Changing the Game: Bloodless Medicine and Surgery

March 27th, 2017|Did You See This?|By

The concept of bloodless medicine first arose in the 1970s, when Denton Cooley, the legendary Johns Hopkins University School of Medicine alumnus and cardiac surgeon, performed operations on a group of patients that most other doctors turned away: Jehovah’s Witnesses. According to their doctrine, Jehovah’s Witnesses are not permitted to receive blood transfusions, largely due to the organization’s interpretation of specific verses of the Old and New Testament. In particular, the religion cites Genesis 9:4, Leviticus 17:10, Deuteronomy 12:23, and Acts 15:28 and 29 as clearly commanding of abstinence from blood. However, Jehovah’s Witnesses do receive and encourage all other forms of medical care, which brings about a complex situation: How does one conduct surgery or other operations without the supplementation of outside blood to restore blood volume, maintain hemoglobin levels required for oxygen transport and replenish other important coagulation factors?

This is a question that the Center for Bloodless Medicine and Surgery answers every day. Steven Frank, director of the center, describes the mechanism of providing bloodless care to patients: “The way we do this is to conserve blood by reducing or eliminating bleeding by stimulating the body to make its own blood cells at an accelerated rate, and by recycling blood that patients lose during surgery and giving them back their own blood.”

The Center for Bloodless Medicine has a variety of techniques to provide quality care for those whose religious traditions forbid the use of blood transfusions.

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Creating the Right Blend
Blood is a mixture of a variety of different components, including red blood cells, white blood cells, platelets, plasma proteins and clotting factors. Although Jehovah’s Witnesses do not allow the transfusion of whole blood, most do permit the transfusion of certain components of blood, such as albumin and individual clotting factors. By taking advantage of this, the center can provide alternative routes of care.

One such example includes giving patients erythropoietin, a hormone responsible for creating red blood cells, before and after surgery to stimulate the production of blood in anticipation of blood loss. Patients may also receive other vitamins, such as vitamin K, that are critical for the formation of blood components. Blood loss can be further minimized by the use of advanced tools, such as the harmonic scalpel, a type of scalpel that cuts and cauterizes at the same time. Additionally, technologies such as the intraoperative blood salvage system can actually recover lost blood from the operating table by washing the red blood cells with saline solution and returning the whole blood to the patient after the impurities and waste components have been removed.

Finally, although still in the development phase, some research labs are investigating the efficacy of artificial hemoglobin synthesized from various chemical compounds called hemoglobin-based oxygen carriers that mimic naturally occurring human hemoglobin, which can then be used for transfusion. These are just a few of the techniques that the center uses to ensure that patients who refuse or cannot take blood transfusions still have successful outcomes. The Center for Bloodless Medicine and Surgery at Johns Hopkins is one of the few centers across the country fostering innovation in the field of blood management. Aligning with Johns Hopkins’ commitment to outstanding medicine, the center applies cutting-edge technology to allow patients of all backgrounds to receive world-class care.

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About the Author

Pranjal Gupta

Pranjal Bodh Gupta is a second-year medical student who arrived at Johns Hopkins from Vanderbilt University where, over the course of four years, he danced in numerous cultural showcases. Throughout these shows, he learned various routines, including a Japanese fisherman dance (“Soran Bushi”), Indian Bollywood dance, Korean pop, Japanese drumming dance (taiko) and Indian Bhangra. As a side hobby, Pranjal made short films and majored in chemical engineering. His latest adventure includes learning medicine and trying to gain social media fame.

Johns Hopkins Medical Students Celebrate Match Day

March 27th, 2017|Events and Happenings|By

This year’s St. Patrick’s Day was celebrated across the country by medical students and residency programs as the eagerly anticipated Match Day. After long months of assembling an application, nervously waiting for interview invites, and flying across the country to visit programs in cities both familiar and foreign, March 17 marked the day on which excited and nervous students learned where they would spend the next several years of their lives training to become independent physicians. Unlike a typical job, where an employer makes you an offer that you can then choose to accept or decline, the National Resident Matching Program uses a statistical algorithm where medical students rank residency programs, residency programs rank medical students, and the algorithm integrates this information to best accommodate the wishes of students and programs alike. Once students and programs participate in the match, the results are binding.

Congratulations Class of 2017!

Image courtesy Ruchi Doshi

While schools have many different types of Match Day ceremonies, Johns Hopkins has a short, simple event. Taking place in the medical education building, students, families and invited faculty members gathered for a brief brunch and to take photos at a St. Patrick’s Day-themed photo booth. Per tradition, first-year students were invited to watch from above, giving them a view of the newly matched fourth-year students in the atrium below and a glimpse into their own futures. A few chosen faculty members and students spoke, reflecting on the journey through medical school and giving advice to get through the first year of residency, otherwise known as intern year, before playing the Match Day video. Put together by the matching class, the video is a tradition that combines the humor, inside jokes and quirky personalities of the matching class. Shortly after the video, students gathered their envelopes, counted down the seconds till noon and simultaneously opened their cards to see where they would be going for residency.

The Big Reveal

Just after noon, the medical education building erupted into a cacophony of screams, cheers and tears. Students celebrated matching at their top-choice institutions, excitedly taking photos of themselves, their envelopes and their friends to share with loved ones who couldn’t attend the event. For some individuals, their match meant making history. For others, matching was a personal milestone, the end of an era spent in Baltimore. While some individuals are continuing their training at Johns Hopkins, many are making their way to a new adventure in a different city — or even a different coast! I was surprised and delighted to discover that I was moving on to my next adventure: Duke University Hospital, to train in internal medicine-pediatrics. Simultaneously, I felt a little sad, realizing that soon, I would be leaving both Johns Hopkins and Baltimore — my homes for the last five years.

Ruchi Doshi and her family at this year's Match Day celebration.

Ruchi Doshi and her family at this year's Match Day celebration.
Image courtesy Ruchi Doshi

I think those feelings sum up Match Day in a lot of ways. There’s excitement, surprise and delight, tinged with sense of poignancy. After four or more years of hard work, it becomes real and strange to know that no matter where you plan to go for residency, whether at Johns Hopkins or elsewhere, many things will soon change — the most important of which is your peers, whom you learned and grew with over the last four years. Soon, medical school will become a part of memories rather than a part of the present. While you keep your friends and mentors — and, for some people, your apartment — little else will stay constant over the next few months.

March 17 was an exciting day, but now the major milestone is graduation, looming in the near future in May. Or is it late June to early July, when most of us start our residency programs? Either way, congratulations to the Johns Hopkins University School of Medicine Class of 2017, and good luck on the adventures ahead!

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Ruchi Doshi

Ruchi Doshi is a third-year medical student pursuing her M.P.H. She is also an avid cook and baker who loves everything Bollywood.

Uncovering a Troubling Truth: When Health Care Isn’t Created Equal

March 23rd, 2017|Recently Published|By

Spurred by the most recent women’s march in Washington, D.C., it is easy to think that the best way to get involved and rally for women’s rights is by donning a pink cap and waving signs. While that is one way to fight for women’s rights, another is to highlight health care disparities specifically affecting women and find ways to change them. This was the topic of a recent symposium at Johns Hopkins on Friday, March 10, during which Robert Bristow, the former division director of gynecologic oncology at The Johns Hopkins Hospital and current chair of the University of California, Irvine’s Department of Obstetrics and Gynecology, was celebrated and honored.

The symposium celebrated a fellowship fund created by Bristow and Diane O’Day, the former fellowship coordinator of the program and current budget analyst of the department, and also highlighted the great gynecologic oncology fellowship program at Johns Hopkins. Bristow, a former graduate of the gynecology and obstetrics residency at Johns Hopkins, took attendees on a journey through his early career, speaking about his fellowship at Cedars-Sinai/UCLA and his subsequent return to The Johns Hopkins Hospital, where he went on to work with the late Frederick Montz. It was during his time working with Montz that he focused his research on ovarian cancer. While Bristow has authored countless textbooks and written over 200 peer-reviewed publications, the research he chose to highlight at this symposium specifically focused on disparities in ovarian cancer care.

Unequal Treatment of a Cancer Diagnosis

The conclusions he presented were eye opening. Through his research, Bristow found that in the U.S., not all women are treated equally in terms of care following an ovarian cancer diagnosis. Using the guidelines in cancer care established by the National Comprehensive Cancer Network, he found that when comparing long-term outcomes across different races for patients diagnosed with the same stage and type of ovarian cancer, black women were more likely to die of ovarian cancer than their white counterparts. The factors related to this included lower socioeconomic status, being less likely to seek care at high-volume centers, less access to surgery or care with high-volume providers, and differences in type of insurance (i.e., private insurance versus Medicare). He was able to extrapolate this data in another study on geospatial mapping and determined that to some extent, these differences in access to care and patient outcomes were related to where the women lived.

quote: by bringing these disparities to light and increasing access to care, we can work to make sure that a patient's treatment outcome it not determined by his or her geographic location and move toward a future in which all patients have the necessary tools to best fight a cancer diagnosis, regardless of the neighborhood they live in or socioeconomic status.Expanding Access to Quality Care

One way of bridging the divide created by geography between patients and hospitals that care for them is ensuring that the barriers are eliminated so that patients have access to the centers that can best care for them. Many hospitals have tried to emulate this model, and if you drive around Baltimore, you may notice that Johns Hopkins has as well, via the Hopkins Access Line, a program that helps streamline the process of referring patients from other health care providers to The Johns Hopkins Hospital for care. Bristow brought to light a problem that tends to be easier to recognize than it is to remedy.

Realizing that major metropolitan centers tend to harbor the cancer centers that ultimately provide the best care for cancer patients is the first step, but his presentation also emphasized how important it is for providers to strive to bring gold-standard cancer care to all populations and work to increase access to better care. By bringing these disparities to light and increasing access to care, we can work to make sure that a patient’s treatment outcome is not determined by his or her geographic location and move toward a future in which all patients have the necessary tools to best fight a cancer diagnosis, regardless of the neighborhood they live in or socioeconomic status.

Realizing that major metropolitan centers tend to harbor the cancer centers that ultimately provide the best care for cancer patients is the first step, but his presentation also emphasized how important it is for providers to strive to bring gold-standard cancer care to all populations and work to increase access to better care. By bringing these disparities to light and increasing access to care, we can work to make sure that a patient’s treatment outcome is not determined by his or her geographic location and move toward a future in which all patients have the necessary tools to best fight a cancer diagnosis, regardless of the neighborhood they live in or socioeconomic status.

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Diana Cholakian

Diana Cholakian is a fourth-year gynecology and obstetrics resident at Johns Hopkins. When she’s not in the OR, she enjoys biking, hiking, and running around the city.

The Widening World of Career Choices

March 20th, 2017|A Day in the Life|By

As any graduate or medical student will well-understand, choosing a career direction to pursue after graduation can be a daunting task. What is your dream job? Where would you like to be located? Where do you see yourself in five years? These decisions require careful reflection and research, and importantly, mentorship and advice from professionals and the institution.

pair of feet standing on a tarmac road with color arrowsIn the past 10 years, there has been a paradigm shift throughout the graduate programs at Johns Hopkins. Previously, Ph.D. students were encouraged only to pursue academic jobs, with most following the traditional postgraduate school path that had been taken by nearly all of their advisers — several years spent as a postdoctoral fellow before going on to start a lab and become a principal investigator. However, the percentage of students with steady, tenure-track positions in their field after graduation has been steadily dropping since the 1970s, and currently only 8 percent of doctoral graduates in life sciences will hold a professorship within five years of completing their Ph.D.

Obviously, it’s untenable for graduate programs to prepare students solely for the academic life, only to have fewer than 10 percent able to find jobs in their field. But the pressure to promote academia is deeply ingrained in the scientific culture. Investigators are often measured by the success of their students, and it can be challenging for professors to advise students on how to best follow a path they themselves have not taken. Debra Silver received her Ph.D. from Johns Hopkins in 1997 and reflected that at the time, “alternative careers were still considered dirty words.”

Now, due to necessity, that perception has shifted. An uncertain funding climate combined with a drastic scarcity of faculty positions has left training institutions with a need to educate and encourage their students to pursue a variety of “alternative positions.” Although a big ship turns slowly, Johns Hopkins graduate programs should be commended for the work they have accomplished to this end in the past 10 years. The Professional Development and Career Office has more than doubled in size and offers a number of services to students throughout their time here.

Specifically, it regularly hosts panel discussions with professionals from a wide variety of career styles to discuss the pros and cons of their professions, as well as the best approaches for students interested in following each path. Professors throughout Johns Hopkins have also begun to recognize the reality of the changing academic climate and have made a concerted effort to help students find the career that will suit them best, whether academic or otherwise. Silver, now a principal investigator at Duke University, has two of her own students going through this process, and she lauds the changes to no longer tout academia over other options while encouraging students to search for careers that will enable them to find their own happiness.

As you approach the end of your time in graduate school and begin to look at the ever-widening world of career options, take the time to think about the right direction for you personally. Don’t be afraid of change — a majority of Ph.D. students find their desired career has shifted during graduate school. There are many advising services available, and professors across the hospital and medical campus have become far more willing to encourage and assist in finding positions outside the traditional academic track. There is a right career for everyone, and the tools to find and join yours are finally here.

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Benjamin Bell

Benjamin Bell studies sleep and circadian rhythms in mice and flies, and is fortunate the mice understand his semi-nocturnal work schedule. When not actively in the lab, you can find him thinking about research and science-writing on his motorcycle, on the hiking trails, or at any local concert venue.

Potential Cuts to Science Funding Threaten US Position as World Leader in Biomedical Research

March 20th, 2017|Did You See This?|By

We Americans are privileged to live in a country that boasts the top scientific research in the world being conducted in our laboratories, research institutions and government establishments, like the National Institutes of Health (NIH). The United States is currently considered the leader in biomedical research, but what most Americans don’t realize is that our place at the top is shaky at best. With other countries, including China and Germany, increasing science funding and surpassing the number of U.S. college graduates in STEM fields, the distance between the top and second place is narrowing at a quick pace.

The recently proposed federal budget further threatens to bring the U.S. toppling from its precarious position as the world leader in scientific research by slashing the NIH budget by a staggering 18 percent, eliminating of funding. As a graduate student at Johns Hopkins, it’s easy to believe that the rest of the population shares my sentiments that this is a detrimental and misguided proposal from the new president and his staff. But when I talk to people outside the biomedical sciences, I’m often confronted with the unfortunate truth — many people don’t understand science funding, how it works, why it matters or why their tax dollars should be spent on it.

NIH budget cuts could hit Johns Hopkins' research budget, but the extent is still unclear.

Investing in scientific research and being a world leader has many unrecognized benefits. America attracts top science students and professors from other countries, who come to our institutions to learn and conduct research — with foreign-born individuals representing 23 percent of scientists working in the United States in 2006. Falling from our top position means that fewer talented scientists will choose to leave their countries to work here, which will also decrease the caliber of research. Furthermore, when scientists from other countries compete with the U.S., there can be economic consequences. A recent example centers on concerns that a French company, Sanofi, will be given an exclusive license to patents for the Zika vaccine, which would allow the company to set a very steep price for Americans hoping to obtain it.

Unfortunately, making the case for science funding can become inherently difficult when it comes to cut-and-dried decisions like setting the federal budget. Although the 1950s saw a surge in support for science funding, much of which was specifically allocated to “basic science” — scientific research that does not have immediately apparent medical applications — the new millennium and the exponential growth within the tech industry have resulted in a shift in public attitude toward one of impatience, accompanied by a desire for swifter returns and an increased pressure from funding sources to pursue scientific questions with clear clinical relevance. It can be frustrating from the public’s perspective to look at the seemingly immense NIH budget and feel that the money invested isn’t giving tangible, obvious results, but this is because science requires time, thought and planning, with significant advances often occurring at an incremental pace as new discoveries are made.

quote: "Falling from our top position means that fewer talented scientists will choose to leave their countries to work here, which will correspondingly decrease the caliber of research "For researchers, this emerging impatience with science can be equally frustrating, but it is important to remember that the scientific process is largely obscured from those not directly involved in it. Researchers and clinicians must find a way to convey that although the benefits of science funding are rarely concrete, this does not negate their importance and often leads to outcomes that are greater than could have been imagined at the start. Indeed, as Fareed Zakaria’s highlights in his 2009 Newsweek article, federal funding has led to “to the development of the internet, lasers, global positioning satellites, magnetic resonance imaging, DNA sequencing and hundreds of other technologies, an accomplishment that should be touted by researchers and better communicated to those outside of the research community.

Therefore, although making the case for science requires convincing the taxpayer to invest in the future, it also requires the researcher to be more vocal about the value of this investment, especially during a time in which instant gratification is becoming increasingly valuable. Researchers must recognize that asking taxpayers to support science funding asks them for altruism, faith and respect for the scientific process, requests that may be met with more acceptance if they include demystifying scientific research. Convincing politicians and the general public that science has inherent value has to come from the people who best understand the intricacies of the process and must include better communication from the scientific community.

quote: Louis Pasteur once said, “Science knows no country because it is the light that illuminates the world,” and it is now the responsibility of all modern scientists to work fervently to make sure that that light cannot be extinguishedResearchers, clinicians and science students can no longer be content to simply mingle with like-minded people within our field and need to strive to make a conscious effort to talk with people outside of science or medicine, while underscoring the importance of research and investing in the scientific process. Louis Pasteur once said, “Science knows no country because it is the light that illuminates the world,” and it is now the responsibility of all modern scientists to work fervently to make sure that that light cannot be extinguished.

About the Author

Emily Fray

Emily is a second-year Ph.D. student in the Biochemistry, Cellular and Molecular Biology Graduate Program. She is passionate about reading and writing about science, learning about infectious diseases, consuming large quantities of caffeine, and studying her personal role model, Louis Pasteur. She hopes to someday combine her loves of English and science to work as an editor for a major journal or textbook company.

The Butterfly Effect: Wing Research Method Shows Promise

March 17th, 2017|Perspectives in Research,Recently Published|By

From the flower on your front porch to your cousin’s lower back tattoo, butterflies are one of the most immediately recognizable insects due to their magnificent wings. Though I am no butterfly expert myself, I can distinguish a few species native to my area by their color patterns. Interestingly, wing patterns and coloration may be important for speciation and adaptation to environmental stimuli, as in the case of the peppered moth.

During the Industrial Revolution, evolutionary biologists recognized that black peppered moths were much more common in smog-covered environments, while mostly white peppered moths were found in clean, less polluted environments. This was because the black moths were better camouflaged on smog-covered trees, while the white moths were easily picked off by predators. On clean backgrounds, the opposite was true. Today, the peppered moth serves as a textbook example of Darwinian evolution

What the Painted Lady Can Tell Us About RNA

Patterns help butterflies blend into their environment to escape predators.

click to enlarge

The importance of butterfly wings for survival is clear, but little is currently known about what controls wing patterns. Scientists at Cornell University recently published a study trying to delve into this issue using new molecular biology techniques. Using the Painted Lady butterfly, V. cardui, as a model system, Zhang and colleagues identified genes that were differentially regulated during pupal development using RNA sequencing. RNA sequencing (RNA-seq), unlike DNA sequencing, is a dynamic method used to quantify and compare changes in gene expression by monitoring the level of certain RNAs within cells as they fluctuate to respond to the needs of different environments and developmental stages.

The difficulty lies in teasing out the expression differences that are relevant to the phenotype of interest. Zhang et al. performed RNA sequencing at different stages of pupal development, when the wings are formed, to identify genes that are differentially expressed as candidates for playing a role in wing coloration and patterning. Some of the genes they found seemed especially promising due to previous studies that had already associated them with the development of pigment in other species and were aptly named after colors, including yellow, pale, ebony and black. Altogether, they isolated 27 genes as candidates for controlling

Zhang et al. performed RNA sequencing at different stages of pupal development, when the wings are formed, to identify genes that are differentially expressed as candidates for playing a role in wing coloration and patterning. Some of the genes they found seemed especially promising due to previous studies that had already associated them with the development of pigment in other species and were aptly named after colors, including yellow, pale, ebony and black. Altogether, they isolated 27 genes as candidates for controlling development of the pigment melanin in V. cardui.

Gene Editing to Narrow Down the Possibilities

The authors then used the new gene editing technology, CRISPR-Cas9, to knock out, or inactivate, some of their candidate genes. By creating mutants with different genes inactivated, the authors were able to discern what the genes normally do during wing color development. One mutant, in which the pale gene was knocked out, showed severe defects, including abnormal wing shape and body scales, along with wing color changing from brown to white with a loss of eyespot pigmentation. Other mutants showed similarly striking phenotypes, including hyperpigmentation, abnormal patterning and some pupal lethality. These knockouts helped to confirm that the candidate genes play a role in melanin production and pattern formation in butterfly wings.

The use of RNA sequencing with CRISPR gene editing may prove extremely valuable not only for understanding the genetic basis of melanin formation in butterflies, but also for biomedical researchers. RNA sequencing is rarely used a primary diagnostic tool but recently has been used when other genome sequencing methods fail to explain the cause of undiagnosed genetic diseases. Functional validation using CRISPR gene editing can help to confirm RNA-seq results and provide further proof of the candidate variant’s impact on patients. Zhang’s method may have a butterfly effect, if you will, for many researchers.

References:
Zhang et al., 2017 Genetics 
Cummings et al., 2016 BioRXiV 

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About the Author

Sarah Robbins

Sarah Robbins is a human genetics Ph.D. student. Her skill at reading recipes has made her able to translate her talents from pies to PCR.

Christianity and Modern Medicine

March 10th, 2017|A Day in the Life|By

Of the greatest miracles performed by Christ was his healing of lepers, the blind and the deaf. Gregor Mendel, a monk, was the father of modern genetics. Christian missionaries like Mother Teresa saved thousands of people in the name of God. The Christian faith and the art of healing have been connected for centuries, and Christianity continues to strongly influence many medical providers today.

Ancient Christian art adorns the Hagia Sophia in Istanbul, a church that has occupied christian and muslims alike. Image courtesy Rabia Karani

Ancient Christian art adorns the Hagia Sophia in Istanbul, a church that has been occupied by Christian and Muslims alike.
Image courtesy Rabia Karani

A recent conference at Johns Hopkins, the Symposium on Christian Faith, Reason, and Vocation, brought to light many of the ways religion and medicine are intertwined in the lives of modern medical professionals. More specifically, the symposium hosted a panel on faith in medicine featuring providers from around Johns Hopkins. It was moderated by Stephanie Wang, a fourth-year medical student at Johns Hopkins.

At the symposium, providers discussed the ways in which faith was expressed in the workplace. From praying silently in the workplace to discussing faith-based topics with patients, providers covered the spectrum regarding religion in the workplace. David Madder, a primary care provider at Johns Hopkins, discussed how his faith encouraged him to view all people as made in the image of God and how that encouraged his treatment of his patients. Danielle Patterson, a histotechnologist, talked about how the “pathology lab is very open about accepting of you and your religion,” and how prayer with a few of her colleagues in the pathology lab was a regular part of her morning routine prior to heading to work.

quote: Medicine is raw and real, and it involves caring for those whom society has often shunned. For most providers, faith also played a pivotal in the selection of health care as a career. The importance of serving others is a common theme among major religions, and Christianity is full of the deeds of those who chose to help others. According to Nancy Schoenborn, a geriatrician at Johns Hopkins, she sees medicine as a “calling that I am called to serve, and that is why I go the extra mile to do that extra stuff [for my patients].” Another provider, Angel Byrd, a fellow in the Department of Dermatology, discussed how her desire to go into medicine came from witnessing her mother’s career as a social worker and seeing the impact her mother had on the mental health of her clients. Byrd eventually developed an interest in serving those who needed to be cared for and “asked God to help me unfold the path that is right for me every step of the way.”

Faith also serves as a day-to-day guide for many providers and is pervasive in every aspect of their life. Along with guiding some providers on patient management, faith also serves as a sort of solace. Medicine is raw and real, and it involves caring for those whom society has often shunned. Medicine also lends itself to continuous failure to improve the health of patients and involves being physically active for long hours. According to Schoenborn, “There’s a lot we can’t do in medicine, and there’s a lot we don’t know in science, and in those moments, my faith is very important to me to remember that I don’t share that burden alone.” Madder discussed the importance of drawing from within oneself the love of Christ and the importance of spreading this love in the workplace.

quote: "There’s a lot we can’t do in medicine, and there’s a lot we don’t know in science, and in those moments, my faith is very important to me to remember that I don’t share that burden alone.”

The symposium was ultimately a small snapshot of the ways in which Christianity and modern medicine engage with each other. The art of healing is complex and very human, and in such a human enterprise, it is expected for faith to play at least some role in the lives of both practitioners and patients. Schoenborn beautifully summarizes what the Christian faith means to many health care providers: “There are tough times in medicine, but there is also incredible joy and incredible purpose. It is a privilege to be made by God in a certain way and to have those gifts by God to be able to serve his people, mirroring that Jesus was a healer and that we are following in his footsteps.”

About this series:

Although medicine is often seen as a field that is distinct from religion, religious beliefs have a significant impact on the way physicians and medical students approach their training, interactions with patients, and understandings of disease and death. Biomedical Odyssey bloggers Rabia Karani and Stephanie Zuo have created a short blog series on faith and medicine to give you a glimpse into the worlds of Johns Hopkins students who have been influenced strongly by and/or are actively practicing their faiths. 

We hope that you come away with a deeper understanding of the profound impact and immense strength that arises when peoples of faith seek to do good work in the medical field with all their hearts, minds and souls.

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Rabia Karani

Rabia Karani just completed her M.P.H., and is now finishing up her last year of medical school. She is passionate about any topic regarding patient care and public health. An anthropologist at heart, she is an avid reader, a Harry Potter enthusiast, and she hopes to use her love for writing to inspire understanding between different groups of people.

In Search of a Cure for Tissue Injury: The Rise of Mesenchymal Stem Cells in Regenerative Medicine

March 9th, 2017|Perspectives in Research|By

Regenerative medicine has been dubbed the vanguard of 21st-century health care. This emerging field places an emphasis on curing rather than treating injured or impaired tissues, and seeks to repair damaged tissues in vivo (in the living body) using techniques that trigger cells’ intrinsic healing ability. In the event that the body is unable to heal itself, scientists can grow new tissues and organs in the lab using regenerative methods and subsequently implant them safely in the body.

Although previously considered radical, the basic concept of introducing live cells into tissues or the bloodstream relies on old technology dating back to the 1950s. Now, with advances in research techniques and tissue engineering, the elusive goal of regenerative tissues on demand seems within reach. Enter the mesenchymal stem cell, which has emerged as the sentinel conductor of the regenerative apparatus.

What Are Mesenchymal Stem Cells (MSCs)?

They are specialized cells, originally named for their unique ability to morph into any other type of cell in the body. They can be found in every tissue and particularly reside adjacent to blood vessels. At this stage, they go by a peculiar name: pericytes. When tissue injury occurs, blood vessels break down and release pericytes. The detached pericytes have specialized sensors that allow them to pick up on changes in the microenvironment of the injury site. MSCs then secrete factors, which stimulate injury repair and growth of replacement cells.

The Body’s Own Emergency Response Team

This fascinating modus operandi of MSCs is better encapsulated by a real-world analogy. Imagine the scene of a major fire outbreak. Rescue personnel — the fire service, paramedics and emergency rescue workers — are summoned to the scene. They put out the fire, rescue and stabilize survivors, survey the field, intervene to mitigate any further damage, clean up residual debris and create a safe space for survivors, who may then be sent to the emergency room for further care.

Did you know: when an injury occurs, MSCs make growth factors that promote angiogenesis - formation of new blood supply - block cell death, stimulate the replacement of dead cells and prevent scar formation. This search-and-rescue system is recapitulated beautifully by MSCs. When an injury occurs, MSCs release a protective film that blocks an overly aggressive immune reaction and make growth factors that promote angiogenesis — formation of new blood supply — block cell death, stimulate the replacement of dead cells and prevent scar formation. If MSCs sense bacteria, they secrete powerful natural antibiotics that kill the bacteria on contact. Some MSCs migrate into the wound itself and morph to replace the old cells. Being quintessential multitaskers, MSCs stabilize the injured tissue, detoxify it and set up the wound for regenerative repair in a complex, multistage process. MSCs also have the unique ability to distinguish foreign material and are able to sequester cell debris from the site of injury.

According to Arnold Caplan, an expert in the field of MSC biology, who originally coined the term MSC, “These cells are so good at what they do. They are like nature’s own repair mechanics or, if you will, natural drugstores.” Caplan has proposed renaming MSCs as medicinal signaling cells. On Feb. 17, 2017, I heard him speak in Broomsfield, Colorado, at the Annual Conference of the Interventional Orthopedics Foundation (IOF), with the theme “Raising the Bar in Interventional Regenerative Medicine.” The IOF provided grants for residents and trainees to participate in the conference, and I was fortunate to be one of the grant recipients. The meeting highlighted major regulatory hurdles in creating and using combination stem cell-based tissue and gene therapies.

Regenerative Medicine Faces Funding Challenges

In the interest of public safety, the Food and Drug Administration’s Public Health Safety Act controls the licensing of biologic products and imposes strict regulations requiring researchers to submit an investigational new drug application to the FDA before studies in human subjects can be initiated. The FDA raise questions about the purity, potency, safety and use of these cell-based therapies, including MSCs, in humans. Currently, products like platelet-rich plasma, cord blood, allogenic fibroblasts and other regenerative products have gained FDA approval for various clinical indications.

quote: Although the industry has a potential $500 billion economic impact in annual revenues, most investments have come from the private sector. The disparity in funding could hamper fundamental research that is necessary to advance knowledge in the field.However, according to the Department of Health and Human Services, one of the biggest challenges is the lack of cohesive, government-driven funding for regenerative medicine. Although the industry has a potential $500 billion economic impact in annual revenues, most investments have come from the private sector. The disparity in funding could hamper fundamental research that is necessary to advance knowledge in the field. At present, researchers work in isolation, and there are few cross-disciplinary research collaborations. While large-scale trials are needed, these are expensive for private companies to conduct, and the shifting landscape of regulatory requirements often leads to confusion about expectations and acceptable uses of these products.

From a global perspective, some countries, like Britain, Germany, Sweden, Japan, China and Australia, have started their own national initiatives in anticipation of making regenerative medicine a reality. To achieve the promise of MSCs and other cell- and tissue-based therapies in the United States, a more proactive federal initiative is needed. As research in the field continues to evolve, it remains evident that understanding how MSCs interact with each other and connect with blood vessels will be key to mass-producing, preserving and engineering tissue and organ-based therapies in the future.

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Charles Odonkor

Charles Odonkor is a resident in physiatry (physical medicine and rehabilitation) and an Armstrong Institute fellow. An old soul and a dreamer, he is awed by the sacred and explores the world via the lens of a rich Afropolitan heritage.

Hopkins Students Craft Their Own Medical School Experience

March 9th, 2017|A Day in the Life|By

Traditionally, medical school is viewed as a continuous four-year educational experience. In reality, the structure of medical education is that of contrasting, dichotomous learning methodologies divided into two sequential stages: preclinical and clinical years. The daily lifestyles, schedules and learning styles of medical students within these two distinct but complementary components of medical school could not be more different, and the transition between them is a time of excitement, anxiety and realization.

quote: sometimes, it seems, experts can forget how to return to square one and lay out the basics for students who are seeing a disease for the first time. - Benjamin OstranderBefore this momentous transition, students learn predominantly from lectures accompanied by slides in the classroom. This is supplemented by small-group learning activities. At the Johns Hopkins University School of Medicine, we have the privilege of having teachers who are expert clinicians and often leaders in their fields. With this expertise comes the complexity and attention to detail that is expected from an individual who has dedicated his or her life to understanding a specific topic or disease. Many of our professors are fantastic at conveying this complexity with skill and thoughtfulness. Yet occasionally, the details are lost on medical students, who seek a broader introductory view of a topic and a foundation from which to build upon. Sometimes, it seems, experts can forget how to return to square one and lay out the basics for students who are seeing a disease for the first time. Learners require a strong overarching framework and a grasp of the vocabulary before grappling with intricacies.

Paradoxically, teaching prowess is not something that is required to become a medical professor. The academic hierarchy in medicine is formed by clinical skill, academic productivity and scientific accomplishment. Master clinicians may be genius diagnosticians and empathic caretakers, but this does not also guarantee they will be great teachers. To muddy the waters even further, teaching is not something that is well-compensated or highly rewarded in academic medicine. Teaching takes time and effort, and does not generate revenue. Finally, the best clinicians and most highly respected teachers are most often promoted to administrative roles, where they have significantly less time to see patients and teach the next generation.

A New Model of Teaching Recognition

Another essential component of preclinical education involves peer-to-peer teaching. Fortunately, there are a number of forces countering these issues with the structure of medical education. Last spring, the Distinguished Teaching Society of the Johns Hopkins University School of Medicine inducted its first group of master educators. This is a student-led initiative aimed at creating a new model of teaching recognition based on student nominations, and it has been extremely well-received by faculty and students alike. This year’s inductees were announced at the beginning of March.

Peer-to-Peer Training and Resources

Another essential component of preclinical education involves peer-to-peer teaching. A common thread within the restructuring of medical education is that it is frequently student-driven. In fact, some of students’ favorite educational tools have been created by other students. When medical student Sam Roman went through the Genes to Society (GTS) curriculum, she meticulously typed notes from every single lecture and slide deck, paring down the curriculum to a no-nonsense, bullet-pointed summary of the most essential facts. She chose to share this resource with her fellow classmates, and now her famous “Roman Notes” have been used by hundreds of students.

“I really never thought [my personal notes] would reach an almost-legendary popularity with the classes to follow,” Roman now recalls. “I really think students appreciate the format for the same reasons I made them for myself — we have lots of competing interests and short attention spans, and the notes contain the important information with helpful graphics in an aesthetically pleasing way.”

quote: as we move forward as students, teachers, clinicians and scientists, we should remember to not only listen to our patients, but to listen to our learners as well. Sometimes students are the best teachers of all. -Benjamin OstranderAnother student, Divine-Favour Anene, started to compile slides and give review lectures to first-year students prior to each exam during his second year of medical school at Johns Hopkins. When asked about his motivation to create these lectures, Divine says he has “always loved teaching and seeing other people succeed,” and wanted to “provide a different ‘student perspective’ on content in the preclinical years.” As a current student, he has an intimate understanding of what topics are important, how they can be easily conveyed in the most fundamental and simple way, and what knowledge will be tested not only during GTS, but also on standardized exams, like the United States Medical Licensing Examination. This firsthand knowledge is something unique that a subspecialized clinical expert 30 years out of medical school often does not possess.

One of my favorite parts about the Johns Hopkins community is the way in which driven colleagues collaborate, teach, learn and push each other to be the best they can be. As we move forward as students, teachers, clinicians and scientists, we should remember to not only listen to our patients, but to listen to our learners as well. Sometimes students are the best teachers of all.

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Benjamin Ostrander

Benjamin Ostrander is a third-year medical student who strives to keep life infinitely interesting through creativity with words, food, music, medicine and more.

Living Out My Faith: Being a Muslim Medical Student at Johns Hopkins

March 7th, 2017|A Day in the Life|By

“I am Muslim,” says Nimrah Baig, a third-year medical student. Her words do not sound like a label, but rather a bold summation of an entire world that she slowly begins to introduce me to. “My faith is something I live every day. My actions, how I treat others and my goals in life are all manifestations of my faith.”

Quote: “My faith is something I live every day. My actions, how I treat others and my goals in life are all manifestations of my faith.” Nimrah BaigBaig prays five times a day, whether she is at home or in a busy hospital ward. She carries a foldable prayer rug in the pocket of her white coat and diligently plans around her clinical schedule so that she might be able to step aside briefly in between seeing patients. She thinks of it as a spiritual break. For Baig, praying is a necessity, as important as eating. She finds that praying gives her spiritual rejuvenation and creates an opportunity for team members to ask questions about her faith.

Prayer is merely one of five pillars of Islam. The other pillars include a declaration of Muslim faith, charity, fasting during Ramadan and pilgrimage to Mecca. A common theme in my conversations with other Muslim medical students was how the pursuit of a career in medicine allows them to actively practice sacrifice, generosity and caring for the underserved, all of which are major themes in Islam. “He who saves a life has saved the entirety of humanity” is one of the principles that Omar Najjar, a first-year medical student, strongly believes in. Rather than merely a religion, Najjar sees his relationship with his Islamic faith as all-encompassing. He self-identifies as a Muslim in the form of the culture and lifestyle that it represents.

Awa Sanneh, a third-year medical student, expresses her faith outwardly by wearing a hijab, or headscarf. She began wearing the hijab after undergoing a spiritual transformation during her high school years and has been on a “journey of self-refinement” ever since. There is a heavy sense of responsibility for Sanneh in wearing the hijab.

Did You Know? The five pillars of Islam include: - Salat: praying five time each day - Shahada: reciting the Muslim declaration of faith - Zakāt: making financial contributions to the poor - Sawm: fasting during Ramadan - Hajj: making a pilgrimage to Mecca. “By wearing the hijab, people see me as a representative of Islam,” she shares. Sanneh is also fully aware of the pressures of the current sociopolitical context in America, which have compelled local advocates, such as Adnan Hyder, a Bloomberg School of Public Health professor, to found the American Muslim Wellness Initiative at Johns Hopkins. She is thus even more intimately aware of the importance of being involved with the Muslim-American community, whether it is through attending faith-based events or pursuing her interest in Muslim-American health.

Through her scholarly research project, Sanneh discovered that Muslim communities in the United States are experiencing health care disparities, likely due to discrimination and a delay in seeking care. For Sanneh, her faith has thus become an essential part of how she sees herself serving her future patients and health care in America. She hopes that in the future, she can address these disparities and be an advocate for patients of her faith and heritage.

About this series:

Although medicine is often seen as a field that is distinct from religion, religious beliefs have a significant impact on the way physicians and medical students approach their training, interactions with patients, and understandings of disease and death. My fellow Biomedical Odyssey blogger Rabia Karani and I have created a short blog series on faith and medicine to give you a glimpse into the worlds of Johns Hopkins students who have been influenced strongly by and/or are actively practicing their faiths. 

We hope that you come away with a deeper understanding of the profound impact and immense strength that arises when peoples of faith seek to do good work in the medical field with all their hearts, minds and souls.

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Stephanie Zuo

Stephanie Zuo is a fourth-year medical student who believes in the healing power of a listening ear.

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