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Author: deborah.wassertzug

Published on Leave a comment on Your Vaccines: Keeping Track and Keeping Up to Date
Gloved hand holding a vial of mRNA COVID vaccine.
Photo by Spencer Davis on Unsplash

August is Immunization Awareness Month. We are all aware of the importance of vaccines, particularly after the COVID-19 pandemic. However, it is easy to lose track of which vaccines we have had, and which may need updating. Because there is no single, centralized national source for individual vaccine records in the United States, here are some tips from the CDC for locating your vaccination records:

  • Begin with your doctor or public health clinic. Keep in mind that vaccination records are maintained at doctor’s offices for a limited number of years.
  • Ask for any existing childhood vaccine records that your parents, caregivers or guardians may have for you, and look through baby books or other childhood documents that were saved.
  • Check with your high school or college health service for dates of any vaccines administered there. (This information is only kept for 1-2 years after a student leaves the system, however.) Check with any previous employers, including the military, which may have required immunizations.
  • Contact your state’s health department. Some states have vaccine registries (Immunization Information Systems) which will include adult vaccines. In the DMV, the Virginia Department of Health has an online portal for requesting a copy of your immunization record. Maryland currently participates in the online vaccine registry platform MyIRMobile, which DC will also be joining soon (DC’s current immunization portal can be accessed here). Other states currently using MyIRMobile are: Arizona, Louisiana, Mississippi, North Dakota, Washington, and West Virginia. MyIRMobile also allows parents or guardians to link to vaccine information for their minor children.

An MyIRMobile vaccine record will receive data from various sources, including chain drugstores. The display looks like this:

Screenshot from a MyIRMobile account

Once you have established as complete a vaccine record as you can using the sources listed above, how do you find out which vaccines you may be missing? Here again, the CDC is your friend. On the CDC website, you can access a continually updated schedule of vaccine recommendations, both for Adults and for children, from Birth to 18 Years. To stay up to date with the latest developments in vaccines, you can follow the AMA’s updates here.

How to keep track of your vaccines if you don’t have access to a centralized system like MyIRMobile? There is an app for mobile devices called The Vaccine App, which is available for both Apple and Android devices. (Reviews of the app are quite mixed, however.) For a more DIY solution, consider creating a cloud-based document, such as a spreadsheet where you record your vaccine dates, both past and present.

Finally, what might happen if, due to incorrect records, you receive an extra dose of a given vaccine? A 2019 study done in the United States and published in the journal Vaccine examined instances of adverse events (AEs) most commonly reported following the administration of excess doses of vaccine in the Vaccine Adverse Event Reporting System (VAERS) from the U.S. Department of Health and Human Services (Moro et al, 2020). The authors of the study state there are several scenarios in which an excess dose of a vaccine might be administered, including when there is a vaccination error arising from documentation or patient recall errors, or where an individual’s vaccination history is uncertain (as may be the case for refugees). The CDC provides continuously updated best practice guidelines for immunizations which cover the administration of excess doses of vaccine, particularly as regards combination vaccines. In examining 366,815 reports submitted to VAERS between the years 2007 and 2017, 1.4% of these reports pertained to an excess dose of vaccine administered. The most frequent type of vaccine included within excess vaccine dose reports was inactivated influenza vaccine. It is interesting to note that manufacturers are by far the most frequent reporters to the VAERS. The most frequent types of adverse events reported were systemic, like fevers, or reactions at the injection site. Of the 158 serious adverse events reported during the period studied, 64 events were found to involve excess vaccine dose. In their discussion, the authors conclude that their findings are generally reassuring, since 75% of reports of excess vaccine dose did not report adverse health events, and where those were present, systemic reactions (fevers) and injection site reactions were the most frequent. The authors concluded that there were no new or unexpected safety issues connected with excess doses of vaccine.

Clearly, it is important to spend some time assembling an accurate vaccine record, using as many data sources as are available to you. If your state provides access to a vaccine registry, great! If not, consider putting together a vaccine record for yourself on a cloud-based storage site, making sure to review it periodically to make sure you are up to date with all of them.

References

Moro, P. L., Arana, J., Marquez, P. L., Ng, C., Barash, F., Hibbs, B. F., & Cano, M. (2019). Is there any harm in administering extra-doses of vaccine to a person? Excess doses of vaccine reported to the Vaccine Adverse Event Reporting System (VAERS), 2007-2017. Vaccine, 37(28), 3730–3734. https://doi.org/10.1016/j.vaccine.2019.04.088

Thank you to Rebecca Kyser for research assistance.

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Comic books have enjoyed popularity for well over a century, and according to a March 2024 report by the market research firm IBIS World, graphic novels are the most popular product in the $2 billion a year comic book publishing sector. 

Within the graphic novel sector is a subgenre known as Graphic Medicine, a term coined in 2007 by Dr. Ian Williams, a cartoonist and the founder of a website of the same name. Graphic Medicine provides comprehensive information about the genre, including reviews of new publications and podcasts. Since 2010, they have also sponsored an annual conference – the 2024 conference just wrapped in Athlone, Ireland.

Graphic medicine is also a subset of the field of narrative medicine, which centers patient narratives in clinical practice, research, and medical education. One practitioner within this field is Dr. Benjamin Schwartz, who completed his medical training, but is now a cartoonist for the New Yorker, and a professor of narrative medicine at Columbia University. You can read an interview with him at the website, Doctors Who Create. You can view some of Schwartz’s work for the New Yorker here.

Some graphic works in Himmelfarb's collection include: Graphic guide to infectious disease, The Infographic guide to medicine, and Clinical Ethics: A Graphic Medicine Casebook.

Did you know you can also search for graphic medicine in PubMed? A search of the medical subject heading, “Graphic Novels as Topic” will help you find both comics published within journals, as well as articles which, for example, examine the impact of comics on public health.

Himmelfarb’s Reference and Instruction Librarian Rebecca Kyser, herself a cartoonist, suggests the following titles to help you delve into the world of graphic medicine:

Kid Gloves: Nine Months of Careful Chaos, by Lucy Knisley (available to borrow through our local consortium) follows the cartoonist as she goes through the process of trying to become pregnant, being pregnant and her birth experience. As she chronicles her own experiences with miscarriage, morning sickness and preeclampsia, Knisley also explores the history of pregnancy, women’s health, myths and superstitions around miscarriage and pregnancy, and the decisions that factor into the choice to have kids in the first place. Entertaining, emotional and well researched, this is a great book for anyone, regardless if they plan to have kids, have kids or never intend to have kids at all.

The Nib (website): The Nib used to be a magazine publisher of anthology comics, usually all revolving around a specific issue, as well as daily comics. While the magazine stopped publishing last year, the entire site is still live for those who wish to buy back issues or view any of the older strips, which sometimes feature medical themes. There’s plenty to check out such as a comic regarding the Covid-19 pandemic’s impact on the Navajo nation, living with OCD during Covid-19, and the high maternal mortality Black women face .

Comics for Choice, Second Edition  (anthology, currently on New Books Shelf) Published after 2021, this anthology takes a look at the history of abortion in the United States from a range of perspectives. From personal stories about their own abortions to narratives about those who sought to provide access even when the procedure was entirely illegal, this collection showcases the multiple ways reproductive choice and access impacts everyone.

Memento Mori by Tiitu Takalo (coming soon to DC Public Library). Takalo, a cartoonist from Finland, tackles her own experience dealing with a cerebral hemorrhage with honesty and a dynamic drawing style. Using color to reflect her own emotions, Takalo takes us through her frightening medical emergency, the monotony of the hospital and her struggle to access proper health care upon her release. It’s an engaging story bringing to light the reality of an experience most people rarely face themselves

Lighter Than My Shadow by Katie Green (available at DC Public Library). Mental health conditions can be hard to understand, especially given that the symptoms are often internal. By using comics as her medium of choice, Green gives physicality to her own battle with an eating disorder in her teens and college years. Black scribbles follow her from page to page, growing more busy and large as her anorexia worsens. Later, a mouth on her stomach grows and grows as she struggles against the urge to binge food. It’s a difficult read at times – as it should be given what Green was facing – but it explores her own battle with empathy and thoughtfulness.

For a break from studying, or for a way to see the health professions from a different perspective, dive into some graphic medicine!

References

Comic book publishing in the US - market size, industry analysis, trends and forecasts (2024-2029): IBISWorld. IBISWorld Industry Reports. (March 2024). https://www.ibisworld.com/united-states/market-research-reports/comic-book-publishing-industry/#IndustryStatisticsAndTrends Accessed 7/23/2024

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Published on 2 Comments on Ultraviolet radiation and you
Hand holding a tube of sunscreen

In summer, the sun is a near-constant companion in many parts of the world. But we know that the sun can be our adversary – particularly the ultraviolet radiation emanating from it. Ultraviolet light is used as phototherapy, in the treatment of conditions including jaundice, psoriasis, and cutaneous T-cell lymphoma. But in honor of UV Safety Awareness Month, we focus here on UV exposure that is environmental and not therapeutic in nature, and how best to achieve protection from harmful UV rays. Use of tanning beds is one dangerous source of ultraviolet radiation, but exposure to them is avoidable via behavioral and lifestyle changes. For other types of exposure, there are fortunately a multitude of products available for protection.

That ultraviolet radiation awareness has increased dramatically in recent years is generally a positive change, but where do consumers go to get informed about UV protection? One prominent result in Google searches is a resource from the Environmental Working Group. EWG is an activist nonprofit focused on chemicals used in agriculture and cosmetics, as well as pollutants in drinking water. The EWG has been compiling an annual review of sunscreens since 2008. Its methodology includes assigning numerical ratings to sunscreens based on their “safety.” The EcoWell, a website dedicated to combating misinformation in the cosmetics industry, has expressed some doubts about the EWG’s methodology, which is disclosed at length on their website, but is not easily evaluated by non-experts. EWG includes the following statement in their page on methodology: “Most people [believe] the government oversees the safety of their cosmetics and other personal care items. Not so.” (EWG, n.d.) Even a non-expert can understand that this position stakes a specific claim, and thus the information is not coming from an unbiased source. Additionally, EWG offers companies an opportunity to become “verified” on their website, which in part involves a financial transaction, and means that verified products appear before others in the database. This information is inconclusive, but doesn’t inspire confidence in a nonprofit that claims to be organized in the public interest. 

While consumers might be grateful for a source that is easily accessible, it is very important to understand that the EWG’s findings are not evidence-based. According to Dr. Adewole Adamson, MD, MPP, speaking to Dermatology Times this month, “None of [the EWG’s] data is actually based on any information that involves actual clinical or actual patient use in the real world. I do not think that patients should change their behavior related to putting on whatever sunscreen it is that they use based on this data.” (Andrus, 2024)

Another important thing to understand about sunscreens on the market in the United States, as opposed to those sold in Europe or Asia, is that in the U.S. sunscreen is regulated as though it were a drug. In Europe and Asia, sunscreen is regulated as a cosmetic. Because drug regulation is a more rigorous process, the U.S. has seen fewer sunscreen filters approved for use than in other countries. As a result, Americans have fewer and more limited product choices for protection.

One recent evidence-based guide to sunscreens is this 2023 review on photoprotection, published in the Archives of Dermatological Research. Photoprotection is the practice of minimizing damage to skin and eyes from damage that ranges in severity from sunburn to photoaging to the development of malignant neoplasms. There are two types of ultraviolet radiation, UVA and UVB. UVB exposure is at its highest level in summer, while UVA exposure is more constant throughout the year and leads to carcinogenesis. Sunscreens which are labeled “broad spectrum” primarily protect from UVB, but also protect from UVA. In addition to UV, 50% of ultraviolet radiation comes from visible light, which causes other types of skin conditions, or else can trigger flares of chronic conditions. While UV radiation is absorbed or scattered, visible light is reflected.

The authors of the review state that people “should be encouraged to avoid outdoor activities during peak sun hours, seek shade, apply sunscreen, wear sun protective clothing, and sunglasses.” (McDonald et al, 2023) Avoiding exposure, then, is our first line of protection. But that isn’t practical for most people, especially those who want to participate in summer activities outdoors. It is important to learn more about the different types of sunscreen products and their pros and cons. Sun Protection Factor, or SPF, is a common measure of the effectiveness of sunscreens.

On an FDA website explaining SPF, we learn that the number associated with a sunscreen product’s SPF is commonly misconstrued as a measure of protection based on the amount of time one is exposed to the sun. This is incorrect because solar intensity differs by time of day. In fact, SPF denotes the amount of UV radiation required to produce sunburn on protected versus unprotected skin. (FDA, 2017) One study cited in the review from Archives of Dermatological Research found that SPF 85 provided significantly more protection against sunburn than did SPF 50. A product with a higher SPF may help compensate for an insufficient amount of sunscreen being applied. Frequency of reapplication of sunscreen is important, particularly when there is water exposure or perspiration.

The two main types of sunscreen are chemical, or organic sunscreens, which represent 75% of products currently on the market, and include chemical filters which absorb UVR. Physical, or inorganic sunscreens approved by the FDA include zinc oxide and titanium dioxide, which form a physical barrier to UV absorption. While chemical sunscreens are absorbed more readily on the skin, physical sunscreens are not. Tinted sunscreens contain iron oxides and synthetic mica for cosmetic purposes, in addition to other sunscreen ingredients. The authors of the review found limited evidence of the use of systemic agents protecting against UVR.

One photoprotective measure whose availability has dramatically increased in recent years is sun protective clothing. When selecting UPF (ultraviolet protection factor) clothing for sun safety, the number associated has to do with how much UVR is able to penetrate through different fabrics. However, the authors note that “UPF does not account for body surface area covered.” (McDonald et al, 2023) In general, most natural fibers provide less protection from UVR than synthetic fabrics or wool, darker colors absorb more UVR, and looser clothing provides more protection from UVR. Clothing marked UPF50+ is considered an excellent source of protection.

Now that we’ve discussed protecting the body, what about our heads and eyes? Wearing sunglasses helps decrease UVR damage to the skin around the eyes, the lens, and the cornea. Wearing a hat protects our vulnerable scalps, with wider brimmed hats providing optimal protection for both head and neck.

The review goes on to discuss evidence on adverse effects from photoprotection, including a comparison of evidence on superficial cutaneous absorption versus systemic absorption, concluding that despite the presence of sunscreen compounds in plasma, there simply is no evidence to date that sunscreen ingredients cause any harm to humans – a conclusion in stark contrast to those drawn by the EWG.

We only have the one skin we’re born with, so learning how best to protect it from UVR is time well spent!

References

Andrus, E. (2024/07/05). Addressing Sunscreen Safety. Dermatology Times, 45(7), 6. https://www.dermatologytimes.com/view/addressing-sunscreen-safety-a-review-of-ewg-s-2024-guide-to-sunscreens

Center for Drug Evaluation and Research. (n.d.). Sun Protection Factor (SPF). U.S. Food and Drug Administration. https://www.fda.gov/about-fda/center-drug-evaluation-and-research-cder/sun-protection-factor-spf#:~:text=SPF%20is%20a%20measure%20of,produce%20sunburn%20on%20unprotected%20skin Accesssed on July 11, 2024

Environmental Working Group. About | Skin Deep | Cosmetics Database. Environmental Working Group. https://www.ewg.org/skindeep/learn_more/about/ Accessed on July 12, 2024 

McDonald, K. A., Lytvyn, Y., Mufti, A., Chan, A. W., & Rosen, C. F. (2023). Review on photoprotection: a clinician's guide to the ingredients, characteristics, adverse effects, and disease-specific benefits of chemical and physical sunscreen compounds. Archives of dermatological research, 315(4), 735–749. https://doi.org/10.1007/s00403-022-02483-4

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one person's hand holding another person's hand

June is Cancer Survivors Month. Any cancer diagnosis induces feelings of anxiety, uncertainty and fear in patients. While novel approaches to and treatments for cancer are improving survival rates, social determinants of health continue to exert significant impact on patients’ ability to experience positive outcomes to treatment. Let’s look at one of these determinants, economic stability, in the context of cancer survival.

The term “cancer-related financial toxicity” was introduced in 2013 by Zafar and Abernethy, and described as, “the patient-level impact of the cost of cancer care” (Zafar and Abernethy, 2013). Even those patients who are privately insured are not protected from financial toxicity, as a 2022 study published in the Journal of the National Cancer Institute found. Out-of-pocket expenditures by privately-insured cancer patients in the United States have increased, due to the rise in high-deductible insurance plans and greater expected patient contribution to medical expenses (Shih et al, 2022).

How best, then, to help patients navigate the potential financial burdens of a cancer diagnosis, and thereby improve their potential treatment outcomes? A 2023 scoping review in Critical Reviews in Oncology/Hematology examined interventions for financial toxicity among cancer survivors. The interventions discussed include: financial navigation, which includes identifying patients at high risk for financial toxicity, offering guidance on out-of-pocket costs, and facilitating access to programs to alleviate financial stress. Financial counseling helps patients access advice and guidance on managing financial toxicity caused by cancer treatment. Insurance education entails providing patients a structured way to develop insurance literacy and assistance in choosing a plan. Other types of interventions examined included multidisciplinary psychosocial supports, intensive symptom assessments, and supportive care (Yuan et al, 2023).

The effectiveness of the interventions, researchers found, were closely tied to the causes of the cancer-related financial toxicity, with socioeconomic and employment status, cancer stage, and type of treatment, type of insurance, as well as coping skills all having a direct impact on how effective financial interventions could be. Looking closely at just one of the interventions mentioned above, engaging with financial navigation helped cancer patients save significant dollar amounts annually by facilitating the procurement of free medication, and insurance premium and co-pay assistance.

The financial interventions described in the evidence reviewed differed greatly, but more generally, the recent focus in the literature on finding ways to alleviate financial toxicity frequently faced by cancer patients is one promising step towards improving outcomes for all patients dealing with cancer.

References

Debela, D. T., Muzazu, S. G., Heraro, K. D., Ndalama, M. T., Mesele, B. W., Haile, D. C., Kitui, S. K., & Manyazewal, T. (2021). New approaches and procedures for cancer treatment: Current perspectives. SAGE open medicine, 9, 20503121211034366. https://doi.org/10.1177/20503121211034366

Lau, L. M. S., Khuong-Quang, D. A., Mayoh, C., Wong, M., Barahona, P., Ajuyah, P., Senapati, A., Nagabushan, S., Sherstyuk, A., Altekoester, A. K., Fuentes-Bolanos, N. A., Yeung, V., Sullivan, A., Omer, N., Diamond, Y., Jessop, S., Battaglia, L., Zhukova, N., Cui, L., Lin, A., … Ziegler, D. S. (2024). Precision-guided treatment in high-risk pediatric cancers. Nature medicine, 10.1038/s41591-024-03044-0. Advance online publication. https://doi.org/10.1038/s41591-024-03044-0

Shih, Y. T., Xu, Y., Bradley, C., Giordano, S. H., Yao, J., & Yabroff, K. R. (2022). Costs Around the First Year of Diagnosis for 4 Common Cancers Among the Privately Insured. Journal of the National Cancer Institute, 114(10), 1392–1399. https://doi.org/10.1093/jnci/djac141

Yuan, X., Zhang, X., He, J., & Xing, W. (2023). Interventions for financial toxicity among cancer survivors: A scoping review. Critical reviews in oncology/hematology, 192, 104140. https://doi.org/10.1016/j.critrevonc.2023.104140

Zafar SY, Abernethy AP. Financial toxicity, Part I: a new name for a growing problem. Oncology (Williston Park, NY). 2013;27(2):80-149.

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a bowl of gazpacho

Summer is right around the corner! Whether you grow your own, have a produce share, or visit a farmer’s market, it is time to lean into tomatoes, which are more local, plentiful, and far more flavorful in season.

While the jury is still out on whether tomatoes contain more nutrients when processed as opposed to eaten fresh, one thing is for sure: they are delicious and full of nutrients.

One great way to beat the summer heat is to make gazpacho, the chilled tomato soup of Spanish origin. There are many different interpretations of this classic dish, some of which are quite elaborate. Here’s a great basic recipe to start you out, adapted from the 1963 Better Homes & Gardens cookbook, Meals with a Foreign Flair:

Gazpacho (Serves 6)

1 c peeled, chopped medium tomato (immerse whole tomato in boiling water for ease in peeling)

1/2 c each minced green pepper, celery, cucumber

1/4 c finely diced onion

2 t chopped parsley

1 t chives, snipped

1 small minced garlic clove

2-3 T tarragon wine vinegar (available in stores, or just infuse a bottle of white wine vinegar with sprigs of fresh tarragon)

2 T olive oil

1 t salt

1/4 t black pepper

1/2 t Worcestershire sauce

2 c tomato juice

Combine all ingredients in a bowl and refrigerate for at least four hours. A note on texture: that’s up to you! If you like it crunchy, dig right in. If you like it smooth, blend away.

To learn much, much more about tomatoes of all types, visit the World Tomato Society. Their site includes a database of over 6500(!) tomato varieties, as well as recipes. If you’d like to make your own tomato juice for the gazpacho, they even provide instructions for doing so.

Did you know? GW’s School of Medicine and Health Sciences sponsors a Culinary Medicine program, as a partner medical school of the American College of Culinary Medicine. Check out recipes from the program here.

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Three male doctors in white coats in a black and white photo taken in 1892
Dr. William Coley (center), public domain photo from https://commons.wikimedia.org/wiki/File:William_Coley_1892.jpg

May is Melanoma Awareness Month, which serves as an annual reminder to visit a dermatologist regularly for a skin check. Melanoma affects every skin tone. Visit Himmelfarb's collection, Diversity in Dermatology, to explore our library resources on this topic.

This year, let’s go back in time to learn about the origin of one tremendous contemporary advance in the treatment of malignant melanoma -- immunotherapy -- and learn about a new development coming for patients diagnosed with melanoma.

Dr. William Coley (1862-1936) was a bone surgeon and cancer researcher who spent his career at the New York Cancer Hospital. At the time, cancers were commonly treated with amputation. Coley’s young patient, 17 year old Elizabeth Dashiell, presented with an aggressive sarcoma in her hand. Despite an amputation, her cancer had metastasized and she died ten weeks later. Coley began to comb through hospital records, and found a patient who had had four recurrences of an inoperable sarcoma, whose disease had gone into remission when he developed a superficial streptococcal infection of the skin. Coley managed to locate the patient, who did not present with any clinical evidence of malignancy. He also found a number of observational publications connecting this particular skin infection with positive outcomes for sarcoma patients.

Cover of a medical monograph from 1914
The Treatment of Malignant Inoperable Tumors, by William B. Coley, MD (1914)

Coley began intentionally inducing this skin infection in his cancer patients, despite the fact that antibiotics were not yet available to help control infections. His practice is of course shocking and unethical in the light of our contemporary understanding of medical ethics. Additionally, the specific infection, erysipelas, was difficult to induce in patients, some of whom never developed the infection, and some of whom were injected repeatedly in the attempt to induce it. Having achieved some results with his initial attempts, Coley began using a heat-killed version of the infection, combined with one other toxin (which is known to us today as Serratia marcescens) to increase the virulence, and in turn, patients’ immune responses. This combination came to be known as “Coley’s toxins.” A summary of the patients treated with Coley’s toxins prior to 1940 shows that 22 soft-tissue sarcoma patients and 8 lymphoma patients were found to be free of clinical evidence of disease for a period of at least 20 years. (Starnes, 1992). Results for other types of cancers varied, but were not nearly as dramatic. You can read Coley’s 1914 report on his treatment of patients with toxins in its entirety online.

The concept of inducing an immune response in patients to address malignancies also underlies the pioneering work done by contemporary researcher James Allison, for which he shared the 2018 Nobel prize with Tasuku Honjo, for their work on immunotherapy. Allison’s work is chronicled in the documentary Breakthrough, which is available to stream on a number of platforms. Immune checkpoint therapy stimulates the patient’s immune system by blocking inhibitory checkpoints, in order to enable T cells to attack the tumor. Currently, immune checkpoint inhibitors which target the molecules CTLA4, PD-1, and PD-L1 are approved. The very first immune checkpoint therapy, ipilimumab, was approved in 2011 for the treatment of melanoma; since then, seven additional immune checkpoint inhibitors have been approved for use in the treatment of an ever-increasing number of cancers.

Research is ongoing towards the development of melanoma vaccines, which also build on the basis of activating patients’ own immune systems. The April 2024 issue of Cancer Research contains a brief comment on the growing body of evidence for vaccines tailored to specific tumor mutations, noting that progress has accelerated and increased during the past five years. (Fritsch & Ott, 2024) 

While the ultimate goal is to prevent patients from developing melanoma in the first place, the results of research are leading to exciting and unprecedented outcomes for patients who have the disease. Dr. Coley’s early work with the immune system of cancer patients reminds us that pioneering ideas may come before their time and before the technology exists to support them, but may nonetheless lead to unimaginable and positive outcomes centuries later.

References

Coley, W. B. The Treatment of Malignant Inoperable Tumors with the Mixed Toxins of Erysipelas and Bacillus Prodigiosus : With a Brief Report of 80 Cases Successfully Treated with the Toxins from 1893 to 1914 / by William B. Coley. M. Weissenbruch, 1914; 1914.

Fritsch, E. F., & Ott, P. A. (2024). Personalized Cancer Vaccines Directed against Tumor Mutations: Building Evidence from Mice to Humans. Cancer research, 84(7), 953–955. https://doi.org/10.1158/0008-5472.CAN-24-0565

Starnes C. O. (1992). Coley's toxins in perspective. Nature, 357(6373), 11–12. https://doi.org/10.1038/357011a0

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Fingers with arthritis resting on a blue cushion
Fingertip arthritis - DIP joint, by handarmdoc on Flickr, licensed under Creative Commons

May was designated as Arthritis Awareness Month by Congress and the President in 1972. An estimated 53.2 million US adults (21.2%) reported being diagnosed with some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia, in response to the CDC’s National Health Interview Survey (Fallon et al., 2023). There are numerous types of arthritis. Because of its prevalence, as well as the financial impact of the various forms of arthritis – for the year 2017, the CDC estimated that osteoarthritis was the second most costly condition treated at US hospitals. Let’s look at a couple of recently published articles examining the impacts of arthritis on population health.

When we consider a condition that is as common within the population as arthritis, and as costly to treat, health disparities are a concern. In a brief report in the July 2023 issue of Arthritis Care & Research, researchers examined healthcare utilization by patients diagnosed with rheumatoid arthritis (RA) or osteoarthritis (OA), focusing on whether these patients live in rural/isolated, largely rural, or urban locations (Desilet et al., 2023) The study was based on questionnaires filled out by over 37,000 RA patients and over 8200 OA patients. A majority of the RA patients responding (74.5%) lived in a rural area, and this proportion was similar for OA patients. By analyzing questionnaire responses indicating healthcare utilization over six months, the research team found that among RA patients, urban residents were more likely to utilize healthcare provided by some type of professional than their rural counterparts. The same was true for OA patients. Patients with both types of arthritis fare better under the care of a rheumatologist, and in rural areas, access to this expertise is more limited. The findings of this study suggest the importance of extending access to rheumatology care in rural communities that are not currently well-served.

A forthcoming article in the journal Rheumatology (d'Elia et al, 2024) reports on a study of symptoms in a primary care database, which tracked prodromal (early) symptoms for the 24 months prior to diagnosis, in over 70,000 RA patients, over a period of 18 years. When analyzed demographically and socioeconomically, the findings were that symptoms were reported differently in new-onset RA across ethnic groups. While some of this may be accounted for due to the way symptoms are reported by patients, delayed diagnosis and treatment is another potential factor. 

Another interesting finding of this study was the fact that of the symptoms reported, there was a discrepancy between the most common symptoms of RA (e.g. painful small joints of the hands, present in over half of RA patients) and the percentage of patients in the database who were reporting this symptom (10.2%). This may point to under-coding of symptoms, which would have an impact on treatment. Future studies may build on these findings delving more deeply into the differences in RA symptoms among different ethnic groups, including their underlying causes and their clinical implications.

Arthritis affects a large proportion of the population in the US and worldwide, and the burden falls more heavily on those who struggle to access care, as well as those who are not served equitably within healthcare settings. This Arthritis Awareness Month, consider how you might be able to contribute to our understanding of these disparities and help to cure them.

References

Fallon, E. A., Boring, M. A., Foster, A. L., Stowe, E. W., Lites, T. D., Odom, E. L., & Seth, P. (2023). Prevalence of Diagnosed Arthritis - United States, 2019-2021. MMWR. Morbidity and mortality weekly report, 72(41), 1101–1107. https://doi.org/10.15585/mmwr.mm7241a1

Desilet, L. W., Pedro, S., Katz, P., & Michaud, K. (2023). Urban and Rural Patterns of Health Care Utilization Among People With Rheumatoid Arthritis and Osteoarthritis in a Large US Patient Registry. Arthritis Care & Research (2010). https://doi.org/10.1002/acr.25192

d'Elia, A., Baranskaya, A., Haroon, S., Hammond, B., Adderley, N. J., Nirantharakumar, K., Chandan, J. S., Falahee, M., & Raza, K. (2024). Prodromal symptoms of rheumatoid arthritis in a primary care database: variation by ethnicity and socioeconomic status. Rheumatology (Oxford, England). Advance online publication.

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Watergate in Bloom by Nicole Gunawansa
Watergate in Bloom, by Nicole Gunawansa, Winner of 2024 Spring Flowers and Blossoms Photo Contest

Himmelfarb Library would like to congratulate Nicole Gunawansa, MPH, the 2024 Spring Flowers & Blossoms Photo Contest winner! Himmelfarb's Healthy Living Committee had their work cut out for them by judging the many excellent entries to this year's contest. With so many fantastic submissions, it was extremely challenging to select a winning photo. Nicole, a graduating fourth year medical student, stopped by Himmelfarb last week to receive congratulations from members of Himmelfarb's Healthy Living Committee, and to pick up her prize -- a coffee mug showcasing her winning photo.

Members of Healthy Living Committee with photo contest winner Nicole Gunawansa

Left to right, Laura Abate, Valerie Bowles, Nicole Gunawansa, Deborah Wassertzug.

Let's get to know Nicole!

Can you share your journey to GW? What led you to pursue an MPH in addition to an MD?

It has actually been a while since my journey at GW started. I graduated from Washington and Lee University in 2014, moved to Japan for a fellowship program where I did research in Sendai (the area affected by the 2011 Great East Japan Earthquake and Tsunami) for about 1.5 years, then came back to the States to work for a bit as a medical scribe because I wanted to make sure that applying to medical school was the right fit for me. Overall, I took 4 years off before coming into medical school in 2018. Actually, I was recommended to apply to GW by a professor from college, because of the focus on public health and advocacy! I had done work with AmeriCorps and had also worked with a 501c3 non-profit in college that focused on addressing food deserts, so going to a medical school that focused on public health was a good match for me.

Honestly, I was on the fence about the MPH at the start of medical school, because it is already such a long journey and because I had taken so much time off before school. However, being a part of the class of 3rd years who got thrown into the hospital/clinic right as COVID was starting in 2020 was what made me ultimately decide to take time off after clerkships to pursue the MPH. Doing rotations during the height of the pandemic made the gaps in our healthcare system glaringly apparent and kind of made me doubt if you can truly be a good doctor within a broken system.

In the end, I did the MPH because I wanted to explore the world of public health and its interaction with medicine, and also because I really needed some time to do some soul searching about what I saw myself doing in the future within the medical field. I am so happy and grateful that I did end up doing the MPH and taking a little extra time off in medical school to figure out what I wanted, because it ultimately led me to the decision to pursue family medicine, and I have found an amazing community of passionate doctors with similar goals about mitigating health disparities within this space. 

How long have you been taking photographs, and what are your favorite subjects?

I have always enjoyed photography, especially of natural landscapes. I remember getting my first camera in high school, before I went on a school trip to Italy and Greece. I don't think I am a pro at all though; very much an amateur photographer who has never taken a photography class but has always wanted to. My favorite subjects are flowers (nature) and animals! I have been told I take pretty good pet photos.

How did you hear about the Spring Flowers & Blossoms Photo Contest?

I found out about it through an email that was sent out to the student body, and thought it would be fun to enter given that I already take so many pictures of flowers and greenery. 

You'll be graduating and heading off for residency soon! Where are you headed and what is your specialty?

I am going to be going back home to the Tidewater area of Virginia. Specifically, to Eastern Virginia Medical School in Norfolk, VA for Family Medicine Residency! Thinking about FMOB or possibly a palliative medicine fellowship in the future.

Published on
Child in a wheelchair and child using an assistive walking device are on a running track with a coach encouraging them
2017 Special Olympics Spring Games Photo by Aaron Hines (public domain image)

Students at GW are doing great things both in the classroom and outside of it. For our ongoing series of spotlights on student organizations, I spoke with Arinze Okeke and Nikki Karri, both of whom are first-year med students, and also the co-presidents of KEEN at GW.

KEEN stands for Kids Enjoy Exercise Now, and the chapter at GW is part of a larger organization which has provided free programs for fitness and recreation for youth with disabilities since 1992.

Volunteers from GW, who are known as coaches, sign up on KEEN’s email list, and then volunteer one of three Saturdays a month to help out with the program. KEEN invites youth between the ages of approximately ten and 20 years old with all types of disabilities to come to a gym or pool and be paired with a coach or coaches. Students from GW’s KEEN chapter, as well as other area universities, serve as coaches for the activity selected by each young participant.

Arinze explained how participants join the KEEN program: “To get involved, kids fill out a profile stating their likes and dislikes, what activities calm them down, and what they like to do for fun. Sometimes their parents are involved in helping complete the profile.” 

Nikki explained how coordination occurs between the coaches and the participants in KEEN, who are known as athletes. “After we recruit our coaches, we work with the KEEN Greater DC area program director, who’s in charge of both us as coaches, and also the athletes.” KEEN provides a list of athlete abilities and activity preferences, based on the first-hand account collected in the athlete questionnaire. “Beth [KEEN’s program director] knows us and the athletes, so she’ll pair us up based on how well she thinks we’ll fit.” With newer coach volunteers, Nikki continued, “Beth will pair them with the athletes she thinks will be a good fit.” Each Saturday session lasts three hours, during which coaches cycle through working with different athletes and different age groups on an hourly basis.

The range of disabilities represented by KEEN athletes is wide, Nikki reported. “Some of them are nonverbal, and a lot of them have intellectual or physical disabilities.”

Once athletes have been matched with a coach, Arinze says, “We hang out with them, play sports with them – whatever they want to do for the hour we’re together.” Nikki elaborates, “Athletes are new to the activities, and they can try things out. While our involvement is solely with coordinating volunteers for the sport and swim activities, KEEN is not only sports. There are different activities offered throughout the week.” 

Before each session, the coaches gather, and Beth or one of her coordinators will hand coaches their papers. Arinze describes what happens next: “We have some time to read through the first-hand account of each athlete’s characteristics, and maybe talk to other coaches who’ve worked with them. Because typically there are people who have worked with them before, who know their likes and dislikes.” 

I asked Nikki whether there is a constant flow of new athletes joining KEEN. “Most are repeat athletes. Some of them even come with their siblings, so that’s very fun. And there are people who won’t come on a given week and then you see them later and say, ‘Oh my gosh, I missed you!’”  Occasionally new athletes also join the program.

In terms of coach volunteers, Nikki explained that a maximum of ten students can sign up for each weekend’s session, in order to ensure a correct ratio of coaches to athletes. “Depending on whether it’s a heavy week with tests and stuff, sometimes we’ll have six or eight people, but sometimes if it’s a test-heavy week it will be [fewer].” Arinze says that the ratio of coaches to athletes is either one on one, or sometimes more than one coach is assigned to an athlete.

Coaches participating in KEEN come from GW and other area universities. Arinze has met KEEN coaches from Howard University’s medical school. Additionally, coaches from area schools may come from undergraduate programs and disciplines other than medicine.

I asked Arinze and Nikki what drew them to becoming involved with KEEN. For Arinze, mentorship is something he has always been drawn to. During his gap year, he had a unique opportunity to be a second grade special education teacher in Southeast DC. He appreciated “being able to spend time with the kids I had on my caseload, day in, day out, [understanding] what each of them specifically learns, what each of them specifically needs to flourish, because it will look different from the full class, but it will also look different across each individual kid on the caseload.”

Arinze found it rewarding to learn “the small things that make a huge difference in the kids’ learning, their confidence, and their experience of school itself.” Having a disability of any type, he reflected, “can get really discouraging. You can get down on yourself. So I was really glad that I was able to encourage them through the process.”

The mentorship aspect is also one that drew Nikki to become involved with KEEN. Throughout high school and her undergraduate studies, she had volunteered working with the elderly at a nursing home. Eventually, she made the transition to working with children, “doing equine and hippotherapy – working with kids and horses.” She saw how their interactions helped make kids’ days better, and shaped and improved their overall well-being. 

In terms of their involvement with KEEN and its influence on their eventual choice of specialty, Nikki said that working with KEEN “pushed me towards pediatrics. I’m between peds and other fields, but I think KEEN really solidified my choice of peds as one of my top contenders.” Arinze is thinking about family medicine: “That would incorporate working with kids and adults. Just because I definitely feel drawn to the mentorship aspect, being a positive adult influence is important.” 

While some other KEEN coaches are interested in pediatrics, Nikki says, the activity is also a draw for students because it carves time out of the week to “do sports, do something completely different than medicine, but still being able to use your skills and build your people skills.”

In terms of what KEEN’s co-presidents are looking for in potential coaches, Arinze emphasizes, “Just being interested in helping the kids is what we need. Being interested and enthusiastic is what we’re looking for at KEEN.” Nikki adds, “All coach volunteers are provided training prior to their first session. We are open to everyone – be self-motivated and willing to help.”

Published on
On the White House lawn, a child high fives an adult at the 2024 White House Easter Egg roll.
Representatives from GW's OT, PT and Speech Language Hearing programs help make the 2024 White House Easter Egg Roll sensory friendly and accessible to all participants.

Let’s spend some time learning about occupational therapy, sensory friendly spaces, and learning about a recent initiative of GW’s Occupational Therapy program.

Occupational therapy is an allied health profession which helps people develop, recover, or maintain the occupations (or activities) of their everyday lives. Occupational therapists are found in a wide variety of settings, from hospitals to nursing homes, schools to mental health centers. OTs frequently work on an interprofessional basis, collaborating with doctors, psychologists, social workers and special education teachers to help their clients carry out their activities of daily living and increase their participation in activities. (Stein & Reed, 2020)

Occupational therapy as a discipline was officially recognized in the United States with the establishment of the National Society for the Promotion of Occupational Therapy in 1917. That organization is known today as the American Occupational Therapy Association (AOTA). The field of occupational therapy has transformed considerably since its inception just over a century ago, and its goal of achieving occupational justice has been made more concrete. AOTA included occupational justice in its Occupational Therapy Practice Framework beginning in 2014. “The framework states that occupational justice is a part of the domain of occupational therapy because environmental forces impact participation in occupation, the provision of occupational therapy services, and patient health outcomes.” (Bailliard et al., 2020) At GW, students within the OT program are trained to engage with the principles of occupational justice to support client empowerment.

One area in which GW’s OT program is engaged is the successful adaptation of environments and programs to be more sensory friendly. Program director Dr. Roger Ideishi explains, “‘Sensory friendly’ refers to creating a supportive and welcoming environment for children with disabilities. The term sensory friendly has been historically used for community programs aimed to support children with neurodevelopmental disabilities. Adaptations are made to the environment such as lessening the sound and lights to accommodate children who have sensory sensitivities.”

Sensory friendly adaptations increase opportunities for children with all types of disabilities to encounter a friendly and accepting environment. According to Ideishi, “a welcoming, non-judgmental environment makes a huge difference to children with disabilities and their families who constantly face discrimination and ridicule in public.” Ideishi has been at the forefront of the sensory friendly movement for two decades, and has advised cultural institutions including the Kennedy Center for the Performing Arts and the Smithsonian Institution.

The White House held its first sensory friendly Easter Egg Roll in 2023. In 2023, over 100 GW students and faculty from Occupational Therapy, Physical Therapy, and Speech, Language and Hearing supported the White House's efforts. This year again, over 100 OT, PT, and Speech students and faculty supported the accessibility and inclusion initiatives at the White House Easter Egg Roll. GW students and faculty contributed to the event in a number of ways, according to Dr. Ann Henshaw, Assistant Professor in the OT Program. GW affiliates assisted with sensory friendly activities; ensured wheelchairs were accessible to those in need; and, because the White House lawn is sloped, which is challenging for those with mobility deficits, they made recommendations around the location of events. Additionally, GW volunteers provided adaptive devices to allow participants with limited mobility to push the egg down the track. These devices were reachers and long handled sponges that were decorated as Peeps®, or hockey sticks with adaptive grips.

Two people stand in front of the White House with aprons that say White House Easter Egg Roll.
Two adults standing on a lawn looking on as children roll Easter eggs. One adult is applauding.
Two adults standing on a lawn looking during the 2024 White House Easter Egg Roll. One adult is applauding.
An adult looks on as a child rolls an Easter egg on the White House lawn.

For those interested in learning more about OT at GW, a student-led information session on the entry-level OTD program will be held on April 17.

References

Bailliard, A. L., Dallman, A. R., Carroll, A., Lee, B. D., & Szendrey, S. (2020). Doing Occupational Justice: A Central Dimension of Everyday Occupational Therapy Practice. Canadian journal of occupational therapy. Revue canadienne d'ergothérapie, 87(2), 144–152. https://doi.org/10.1177/0008417419898930

Stein, F., & Reed, K. L. (2020). Occupational therapy : A guide for prospective students, consumers and advocates. SLACK, Incorporated.

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