genders,” says Sciences, “Ethological Laura Jones, a postdoctoral research fellow with Living Links. “This is why higher-ups in the social hierarchy, such as the alpha individual, need to assert Observations of Social their status, especially vis-a-vis their own gender. This dynamic may explain Behavior in the Operat- our results.” ing Room.” Lead author Researchers mainly looked at cooperation versus conflict. Cooperation Frans B. M. de Waal, was defined as affiliative behavior and team building, including chit-chat, Yerkes National Pri- exchanging pleasantries, two-way joking, and teaching. Conflict was defined as mate Research Center. team-disintegrating behaviors, including yelling, being curt or disrespectful, and one-way joking. The study was conducted between 2014 and 2016 at three large, urban teaching hospitals and included the participation of 400 different clinicians, including attending surgeons, surgical fellows or residents, anesthesia providers, circulating nurses, and surgical scrub personnel. EHD

6 EMORY HEALTH DIGEST think well

Political Clout

While Emory nursing instructor Jasmine Clark has been politically active for years, she is now an elected official, representing District 108 of the Georgia House of Representatives. Clark has a PhD in microbiology from Emory and serves as an instructor at the Nell Hodgson Woodruff School of Nursing. “I’m a foundation builder,” she says. She served as director of the 2017 March for Science in Atlanta and continues to work with groups like the Georgia Alliance for Social Justice. “I want to be a voice for the totality of Georgia,” she says. “I want to inject facts into our decision making.” Clark teaches anatomy and physiology I and II and microbiology. She joins two Emory colleagues in the Georgia legislature: State Representative Kim Schofield, who has represented District 60 since 2017 and is a lupus researcher with Emory rheumatologist Sam Lim; and State Senator Chuck Hufstetler, who has represented District 52 since 2012 and is an anes- thetist at Redmond Regional Hospital in Rome, an adjunct professor at Emory School of Medicine, and an alumnus of the medical science in anesthesiology program at Emory’s School of Medicine. EHD STEVE ELLWOOD The Hazards of Hot Soup

Nearly one of every five burns examined National Electronic that send children to emergen- Injury Surveillance System data cy rooms are from instant soups from 2006 to 2016 to identify and noodles.These microwav- pediatric patients whose scald able, prepackaged products, say burns were caused by either researchers, injure more than microwavable instant soup, 9,500 kids between the ages of instant noodles, cups of soup, or 4 and 12 each year. water for making instant soup. “Scald burns are a major The peak age for instant soup cause of preventable injury spill injuries was 7, and the most among children, and our research found that instant soup commonly burned area of the body was the child’s torso spills are responsible for a large number of these painful (40 percent of the injuries.) burns,” says Courtney Allen, a pediatric emergency fellow at “Caregivers need to closely supervise younger children Emory who led the research with colleagues. “It’s important who might otherwise get hurt if cooking for themselves,” for us and for parents to remember that these are just thin Allen says, adding that manufacturers could also make the containers with boiling water in them.” The researchers containers more stable.

WINTER 2019 7 BEHIND THE SCENES Spin Cycle

9:30 pm Driver Eric Norman and other staff transport laundry to and from Emory Healthcare facilities at night to avoid Atlanta’s worst traffic congestion.

Hospitals produce a and elevator use, most lot of dirty laundry— $5.5 drivers arrive at around sheets, towels, gowns, millon a year midnight, bringing and other linens that fresh linens to stock must be cleaned and the hospitals and clinics replaced daily. 600,000 lbs in preparation for a 12:00 am Veronica Cruz of laundry every month Cornejo at Crothall Health- Emory Healthcare’s new day. care in Rome, where laundry Laundry and Linen Ser- The service, is cleaned, dried, and folded. vices works around the which costs more than clock to handle more 29 $5.5 million a year, is staff members than 600,000 pounds of a crucial one. laundry every month. “This is basically Its team serves a dozen 24/7 a 24/7 operation,” says locations throughout operation director Jerry Lewis. the Emory Healthcare “If you have delays on system. the distribution of carts, Each day, soiled linens are then patient care could be affected, collected and taken to Emory’s dis- so staying on a tight and consistent tribution center in Clarkston, where schedule is really important.” they are loaded onto large trucks Sindy Charles, assistant director, and driven to Crothall Healthcare in says turnover among their 29-mem- 9:00 am Sanitized and Rome, Georgia, for washing, sani- ber team is low. “Our staff members folded laundry waits to be tizing, drying, and folding. The laun- take a lot of pride in their jobs, with distributed on special carts dry is then returned to Clarkston for many of them staying with us until at Emory University Hospital sorting and loading for delivery back they reach retirement,” she says. Tower. to Emory. To minimize traffic delays —Janet Christenbury

8 EMORY HEALTH DIGEST AngelFlightEmoryMedMagFullPg_6.75x9.5.pdf 1 11/20/18 10:30 AM

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WINTER 2018 9 age well

Medication Psychosis Too many prescriptions can harm patients, especially the elderly

Mrs. Smith is diabetic and recently had a stroke. She also has issues with depression and needs psychiatric help. “She’s going to be on insulin and probably another glu- cose-control drug, at least one drug to control her heart rate, at least one drug to thin her blood, and maybe baby aspirin, too,” says Timothy Moore, chief of inpatient psychiatry at Emory University Hospital at Wesley Woods. “You need to apply “She’s already on five medications before she ever sees a psychiatrist, which makes things some precision pretty complicated.” in what you’re While no two patients are the same, Moore’s example is typical of an elderly patient at risk doing so you’re for medication-induced psychosis. not just ‘carpet “We’re in an era of polypharmacy,” Moore says. “There’s a pill for every symp- bombing’ patients tom. Patients can wind up taking enormous with pills.” amounts of medication and that can be a pretty dark road to follow. It’s a very expen- —Dr. Timothy Moore sive way to treat people as well.”

10 EMORY HEALTH DIGEST age well

These drugs—along with however, medications are left off for about four hours, five morn- alcohol, over-the-counter med- the list or not all negative drug ings a week. ications, and dietary and herbal interactions are known. Wesley Woods provides supplements—can interact in Wesley Woods, an adult and inpatient services in situations unexpected ways and in some geriatric psychiatric facility on where major changes are nec- instances produce severe psy- the Emory campus, provides essary. “Generally, people don’t chological problems, includ- inpatient and outpatient services like being in a hospital, so we try ing hallucinations, aggressive through an interdisciplinary to minimize the amount of time behavior, delusions, memory team of physicians, nurses, social they’re here—the hospital stays loss, and catatonia. “The most workers, and counselors. Among average between seven and common medication-induced the conditions they address is 11 days,” Moore says. psychosis we see is caused by medication-induced psychosis. Inpatient care gives doctors amphetamines, followed by ste- Moore’s objective is to treat space to make changes and start roids, which are well-known for patients’ psychological problems to simplify treatment. “You can Medication Psychosis producing psychotic symptoms,” with a minimum number of very quickly stop medications he says. “These patients are in antipsychotic drugs and with entirely as you look for the Too many prescriptions can harm pretty rough shape. They usually consideration of other medica- minimum effective treatment look profoundly confused. They tions they may be taking. It’s a that you need,” Moore says. “You don’t know where they are, and complicated dynamic that takes don’t have to worry about bad patients, especially the elderly sometimes they hear voices.” into account any underlying outcomes because patients are Elderly patients are par- pre-existing mental illness, and under close supervision in a safe, ticularly vulnerable to medi- if prescribed medication is being secure, controlled environment. cation-induced psychosis for taken properly and in the correct You don’t have to worry about several reasons. These include: dosage. Also, some drugs lose grandpa being off his medica- • Older people don’t tolerate a their effectiveness over time as tion and going out for a drive large number of pills as well as the patient gets older. or giving the neighbor a piece younger people. “Very few psychological of his mind. The worst that can • Nevertheless, they usually conditions call for more than happen is the nurses call you at take more prescribed medi- three medications,” says Moore. night and say grandpa is getting cations because they get sick Depending on the person’s situa- out of hand.” more frequently and may have tion, he may start them on a few People have high expec- chronic illnesses that require different antipsychotic drugs and tations for medications, says daily medications. then adjust them one by one over Moore, but there is not a pill for • They tend to see a number three to six months until he everything. “For example, of specialists, each of whom finds the long-term we have effective writes prescriptions address- treatment that pro- treatments for ing their area of expertise. vides the greatest depression, but Health care providers in the benefit and the there’s not a lot same system can prevent some least side effects. we can do about adverse drug interactions by Patients are dementia,” he communicating through “medi- assessed during says. “Even if you cation reconciliations” at hospi- this time through can’t completely tals. Such reconciliations involve one of two intensive eliminate every making a list of all medications a outpatient programs. In symptom, you hope patient is taking—including drug one, the patient sees a psychi- to keep the patient’s over- name, dosage, frequency, and atrist and therapist for four to six all mental health from getting route—and comparing it with the hours a day, three days a week. worse by cautiously prescribing physician’s admission, transfer, Another program, intended the minimum of necessary med- and discharge orders. Sometimes, primarily for the elderly, meets ications.”—Gary Goettling

WINTER 2019 11 live well

Heart Disease Disparity

Heart disease remains a frequent killer. Of every four deaths in the United States, one is from heart disease. And blacks die of heart disease at a much higher rate than whites. Although heart disease death rates fell steeply from 1968 to 2015, decreasing by 68 percent, the benefits were experienced by whites more than blacks, resulting in increased disparities. Rollins School of Public Health researchers Miriam Van Dyke, a doctoral student in epidemiology, and Michael Kramer, associate professor of epidemiology, worked on a team that analyzed data from the National Vital Statistics System. The team found that heart disease death rates for blacks and whites were similar at the start of the study period but began to diverge in the late 1970s, when rates for blacks plateaued while rates for whites continued to decrease. The largest increases in disparities occurred in the 1970s and 1980s. Although not as large, disparities remain today: heart disease death rates are 21 percent higher among blacks than whites. The researchers urge the use not only of evidence-based strategies and standard treatment protocols but also culturally relevant tools to promote heart-healthy living. EHD

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12EHDNY EMORY HEALTH DIGEST PM travel well

Just Say No to Mosquitoes

If you are visiting a country where area or planning to spend a lot of the climate is wet and warm, you time outdoors, you’ll need to be more Tips for Mosquito are likely to be bitten by a mosqui- mindful of mosquitoes.” Avoidance to. If you’re lucky, your only Prevention also varies by discomfort will be an itchy welt. disease. Malaria can be thwarted • Mosquitoes bite any And if you’re not? by taking a pill once a day or once time of day. Wear long Well, consider that just one a week, before and after a trip. sleeves and pants. species of mosquito—the Aedes— Vaccines are available for yellow When possible, stay in can carry chikungunya, dengue fever, fever and Japanese encephalitis, a places with air-condi- lymphatic filariasis, Rift Valley fever, disease endemic to Asia. tioning. yellow fever, and Zika. Currently, no vaccines or • Keep windows closed. In all, there are about 3,500 medicines are available for dengue • Even with window mosquito species, many of which fever, chikungunya, West Nile, or screens, mosquitoes carry disease. Travelers should Zika virus. In 2016, Zika occurred can find a way in. Sleep always protect themselves from at an unusually high rate in Brazil, under a bed net treated these tiny vectors. where children born to infected with insecticide. Consider malaria and yellow mothers had a greater number of • Use an insect repellant fever. Although both diseases were birth defects. The Zika virus infection with a 20 percent to 40 eliminated from the United States rate has since decreased in Brazil, percent concentration in the 20th century, they still affect which scientists attribute to greater of DEET. Apply on top of millions of people worldwide. The immune resistance, also known as sunscreen, after waiting 2018 edition of the CDC Yellow Book, herd immunity, in the population. 15 minutes. Reapply which provides health information For now, the best prevention for after swimming. Combi- for international travel, devotes more these diseases is mosquito avoidance. nation sunscreen/repel- than 50 pages to travel information And should you become ill with a lants are less effective. about malaria and yellow fever in high fever, headache, body aches, and • Wear clothes treated 247 countries, islands, and territories. nausea while traveling, don’t put off with permethrin. You Malaria occurs in Africa, Asia, seeking medical attention. “If you can buy pre-treated parts of the Caribbean, Eastern have a fever that’s out of the ordinary clothes, spray it on your Europe, and the South Pacific. for you, don’t wait for it to come clothes, or wash your clothes in it. A treatment Yellow fever is also widespread, down. That can get you into trouble,” lasts for six washes. occurring primarily in Africa, Waggoner advises. “Get to someplace South America, and parts of Central where you can be evaluated. If you’re • Remove or empty America. Many countries require not sure where to go, contact us at standing water around dwellings. proof of yellow fever vaccination as TravelWell. We can recommend good a condition of entry. medical facilities in major cities. The risk for these diseases Depending on how you are doing, varies from person to person you may be able to come home.” and country to country, as well When planning overseas travel, as by type of activity, says Jesse allow a month or more to get Waggoner, a physician with Emory vaccines or medicine. To learn TravelWell Center. more, call Emory TravelWell “Your risk is much lower if Center, Emory University you’re going to a city and staying in Hospital Midtown, 404-686-5885. a hotel with air-conditioning,” says —Pam Auchmutey Waggoner. “If you’re going to a rural

WINTER 2019 13 eat well

Help for Kids with 4Q Scrubbing Veggies Peanut Allergies HOW SHOULD YOU WASH PRODUCE? Two in 100 children are allergic to For delicate produce, rinse peanuts. Some have so severe an under water to preserve allergy, they could become acutely ill by the integrity of the fruit or a kiss from someone who just ate vegetable. For firmer produce, a peanut butter sandwich or a sugar Juan Leon, as- such as apples, cucumber, cookie made in a plant that also process- sociate professor, and melons, scrub the surface es peanut products. Rollins School of under running water with While deaths from peanut allergies are still a clean brush and then do a Public Health rare, peanuts are thought to cause anaphylactic final rinse. Commercial fruit shock more often than any other food allergen. and vegetable washes are A treatment is in clinical trials that may mostly water and haven’t been shown to be reduce children’s sensitivity to peanut allergens. more effective than water alone. The process involves gradually exposing the child to increasing amounts of peanut protein SHOULD YOU TAKE EXTRA CARE under medical supervision. (Doctors empha- WITH SOME PRODUCE? size that parents should not try this at home.) Rough surfaces like to capture pathogens. Use a The trial was led by Brian Vickery, asso- produce brush to scrub fruits and vegetables and ciate professor of pulmonology, allergy, and then clean the brush in the dishwasher. Certain immunology at Emory School of Medicine and foods—sprouts, herbs like parsley and cilantro, director of the Children’s Healthcare of Atlanta berries, and cantaloupe melons—are more at risk Food Allergy Program. for becoming contaminated with pathogens like After six months of treatment, followed by viruses, bacteria, and parasites. Scrub the outside six months of maintenance therapy, two-thirds of a cantaloupe before cutting into it with a of children were able to ingest the equivalent knife. Also, produce that is eaten raw presents an of two peanuts without developing allergic increased risk—cooking produce lowers the risk. symptoms. The children must continue to eat a small amount of peanut every day to maintain WHAT OTHER PRECAUTIONS their tolerance. The idea of oral immunother- SHOULD YOU TAKE WHEN PREPAR- apy dates back to 1908, when a British doctor ING FOOD? first reported desensitizing a child with an egg Use common sense: Wash hands before handling allergy by giving him small amounts of egg to produce. Don’t hold a baby while preparing eat over time. food. Don’t handle meat and produce in the “You exchange that uncertain, unpredict- same spot or with the same equipment. able risk of having an accidental reaction that spirals out of control for these sort of lower WHICH IS SAFER, EATING OUT level, mostly mild or moderate symptoms that OR EATING AT HOME? are manageable for most Eating at home can lower your risk. When you patients,” says Vickery, eat in is when you have the most control. When of Emory + Chil- you eat out you lose control not only of the pro- dren’s Pediatric duce being used but all the other steps of people Institute. EHD handling and cooking for you, the water, the cleanliness. There are a lot more things that can go wrong.—Martha McKenzie

14 EMORY HEALTH DIGEST live well

Pay it Forward For the love of a child, four strangers were saved

Jamie McNeil’s twin granddaughters, The paired-donor exchange program is available Adele and Aubrey, were born two years ago. for recipients who do not have a donor match, but Adele, known as “Delly,” was soon diagnosed who have a donor willing to match with someone with multicystic else so their loved one kidney disease. can receive a kidney. McNeil, a nurse, “The day I donated began researching my kidney was one of how she could best the most significant help Delly. She found days of my life,” said her answer through McNeil, who had her the Emory Transplant surgery in September. Center and the National “It was one of the best Kidney Registry’s donor feelings in the world to voucher program. be able to give the gift The voucher proof a kidney donation gram creates a safety to someone.” net for Delly, while With more than also starting a chain 100,000 people waiting of kidney transplants for a kidney on the de- that involved eight ceased-donor list, living patients—four of them kidney donor programs recipients—across the are making a huge dif- United States. McNeil ference. Emory’s kidney was Emory’s first par- transplant program ticipant in the voucher has performed more

donor program. FAMILY PROVIDED BY PHOTO than 1,300 living donor “My mom’s selfless Jamie McNeil with twin granddaughters Adele and transplants to date. “Jamie is our first decision to donate her Aubrey, soon after they were born. Adele has a condi- kidney to a stranger patient who has come tion that may result in the need for a new kidney later, makes her a true hero,” forward to be a voucher which her grandmother’s current donation secures. says Meghann Adams, donor,” says Nicole Aubrey and Adele’s Turgeon, professor of mother. “I can’t wait until Delly is old enough to surgery in the division of transplantation at Emory. truly understand the sacrifice her grandma has “She immediately let us know that this was for her made for her.” granddaughter, Adele, who does not need a kidney Voucher recipients like Adele receive a “virtual at this time but may in the future. Now Adele will voucher” for a living donor kidney to redeem when have the opportunity to get a living-donor kidney and if they need it, and they are registered on the later in life if she needs one, as a result of Jamie’s national registry’s inactive list, often for many years. good will.”—Janet Christenbury The national registry’s voucher program site gave McNeil the chance to help Adele as well as a strang- To learn more about kidney transplant and Emory’s er waiting for a match on the paired kidney donor Living Donor Kidney Program, visit emoryhealthcare.org/ exchange list. kidneytransplant or call 855-366-7989.

WINTER 2019 15 future well

Regenerating Fish Hearts

After a heart attack, cardiac muscle cells tem for culturing zebrafish hearts outside the die because they are deprived of blood body. He is investigating the regeneration of and oxygen. In an adult human, those cells coronary blood vessels, and his lab is making represent a dead end. fish with fluorescent hearts through the use In adult fish, however, the heart can of gene editing technology CRISPR/Cas9. The regenerate. Why can’t the human heart be fluorescence allows researchers to work more more fishy? efficiently, checking fish eggs for proper gene At Emory, researcher Jinhu Wang is seek- editing over just a few days. ing answers that could guide the development In his earlier work on zebrafish, Wang of regenerative therapies. demonstrated the importance of the epicardi- “If we want to understand cardiac regener- um, the heart’s outer layer. If the epicardium ation in mammals, we can look at it from the is destroyed, the ability of the cardiac muscle viewpoint of the fish,” he says. to regenerate is impaired. The zebrafish After an injury, zebrafish heart cells “go epicardium displays an amazing ability to back in time” and multiply, although their regenerate, coming back after 90 percent loss capacity to regenerate may vary with the age of in just two weeks. the animal, Wang says. Overall, zebrafish are a helpful genetic Zebrafish hearts are simpler than mam- model in developmental biology, since their mals’ hearts: they have just two chambers, embryos are transparent, making it easy to while humans have four. spot abnormalities. Also, zebrafish are cheaper Previous research by Wang and colleagues than mice, and are small and hardy. at Duke University showed that zebrafish can They make up a biological system that can recover from having half of their heart muscle be easily manipulated genetically, says Wang’s cut out. colleague Ahsan Husain. Other scientists Wang also developed a way to chemically at Emory working with zebrafish include cause a heart attack in fish. After an induced Andreas Fritz and Iain Shepherd in the De- heart attack, the fish are sluggish and appear to partment of Biology, who are using them to gasp. A month later, they have recovered. study embryonic and nervous system develop- More recently, Wang has developed a sys- ment.—Quinn Eastman

To learn about ways to support this and other types of cardiology research, please contact Jason Zwang at (404) 727-2512 or [email protected].

Jinhu Wang’s fish room in the basement of Emory’s Rollins Research Center contains more than 1000 fish tanks and an elaborate water recycling system. The adult fish eat brine shrimp stored in vats.

16 EMORY HEALTH DIGEST WINTER 2019 17 travellive well well

Yes, Exercise Really Does Play a Role in Weight Loss by J. David Prologo

“Exercise isn’t really important for weight loss” for weight loss gets a bad rap. has become a popular sentiment in the weight- First, people are looking, in large part, for a loss community. “It’s all about diet,” many say. quick fix, and the diet and weight-loss industry “Don’t worry about exercise so much.” exploits this consumer desire for an immediate solu- This idea crept out amid infinite theories about tion. Many studies have shown that exercise changes dieting and weight loss, and it quickly gained your body’s composition, improves your resting popularity, with one article alone citing 60 studies to metabolism, and alters your food preferences. These support and spread this notion like wildfire. plain, simple facts have stood the test of time but go The truth is that you absolutely can—and largely unnoticed compared with most sensation- should—exercise your way to weight alized diet products. Change through loss. So why is anyone saying otherwise? exercise over time is a much tougher For 10 years, I have been studying sell than a five-day “cleanse.” More- the epidemic of failed weight-loss ef- over, many people consider one hour a forts and researching the phenomenon day for exercise to be unreasonable or of hundreds of millions of people em- undoable and find themselves looking barking on weight-loss attempts, then elsewhere for an easier fix. quitting. Meanwhile, exercise remains Second, doctors and nutritionists the most common practice among na- have done a poor job of explaining the J. David Prologo is tionally tracked persons who are able to link between exercise and dietary hab- maintain weight loss over time. Ninety an associate professor its, perhaps because they often exist as percent of people who lose significant in the Department of separate camps. Exercise directly chang- weight and keep it off exercise at least Radiology and Imaging es our dietary habits, which means we one hour every day, on average. Sciences at Emory actually have an easier time making There are a few reasons exercise School of Medicine. healthier choices when engaged in

18 EMORY HEALTH DIGEST live well

Change through exercise over time is a much tougher sell than a five-day “cleanse.” exercise over time. Without What is missing from this exercise, abrupt changes in dietary logic is that people can change habits, especially if they result exercise capacity. As exercise in calorie restrictions, are very capacity goes up for an otherwise difficult for dieters to sustain. sedentary person and approaches In addition, the longer we make that of a lean person, the ability to those healthy choices, the more lose weight with exercise dramati- likely they will become habit. cally changes. For example, when a 42-year- It’s like giving the participant old female who is 5-foot-4 and in our pool-emptying example a weighs 240 pounds decides to lose bucket, or even a hose. The ability weight on her own, she is likely to to jog for 30 minutes uninter- struggle with abruptly switching rupted, or ride a bicycle for 60 her food choices to vegetables and minutes, is what separates so broiled fish, mostly because she many would-be dieters from their will feel overwhelming hunger lean counterparts and accounts pangs (as well as other reasons, for most tried and failed weight- such as fatigue, soreness, depres- loss attempts. Moreover, once a sion, and irritability). If we take person achieves a critical point of that same person and increase exercise capacity, the experience her exercise capacity to a critical of exercise itself becomes more point, however, those choices pleasant, even fun. become much easier to endure. So, can you exercise your way Third, there is the factor of to weight loss? Absolutely. limited capacity. Exercise original- Of course, abrupt calorie rely got “demoted” following a series strictions will result in weight loss of studies that enrolled overweight for the short run, but it is extreme- or obese folks looking to lose ly difficult for folks to maintain weight who had limited ability to that restriction for significant exercise. Asking someone with lengths of time. Most end up quit- limited ability to use exercise to ting and regaining lost weight. lose weight is like telling someone Exercise, however, is a tried- to empty a pool full of water with and-true way to make dietary a plastic cup. It cannot be accom- changes more tolerable. plished in any reasonable amount Focusing on exercise and of time. changing exercise capacity makes So, when you measure how it easier to ultimately make better much weight they can “burn off” food choices and enjoy clean over time, the answer is not much, living, which means significant because most sedentary patients weight loss that can be maintained can burn 500 or fewer calories over time. a week. As a result, the shaky conclusion that exercise was less This essay was originally published important for weight loss emerged at theconversation.com and is shared and was quickly sensationalized. through creative.commons.

WINTER 2019 19 FLU IS COMING contaInfectious disease experts have had gion are we plenty to worry about in the past sever-

ready for al decades, including HIV/AIDS, SARS, the next Ebola, and Zika. But one disease scares pandemic? them above all others—influenza. That’s right, the flu. Even though many peo-

ple dismiss and misunderstand it, calling

everything from a cold to a stomach bug

“the flu,” influenza claims between 12,000

and 56,000 lives in the U.S. every year. And by Martha McKenzie illustrations by Paul Oakley that’s in a normal flu season.

20 EMORY HEALTH DIGEST

Every so often, a flu pandemic emerges. Not really. Influenza is a wily adversary. It conta gionThat’s when a new strain appears that is so hides in its host for a day or so before making different from what has circulated before that its presence known, so the infected person can people have no immunity to it. A hundred unknowingly spread the germ to countless oth- years ago, the 1918 H1N1 pandemic swept the ers just by going about daily routines of school globe, infecting about a third of the world’s or work, grocery shopping, or working out at population and killing 50 million to 100 million the gym. The virus is contagious, spread largely people. Since then, there have been three more by droplets produced when those infected flu pandemics, in 1957, 1968, and 2009. sneeze, cough, or talk. Flu germs can leap to The next pandemic, say experts, is a other people up to six feet away and linger on question of when, not if. Are we ready? “We’ve hard surfaces for 24 hours. come a long way, but we are still vulnerable,” And, most worrisome, the virus constant- says Ruth Berkelman, emeritus director of ly morphs and changes to outwit vaccines. the Center for Public Health Preparedness and “You can do a lot to get ready, but at the end Research at the Rollins School of Public Health. of the day, the flu seems to find a way around “Influenza spreads quickly. It mutates quickly. everything you’ve done,” says Lynnette Bram- And it’s persistent in the environment. It’s one mer, who leads the CDC’s domestic influenza of the biggest catastrophic threats we face.” surveillance team. But we have vaccines to help prevent infection, antivirals to cut a bout of flu short, and ‘a mind of its own’ antibiotics to combat the bacterial infections Brammer has a Game of Thrones-inspired sign that often arise after the flu. We’re safer now in her office that reads, “Flu is Coming.” than ever before, right? “It’s almost like influenza has a mind of

WINTER 2019 21 Pregnancy and flu TIMES YORK THE NEW BANKS FOR WALTER DAVID Sarah Spitz, then 18 and an Emory student from Boston, Mass., recovered Influenza is particularly dan- from the swine flu in September 2009 in Turman South, the designated “flu gerous for pregnant wom- dorm” on campus. en, causing complications like pneumonia or even death. Flu can also lead to its own,” she says. “It’s wildly un- response to the outbreak. CEPAR, preterm delivery and still- predictable.” in collaboration with Emory faculty birth. Doctors suggest that Consider the 2009 pandemic. and other partners, developed the pregnant women get the Flu watchers had been convinced Strategy for Off-Site Rapid Triage inactivated flu shot rather the next pandemic would come (SORT), an assessment of illness than the nasal vaccine, from an avian influenza strain out severity and risk factors that would which is made from a weak- of Asia. But it actually came from determine the most appropriate ened live flu virus. “We a strain that circulated among place for people to recover. This have very good evidence swine, H1N1 (a variant of the strain might be home, for convalescence, that flu vaccines are safe responsible for the 1918 pandemic), or a clinic/ER, for further evaluation for pregnant women,” says and emerged from Mexico. and care. Saad Omer, professor at The outbreak began in April, Emory students who had con- the Rollins School of Public when flu is not typically circulating firmed or suspected swine flu had Health. “The vaccines not in the Northern Hemisphere. the option of staying on campus only protect the mother, “It started in such a strange lo- and being housed in a voluntary there is strong evidence to cation and at such a strange time of “quarantine dorm.” suggest they protect the year, taking everyone by surprise,” “The residents of Turman South babies in their first four says Allison Chamberlain, acting receive free meals, do not attend months of life, before they director of the Center for Public class, and travel to the pharmacy are able to be vaccinated.” Health Preparedness and Research in a van they call the Flying Pig,” For more, visit MomVax.org. and research assistant professor of wrote Emory College journal- epidemiology at Rollins. “It just ism alumnus Robbie Brown, who underscores how hard it is to stay covered the event for The New York ahead of the flu.” Times in September 2009. “Linens That fall, Emory’s Office of are changed daily. A staff member Critical Event Preparedness and Re- brings grocery bags of Tamiflu, sponse (CEPAR), directed by emer- granola, sports drinks, soup and gency medicine physician Alex Isa- thermometers. The goal is prevent- kov, coordinated a university-wide ing the infected from sniffling and

22 EMORY HEALTH DIGEST 100 Years of Flu Pandemics

By the time the 1918 flu pandemic ended, 50 million to 100 million people had died in 15 months.

PANDEMIC TIMELINE

he pandemic that would become for fear it would hurt morale. “The the deadliest disease outbreak 1918-1919 Surgeon General said there was no cause in history started mildly. The first for alarm. Media and government officials T SPANISH FLU wave hit in spring 1918, causing the usual all said no big deal,” said John Barry, chills and fevers. The second wave was Strain H1N1 author of The Great Influenza: The Story different. The H1N1 strain that crashed Mortality 50 - 100 million of the Deadliest Pandemic in History, who over the world in the fall of that year was also spoke at the Emory flu conference. the stuff of disaster movies. Many victims But people knew they were being lied were young, healthy adults, who often 1957-1958 to because they saw the flu strike down died within hours or days of developing co-workers, neighbors, and family. In the ASIAN FLU horrifying symptoms—their skin turned absence of truthful information, hysteria blue, they coughed up blood, their lungs Strain H2N2 ensued. Communities imposed quaran- filled with fluid that caused them to Mortality 1.5 - 2 million tines, ordered citizens to wear masks, and suffocate. “You could be well at breakfast, closed public gathering spots. Schools sick at lunch, and dead by dinner,” said and businesses shut down. Towns ran out Robert Gaynes, an Emory professor and 1968-1969 of coffins. infectious disease doctor who spoke The Spanish flu’s lethality stemmed HONG KONG at a recent Rollins/CDC flu pandemic from an unusual feature. The 1918 H1N1 Strain conference. H3N2 strain not only bound to the upper With no vaccines or antivirals, the dis- Mortality 1 million respiratory track, like most flus, but also ease quickly spread, helped by the move- penetrated deep into the lungs, damaging ment of troops in World War I. It came to tissue and often resulting in a deadly viral be known as the Spanish flu not because 2009 and bacterial pneumonia. it originated in Spain but because the SWINE FLU The H1N1 strain responsible for the Spanish press covered it widely. News devastation has not gone away but, Strain H1N1 outlets in countries that were embroiled in fortunately, it evolved into a much milder Mortality 284,000* the Great War downplayed the outbreak seasonal flu. EHD *CDC estimate

WINTER 2019 23 Protect Your Child During a bad flu season, Walter Orenstein, director of the Emory Program on Vaccine Policy and Develop- about 20,000 children under ment, oversees labs that are working to identify factors that make flu strains more 5 are hospitalized and about virulent. 100 die. Emory infectious disease physician Marshall Lyon offers these tips: hacking their way into an epidemic.” Serious Communicable Diseases 1. Vaccinate early. Flu shots More than 100 students passed Unit (SCDU). The federal govern- are approved by age 6 through the dorm. A typical stay ment has called upon SCDU to months and nasal spray lasted three days, with students care for more patients with special at 2 years. checking out after going 24 hours pathogens than any other health without a fever or medication. care institution in the United States. 2. Encourage everyone around your child to get Emory has leveraged this exper- guarding against the flu vaccine. tise to conduct research, validate a shape shifter clinical practice and technology, 3. Discourage children Influenza’s propensity to shape-shift translate discoveries into training from touching their makes formulating vaccines some- and education programs for health eyes, nose, mouth. thing of a guessing game. care providers and ultimately In February, the U.S. Food and improve patient care outcomes 4. Ask your child to cough Drug Administration, with recom- and worker safety in the event of or sneeze into a tissue mendations from the World Health pandemic flu or other infectious or their sleeve. Organization, decides which three disease outbreaks. or four strains to include in the A main focus of Emory’s re- 5. Encourage frequent hand U.S. vaccine for the next flu season, search is creating a more effective washing. Alcohol-based based on which ones have been cir- vaccine. Flu vaccines are only 40 hand cleansers also are culating to that point. But in the six percent to 60 percent effective in very effective at killing or more months it takes to produce the best years. Compounding the influenza virus. and distribute a new vaccine, the vi- problem, less than half of Ameri- 6. Don’t allow sharing of rus may have morphed into a strain cans get their annual flu shot, and cups or utensils. different enough from the original vaccination rates are far less than that the vaccine is ineffective. that in developing countries. 7. Seek medical attention That’s exactly what happened “If I get myself vaccinated but immediately if your child last year, according to Marshall everyone else around me skips the develops flu symptoms. Lyon, an infectious disease physi- vaccine, I am more at risk,” says cian and a team member of Emory’s Walter Orenstein, director of the

24 EMORY HEALTH DIGEST Emory Program on Vaccine Policy says Jeffrey Lennox, an Emory and Development. “That’s because professor of medicine and chief of the general herd immunity thresh- infectious disease at Grady. old for influenza is thought to be 50 percent.” That means if at least working toward half of the population is immune, a universal vaccine influenza can’t get enough of a The best defense against a pandemic foothold to cause a pandemic. So would be a universal vaccine—a if a vaccine is 60 percent effective, vaccine effective against all strains 85 percent of the population would of the flu that would last many need to get vaccinated to achieve years, if not a lifetime. Researchers that herd immunity threshold. say such a vaccine is still years away, Last year’s flu season was the but important work is being done deadliest in 40 years, killing an esti- at Emory, which partners with the mated 80,000 Americans, including University of Georgia as one of five 180 children. The severity of the Centers of Excellence for Influenza epidemic highlighted other short- Research and Surveillance (CEIRS). comings. Demand for hospital beds These centers are responsible for and services quickly outstripped pandemic planning for the U.S. supply. Atlanta’s Grady Memorial government. Hospital converted waiting rooms The two main types of influenza Flu Shot into inpatient units, rented “mobile virus that infect humans are A and Facts ERs” for the parking lot, and asked B. Both are associated with seasonal staff to work overtime. “If you are epidemics, but only type A viruses • The flu shot cannot depending on hospitals to have have caused pandemics. Influen- give you the flu. extra capacity if major disaster hits, za A viruses are further broken you need to rethink your plans,” down according to two surface • Flu shots are recommended for ages 6 months and Rafi Ahmed, director of the Emory Vaccine Center, is working toward a uni- older. versal vaccine by targeting an area of the flu virus that does not change from strain to strain. • The flu mist is considered safe for ages 2 years and older.

• Getting a flu shot every year protects others who can’t.

• If, even after getting the vaccine, you develop flu symptoms, go to the doctor immediately. Antivirals are most effective within 24 hours of noticing symptoms.

WINTER 2019 25 Ioanna Skountzou, associate professor of microbiology and immunology, is taking a novel approach to vaccine development by using a method that doesn’t rely on growing the virus in eggs.

proteins—hemagglutinin (HA) and discovery that people infected with neuraminidase (NA). These proteins the H1N1 strain produced antibod- on the cell’s surface are like finger- ies that attacked the stalk region, prints, unique to that virus. Small not the head. That opened the door Flu 101 mutations in either of these proteins to developing vaccines that do the result in a new subtype, which is same thing. Two main types of influenza why flu vaccines have to be updated “We’ve been able to identi- virus infect humans, A and annually. A bigger mutation could fy many antibodies that bind to B. Both are associated with result in a strain that humans hav- the stem region and also to some seasonal epidemics, but en’t encountered before, so they lack conserved areas of the head,” says only type A viruses have any immunity to it. And that could Ahmed. “We are collaborating with caused pandemics. Influ- lead to a pandemic. Mount Sinai to develop a vaccine, enza A viruses are further TheHA molecule—the most but we are still in the early days.” broken down according to predominant—is shaped something Ahmed’s lab also is looking at two surface proteins, hem- like a tree, with a large head and what could be done to make the agglutinin (HA) and neur- a smaller stem or stalk. The head vaccine long-lasting, be it adding an- aminidase (NA). There are 18 binds the virus to cells and is the other compound, altering the design, different HA subtypes and part that changes from year to year. or using a different delivery method. 11 NA subtypes, and they Influenza vaccines usually target the In another Emory lab, Ioanna combine to cause different head of the HA. But Rafi Ahmed, Skountzou, associate professor strains—H1N1, H3N2, etc. director of the Emory Vaccine Cen- of microbiology and immunolo- Small mutations in either ter, is working to develop a vaccine gy in the school of medicine and of these proteins result in that targets the stalk. Since the stalk a researcher for the Emory/UGA a new subtype, which is does not tend to change from strain CEIRS, is taking the novel approach why flu vaccines have to be to strain, this would work for many, of targeting the virus’s NA molecule, updated annually. A bigger if not all, strains of influenza A. which changes less frequently than mutation could result in a Ahmed and his team started down HA. She is also using a method that pandemic. this road after the 2009 pandemic, doesn’t rely on growing the live when they made the surprising virus in eggs. Instead, she is using

26 EMORY HEALTH DIGEST virus-like particles (VLPs). VLPs are on identifying a new potential pan- man-made decoys of natural viruses demic. Flu watchers are particularly that are not infectious, making concerned about a bird flu strain them safer to produce and less likely that has been circulating for years in to cause side effects. Skountzou’s China. The highly pathogenicH7N9 The Future lab has produced VLPs that express strain has evolved to be able to jump NAs on their surface and has begun from birds to humans—typically on of Flu Shots testing them in mice with promis- poultry farms or in live bird mar- Emory researchers, in ing results. The next step will be to kets—and it kills about 40 percent collaboration with Georgia administer the vaccine(s) into the of the people it infects. So far, it can’t Tech, are testing a new way skin using microneedle patches in spread from person to person, but if to deliver the flu vaccine: a collaboration with Texas Tech. it were to gain that ability it would microneedle patch. pose a serious threat. The patches have monitoring birds Emory’s Hope Clinic and microscopic, barely visible and pigs Emory-Children’s Center are testing needles on their surfaces, Experts agree that a universal vac- H7N9 vaccines based on the strain which are coated with a cine is still some distance away, so that circulated in China last year. vaccine. Emory researchers are preparing for They already had tested anH7N9 Applying the patch is an influenza pandemic without one. vaccine based on the first wave of painless, and the skin acts This involves monitoring flu strains found, but strains from the like an amplifier, boosting strains that are circulating and fifth wave, which circulated last the immune response. Since looking for new ones, particularly year, are not neutralized by the the patches don’t have to be in birds and pigs, where pandem- previous vaccines. So they are refrigerated, can be shipped ic strains tend to emerge. Emory back to the drawing board to easily, and can be self-ad- partners with Harbin Veterinary develop a vaccine that can tackle ministered, they could be Research Institute to monitor live the latest strain. a valuable tool during a bird markets and bird and swine The center is recruiting volun- pandemic. farms in southeastern China. teers to test this vaccine. (Anyone In clinical trials, patches The work is labor-intensive, who would like to participate have been proven to be as time-consuming, and expensive and should call 404-712-1371.) “If this effective as shots—and less involves sending people into the vaccine proves effective against the painful. field to collect samples, which are fifth wave of H7N9, the goal would brought back to the lab to analyze. be to start stockpiling it in prepara- “Surveillance is like an insurance tion for a possible pandemic,” says policy,” says Orenstein. “It’s a hard Nadine Rouphael, interim director thing to sell and it’s often the first of Emory’s Hope Clinic. thing cut when budgets get tight. The threat is ever present, say ex- But it’s essential to catch a pandemic perts. “Starting in 2001, we had 9/11, strain as early as possible so a then anthrax, then West Nile, then vaccine can be produced and dis- SARS,” says Julie Gerberding, former tributed.” director of the CDC. “That set the Several Emory labs are trying stage for a period of investment in to identify the factors that make an public health that was unprecedent- influenza strain more virulent—bet- ed. I feel really sad looking at what ter able to jump from birds or pigs has happened since: 50,000 public To support the work of the to humans and to pass easily from health jobs lost, budgets declining. Emory Vaccine Center, contact human to human. Researchers can Preparedness has to be a sustainable Jonathan Russell, 404.727.6416, then watch for these characteristics function—it can’t be year to year, [email protected], or in circulating strains, getting a jump crisis to crisis.” EHD visit vaccines.emory.edu.

WINTER 2019 27 Flu: A Formidable Foe Infectious disease experts gathered at Emory for a Rollins School of Public Health/CDC conference on pandemic preparedness on the 100th anniversary of the 1918 pandemic. Here’s what they had to say.

Flu Tents 1918 Epidemic

“Pandemic flu is our No. 1 “I’ve come to health security threat. Closing borders does not work.” believe influen- Luciana Borio, director for Medical and Biodefense za is the most Preparedness Policy at the National Security Council formidable and challenging “There is a saying, ‘If you’ve seen virus we see one pandemic, you’ve seen one pan- in the world. demic.’ I know less about influenza today than I did 10 years ago.” There is noth- Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the ing that scares University of Minnesota me more than influenza.” James Curran, Dean, “The status quo Rollins School of Public Health is not acceptable.” Luciana Borio

28 EMORY HEALTH DIGEST Flu Tents at Grady Hospital 2018

“You don’t manage “Without a universal flu vaccine, the truth, you tell we can only chase the virus the truth. That idea and try to predict it.” is incorporated in Florian Krammer, associate professor at the Icahn School of Medicine at Mount Sinai every preparedness plan I know of, but it still has to be “The vast majority of critical medical sup- plies we need are not made here. We don’t executed.” understand how dependent our health care John Barry, author of The Great Influenza: The Story of the Deadli- infrastructure is on foreign activities.” est Pandemic in History Michael Osterholm

“Federal funding for emergency preparedness is about 30 percent lower than in 2003 and funding for hospital preparedness is about 50 percent lower, which means there is less capacity in the event of pandemic.” John Auerback, president and CEO of Trust for America’s Health

WINTER 2019 29 Crash Into Me by Marlene Goldman

Driver behavior—from speeding to distraction—causes most auto accidents. What can be done to reduce the risk? Until self-driving cars become the norm, human error will remain the primary cause of motor vehicle accidents. The most fatal mistakes when behind the wheel include driving too fast, driving under the influence, tailgating, and distracted driving. Eating in the car (read: spilled food) used to be the No. 1 cause of drivers taking their eyes off the road, but errant French fries and dripping milkshakes have been replaced by cell phone talking, texting, and tapping.

30 EMORY HEALTH DIGEST What might seem like a quick to the Centers for Disease Control glance at a message or typing in a and Prevention. phone number can have dire conse- States like Georgia have enacted quences for the driver and anyone new laws to help ensure that people they hit. pay more attention to driving and Consider these recent accidents: less to their mobile devices. And Last spring, a seven-month-old many modern cars have features to boy in southwest Atlanta ended up compensate for distractions, such as in intensive care with every bone in voice control systems that help keep his neck broken after a driver, who drivers’ eyes on the road. was on his cell phone, collided with a car driven by the baby’s mother. Although the child survived, he has Into Me lifelong disabilities from the crash. In May, an 18-year-old driver was charged in a crash that killed three pedestrians, including a three- month-old infant, as the group was crossing a street in Woodstock. The driver was putting away her phone when the collision happened. Injuries from motor vehicle accidents are the No. 1 trauma seen at Atlanta’s Grady Memorial Hospi- tal, resulting in thousands of crash victims each year. A PREVENTABLE EPIDEMIC On average, drivers report being distracted more than half the dura- IT’S HARD TO CHANGE PEOPLE’S seven CIREN centers in tion of a car trip—and not just by HABITS, THOUGH the U.S. and one of just cell phones. Emory and Grady researchers hope two programs in the Distractions can be as simple that a new study of accident victims country designated as as looking down to adjust a radio in the metro Atlanta area will result both a medical and an station or glancing at the GPS, talking in car designs that better protect engineering center. to passengers, looking at something drivers, pedestrians, and motor- Over the next five on the side of the road, or putting cyclists, and reduce the severity of years, information on makeup. injuries in the event of a crash. about 300 accident The toll of distraction is huge. The Crash Injury Research and victims who seek care Every day in the United States, nine Engineering Network (CIREN) study for their injuries at the people die and more than 1,000 are is being conducted by Emory’s Injury Marcus Trauma Center injured in crashes involving a dis- Prevention Research Center, along will be entered into tracted driver. The most recent count, with Grady’s emergency department a federal database, as in 2015, showed that 3,477 people and engineering experts at the Uni- will information about died and another 391,000 were in- versity of Michigan. the damage to their jured by drivers who were talking or CIREN is funded by a $4 million vehicles. texting on their cell phones. Drivers grant from the National Highway “Data from CIREN under 20 have the most distrac- and Traffic Safety Administration. centers help drive tion-related fatal crashes, according The Emory/Grady effort is one of rulemaking to make

WINTER 2019 31 vehicles safer for passengers and and engineering are collecting and support injury prevention through analyzing data to better understand regulation and consumer advocacy the mechanisms of injuries from testing,” says Jonathan Rupp, associ- modern automobiles. After the Crash ate professor of emergency medicine Patients with qualifying inju- and principal investigator of the new ries—including brain bleeds, ankle Where were you CIREN. “Grady and Emory together fractures, broken ribs, and organ are an ideal location for a CIREN injuries—answer questions about seated in the car? center, which requires a high-volume how the injury occurred level one trauma center like Grady’s With police reports in hand, Were you wearing Marcus Trauma Center coupled with crash investigators scour the crash strong biomedical researchers.” scenes. They photograph the vehicles a seat belt? inside and out, download the event TRAFFIC ACCIDENTS TOP PRIORITY recorder (similar to the black box in Was it properly Rupp speaks from experience. The an airplane), and use a laser mea- biomedical engineer was involved in surement system to calculate how the positioned? CIREN at the University of Michigan vehicle was impacted. for more than a decade before being They look for evidence of seat Who else was recruited to Emory last year, when belt use, like stretch marks or scuff in the car? the Emory Injury Prevention Re- marks, as well as signs of bodily con- search Center decided that reducing tact and injury, such as blood stains injuries from traffic accidents should inside the car. They also take note of What were be its top priority. Upon arrival in where the seat is in relation to the you doing (when Atlanta, Rupp successfully applied steering wheel and how much of the for a CIREN grant. vehicle’s interior compartment got the crash hap- More than a dozen collaborators pushed into the occupant compart- pened)? in emergency medicine, trauma sur- ment. “The idea is to formally define gery, radiology, crash investigation, all the factors that could influence What type of clothes were you wearing?

Were you wearing glasses?

Has the vehicle been in previous crashes?

CIREN investigators Jonathan Rupp and David Wright talk with crash investigator Ron Tomblin and project coordinator Harriet Howlett-Smith.

32 EMORY HEALTH DIGEST how an injury occurred, from the LESSONS FROM THE REAL WORLD those, more than half initial contact to how the force was The transportation industry doesn’t were in crashes that transmitted through the body,” do this kind of research itself for a were frontal impacts, Rupp says. myriad of reasons, including cost and most of the injuries Other variables—say, for in- and inability to access patient data involved head, chest, or stance, pre-existing conditions like because of privacy rules. lower extremities. osteoporosis or obesity—might con- The automobile industry could Eventually, the team tribute to the severity of the patient’s do “tons of test dummy work and put plans to investigate injuries. And medications, such as test dummies all sensored up into a crashes involving pedestrians and motorcyclists, both vulnerable populations. “If we look at the future of mobility and safety, increased walking is going to be a big part of that,” Rupp says. “We need to design vehicles and pedestrian infrastructure to make those interactions safer.” Visibility is a big challenge, especially at night. Some pre-crash or collision-avoidance systems now recognize pedestrians so that if a pedestrian darts out in front of the vehicle it will apply the brakes or anticoagulants, taken by crash vic- car and crash them into brick walls,” alert the driver. tims could affect the amount of blood says CIREN co-principal investigator While the goal of or the size of bruises. David Wright, who co-leads the the study is to under- A radiologist reviews all medical Injury Prevention Research Center. stand how injuries records to make sure the team “But the variability in what happens occur and ultimately, to hasn’t missed injuries that developed on the real highway when a car goes prevent as many as pos- over time. down an embankment, hits a light sible, CIREN’s impact is Next, engineers at one of the six post or a tree, and rolls over—all the expected to exceed that. other CIREN centers in the U.S. ana- different scenarios can’t be modeled. “Motor vehi- lyze damage to the vehicle, the con- You have to put it out in the real cle crashes take up tact, how the vehicle moved, how it world to see what actually happens.” substantial bandwidth struck other objects, etc. Likewise, The Emory/Grady CIREN study in the emergency Grady-Emory CIREN team members launched in 2017 and enrolled its department and the review data from other centers. first patients in October of that year. Marcus Trauma Center. “The engineering review brings Since then more than 7,200 people Anything we can do in another set of eyes,” Rupp says. injured in motor vehicle crashes and to reduce that makes “We don’t want to quality control taken to Grady have been screened, us more able to care ourselves and it’s better to have a 92 agreed to participate, and to date, for other people,” second opinion.” 49 have become CIREN cases. Of Rupp says.

WINTER 2019 33 Another outgrowth of the CIREN study is the Injury Prevention Research Center’s part- nership with police and EMS all over the state, including classes on how to download event data recorders, as well as with state lawmakers to help reduce impaired driving and increase seatbelt use.

‘WE SEE JUST ABOUT EVERYTHING’ While in the past, Em- ory’s Injury Prevention Research Center had concentrated on vio- lence, it refocused its efforts several years ago after analyzing statistics about the top causes of injury in the metro Atlanta area. “The data Atlanta is No. 4 in the country in enough to get into an ambulance and was stunning,” says pedestrians struck by vehicles, and make it to the hospital, they are going Wright. Heading the Grady has one of the busiest trau- to end up in our shop.” list were transporta- ma centers in the U.S., with some A countless number of scenarios tion-related injuries. 150,000 patients seeking care there can, and do, occur. each year. About 10,000 patients “The beauty of this study is, it annually are admitted for trauma or links what was damaged in the ve- injury-related issues. hicle and what was damaged in the The most common transporta- human,” Wright says. “We’re looking tion-related death is from traumatic for red flags that cause more severe brain injury, says Wright, who also is injury, and by feeding that informa- director of emergency neurosciences tion back to the National Highway at Emory. Working with residents, Traffic Safety Administration, we he typically sees 40-some patients help them with policy, and help au- during his eight-hour shifts at the tomobile makers redesign their cars Grady trauma unit. to make them safer.” “It’s unbelievable how many The program is ongoing, since collisions and crashes and injuries we every year brings design changes to get,” Wright says. “We see just about vehicles and changes in the environ- everything that could happen to a ment; even the human population human body in a motor vehicle— is changing. The average car—seat head, chest, abdominal, extremity belts, steering wheel, safety mecha- injuries—and any of them can be nisms, and more—is designed for a devastating. If victims survive long 170-pound, 5-foot-9-inch man or a

34 EMORY HEALTH DIGEST 105-pound, 5-foot woman. “But if you put an obese person or an elderly frail Driving is ‘Serious Business’ person in a car, injury patterns are a On a clear and lot different than for an average-sized bright November human,” Wright says, “so there’s still a afternoon, Marion lot to be learned.” Farmer had just fin- THE CASE FOR SELF-DRIVING CARS ished her coffee at a Starbucks in Buckhead Autonomous vehicles hold great promise for injury prevention, but no and was on her way vehicles currently sold in the U.S. are to see her husband completely self-driving. Most are “sit- at an assisted living uationally” autonomous, with features facility nearby. As she drove up Peachtree Street, a large, older that have been around for a while, like car hung a left out of a church parking lot. It crossed four adaptive cruise control and electronic lanes of traffic then rammed into Farmer’s beloved, robin’s- stability control. egg blue Mini Cooper in the fifth lane and spun it around. Lane departure prevention systems, The impact crushed the driver’s side, pinning the 77-year- lane change assist, backup cameras old grandmother inside. “I knew I was injured; I couldn’t and warnings, and other features are move,” Farmer remembers. First responders had to saw becoming standard features and pro- through the bent steel frame before they could extract her viding “substantial benefits” in terms from the car and rush her to Grady Memorial Hospital. of preventing crashes, according to the A fractured clavicle and broken ribs kept her there for a Insurance Institute for Highway Safety. week before she was transferred to a nursing care facility, As more autonomous features show where she spent two months in rehab to rebuild the strength up on the road, the “geometries of on her left side. vehicles inside and outside are going to change,” says Rupp. While at Grady, Farmer agreed to participate in CIREN, a GM, for example, hopes to put cars study that may someday result in cars that better protect driv- without steering wheels and pedals ers, pedestrians, and motorcyclists alike and reduce the severity on the road next year. “That’s going to of injuries if they are in a crash. change the interior geometry of the Farmer says her injuries have been life changing. She is car and how it’s going to perform in still weak on her left side and her memory is not as good as a crash,” he says, “and that will affect before the crash. Previously “always on the go,” she now how to protect occupants.” depends on friends, family, or car services to take her to run Someday, car manufacturers may errands or to visit her husband. even veer away from one-size-fits-all to She no longer feels strong enough to drive, much less more personalized vehicles. “You might run the-mile-and-a-half loop from her condo to St. Philips even have the option of an elderly Cathedral like she did before the accident. But she’s held on package upgrade just like you can up- to her driver’s license, waiting for the day she can buy a “big, grade your sound system,” Wright says. old car” to do nearby errands on her own. “If a car has multiple drivers, that might A former faculty administrator at a federal research uni- not make sense but, in theory, special versity, Farmer didn’t hesitate when asked to join the CIREN packages for the obese or elderly could be specially tailored. This would come study and hopes that it will help others. at a cost, but it can be done.” “Driving in Atlanta is serious business,” she says. “Motor In the meantime, CIREN partici- vehicle accidents are just pure scary. I think that being aware pants will help determine how cars can of what’s going on and trying to prevent accidents should be be made safer in the future, reducing foremost in our minds.” EHD the chance of injury for all. EHD

WINTER 2019 35 Taming the ‘Hunger Nerve’ A preliminary study of a promising new treatment for weight loss

by Mary Loftus • Main illustration by Joey Guidone

Jessica Knight had tried every diet out there, from low-carb to South Beach to a mail-order boxed meal plan. Ideally, she wanted to lose 50 pounds and lower her BMI, which at more than 30 was in the obese range. But she was losing hope.

36 EMORY HEALTH DIGEST Knight tried to stick to stops or shuts down the signals 1-cm-by-2-cm segment near that each new diet, but all the effort in the nerve indicating hunger to junction.” just didn’t seem worth it. “The the brain,” he says. The first week, says Knight, weight loss never lasted,” says the Knight says she is “deathly she felt the same as usual. “I 36-year-old accountant, who lives afraid of needles,” but was de- thought, what if it didn’t work? in Melbourne, Florida, with her termined to regain her health— What if nothing changed?” husband and two daughters, ages which meant losing weight. She Then she noticed she was 6 and 9. “It didn’t help that I had a remembers being given an IV and cutting down on her food por- job where I worked 60-plus-hour wheeled back to a room. Then tions and becoming more active. weeks and sat at a desk all day.” the twilight sedation kicked in. “I “I still felt hunger but I didn’t get Then her sister, a nurse at could sense things, but it was like hangry,” she says. The next week, Emory Johns Creek Hospital, told a dream state,” she says. “My sis- she had to remind herself to eat. her about a feasibility study being conducted out of the hospital Jessica Knight says that, after the procedure, she feels “happy, healthy, and that involved an image-guided active, a good role model for my kids.” procedure for weight loss. Interventional radiologist J. David Prologo, associate professor in the Department of Radiology and Imaging Sciences in Emory’s School of Medicine, was enlisting 20 men and women who were mildly to moderately obese for the study, and spots were filling quickly. The procedure takes about 30 minutes. After the patient is sedated, the radiologist inserts a needle filled with freezing gas into the vagus nerve, using CT guidance. The vagus nerve, the longest and most complex of the 12 cranial nerves, runs from the ter took me home afterward, and “I couldn’t eat a full portion. Like, brain to the abdomen and is a when I checked the site where I could only eat half a cheese- main part of the parasympathetic the needle went in, I couldn’t burger. I felt full quickly.” nervous system, which oversees even see anything, it was just a This was happening across crucial bodily functions, includ- little tender between my shoulder the board with all the study ing digestion. blades. The spot was covered by a participants, says Prologo. Six In effect, the vagus nerve con- BAND-AID.” months after the procedure, pa- nects the brain and the gastroin- Prologo, who is board certi- tients reported decreased hunger testinal (GI) tract. fied in interventional radiology at 95 percent of their follow-up New attention is being paid to and obesity management, had contacts, and most described the nerve by researchers for treat- used a CT scanner to guide eating less at each meal. ing disorders from inflammatory the needle to the vagus nerve, It’s important to note, he says, bowel disease to depression. specifically to the area where the that participants weren’t asked to Prologo believes that freezing stomach meets the esophagus. limit calories or follow any type the vagus nerve could be thera- “It takes two minutes to freeze of dietary restrictions or exercise peutic as a weight-loss tool. “An the nerve, at minus-40 degrees programs. “Primarily, we wanted ablation zone is created which Celsius,” he says. “The spot is a to make sure the procedure was

WINTER 2019 37

safe,” he says. “We didn’t want pain point: She raised three boys, lege, Knight still works out four tients doing anything other than went to night school, dealt with to six days a week to videos in the listening to their bodies.” financial strain, and was a care- morning—cardio and weights. A surprising effect of the taker to her own sick parents. “I’d say my zest for exercise has treatment, Knight says, is that she “Yet my mom could not lose returned,” she says. now craves healthy foods. “If I try weight,” he says. “When critics Knight recently visited to eat a piece of cake, I feel like say people who are overweight Australia, where she snorkled the crap afterward. The joy I once got or obese don’t have will power or Great Barrier Reef and took part out of eating cake is gone,” she perseverance, I know that can’t in a three-mile cliff hike. “There says. “Now I crave salad, vege- possibly be true.” has been more than a change in tables, and grilled meat. I mean, The patients in the study lost my weight; there’s been a change it’s not a magic pill, I do have to an average of 5.6 percent of their in my whole attitude and my make conscious choices to eat initial total weight, corresponding outlook on weight loss,” she says. healthfully. But it’s much easier. to about a 23 percent reduction “I don’t ever weigh myself any- Before, it was torture.” in excess body mass index (BMI), more. I’m more addicted to the When people diet, says Prolo- says Prologo. No adverse events way I feel.” go, their body and brain conspire occurred over the six month fol- Prologo is planning a new to sabotage them: “The first 30 study, a clinical trial to prove the to 60 days of a diet, the body procedure’s effectiveness. “We are resists and rebels in the name of not trying to prove that freez- survival, thinking it’s starving. It ing the vagus nerve necessarily slows everything down. It does equals weight loss,” he says, “but 10 to 15 different things to block that it makes dieting easier.” weight loss. Most people cannot He is working with Emory overcome that and will succumb.” physician Sharon Bergquist There is a critical point to determine how a weight where the body readjusts to loss plan will work for patients a new set point and dieting with BMIs of 25 to 35, with and becomes easier, he says, but without “vagotomies.” Their goal 90 percent of dieters never get is to determine how the vagus there because of their body’s nerve-freezing procedure can backlash. That point, which best be used to “stop the train” he calls the “catching point,” is and reverse weight gain, along where Prologo tries to get people with its host of associated diseas- to by freezing the vagus nerve. J. David Prologo, with patient Jes- es like diabetes and heart disease. sica Knight, says he wants to “reduce “Since the discovery of the The treatment is temporary, he the downward spiral” of obesity. says, and probably lasts eight to appetite hormone, leptin, in the 12 months. “It pulls the hunger 1990s, there has been an expo- response from you just long low-up, and no procedure-related nential increase in research in enough,” he says, “that losing complications were noted. obesity,” Bergquist says. “We now weight becomes relatively easy.” As for Knight, by the end of understand that obesity is a dis- People shouldn’t be shamed December—eight months after ease where hormones get dysreg- for their inability to lose weight, the procedure—she had lost 30 ulated and the body fights back he says. “There’s a real biological pounds. “There are drops and against weight loss. We’re dealing backlash that happens when plateaus. I’ve gone one to two with something far greater than people embark on mainstream weeks without losing anything,” willpower.” diets and calorie restriction. It’s she says. “But I feel like my body not about being weak.” and my appetite have been reset.” His own mother is a case An athlete in high school and col-

38 EMORY HEALTH DIGEST Reducing Harm from Alarms by Pam Auchmutey • Illustration by Damien Scogin

Here’s how one ICU dealt with the cacophony of monitor alarms.

stay in the Intensive Care Unit (ICU) is no picnic when you’re Arecovering from major surgery, severe trauma, or serious illness. Patients endure their share of discomfort—IVs, needle sticks, staples or su- tures, bandages, chest tubes, cannulas, catheters, bright lights, and noise.

WINTER 2019 39 3 things to Among the sounds that surround reducing alarm fatigue a national safety patients: the incessant beeping of the goal in 2014. But years before that, know about ICU monitor that tracks their vital signs. two nurses in the medical ICU at Emory alarm fatigue: When the monitor emits an alarm, Hospital already had recognized it as *A majority of clinical it’s meant to alert their nurse when vital a priority: With 14 beds on two floors, signs such as blood pressure, heart the unit averaged 1,400 alarms per bed alarms are false. rate, blood oxygen level, and respiration per day. How could the unit reduce this *Two main reasons fall below safe levels. overwhelming number? Today’s sophisticated ICU monitors Ray Snider, medical ICU director, for false alarms are can produce hundreds of different alarm and Pam Cosper, the hospital’s critical parameters that are sounds. Even a slight change in a vital care services director, came up with a sign can cause a monitor to alert. But plan. They collected data in real time too narrow and set- are more alarms necessarily better? from the monitor vendor. Once a month, tings not adjusted to Definitely not, say Emory University a unit nurse counted the number of individual patients. Hospital nurses familiar with medical alarms and how nurses responded alarm fatigue. to them. The majority of alarms, they *Too many alarms can Alarm fatigue affects hospital staffs found, were false. The average number cause disruption in nationwide and occurs when workers per bed per day in Emory Hospital’s become desensitized to the excessive medical ICU dropped from 1,400 to 300, patient care, desensi- number of alarms emitted by medical primarily from the elimination of false tization, anxiety, sleep devices. While most alarms are not alarms. deprivation, depressed urgent, missing an alarm that is urgent potentially could harm a patient. And Targeting false alarms immune system, and the stress of all those alarms can create Three common alarms caused the most missed critical events. burnout among health care workers. false alerts. These occurred when an The Joint Commission, the agency EKG electrode came loose, a pulse that accredits U.S. hospitals, made oximetry sensor (which measures pulse

40 EMORY HEALTH DIGEST rate and blood oxygen levels) slipped “Every time an ICU patient had one off a patient’s finger, or a patient’s pulse PVC, we got an alarm,” says Snider. ox changed slightly yet was still within a “We turned that functionality off. That safe range. one intervention reduced the number Unit nurses reduced alarm sounds of alarms significantly.” based on two goals set by Snider and To further prevent false alarms, Cosper. First, nurses programmed ICU nurses change EKG electrodes and What’s it like to monitors to make only “actionable pulse ox sensors daily so that they work in an ICU alarms”—those that require a nurse to function properly. They keep track of check on their patient at the bedside. their patients with the help of large with less beep- Second, instead of a one-size-fits-all TV screens placed throughout a newer ing, buzzing, approach, nurses began using “individu- 17-bed medical ICU, located in the and dinging? alized monitoring” for patients. Emory University Hospital Tower. The screens show each patient’s “The best testament Choose then customize vital signs and emit an audible alert, I can give is when “As we’ve upgraded our ICU monitors supplementing what clinicians see in the past two years, we’ve put a lot and hear on computer monitors at the nurses who typically of effort into choosing the right alarms nurse’s station. don’t work in our for our patients,” says Snider. “We As ICU monitoring technology unit come in and customize them for every new patient. continues to evolve, patient care will We start out with the same default become even more complex. But comment on how settings and work from there.” nothing can surpass the skills of a much quieter it is,” Doctors and nurses also good nurse. determined which alarms were not “The ICU monitors are just one says Snider. “We’ve needed and turned them off. The alarm piece of what nurses do,” Cosper worked on reducing for premature ventricular contractions notes. “Patients are surrounded by (PVCs) is a prime example. Healthy all types of equipment that alarm, alarm sounds for so people have a PVC—an irregular from ventilators to IV monitors. long that our staff heartbeat—from time to time. Sick One thing that nurses can’t lose are accustomed to people have more of them. Unless they sight of is having eyes on what’s have several in a row, PVCs don’t pose happening with their patients the fact that it’s a health problem. at the bedside.” EHD quieter. They don’t remember what it was like when we had 1,400 alarms per bed per day. Ulti- mately, that’s better for our patients.”

Ray Snider (back row, left), Pam Cosper (back row, second from left) developed ways to reduce alarms and make the ICU a quieter, more peaceful environment for staff and patients.

WINTER 2019 41 PATIENT POV My grandmother died of breast cancer. My mom is a survivor.

But I never thought I would get it. I’m a man.—Eric Dunlap

It was 2000 and I was 34, the dad of two young pens. Because I had exercised so vigorously, my chest sons, Jordan and Christopher, with my beautiful, muscle pressed against the tumor, and the tumor smart wife, Felecia. I had always wanted to be a pressed against a nerve. The pain alerted me to the husband and a dad. I loved having breakfast with problem. Most people never feel breast cancer; there my sons every morning, coaching the soccer team, is no pain. and just being there for my family. My mother had been diagnosed with breast can- After seeing an old photo on the beach from my cer four years previous, and her surgical oncologist, honeymoon, I’d decided I was going to get back into Toncred Styblo at Emory’s Winship Cancer Insti- shape. I went down into tute, and I had developed our basement to work a rapport. I trusted her out. I completed about and chose her to be my 100 push-ups when I doctor. I was diagnosed suddenly felt an intense, with stage two breast excruciating pain in my cancer, since the testing chest. I couldn’t get up off showed that the cancer the ground. I called to my was in my lymph nodes. wife who came down and I had a radical mas- helped me up. I clutched tectomy and simultaneous my chest and felt a lump reconstruction. They “just above my right nipple. removed all the breast That was where the pain tissue on my right side was radiating from. and then extracted muscle When I went to the from my back and put it doctor the next morning, in my chest so it would be he asked me how long symmetrical. the lump had been there. During my recovery, I said I had just noticed my youngest son, Chris- it last evening. He told topher, would ask me to me it was a hard mass, pick him up. After sur- and wrote a referral to gery, I could not. I would see a surgical oncologist lie down on the floor and immediately. Immediately. let him climb up on me That’s when I became for a hug. concerned. Next, I endured six The next day, I had a months of chemotherapy. needle aspiration. Three It was difficult to find Eric Dunlap, his wife, Felecia, and sons Jordan days later the doctor con- men diagnosed with breast and Christopher enjoy taking in an Atlanta United firmed that I had breast game. “We’re huge soccer fans,” he says. cancer. The actor Richard cancer. I was young, didn’t Roundtree, who played smoke or drink, and was Shaft in the 1970s, was one. in decent shape—I’d never even had a cavity. And I He had been hesitant to talk about it for a number of was a man. How was this possible? “Are you sure you years, afraid that it would hurt his chance to get roles. don’t have the wrong file?” I asked. Does breast cancer take your tough-guy edge away? He told me it was very rare in men, but it hap- In reality, it makes you tougher.

42 EMORY HEALTH DIGEST “I was diagnosed when my children were 13 months and 3 years old. I wanted to see them grow up to become productive citizens in the world. That’s what I prayed about. A lot.”

My grandmother, my nana, died from breast cancer when she was 55, in 1974; it had metastasized rapidly. She was the best grandmother in the world. She could cook anything and made you feel important and loved. She had a radical mastectomy, and her chemotherapy was horrible. She was in hospice and receiving morphine for the pain. I was 7 years old and, holding her hand, I told her, “One day, I’m going to do something about cancer.” She opened her eyes and looked at me and said, “I know you will.” When my mom was diagnosed, I had a flashback of what nana went through. My mother was 55 as well. She beat breast cancer twice: once before I was diagnosed, and then 10 years later in the other breast. She taught me how to fight it. As guys, we’re preconditioned to dismiss things. Eric Dunlap with his family around the time he And many physicians don’t think of breast cancer was diagnosed with breast cancer. right away with men because the percentages are low. I think about my sons, who are now young men. I want them to always get checked out. Now Chris is 19, and Jordan is 22. Not only did I see my sons graduate from high school, they both graduated with honors, and Jordan just graduated from Georgia State. I didn’t know if I was going to be here to see those milestones. My mom’s birthday was on Thanksgiving last year; she is 76 and remains active. I give lectures to universities, the media, physicians, churches, and patients. For the past 18 years, I’ve worked with the American Cancer Eric Dunlap (left) now speaks for the American Society’s speakers’ bureau to increase awareness and Cancer Society, keeping a promise he made to his raise funds. I guess I’m keeping that promise to my grandmother (with baby Eric, above). grandmother. EHD

Private philanthropy enables our physicians and scientists to search for cures and care for patients. To support Winship Cancer Institute at Emory visit winshipcancer.emory.edu/support-winship/give or call 404.778.5175.

WINTER 2019 43 POLICY WISE Imagine a World Where a Simple Cut Could be Deadly

soldier is wounded by a roadside bomb. His serious injuries are survivable, but the wound is Ainfected with antibiotic-resistant bacteria and the soldier dies from the infection. A severely premature infant is growing and gaining strength, but she gets a drug-resistant lung infection that spreads to her blood and she dies. A teenager gets a cut on a hike. The cut becomes infected, and this otherwise healthy adolescent succumbs to what should be a treatable infection. Antibiotic resistance may be the greatest medical challenge of our time. It threatens major advances of modern medicine, including organ transplants, cancer chemotherapy, Researchers discovered that some highly antibiotic- and routine surgical procedures that would not be possible resistant Klebsiella have acquired genes that make them without these life-saving drugs. We are all at risk. 10,000 times more virulent than previous strains. These The Centers for Disease Control and Prevention (CDC) genes, also, are in a mobile form that can be shared easily estimates that at least 2 million illnesses per year in the between bacteria and spread rapidly. Such strains led to United States are caused by antibiotic-resistant bacteria. a recent outbreak in a Chinese hospital that killed all five That translates to 8 million extra days of hospitalization, infected patients. 23,000 deaths, and more than $20 billion in additional The bacteria are not slowing down, and they certainly health care costs. Worldwide, an estimated 700,000 deaths aren’t waiting for us to catch up. We must act now if we are per year are caused by antibiotic-resistant organisms, and to keep pace with this threat to the nation’s public health, if current trends continue, annual deaths are predicted to economy, and security. With the largest economy in the reach a shocking 10 million by the year 2050. world, we can clearly afford to do more. Just as we have led This crisis has been looming for decades, and research technological advances for decades, so should we lead the shows the situation is getting worse. Take, for instance, an fight against antibiotic-resistant bacteria. antibiotic called colistin. It’s a “last resort” drug used to treat How do we do this? Scientists have warned us for years infections caused by a group of highly antibiotic-resistant that we must develop new antibiotics. But we can’t fight an bacteria: carbapenem-resistant enterobacteriaceae (CRE). always-evolving enemy without fully understanding where it CRE, including the bacterium Klebsiella, cause infections is and what makes it tick. We must invest heavily in research with an alarmingly high mortality rate of 40 percent. Re- just to catch up—to discover the new and ever-changing searchers have discovered a new bacterial gene that causes ways in which bacteria resist an- resistance to colistin, and it is in a mobile form that can be tibiotics and become more viru- shared between different strains, allowing resistance to lent. We must be able to respond spread rapidly. in real-time to current and newly But it gets worse. We and other researchers at the emerging threats by more widely Emory Antibiotic Resistance Center found a form of resis- and carefully tracking the spread tance to colistin that is “disguised” by the bacteria and of antibiotic-resistant bacteria therefore goes undetected. This could lead to a scenario in in humans as well as in animals. which clinicians unwittingly prescribe colistin for infections it And we must develop more This essay by David can’t treat, increasing illnesses and deaths. sensitive diagnostics that rapidly Weiss, director of the We are now living with a long-feared “nightmare” detect all forms of antibiotic Emory Antibiotic Resis- scenario, in which bacteria gain both increased virulence resistance and more effectively tance Center, originally and resistance to antibiotics. guide patient treatment. EHD ran in TheHill.com.

44 EMORY HEALTH DIGEST This is my legacy.

Sylvia Dodson lost her late husband James—a gentle, kind, and compassionate man—to Alzheimer’s. Determined to support research at Emory School of Medicine and to help Emory researchers learn more about the disease, Sylvia has made a bequest to fund future Alzheimer’s studies.

“My husband would be proud of what I am doing.”

Sylvia Dodson Lilburn, Georgia

Have you planned your legacy? giftplanning.emory.edu 404.727.8875

WINTER 2019 45 Across the State and Around the Corner Winship Cancer Network has three locations. locations in 26 counties, and 19regional affiliate hospitals in17 counties. with locations over all including Georgia, 11hospitals, 143outpatient HealthcareEmory is most the comprehensive system health state, inthe HealthcareEmory inGeorgia

75 11 5 85 4 10 9 8 7

6 3 2 1 1

The Clifton Corridor ... and Beyond

1. Emory University Hospital 7. Woodruff Health Sciences Center 2. Emory Clinic (multiple buildings) Administration Building 3. Winship Cancer Institute 8. Rollins School of Public Health 4. Emory Rehabilitation Hospital 9. Nell Hodgson Woodruff School of Nursing 5. Yerkes National Primate Research Center 10. Emory University Hospital Midtown 6. Emory School of Medicine (education and 11. Executive Park (Emory Healthcare clinics research buildings) in brain health, orthopaedics, and sports medicine) Emory University Alumni Records Office 1762 Clifton Road Atlanta, Georgia 30322

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MUST SEE TV The Emory Brain Health Center is partnering with Georgia Public Broadcasting (GPB) on a news magazine program that airs Mondays at 8 p.m. Your Fantastic Mind, hosted by Emory’s Jaye Watson (below), highlights patient stories, research, and clinical advances.

46 EMORY HEALTH DIGEST