Nguyen and his Italian colleagues prepare for robotic surgery.

“This is an obvious upside for patients, but for hospitals too,” says Hiep Nguyen, MD, director of Boston Children’s Hospitals’ Robotic Surgery Research and Training Program. “If a patient leaves the hospital in one day rather than in four, then doctors can help more patients and reduce their wait time for treatment.”

Robotic surgery has not yet been embraced on a global scale. In Europe, for example, doctors have hesitated to practice it in children. But with Nguyen as their mentor, that reluctance may soon change.

Nguyen

“Part of our mission is to help develop centers of excellence all over the world,” says Nguyen.

Since proper training has historically been a stumbling block for starting a successful robotic surgery program, Nguyen takes a collaborative approach that gradually transfers control over to the Italian physicians in a sustainable way.

“Since these doctors had never performed robotic surgery on a child, they were a little hesitant at first and had a lot of concerns,” he says. “But they trusted our team’s experience.”

De Gennaro and Torino first came to Boston Children’s to watch Nguyen and anesthesiologist Constance Houck, MD, perform a pyeloplasty (which repairs a blockage in the kidneys) and then a ureteral reimplant (which changes the way a ureter connects with the bladder). “Our Italian colleagues watched me use the robot in a real case, and then they learned how to put the robot on and safely operate it themselves,” explains Nguyen.

Having learned the equipment under Nguyen’s guidance, both teams headed to Rome, where Nguyen could accompany De Gennaro and Torino as they performed not only their first pediatric robotic ureteral reimplant, but the first in Europe’s history.

“It’s not just about these doctors coming over to the U.S. to observe,” says Nguyen. “We need to make sure they’re comfortable and safe performing the surgery in their own environment, so they can be independently successful. On their turf, I’m just present to offer suggestions, observations and coaching.”

Nguyen and Houck successfully coached De Gennaro and Torino through the two procedures without encountering any problems. “By demonstrating how our team works in Boston, our Italian colleagues were able to experience how a team approach is essential in the success of robotic surgery in the pediatric population,” says Nguyen. “By the end of the two cases, we were rewarded with great smiles and cheers and shared a wonderful dinner.”

De Gennaro and Torino went on to perform successful pyleoplasties as well, a promising start to Bambino Gesù’s budding pediatric robotic surgery program. Before passing the baton, Nguyen’s final step was to check in on the patients’ recovery, and he found that they were all healing well.

Though the team at Bambino Gesù benefitted from Boston Children’s time and expertise, Nguyen says that his own team gained just as much from the partnership.

“We can mentor them and help them see when it’s appropriate for them to use robotic surgery, but during that exchange, they helped us as well. They inspired us to learn and develop new techniques, procedures and ideas.” Currently, the teams are talking about developing a new method of intravesical bladder neck surgery (which improves continence). They hope to work on it in animal models, and then in patients.

In July, Nguyen and his team will head to Rambam Hospital, in Haifa, Israel, to help a surgical team there do the same thing.

“As usual, our goal is to disseminate our expertise and technology and make it available around the world,” he says. “We’re trying to benefit children everywhere.”

What you like on Facebook might say something about how obese your neighborhood is. (Dry Martini/Wikimedia Commons)

But if a researcher were to look across Boston at what people who are like me like—and post and share—on Facebook, a snapshot of data could tell them something else: roughly how obese metro Boston is.

That’s essentially what John Brownstein, PhD, and Rumi Chunara, PhD, concluded in a study recently published in the journal PLoS ONE. In it, they combined Facebook interest data—an aggregate of what people “like,” post on their timeline or share on others’ timelines—with health survey data to geographically correlate activity or television interests with obesity rates. 

The take-home message from their study was that as the proportion of Facebook users in a given geographic area with an interest in television-related topics increased, so too did that area’s rate of obesity. On the flip side, as the proportion of users within an area with health & wellness- or outdoor activity-related interests grew, the obesity rate shrank.

The results, which held true for both national obesity estimates and those for just New York City, suggest that social networks like Facebook could hold great power for helping map data about obesity (and other chronic diseases) down to a fine level of geographic detail. And given Facebook’s capability to target advertisements geographically, the study may also open the door to new ways of delivering information for combatting obesity.

The research also adds to the growing evidence that all manner of digital data—Facebook, Twitter, Google searches and more—hold great power for augmenting traditional methods of chronic and communicable disease surveillance.

“Online social networks like Facebook represent a new high-value, low-cost data stream for looking at health at a population level,” Brownstein, who runs the Computational Epidemiology Group within CHIP, said in a press release. “The tight correlation between Facebook users’ interests and obesity data suggest that this kind of social network analysis could help generate real-time estimates of obesity levels in an area, help target public health campaigns that would promote healthy behavior change and assess the success of those campaigns.”

So what does your Facebook page say about your neighborhood?

A pair of maps correlating Facebook TV interests (right) with obesity rates (left) in New York City neighborhoods. Red means higher obesity rate or higher proportion of Facebook users with TV interests, and green the opposite. (PLoS ONE, doi:10.1371/journal.pone.0061373.g004)

Newborns like this child have a high risk of hypothermia, even in warm climates. An innovative warming pad could be one potential fix. (Courtesy of Anne Hansen)

Even in places with warm climates such as sub-Saharan Africa and South Asia, babies can quickly lose heat, and how hypothermia in newborns is treated reveals a dramatic contrast with the developed world.

The playing field may soon get more level, thanks to a device Boston Children’s Hospital’s Anne Hansen, MD, MPH, has been developing with collaborators at Lawrence Berkeley National Laboratory’s Institute for Globally Transformative Technology (LIGTT) since visiting Rwanda in 2010. That device is a warming pad that can keep a newborn warm for hours at a time with no electricity, and which can be used in a home, clinic, hospital or transport setting.

Heat source

A number of factors can make newborns in resource-limited environments susceptible to hypothermia. Some are clinical, such as delivery rooms that are not adequately heated, and some are procedural, such as not drying and wrapping the baby immediately after birth.

Others are cultural, including practices like oil massage, which families and caregivers believe improves the health of a baby’s skin but which can actually weaken it.

Biology plays an important role as well. Underweight and premature babies are especially susceptible to hypothermia, in part because they have less brown fat, a form of fat the body metabolizes to produce heat.

Nature provides newborns with a great source of warmth: the mother. Unfortunately, skin-to-skin contact with the mother, called “kangaroo care,” may be taboo in the culture, or the mother may fall ill or die after delivery, or she may simply have to return immediately to work.

In the U.S., incubators can effectively substitute for a mother’s warmth. But they are not necessarily a solution for developing countries. “Incubators are really expensive, require electricity, are hard to clean and complicated to use,” says Hansen, who is the medical director of Boston Children’s Neonatal Intensive Care Unit. “I thought there must be a simpler solution, a non-electric warmer based on the concept of a heating pad. Something inexpensive to make, simple to use and easy to clean.”

‘Baby burrito’

A prototype of the warming pad. The white color indicates that the pad's "phase-change" material is in its solid state. (Courtesy of Anne Hansen)

The result of Hansen and her LIGTT collaborators’ efforts may be the first to fit those criteria.

The warming pad is made up of two waxes that form a “phase-change” material—something that is hard at cool temperatures and becomes soft and pliable when heated, and that can retain heat for hours. Its plastic coating can easily be washed with soapy water, making it readily reusable.

To warm the pad, Hansen has turned to something all human cultures can access: hot water. Parents or caregivers can roll up the pad, roughly the size of a manila folder, and put it in a thermos with hot water. Hansen is working to add a color indicator to the pad, so that it’s visually clear when it’s warm enough, but not too warm.

When the temperature is right, a caregiver can put the baby on the unrolled pad as a flat surface. Or, if the baby is preterm, low birth weight, sick or already hypothermic, the pad can be wrapped around the baby, “like a baby burrito,” says Hansen.

A prototype of the pad has already been developed and shown to health care providers in Rwanda. Hansen is working with the Rwandan Ministry of Health, Partners in Health and LIGGT to study its safety and efficacy.

Although it’s not ready for mass production, Hansen hopes to design the infant warmer so it could be manufactured locally, allowing Rwandans to produce and sell the pads on their own terms. And if she can keep the price point low enough, hospitals, clinics and midwives could potentially purchase multiple pads, warming one up as another cools and keeping a newborn warm for days on end.

As the world struggles to meet the Millennium Development Goals, including reducing child mortality by two-thirds by 2015, the infant warmer could provide a simple, safe and inexpensive solution to hypothermia, whether for midwives delivering babies at home, for care providers in resource-strapped clinics, or during transport to a higher level of care.

“It’s 2013,” says Hansen. “Babies should not be dying of hypothermia. This has to be a fixable problem.”

A Queens College gymnasium served as an evacuation center after Hurricane Sandy.

Shannon Manzi, PharmD, chief pharmacist for the Massachusetts–1 Disaster Medical Assistance Team, directs the Clinical Pharmacogenomics Service at Boston Children’s Hospital and is team leader for Emergency and Combined Services in the hospital’s Department of Pharmacy. With MA-1 DMAT, she has deployed to Louisiana after Hurricane Katrina in 2005 and Hurricane Gustav in 2008 and to Haiti after the 2010 earthquake.

As I watch the Arizona-1 and Texas-3 Disaster Medical Assistance Teams (DMATs) respond to the tornado in Moore, Okla., I know they will serve with great skill and caring. But I wish the Massachusetts-1 DMAT was the team on call this month. Although we’re unlikely to be deployed for this disaster, our hearts are with the people of Moore and all our fellow responders.

Manzi

Thirteen years ago, I was asked to join the MA-1 DMAT as the pediatric pharmacist. It’s been one of the most grueling and difficult commitments of my life, but I’ve never looked back. I love it.

I have slept for weeks on the ground, not being able to shower or eat anything other than MREs (meals-ready-to-eat)—all while working 18- to 20-hour days. However, I hold no illusions that what we do is heroic. I can go home in two to three weeks to an intact house and family. This is not the case for the people we serve.

When you serve on a medical disaster team, you often are responsible for creating a new, temporary health care infrastructure. Being first on the ground means that there is nothing established before you arrive. Everything from patient care areas to a clean water supply must be built and created from what is available and the small amount of equipment that travels with us.

Creating a disaster field hospital requires years of pre-planning and training. Logistics are paramount: personnel movement, shift rotations, resupply, trash removal, medical waste disposal, food for the patients, medication and oxygen, communications with other responders and many, many other duties.

This was very evident during our deployment to Queens, N.Y., for superstorm Sandy last October. We had the complex task of integrating dozens of patients with behavioral health needs with a high-acuity nursing-home population in a college gymnasium (turned into a medical shelter). Simply identifying the patients took days, let alone ensuring that they were taking the correct medications and therapies for their conditions. Many were delusional or had signs of advanced dementia and could not provide reliable histories. Effectively and safely caring for all these patients required enormous cooperation between the local hospital supporting the shelter, the college, the force protection entity, the federal and state governments and non-governmental relief organizations such as the Red Cross.

During the Boston Marathon response in April, my disaster training was again put to the test here at home. Along with other members of MA-1 DMAT, I was staffing a medical tent along the route, but I was not at the finish line. When I received the page from the emergency department, I diverted immediately to Boston Children’s Hospital and organized my staff to ensure there was a pharmacist on every team, and that we had enough code carts and medications for every patient we received or might receive. My years of training in mass casualty event management were now being tested. I just never imagined it would be on my home turf.

In any disaster situation, we must be flexible and adapt to the needs of the community. At no time can we become a draw on already scarce resources. This often happens with “self-deployers,” generally good people who may or may not have a medical background and show up to help at the disaster area—with no food, no shelter, no extra fuel, no safety plan. They become liabilities.

We saw this particularly during Hurricane Katrina and after the devastating earthquake in Haiti. Well-meaning health care professionals have become ill and, in some cases, have been physically assaulted and hurt when self-deploying to an area with no plan or disaster training. As I watch the aftermath of the Oklahoma tornado disaster I worry again about the uninvited self-deployers.

Don’t go to a disaster area with no means of self-sustenance. If you desire to help, get trained. Join a reputable response organization that has a plan for food, shelter and security for the responders. In the meantime, send a donation to a trusted organization. In the end, it will do more good.

Ed note: Learn more on our sister blog, Thriving, about how to make a disaster plan of your own.

In the developing world, health care providers often don’t have access to diagnostic technologies like the automated lab tests taken for granted in the resource-rich United States. Specimens often have to be sent to a distant central lab, and it can be weeks before an answer wends its way back.

That’s a tough situation when you’re, say, trying to assess whether a patient is having liver toxicity from a drug, such as drugs used to treat tuberculosis (TB) and HIV. By the time the results come back and indicate you need to stop or switch medications, the patient may be long gone, unable to travel back to the clinic.

For the past four years, Nira Pollock, MD, PhD, associate medical director of the Infectious Diseases Diagnostics Lab at Boston Children’s Hospital, has been working with Diagnostics For All (DFA), a nonprofit organization based in Cambridge, Mass., to develop and test a low-cost diagnostic device that works on the spot, involving just a finger-stick and a square of paper. The technology is all in the paper square—using wax printing and microfluidics techniques initially developed by DFA’s founder, George Whitesides, PhD, of Harvard University.

The result is a multilayered paper device that splits a small blood sample into streams, allowing multiple tests to be done at once without the need for multiple finger-sticks—at a cost of pennies per test.

“The wax creates channels that steer the fluid to certain places as it wicks through the paper,” explains Pollock, also a member of the Division of Infectious Diseases at Beth Israel Deaconess Medical Center (BIDMC). “You put a drop of blood on the center of the device, and a filter separates blood cells from the plasma, which continues down to the layers of paper underneath and wicks to different detection zones. You can spot different reagents in different zones on the paper to perform multiplexed assays.”

Readouts take approximately 15 minutes: the paper in the detection zones changes color to indicate results, which can be matched by eye with a range of expected colors on a chart. Or, through telemedicine, photos of the device (i.e., the paper) can potentially be sent to an expert reader.

DFA and Pollock’s test, evaluating liver function, may emerge as the first clinical diagnostic of this kind. With eradication of TB and HIV as a global priority from the World Health Organization, liver toxicity from regimens used to treat these diseases is important to detect and address. The paper test measures levels of enzymes like AST and ALT, which are good indicators of liver damage.

In a study published in Science Translational Medicine last fall, funded in part by the Boston-based Center for Integration of Medicine and Innovative Technology (CIMIT), Pollock and her DFA colleagues tested the device using 223 blood samples obtained by venipuncture and 10 finger-stick samples from healthy volunteers. The test allowed visual measurements of AST and ALT, in both whole blood and serum, that could be placed into three standard readout categories (AST or ALT less than three times the upper limit of normal (ULN), three to five times the ULN and more than five times the ULN)—with more than 90 percent accuracy.

In a pilot finger-stick study last summer in Vietnam, funded by PATH (Seattle, Wash.), Pollock and collaborators trained nurses to perform the test and interpret the color changes on the devices. In this collaboration between PATH, BIDMC, DFA, the Hospital for Tropical Diseases in Vietnam and the Harvard Medical School AIDS Initiative in Vietnam, the team looked at factors like ease of interpretation, consistency of results and lot-to-lot variability.

With those findings, they’re tweaking and optimizing the paper test and planning a follow-up finger-stick study to take place this summer in collaboration with colleagues from the BIDMC Liver Center and Infectious Diseases clinics, supported in part by another CIMIT grant. The team will also test transmitting pictures of the devices (taken by cellphone cameras) to a remote reader.

“In the future, we could potentially even develop tests like this for home use, like people do glucose monitoring now,” says Pollock.

A big question in point-of-care (POC) diagnostics, she notes, is “how accurate does the test have to be in order to be useful?” Even if the paper test doesn’t perform as well as the gold standard, it could still have a big impact on global health; in equivocal cases, venipuncture samples could still be sent for automated testing.

“People are starting to argue that all the benefits of point-of-care use might ultimately make low-cost POC tests a better choice,” Pollock says.

Babies with newborn jaundice need phototherapy. In the developed world that's easy; in the developing world, not so much. (Bruce R. Wahl/Beth Israel Deaconess Medical Center)

Note that I said “developed world.” The story in the developing world is quite different. Sometimes the nearest hospital with phototherapy equipment is hours’ or days’ travel away. Even though it’s simple, phototherapy is power intensive; no power, no treatment.

And untreated jaundice can have devastating consequences. The yellow pigment, called bilirubin, can accumulate in the brain and cause permanent brain damage or death.

The best solution for regions with few resources would have to be small and portable, run on batteries or other off-grid power sources, cost little, but still be safe and deliver the right wavelength and intensity of light. This is where Donna Brezinski, MD, wants to make a difference. And the Bili-Hut is her answer.

“There are 133 million babies born in the world every year, or about four every second,” says Brezinski, an attending neonatologist with Boston Children’s Hospital’s Division of Newborn Medicine. “Roughly 8 percent are born with neonatal jaundice severe enough to need treatment.”

However, she continues, “about 70 percent of India, for example, doesn’t have access to the electrical grid, which right now means that children in these areas just can’t access phototherapy. Even the areas that have hospitals with phototherapy equipment often have devices that either don’t deliver therapeutic light doses or are in disrepair. Which is why between 15 and 30 percent of neonatal deaths in rural India are either directly attributable or associated with jaundice.”

Which brings us to the Bili-Hut. Designed at Brezinski’s dining room table, it’s basically a battery powered pop-up tent lined with LEDs. Collapsible and highly portable—it can fit into a shipping tube—it’s still big enough for a newborn to fit inside comfortably and completely. The LEDs that line its inner surface are arranged in a radial array, and can shine the right kind of blue light at the right intensity over a baby’s entire body.

All the parts are off-the-shelf. The interior lining, for example, is made from a material used for hydroponic gardening. And it can run off 12-volt power—like the power from a car battery—for one month but can also be plugged into a wall socket if grid or solar power is available.

“We want to make this appropriate for use in developing countries,” Brezinski explains. “It can work completely off the grid. And we’re trying to keep fabrication simple, so that local textile mills or other factories could make them. That will keep costs low, add to the local economy and make it easy for clinics nearby to acquire them.

A prototype of the Bili-Hut. The whole thing can be collapsed and fit into a shipping tube. (Donna Brezinski)

“Our most recent set of prototypes,” she notes, “was built by a company that makes roofs for convertible cars.”

Brezinski has launched a company, Little Sparrows Technologies, to develop and commercialize the Bili-Hut, which took top honors at last week’s M2D2 New Venture Competition, an innovation contest run out of the University of Massachusetts at Lowell. She’s working with Massachusetts General Hospital and the Lata Medical Research Foundation, an Indian non-profit, to raise funds and field test the system in India, but she could foresee using the Bili-Hut in any area with high infant mortality related to jaundice.

Brezinski sees the problem of neonatal jaundice in developing countries as a combination of “clinical pull”—a medical need crying out for a solution—and ethical calling.  “From both a clinician’s and an inventor’s point of view, if you’re interested in developing a need-based solution that’s both low cost and highly effective, there’s nothing more satisfying than neonatal jaundice. And because neonatal jaundice is nearly 100 percent curable with phototherapy, it’s essentially unethical not to solve this problem.”

If we could immunize infants at birth, far more could be protected from infections.(DFID-UK Dept for International Development)

Right now, immunizations against most infections begin at 2 months of age. But that leaves newborns at risk for infections like rotavirus, whooping cough and pneumococcus during a highly vulnerable time.

In resource-poor countries, this is a serious problem: Many children see a health care provider only at birth, so may miss their chance to be protected. Worldwide, each year, more than 2 million infants under 6 months old die from infections, especially pneumonia. If we could immunize infants at birth, it would be a huge win for global health.

Unfortunately, though, newborns don’t respond to most vaccines. Their immune systems are too immature—which is why few vaccines for newborns exist.

But back in 2006, a lab led by Ofer Levy, MD, PhD, of the Division of Infectious Diseases at Boston Children’s Hospital, demonstrated that while a newborn’s immune response is weak to nonexistent, one piece rallies robustly: a receptor on white blood cells known as Toll-like receptor 8 (TLR 8). It’s one of 10 known TLRs that are part of our innate immune response—our first, rapid defense against infections.

Also in 2006, as it happens, VentiRx Pharmaceuticals was founded. The Seattle-based company focuses on the development of small-molecule compounds that specifically target TLR8. Rob Hershberg, MD, PhD, the company’s founder and CEO, saw Levy’s publications and recognized a scientist who appreciated TLR8’s appeal. He flew to Boston and began to collaborate with Levy’s lab, providing a panel of synthetic TLR8 stimulators known as benzazepines, already in clinical trials for several cancers with the aim of enhancing anti-tumor immune responses.

“I told him that our compounds would be better than anything he’s worked on,” Hershberg recalls.

Indeed, one of them, VTX-294, proved more potent than anything ever tested. In a study reported last week in the online open-access journal PLoS ONE, it induced an exuberant production of cytokines (chemicals that rally the immune response) in newborns’ white blood cells, at levels at least 10-fold that of the best activator of TLR8 known previously.

“VTX-294 not only produced an equal cytokine response in newborns, it was sometimes actually more effective in newborns than adults,” Levy says.

The compound also triggered production of so-called co-stimulatory molecules that enhance immune responses. Better still, even very small amounts of VTX-294 strongly activated antigen-presenting cells, specialized white blood cells that engulf pathogens and display bits of them to the long-term-memory part of the immune system, creating a memory of the invader. Activating these cells is critical for a vaccine’s effectiveness.

“This one receptor seems to lead to more adult-like responses—immediate, short-term responses that are more appropriate for fighting infections,” says David Dowling, PhD, co-first author on the study.

Could VTX-294 make vaccines effective right at birth? Dowling and Levy hope so. With encouraging results in newborn infants’ cells, they now hope to formulate the compound, or a similar TLR8 stimulator, and test it as a vaccine adjuvant in newborn monkeys—a model in which the lab has expertise, and whose responses to TLR8 closely resemble humans’.

“We’re excited about the benzazepines because they are already in the clinical pipeline. That advances the potential for using them in a clinical study in human newborns, once they have been proven safe in animal studies.”

For further background on the Levy lab’s work, see this blog post from 2010.

Sharing via social media is a great opportunity for collecting better public health data and encouraging healthy behavior changes. (bengrey/Flickr)

We humans are sharing creatures. We talk about ourselves, what we think, what we know. If we weren’t like this, cocktail parties would be really boring, and Facebook and Twitter wouldn’t exist.

Nor would health care. At the most basic level, health care relies on give-and-take between patients and doctors—patients sharing their symptoms and concerns with doctors, and doctors sharing their knowledge with patients.

The same holds true for public health. Prevention and control efforts require lots of patients and doctors to share information so that public health agencies know where to target their resources.

But the give-and-take in public health is often slow and cannot always detect conditions or complications at rates that reflect reality. And usually it’s one-way—from the patient or public to surveyors.

Making disease surveillance a conversation

Kenneth Mandl, MD, MPH, and Elissa Weitzman, ScD, MSc, of our informatics program’s Intelligent Health Laboratory understand these gaps all too well. In response, they’ve advocated for a “participatory” approach to public health surveillance, one that relies largely on social media platforms.

“Participatory surveillance establishes a bidirectional communications link between public health and consumers,” says Mandl, who directs the IHL. “It lets us tap the community for crowd-sourced information, but also feed results back and implement behavior change strategies. We see it as a new model for public health reporting across conditions and health issues.”

The diabetes example

Participatory surveillance taps the community for crowd-sourced information and feeds results back and implement behavior change strategies.

Weitzman and Mandl have spent the last couple of years testing this approach in patients with diabetes. Together with the Diabetes Hands Foundation, the pair is collecting diabetes surveillance data from members of a social network called TuDiabetes.org using an online app called TuAnalyze. The app allows TuDiabetes community members to share information about their health status with researchers and, if they choose, with the rest of the community.

That sharing began with information about their hemoglobin A1C status, a health metric used to measure long-term diabetes control.

Now Weitzman and Mandl are using TuAnalyze to look at an under-studied aspect of diabetes: episodes of hypoglycemia, or low blood sugar. At the moment, hypoglycemia surveillance data only come from emergency rooms reports and clinical trials.

“We don’t know much about how populations with diabetes in general experience insulin effects and complications like hypoglycemia,” Weitzman, a social-behavioral scientist, said in a recent press release. “Insulin is widely used, but we don’t have a grasp of how many patients experience hypoglycemic episodes that are not severe enough to merit emergency treatment.”

Results and reactions

Using TuAnalyze, Weitzman and Mandl found just how much hypoglycemia is being underestimated. In a paper just published in JAMA Internal Medicine (you can read the abstract here), they report that in a 613-person sample of TuAnalyze users, more than half said they had “gone low” in the previous two weeks, and about 30 percent had experienced a severe hypoglycemic episode, such as one causing them to pass out or have a seizure. More than half of the respondents also reported other health and lifestyle impacts related to hypoglycemia or worries about it.

The TuAnalyze team's hypoglycemia survey and research blog. The blog lets them feed aggregated results back to the community quickly and encourage action.

“Because there are no gold-standard data sets or national tracking systems in place for hypoglycemia, we don’t have a solid baseline against which to compare our results,” Weitzman notes. “But our estimates align with those few available from clinical studies, so we don’t think we’re off-base.”

The good news is that when aggregate results were posted to a research blog Weitzman and Mandl run within TuDiabetes, the community responded quickly and enthusiastically.

“People in the community picked up on the data and started talking about how to better manage their diabetes day to day,” according to Weitzman. “Seeing that conversation, we could make midstream corrections in how we presented the data, so as to increase the health impact and keep them more aware of what was going on.”

But is it a sustainable kind of sharing?

“I wasn’t surprised by the reported frequency of hypoglycemia in the study,” says Maryanne Quinn, MD, MPH, a diabetologist at Boston Children’s and one of the study’s coauthors. “Patients are sometimes more likely to share their experiences with a peer group than with physicians because the group members who may have similar experiences with hypoglycemia.

“The long term question,” she adds, “is whether social media can help patients maintain those group connections in ways that promote diabetes management.”

Weitzman is thinking the same thing. “The burden is now on us as researchers and public health practitioners to devise strategies to encourage these conversations and build tools that are impactful and effective for promoting better health outcomes.”

Gretchen Hamn (L) and Margie Young screen a premature infant for retinopathy of prematurity. (Photos: Katherine C. Cohen)

We’re in the Neonatal Intensive Care Unit at South Shore Hospital. Six tiny, swaddled preemies are ready to be examined, their eyes numbed and their pupils dilated with special drops.

Gretchen Hamn, NNP, and medical assistant Margie Young go from isolette to isolette. Young tends to the first baby and gently positions him for his exam. Hamn pulls over a cart and extends a kind of hose with a camera at the tip. This she places directly on each of the baby’s eyes, taking a digital video of his retinas. His heart rate alarm goes off, a sign that he’s not happy with this exam, and he lets out a weak cry. Within a minute or so, the exam is over, and Young tucks him back in.

Hamn is screening the six babies for retinopathy of prematurity (ROP), a major cause of blindness (blind Motown artist Stevie Wonder had it). ROP screening is required for babies born at or before 30 weeks gestation or weighing 1500 grams or less.  The more premature the baby, the greater the risk: About 10 percent of babies born at 32 weeks’ gestation, and as many as 95 percent of babies born at 23 weeks, develop ROP. If ROP is caught early enough, it can be treated with laser therapy or medication.

Hamn now reviews the video, freezing it from time to time and saving still images—six different views—that will help ophthalmologists at Boston Children’s Hospital determine whether the baby is developing ROP. Later she’ll transmit these images to Boston Children’s through a secure system.

The first two babies are free and clear, but Hamn readily spots a telltale light line that indicates ROP on the third baby’s retina. It’s a sign of abnormal growth of the blood vessels that feed the retina. The leaky, tangled vessels form a rigid band of tissue. If this worsens and is left untreated, it could cause the retina to detach and the baby to go blind.

Doctors used to come to South Shore Hospital’s NICU to do this exam manually, looking directly into the retina through the pupil and drawing by hand pictures of what they saw. “They would have to use a speculum to open the eye and a probe to move the eye around and look through a magnifying glass,” says Hamn. “The baby would be crying the whole time. Now, I can take a picture directly, and I like that everyone is seeing the same thing.”

Later, in her office at Boston Children’s, ophthalmologist Carolyn Wu, MD, calls up the images on her computer screen (in urgent cases, they can be viewed on iPhones) and identifies which babies have ROP, and at which stage. She can track their progress on repeat camera screenings, done at least weekly while the babies are in the NICU. “Most ROP goes away,” says Wu. “Less than 10 percent of babies who are screened develop ROP that requires treatment.”

At left, a peripheral view of a healthy retina. At right, a retina with ROP (note the semicircular light band along the right side, beyond which no blood vessels grow).

Any baby with ROP findings warranting referral is transferred from South Shore Hospital to Boston Children’s NICU for further evaluation and treatment. After hospital discharge, all babies who qualified for ROP screening (whether or not ROP was found) see Wu or one of her colleagues in person for a manual exam, either in Boston or in the outpatient clinic in Weymouth.

Physicians used to look directly into the eye and draw what they saw by hand.

The telemedicine system, which Boston Children’s hopes to take to other hospitals in its network, solves a major problem for South Shore Hospital. Multimillion dollar lawsuits around the country, involving babies that went blind, have led many community ophthalmologists to drop ROP screening from their practices. If ROP is missed, or caught but not treated soon enough, physicians are held liable—even when patients don’t come to their appointments.

“We had an ophthalmologist, but his practice opted to no longer perform this service because of the malpractice insurance costs,” says Hamn. “If we couldn’t establish a way for the infants to be screened, we would have had to start transferring them to Boston Children’s for screening.”

Boston Children’s Hospital, with its large Ophthalmology team, is often asked by NICUs around Massachusetts to perform ROP screenings. But even for nearby South Shore Hospital, the screenings would take the Boston physicians half a day, between travel time and waiting while the babies were cared for and for the drops to take effect.

“Previously, we had to say ‘no’ to a lot of NICUs. We just didn’t have the capacity,” says David Hunter, MD, PhD, ophthalmologist-in-chief at Boston Children’s. “Now, the nurses can do the screening when it makes sense to them, without the intrusion of us coming in, and without our ROP specialists having to travel around the state. Patients can stay at the community hospital, and families can be closer to their new baby.”

Tele-ROP, as the project is called, began with work Wu did as a fellow nearly a decade ago with Boston Children’s ophthalmologist Deborah VanderVeen, MD. She tested the digital retinal camera in the NICU in 43 infants and found it compared well with her manual exams, missing no instances of treatable disease.

The collaboration represents a new business model for both hospitals. Health insurers reimburse South Shore’s NICU for the screenings, and the NICU, in turn, pays Boston Children’s ophthalmology department under a separate annual contract.

“Initially it seemed like a foreign concept for one hospital to pay another for this service,” says Gordon Massey, MBA, Ophthalmology administrator. “But given the high liability risk and the better access to screening, outlying hospitals are starting to understand the wisdom of the practice.”

The Tele-ROP program is part of a larger telehealth and telemedicine initiative led by Boston Children’s Hospital’s Innovation Acceleration Program. A similar initiative called TeleConnect allows critical care staff at Boston Children’s to evaluate emergency room patients at South Shore when a transfer is contemplated.

“This type of virtual clinical evaluation is a care delivery model of the future,” says Chief Innovation Officer Naomi Fried. “We look forward to creating similar partnerships with community hospitals for a variety of medical conditions.”

The exceedingly complex life cycle of malaria. Within it lies the key to developing a vaccine against the parasite. (CDC)

The malaria parasite (or parasites: four species of Plasmodium can cause malaria in people) has a really complex life cycle.  That complexity has allowed this mosquito-borne parasite from bringing untold misery to the human race for millennia. The World Health Organization thinks it causes 216 million cases of disease every year, while the U.S. Centers for Disease Control and Prevention estimates that some 3.3 billion people live at risk of malaria infection around the globe. Even in the United States, where malaria was officially eradicated 60 years ago, there are still about 1,500 cases every year.

All these numbers add up to one fact: we need a vaccine, badly. This is where malaria’s complexity becomes a problem.

The parasite’s surface proteins—and available vaccine targets—change with each step in its life cycle, meaning that a vaccine against trophozoites won’t work against schizonts.

There is a promising pair of vaccine targets being investigated now. One of these is TRAP, a protein that helps the parasite move around in its sporozoite stage (the form passed from mosquitoes to people). But even there we have an obstacle. While we know the sequence of amino acids that makes up TRAP, we’ve never completely understood its shape, which can greatly influence how the body reacts upon seeing it both in a vaccine and on the real thing.

A team led by Timothy A. Springer, PhD, of Boston Children’s Program in Cellular and Molecular Medicine, used X-ray crystallography to work out both the three-dimensional structure of TRAP and how it changes shape as it helps the parasite move about. This information, reported in the Proceedings of the National Academy of Sciences, could help vaccine developers use TRAP to teach the immune system to attack malaria parasites when it sees them.

“There has been a misunderstanding in the field that TRAP is not immunogenic. However, we find that TRAP is highly immunogenic when it is correctly folded,” says Springer, who earlier this year analyzed the crystal structure of another major sporozoite protein, circumsporozoite, and found that a portion of it could be vulnerable to immune attack. “We will soon be testing TRAP vaccines in animals for complete protection against infection.

“Since TRAP is required for migration of sporozoites in the human body and for the first step in infection of liver cells in malaria,” he continues, “we are highly optimistic about its efficacy as a vaccine target, either alone or combined with circumsporozoite protein.”