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Big problems, big science, better health
The numbers are sobering. A third of the world's 40 million people with HIV/AIDS are also infected with TB. Of those, 90% die within months of contracting TB if they are not treated properly. Finding effective treatments is growing more difficult as various strains of TB are becoming more widespread and more virulent, especially in sub-Saharan Africa and India.
     Researchers at Emory and in India are determined to find a solution. Emory's Global Health Institute, the Emory Vaccine Center, and the International Center for Genetic Engineering and Biotechnology (ICGEB) have created the Center for Global Vaccines, based at the ICGEB in New Delhi.
     "Our initial studies will focus on the basic aspects of HIV/TB co-infection," says Rafi Ahmed, director of the Emory Vaccine Center. "In fact, the World Health Organization has just classified HIV/TB as a unique disease."
     India now has the largest number of HIV-infected people in the world, and 5.7 million of them have HIV/TB. Although a vaccine exists to prevent TB, it can be used only in limited circumstances. Thus, Emory and the ICGEB will focus on developing a therapeutic vaccine that can be used more widely—one that can be given to people already infected with HIV/TB. "We want to tackle very big problems, and this is a very big problem," says Ahmed. "This is very big science."
     "Big" also describes the new Global Health Institute, a multidisciplinary umbrella for Emory faculty, students, and alumni who want to solve the world's critical health problems. Led by Jeffrey Koplan, vice president for academic health affairs and former CDC director, the institute builds on Emory's history of global partnerships in medicine, public health, and other disciplines.
     The institute represents a major commitment by the university. Its $110 million budget includes $55 million from the university and $55 million from sources in and outside of Emory.
     Among the institute's new programs is the Republic of South Africa Drug Discovery Training Program to provide young African scientists with experience in translating research into health care solutions. Emory chemist Dennis Liotta, co-inventor of several successful anti-HIV/AIDS drugs, leads the program. Reynaldo Martorell, public health professor, directs the Partners in Global Health Program, an expanded collaboration with the National Institute of Public Health in Mexico.
     Other global health projects will focus on public health research and training in developing nations, health care workforce shortages, international bioethics, and the health impact of global migration.
A separate program affiliated with the institute is the International Association of National Public Health Institutes, an alliance of CDC-like agencies dedicated to optimizing global health by improving public health infrastructure around the world. Koplan serves as association president.

Learn more about the Global Health Institute.

The stress of battle
Despite ongoing media coverage, it's still hard to fathom the mental toll of the Iraq war on U.S. veterans. In a study funded by the Department of Veterans Affairs, Emory researchers are testing a new method for treating post-traumatic stress disorder that may help soldiers deal with troubling memories before depression, memory loss, drug abuse, and other health problems occur.
     The treatment, mindful based stress reduction (MBSR), is an eight-week program that teaches participants how to "intentionally pay attention to present-moment experiences" such as physical sensations or perceptions without evaluating those experiences. During each session, participants are introduced to techniques such as yoga and meditation. MBSR uses "teachers" and "students" instead of "patients" and "therapists."
     "We know that medications sometimes have unpleasant side effects or don't work at all," says lead investigator J. Douglas Bremner, director of mental health research at the Atlanta VA Medical Center. "MBSR is an intervention that not only teaches a soldier how to cope with painful memories from battle, but can also be beneficial as a coping skill for life in general."

40 life-changing minutes
The 40 minutes the doctor spent with Amy changed her life. It appeared to be a simple case: She needed the stitches in her arm removed. But only when Sheryl Heron questioned her about why she put her hand through a window did the truth come out. Amy was a victim of intimate partner violence.
     Heron gave her information on resources to help her should she decide to leave her abuser—often the time when abuse is especially violent—and then Amy was on her way. Only a year later did Heron know the extent of her influence. Amy emailed her that she had left the relationship, moved to Florida, and re-enrolled in college.
     Gone are the days of patch ‘em up, move ‘em out. Emergency room doctors and residents now know if they look beyond the injury or complaint and find domestic violence, addressing the root cause will help prevent future visits and thus ease the caseload in the ER. "If you take the time on the front end to manage what is bringing them in on the back end, they don't come back," says Heron. "In the end, you have to consider we are talking about human beings and their lives."
     However, most medical schools don't have dedicated curricula on domestic violence, be it children, intimate partner, or elderly. As the new assistant dean for medical education and student affairs at Grady Hospital, Heron decided a family violence workshop was in order for M3 students. The daylong workshop last fall featured a number of experts in and outside of Emory, including a staff member of the Grady Rape Crisis Center; former juvenile court judge Robin Nash, now director of the Barton Child Law and Policy Clinic in Emory's School of Law; and a survivor of sexual abuse. All provided insight on their experiences.
     "Medicine teaches us to fix things," says Heron. "Laceration? Suture it. Infection? Give an antibiotic. Domestic violence doesn't have a magic pill, a magic solution. I try to teach physicians it takes six or seven times for a woman to tell about violence. We need to consider how we impact people's lives."

Progesterone and traumatic brain injury
Progesterone may be key to reducing death and disability in patients with traumatic brain injury (TBI). It also appears to be safe. Emory researchers based these findings on the first clinical study of its type in the world.
     Prior to this study, progesterone treatment for TBI was studied in laboratory animals for as long as 15 years. The researchers conducting the clinical trial based their work on the foundation laid by Emory neurobiologist Donald Stein, who discovered the neuroprotective effects of progesterone in the laboratory.
     Patients enrolled in the double-blind study at Grady Hospital had to reach the hospital within 11 hours of injury. Patients in the study had a blunt traumatic injury, typically caused by a car accident, motorcycle crash, or fall. Enrolled patients had an initial Glasgow coma scale (GCS) score ranging from 4 to 12. A score of 4 to 8 signals severe TBI, usually accompanied by coma, while a score of 8 to 12 signals moderate TBI. Four out of every five patients enrolled received intravenous progesterone, and one of every five patients received a placebo. Thirty days after injury, researchers used objective rating scales to assess each patient's neurologic function and level of disability.
     "We found encouraging evidence that progesterone is safe in the setting of TBI, with no evidence of side effects or serious harmful events," says David Wright, the emergency medicine physician who led the study. "In addition, we found a 50% reduction in the rate of death in the progesterone-treated group. Furthermore, we found a significant improvement in the functional outcome and level of disability among patients with moderate brain injury."
     Wright's team found no major differences in the rate of adverse effects among patients who received progesterone compared with those who received placebo. About 30% of patients given placebo died within 30 days of injury, compared with only 13% of those given progesterone. Most patients who died had severe TBI. Because more severe TBI patients in the progesterone group survived, it was not surprising that they had a higher average level of disability at 30 days than survivors in the placebo group.
     Progesterone is a promising treatment for TBI because it is inexpensive, widely available, and has a long track record of safe use in humans to treat other diseases. Wright's team is planning a large, multicenter Phase III trial to test the effectiveness of progesterone in 1,000 patients with TBI. In the future, they plan to study the effects of progesterone treatment in animal models of blast-related injury, a major cause of death among combat personnel. They also hope to study the use of progesterone to treat children with brain injuries.

View a video about the progesterone study

New synergy in cancer
Brian Leyland-Jones is the new associate vice president and director of the Winship Cancer Institute. Leyland-Jones, who specializes in breast cancer, is known internationally for developing individualized therapies and novel clinical trials. He comes to Emory from McGill University in Montreal, where he served as the Minda de Gunzberg Chair in oncology, professor of medicine, and director of McGill's Comprehensive Cancer Center.
     At McGill, he led the development of a clinical trials operation that integrated research with five clinical trial cooperative groups and more than 40 pharmaceutical companies. His research interests include pharmacodynamics, pharmacokinetics, and pharmacogenetics in clinical trials; translation of preclinical models into the clinic; biomarker endpoints in Phase I/II clinical trials; and screening and mechanistic studies of novel targeted and chemotherapeutic anti-cancer agents.

Tracking brain tumor treatment
A newly identified novel biomarker potentially could help physicians better determine when a brain tumor spreads or recurs after treatment, reports Winship Cancer Institute researcher Erwin Van Meir.
     The biomarker, a protein known as "soluble attractin," is normally absent in the central nervous system (CNS) and undetectable in cerebral spinal fluid (CSF) unless malignant astrocytomas—the most common form of intracranial tumors—are present in the CNS. The CSF can be sampled for analysis of proteins secreted by CNS tumors.
     This newfound ability to identify biomarkers for malignant astrocytomas means that physicians will have a minimally invasive method to track the success of treatments. These biomarkers, singly or in combination, will provide a fingerprint of the disease and in the future better define the disease, predict what type of treatment to use, and allow doctors to monitor how well the tumor responds to treatment.
     "Using proteomic analysis of the CNS of patients with brain tumors, we have identified for the first time that attractin levels are elevated in patients with high-grade astrocytoma," says Van Meir, who led the study in collaboration with the Dana Farber Cancer Institute. "Because few noninvasive methods are available for monitoring CNS malignancies, there is an urgent need to find reliable indicators."

Michael Johns,
who has led the Woodruff Health Sciences Center for 11 years, will become chancellor of Emory this fall. In addition to advising the president and the board of trustees, Johns will represent the university on health care policy and building partnerships, such as Emory's research collaboration with Georgia Tech.

For the first time,
two Emory health administrators hold top leadership positions with the Association of American Medical Colleges (AAMC). Michael Johns, CEO of the Woodruff Health Sciences Center, is immediate past chair of the Council of Teaching Hospitals and Health Systems. Thomas Lawley, dean of the School of Medicine, chairs the AAMC's Council of Deans.

Physicians with
Emory Healthcare provided $70.7 million in charity care in 2005–2006, a 7% increase over the previous year. At publicly funded Grady Hospital, Emory provided $24.7 million in uncompensated care, up $2.7 million from the previous year. About 85% of the physicians at Grady are Emory medical faculty.

Built from scratch

Emory University Hospital opened a neuro critical care unit that centralizes most critical medical services for patients suffering from severe neurologic trauma—including severe brain injury, strokes, and aneurysms. Just as important,
the unit's design incorporates the importance of family in the patient's healing.
     One of the largest in the United States and one of only a few of its type in the Southeast, the unit is staffed by
neurointensivists, critical care nurses, nurse practitioners, and pharmacists. All played a role in creating the unit, along with social workers, former patients, and family members.
     "Plans for the neuro ICU incorporate core principles of evidence-based, patient-centered design—a holistic approach that focuses on the patient's physical environment as a tool for healing," says Owen Samuels (shown left), director of neuroscience critical care. The unit's design takes into account factors such as the effects of natural light, noise reduction, and increasing staff efficiencies.
     Also key is sufficient space to perform intricate procedures at the bedside and thus reduce transporting fragile patients across the hospital. A high-resolution CT machine is housed in the unit, allowing patients to be scanned upon admission and during their stay. "This unit," says Emory Healthcare president and CEO John Fox, "has raised the proverbial ‘bar' and set the standard, locally and nationally, for critical care."

Learn more the neuro icu.

High marks from NIH
The School of Medicine now ranks 18th among all U.S. medical schools in total research grants awarded by NIH for 2006. The school has climbed steadily in research funding, having ranked 31st in 1996.

A new formula for matching kidneys
Many patients on the national waiting list for kidney transplants have only a small chance of receiving a new organ, no matter how long they wait. Because of previous transplants, pregnancies, or blood transfusions, these patients have developed antibodies that make it difficult to match them with donor organs.
    Emory researchers have developed the Emory Algorithm, a decision process that may give new hope to these highly sensitized patients. The algorithm may even change the way kidneys from deceased donors are allocated in the United States.
     Sensitized patients have developed antibodies against human leukocyte antigens (HLAs), which play an important role in the body's immune response to foreign tissue. While these patients represent one-third of the national waiting list for kidney transplant patients (and 50% in Georgia), they receive about 15% of deceased-donor kidney transplants each year.
     The United Network for Organ Sharing coordinates the nation's transplant system through a point system primarily based on wait time, sensitization, and HLA matching. When a "perfect match" occurs, the kidney is offered to the person at the top of the national list. If there are no perfect matches, the kidney becomes available to transplant centers in the region from which it came.
     The Emory Algorithm follows these guidelines but also allows a transplant center to predict which sensitized patients on the list will be compatible with any given donor. A five-year study, published in the American Journal of Transplantation, found the algorithm raised the kidney transplant rate from 15% to 25% by accurately predicting which sensitized patients would be compatible with the donor kidney. In the study, the survival rate for sensitized patients was almost identical to that of unsensitized recipients—66% versus 70%.
     Immunologists Robert Bray and Howard Gebel, along with transplant surgeons Christian Larsen and Thomas Pearson, developed the algorithm. They used a relatively new technology of single-antigen bead assays. This method analyzes HLA antibodies more specifically by identifying a single antibody at a time versus general groups of antibodies. The algorithm allows immunologists to inform transplant surgeons with a high degree of confidence whether a kidney from a deceased donor is a compatible match with a recipient.



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