University of Miami Miller School of Medicine Volume 9 Spring 2021
From the Dean
“One of my overarching goals for the Miller School of Medicine is to establish its pre-eminence in scientific research and to promote the translation of discoveries into interventions that will transform lives, build healthier communities, and improve health globally. The importance of this vision has been underscored by the extraordinary toll on human life caused by the virus, SARSCoV-2, which causes the pneumonia-like illness known as COVID-19. I am delighted to report that Miller School scientists have been at the forefront of attempts to find not only rapid diagnostic tests, but also therapeutic interventions and vaccines to combat this vexing virus and stop this global pandemic. We are continuously driven by our mission to challenge and inspire our talented students to engage in basic science, clinical, and health services research. The Miller School is committed to establishing a culture of innovation and scientific excellence that will allow the next generation of physician scientists to extend the boundaries of discovery to improve the health of humanity. Paramount to this aim is ensuring that all of our students thrive by creating a supportive environment dedicated to improving their overall wellbeing. Amidst the economic and social challenges brought about by the COVID-19 pandemic, student wellness has never been more important, and we are amazed by the extraordinary resilience of our students. Their perseverance reminds us of the strength of humanity. In that spirit, I am proud to present the ninth annual edition of The Medical I.B.I.S., the University of Miami Miller School of Medicine student-produced research publication. It highlights the wonderful contributions from our emerging group of world-class researchers and physicians who are poised to transform lives and inspired to serve our global community.”
Henri Ford, MD, MHA Dean and Chief Academic Officer, UMMSM There is much talk about a new normal. I believe we have a once in a century opportunity to build a better normal. We owe it to those who have suffered as a result of the pandemic to apply the lessons we are learning. One of those lessons is the vital role health care professionals play in the fabric of our society. Those on the front lines have emerged as role models and connectors, exemplifying the spirit of service that is a key aspect of our mission. The University of Miami Leonard M. Miller School of Medicine has successfully developed protocols and implemented new ways to teach, serve patients, and conduct research in an environment where Covid-19 remains prevalent. As we continue to navigate this unique circumstance, the University is focused on ensuring the health and safety of our students, as well as supporting their wellbeing.
From the
President
As president of this university and a physician, I fully understand the challenges brought about by the pandemic. I am certain that there are multiple opportunities for medical students to make meaningful contributions to research and care. The University encourages students to utilize varying ways to safely study, work, and socialize. The adaptability and determination of students impresses me daily, and I look forward to witnessing their success in the next phase of their academic careers. With my best wishes for a safe, healthy, and meaningful 2021,
Julio Frenk, MD, MPH, PhD President, University of Miami
A Letter from the Editor Dear Readers, We are delighted to present to you the ninth edition of The Medical I.B.I.S., an Executive Student Government publication generated by students at the University of Miami Leonard M. Miller School of Medicine (UMMSM). With generous support from exceptional faculty and staff here, we have the opportunity to feature some of the most exciting student research conducted at UMMSM each year. In this issue, we bring to you an array of leading-edge projects from uveal melanoma and spinal cord injury to maintaining wellness and overcoming disparities during the pandemic. I am very proud of and grateful for the entire Medical I.B.I.S. team for their efforts in making this issue possible. We look forward to showcasing innovative advances in science and medicine in many more years to come and hope that you continue enjoying our content. Thank you,
Akshara Sree Challa Editor-in-Chief, Medical I.B.I.S.
The Medical IBIS | 3
Masthead Editor-in-Chief Managing Editors Senior Editors Editors
Writers
Selection Committee Chair Selection Committee Members
Layout
4 | Spring 2021
Akshara Sree Challa
Julia Cavati de Abreu John Zizzo Rhiya Mittal Hardik Patel Sherry Luo Matt Drewes Roshni Lalwani Miguel Rojas Leo Kleyman Jamie Burgess Juan Lizardi Matt Drewes John Zizzo Jeffrey Brown Jason Greenfield Maya Lubarsky Julia Cavati de Abreu Poorva Jain Apoorva Rangan Miguel Rojas Ahmed Yousef Sai Polineni Brett Colbert Michael Durante Jeffrey Lowell Logan Stone Sherry Luo
Akshara Sree Challa
Julia Cavati de Abreu
John Zizzo
Rhiya Mittal
Hardik Patel
Sherry Luo
Matt Drewes
Roshni Lalwani
Miguel Rojas
Leo Kleyman
Jamie Burgess
Juan Lizardi
Jeffrey Brown
Jason Greenfield
Maya Lubarsky
Poorva Jain
Apoorva Rangan
Ahmed Yousef
Sai Polineni
Brett Colbert
Michael Durante
Jeffrey Lowell
Logan Stone
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Table Table Table Table
of Contents Contents Contents Contents
Patient, R Doctor: A Kidney Dise Persp
by Jami
8
Invested in I Radi
by Maya
1
Practice Dis Adolescen Adult (AYA with Extremi NCDB
by Jeffr
1
The Psychos on Individua HIV due to t Pand
by Jason
2
Researcher, Approaching ease from All pectives
ie Burgess
8
Interventional iology
a Lubarsky
12
Histopathology and Ultrastructural Implications in the Testes Following COVID-19 Infection: A PostMortem Analysis
The Influence of Insulin Sensitivity on Cardiometabolic Health of Patients after Spinal Cord Injury
by John Zizzo
by Poorva Jain
New Methods - Old Questions
Treating Opioid Use Disorder During the COVID-19 era: A Student-led Initiative for Prescription via Telehealth
9
by Miguel Rojas
13
10
by Matt Drewes
14
Assessment of the Unintended Disparities Arising from a Crisis Standards of Care Resource Allocation Algorithm
sparities in the nt and Young A) Population ity Sarcoma: A Analysis
Adipose to Androgens: The Interconnectedness of Medicine
social Burden als Living with the COVID-19 demic
Identifying a Novel Approach for Treating Uveal Melanoma
How Have You Adapted to the Changes Caused by the Pandemic?
22
23
rey Brown
16
by Juan Lizardi
17 by Apoorva Rangan
by Julia Cavati de Abreu
18
n Greenfield
20
The Medical IBIS | 7
Patient, Researcher, Doctor: Approaching Kidney Disease from All Perspectives by Jamie Burgess
As a beneficiary of kidney research, Antonio chose to pay it forward by further exploring the pathways and mechanisms of glomerular kidney disease beginning as an undergraduate in Dr. Fornoni’s lab at the Katz Family Drug Discovery Center. Under the guidance of both Dr. Fornoni and Dr. Alla Mitrofanova, Ph.D., Antonio found that the cGAS-STING pathway, a pathway implicated in inflammatory diseases and cancer, is also expressed in podocytes. Podocytes are barrier cells of the kidney that play an active role in glomerular filtration and the innate immune system. The team found that cGAS-STING pathway activation impairs
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renal filtration and is associated with diabetic kidney disease. Interestingly, mice with an impaired cGAS-STING pathway fare better than wild-type mice when induced with diabetes. With this discovery, the group hopes to one day develop a pharmacological inhibitor of the cGAS-STING pathway to improve renal function in the setting of diabetic kidney disease.
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That is what [kidney] research is for me…it’s something that I have dealt with, and I get to push that fight forward.
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W
hile interview season for any medical school applicant is stressful, Antonio Fontanella had to juggle another concern: his kidney health. At the age of 14, Antonio received a kidney transplant which was quickly complicated by the development of focal segmental glomerulosclerosis (FSGS). He was successfully treated after enrollment in a trial for an off-label application of the drug abatacept for recurrent FSGS, a study led in part by Antonio’s current research mentor Dr. Alessia Fornoni, M.D., Ph.D. While he had FSGS recurrence during the 2019 interview season, another round of treatment with abatacept had his kidney functioning as good as new and ready to embrace the challenges of beginning a Medical Scientist Training dual degree M.D./Ph.D. Program (MSTP) during a global pandemic.
Any researcher would tell you that the road to discovery is not easy. However, for Antonio there is no other place he would rather be. He states, “I get a sense of fulfillment, even when things aren’t going the right way. I just feel like I am where I am supposed to be. That is what [kidney] research is for me…it’s something that I have dealt with, and I get to push that fight forward.”
Antonio Fontanella MD/PhD Class of 2028
Honors/Presentations: October 2020 Academic Society of Nephrology Kidney Week Poster Presentations; November 2020 Virtual UMMSM MSTP Symposium Poster Presentation Mentors: Dr. Alessia Fornoni, MD,PhD; Dr. Alla Mitrofanova, PhD Other Interests: CHAMP, DOCS, Medical Humanities Book Club, and MSTP Equity & Inclusion Committee Future Goals: Research Residency in Nephrology
To balance his life as both a student and a researcher, Antonio prioritizes his time by knowing his limits and working within them. During his free time, he relaxes by playing guitar, chess, and video games with his friends. Antonio is looking forward to continuing kidneyfocused research during his Ph.D. years and aspires to one day be running his own basic science research lab as a nephrology program director.
Justin Achua
Histopathology and Ultrastructural Implications in the Testes Following COVID-19 Infection: A Post-Mortem Analysis by John Zizzo
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Social media, in particular, Twitter for urology, is a great way to brand yourself and share your research with potential residency programs.
MD Class of 2021
Honors: Podium presentation at the American Society for Reproductive Medicine, October 2020; Publication in The World Journal of Men’s Health (PMID: 33151050) Mentor: Dr. Ranjith Ramasamy, MD Other Interests: Playing Dungeons & Dragons with friends, involved in DOCS and the Urology Interest Group Future Goals: Urology and further research in andrology
J
ustin Achua is a 4th year MD student researching the effects of COVID-19 infection on the testes under the supervision of Dr. Ranjith Ramasamy, MD at the Department of Urology and Department of Pathology at the University of Miami Miller School of Medicine (UMMSM). Justin completed his Bachelor of Science at the University of South Dakota, majoring in cell biology and anatomy. After his graduation, he was accepted into a Research Master’s program at the University of South Dakota, where he discovered his passion for immunohistochemistry and wet bench laboratory techniques. Empowered by his strong research experience, Justin decided to pursue his interest in medicine by joining the UMMSM Class of 2021. He is currently in his fourth and final year and is excited to start residency and begin his career in the field of urology. Justin is very grateful for the opportunity to utilize his immunohistochemistry knowledge and interest in andrology to contribute essential knowledge about COVID-19 infection for current and future patients. Before the COVID-19 pandemic, Justin began working with Dr. Ramasamy on various projects in urology. Justin describes Dr. Ramasamy as a very welcoming and empowering mentor, who has provided him with invaluable guidance on his research interests and career goals. In mid-January, Justin and Dr. Ramasamy became aware of the COVID-19 pandemic, caused by an outbreak of SARS-CoV-2, that was quickly spreading and wreaking havoc
across the globe. During a time of widespread uncertainty, Justin took initiative and conducted a research review regarding potential pathological changes to the testes of patients who died or recovered from COVID-19 complications. He then sought to further study these potential changes in human patients, which resulted in the formulation of the present study. Postmortem and live specimens of testes were obtained from patients who died of SARS-CoV-2 pneumonia and subsequently taken to be processed and analyzed for qualitative and quantitative interpretation. Justin’s team found that COVID-19 has an affinity for ACE-2 receptors, suggesting that the testes may be a target of COVID-19 infection. Another key finding was that COVID-19 may cause infertility. Justin reflects on this project as a rewarding experience, with deep found respect and gratitude to the consenting live donors and next-ofkin who made the study possible. He acknowledges that the findings open the door to a host of questions that must be addressed in future studies, including the implications of long-term pathological findings of COVID-19 infection on the testes. Justin’s advice for medical students is to identify an interest and seek out researchers who share that interest. His experience is a testament to the importance of having a strong mentor, and he looks forward to teaching and mentoring medical students in his future career as an academic physician.
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The Influence of Insulin Sensitiv Health of Patients with Spinal C
F
ounded here at UMMSM, the Miami Project to Cure Paralysis created a vast multidisciplinary network of scientists and clinicians dedicated to improving outcomes in patients living with spinal cord injury (SCI). The Miami Project is at the forefront of innovation and is translating therapies like cell transplantation, neural stimulation, and targeted exercise programs. As medical students, we have the awesome opportunity to work at one of the most comprehensive SCI research centers and tangibly change the landscape of how future clinicians treat SCI. Adam Burton, a second-year medical student, took advantage of this opportunity when he started working with Dr. David Gater MD, PhD, who is faculty at the Miami Project and also chair of Physical Medicine and Rehabilitation at UMMSM. Dr. Gater is interested in leveraging the impact of diet and exercise on body composition and metabolic health in persons with SCI in order to identify more effective methods to improve these patients’ overall health. After personal experiences managing health and weight and previous research in exercise physiology, Adam was motivated to join a lab that examines the far-reaching effects of nutrition and exercise. Adam described Dr. Gater as the “perfect person to reach out to” due to his interdisciplinary focus in exercise physiology, nutrition, long term care, and SCI. SCI refers to the interruption or damage of axons in the spinal cord often due to traumatic injury. Depending on the extent of the injury, SCI presents with varying levels of impaired function and sensation below the level of the lesion. A national survey completed by the Christopher Reeve Foundation estimated almost 1.5 million people are living with SCI in the United states alone. Furthermore, the National Spinal Cord Injury Statistics Center reports almost 60% of people with SCI have impaired or loss of function in all four limbs, and less than 1% of patients experience complete neurologic recovery after their hospital discharge. After the initial injury, persons with SCI often develop secondary medical complications that reduce quality of life and increase morbidity. Recent work has demonstrated significant metabolic changes—such as glucose intolerance, lipid abnormalities, skeletal muscle atrophy, and obesity—in persons with SCI. In combination with their decreased physical mobility, these metabolic changes often lead to increased incidence of comorbidities like type 2 diabetes mellitus and cardiovascular diseases (e.g., hypertension). Under the guidance of Dr. Gater and post-doctoral fellow Dr. Gary Farkas PhD, Adam was interested in addressing the hypothesis that impaired insulin sensitivity is associated with worsened cardiometabolic health and body composition in persons with SCI. In order to test this claim, Adam used data from a comprehensive cross-sectional study completed at the Hunter Holmes McGuire VA in Richmond, Virginia. Insulin sensitivity was measured using a technique called the intravenous glucose tolerance test (which essentially measures serum glucose and insulin levels over time after a glucose infusion). To describe cardiometabolic
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… group of “ anandunderrepresented specific health care needs tha
vity on Cardiometabolic Cord Injury by Poorva Jain health, Adam used blood pressure readings and lipid profiles. To characterize body composition, he used MRI and dual x-ray absorptiometry (DXA) quantification of visceral and subcutaneous adipose tissue and percent total body fat. Based on the intravenous glucose tolerance test, Adam categorized patients into three groups: high, medium, and low insulin sensitivity. He then used one-way analysis of variance with Tukey’s post-hoc tests to compare cardiometabolic outcomes and body composition between the groups. Strikingly, Adam found that lower insulin sensitivity is associated with worsened glucose metabolism, detrimental lipid profiles, raised systolic blood pressure, and greater visceral and overall adiposity. This is just the beginning and much more work is required to examine the mechanism by which insulin sensitivity may alter body composition and cardiometabolic health in persons with SCI. When asked about why he pursued research, Adam conveyed excitement about how “every piece of research is … a little building block on top of another.” Equivalently, his current work serves as just such a building block for future innovation in physical medicine and rehabilitation in SCI. His research findings will potentially inform interventional clinical trials that will test the effect of therapies that modify insulin sensitivity such as lifestyle changes or targeted cardiometabolic medications for persons with SCI. Adam is excited to move forward by contributing to a new project in Dr. Gater’s lab, Spinal Cord Injury Exercise and Nutrition: Conceptual Engagement (SCIENCE), which has received R01 funding. The goal of this project is to assess the impact of home-based, functional, electrically stimulated leg-cycle exercise (with and without diet modification) on body composition, insulin sensitivity, glucose effectiveness, basal metabolic rate, and bone mineral density in adults with motor complete SCI. Like many medical students, Adam juggles research alongside academics, community service, and family commitments. He acknowledges that it is a challenging balance and relies on a “strict routine” to keep pace. He prioritizes healthy sleep hours, daily exercise, and a good work-life balance. While COVID-19 has significantly delayed some of Adam’s other projects, he was, fortunately, able to work diligently over a couple months to complete this research virtually. That said, Adam eagerly anticipates returning to in-person work with friends and colleagues. In the process of completing this project, Adam was particularly impacted by the people. Describing the community with SCI, he stated how it is made up of “an underrepresented … group of patients … with very unique and specific health care needs that are not necessarily always met.” Commendably, Adam has joined forces with the Miami Project to serve as one of the very necessary advocates for this patient population.
MD Class of 2023
Honors: ESRF (Oral Presentation, Virtual, February 2021) | Association of Academic Physiatrists annual meeting (Poster Presentation, Virtual, February 2021) Mentor: Dr. David Gater MD, PhD Other Interests: Ophthalmology Station Manager and Nutrition Education Awareness for DOCS, PM&R Interest Group Exec Member, AMA-Medical Students Section Committee on Long-Range Planning
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f patients … with very unique at are not necessarily always met.
Adam Burton
The Medical IBIS | 11
Invested in Interventional Radiology by Maya Lubarsky
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Mentored by Dr. Shivank Bhatia, MD, Chair of the Department of Interventional Radiology & Professor of Interventional Radiology & Urology at the Miller School of Medicine, Vedant joined the research team to investigate prostatic artery embolization (PAE), a relatively new, minimally invasive, outpatient, image-guided technique to treat benign prostatic hyperplasia (BPH). This procedure is beneficial for certain men with larger prostates or underlying illness, who may not tolerate or be willing to undergo surgery. When performing PAE, there is a theoretical risk of erectile dysfunction secondary to non-target embolization of the penis leading to compromised blood flow to the area. Therefore, Vedant decided to begin a yearlong project aimed at evaluating the effect of PAE on erectile function. From 2014-2019, a standardized 5-item questionnaire, the Sexual Health Inventory for Men (SHIM), was prospectively administered to evaluate patients’ erectile function pre- and post-procedure.
Continuing to build off those patient-relevant questions is a really cool part of research that is why I am very interested in our followup project to evaluate the effects of PAE on ejaculatory function.
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12 | Spring 2021
MD Class of 2021
Honors/Presentations: Sexual Medicine Society of North America (SMSNA) Best Presentation: Resident’s Arena (2020) Mentors: Dr. Shivank Bhatia, MD Other Interests: DOCS Executive Director 2018-2019, MSAT Founder, Doctor’s Note Member Future Goals: Residency in Interventional Radiology
hen Vedant Acharya discovered Interventional Radiology (IR) during his third year at the University of Miami Miller School of Medicine, he was inspired to pursue it further. Not willing to settle for passive exposure, Vedant decided to take a research year to explore and immerse himself in the specialty.
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Vedant Acharya
At 3 months post-PAE, the research team found that there was a slight improvement in erectile function for the entire cohort. Additionally, no association was found between erectile function changes and any technical or clinical parameters. These results were similar to other BPH procedures such as Transurethral Resection of the Prostate (TURP), which is the current standard of care. While this information is meaningful to physicians who can use this data when discussing BPH treatment options, Vedant is most excited about how the data can help patients. Vedant states, “Once patients know a BPH treatment is effective, their second question is asking about an intervention’s effect on their erectile and ejaculatory function. Continuing to build off those patient-relevant questions is a really cool part of research - that is why I am very interested in our follow-up project to evaluate the effects of PAE on ejaculatory function. IR is a very innovative field, and the language of science allows [IR] to communicate to other practitioners and patients to show the value that the field can provide.” Going forward, Vedant plans on being involved in a wide variety of interventional radiology research projects throughout residency, including interventional oncology, embolic therapy, and ethics in IR. When asked about balancing his personal time to maintain wellness with his passion for research, he says, “Sometimes, just talking about the stressful situations you may observe in medicine can be beneficial; there is a certain existential component in medicine that is not talked about enough, and processing those experiences is a part of wellness.”
New Methods - Old Questions by Miguel Rojas
I
f you ask any healthcare professional about the vasculature, you would get some interesting plumbing analogies. However, if you zoom in on a cellular level, you would see that the complexities of vascular tissues are infinite. Vascular smooth muscle cells, the ones canonically responsible for arterial contractility, are some of the most plastic and heterogeneous cells in your body. They can assume multiple phenotypes and revert to an undifferentiated state, assuming macrophage, fibroblast, and even adipocyte characteristics. Single-cell transcriptomics offers unparalleled resolution, analyzing RNA expression of every cell in a tissue.
This wealth of information has led to revolutions in many fields, including vascular biology. Excellent examples include the recent publications by Chen et al and Li et al1,2 addressing aortic aneurysms and atherosclerosis. Their technical mastery is evident not only from their high-throughput techniques but also from the expertise required to analyze and make sense of the incomprehensible amount of information produced. Today, we perform seemingly esoteric tasks such as modeling the lineage trajectory of a group of cells in a particular tissue, but these same models will be used to guide pharmacological and surgical interventions in the not-so-distant future. In fact, when I wrote this article, the AlphaFold2, an artificial intelligence program that conceives 3D protein structures, was released. AlphaFold2 is predicted to be as accurate Resources: 1. Li et al. Single-Cell Transcriptome Analysis Reveals Dynamic Cell Populations and Differential Gene Expression Patterns in Control and Aneurysmal Human Aortic Tissue. Circulation. 2020 Oct 6;142(14):1374-1388. doi: 10.1161/CIRCULATIONAHA.120.046528. 2. Chen et al. Smooth Muscle Cell Reprogramming in Aortic Aneurysms, Cell Stem Cell, https://doi.org/10.1016/j.stem.2020.02.013. 3. Callaway, Ewen. Nature 588, 203-204 (2020), doi: https://doi. org/10.1038/d41586-020-03348-4 4. Dr. Kellis’s lectures: https://www.youtube.com/c/ManolisKellis1/ playlists
as traditional time-consuming experimental methods3. We are witnessing a biological revolution, and it is up to us to translate it into clinically relevant applications.
But what do you do if you have complex questions and zero programming experience? I was in a similar situation several years ago. Dr. Daniel Isom, an excellent lecturer and faculty member in the Department of Molecular and Cellular Pharmacology, introduced me to programming. I am by no means a programming expert, but after taking Dr. Isom’s course, I began to think of how I could apply programming principles in a translational and surgically-oriented lab. I have also found inspiration in Dr. Manollis Kellis. He is not a professor at UM, nor have I met him in person, but he kindly shares his lectures at MIT and makes them available for free. Two of his courses, “Deep Learning in Life Sciences” and “Machine Learning for Genomics,”4 have had a great impact on my newly found passion for the application of these methods in Medicine.
Miguel G. Rojas MD/PhD Class of 2028
Other Interests: Mixed Martial Arts, Artificial Intelligence, Cooking. Future Goals: Academic medicine and research
The Medical IBIS | 13
Treating Opioid Use Disorder A Student-led Initiative for Pre Pr
Second year medical students Marcus Castillo and Sam Hinkes are among the resourceful researchers around the world who, rather than trying to create new modalities from scratch, have adapted tools and programs already in place to tackle the challenges imposed by the pandemic. Under the mentorship of IDEA Exchange founder and medical director Hansel E. Tookes III, MD, MPH, Marcus and Sam seized an opportunity to continue patient care alongside their teammates at the IDEA Clinic while operating within the restraints of large-scale physical distancing, quarantine, and isolation. In response to COVID-19, Drug Enforcement Agency requirements for face-to-face visits prior to prescription of medication for opioid use disorder (MOUD) were lifted, and urine drug screenings as prescribed by the Substance Abuse and Mental Health Services Administration’s guidelines were also waived. These developments lowered existing barriers to care and opened the doors to utilization of telehealth technology for the treatment of opioid use disorder, including provider-patient interactions over the phone. Marcus, who in February, 2020, took over as project manager at the student clinic, says the goal of the project was to see if it would be possible to effectively initiate MOUD via telehealth at the clinic and educate students on the use of this medication. Working with a team of medical students, Marcus and Sam advertised services on social media, scheduled appointments, conducted interviews,
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assisted patients in obtaining buprenorphine prescribed by attending physicians, and provided follow-up support. Within the first couple of months of operation, the team completed 22 initial telehealth appointments. Moreover, all patients needing MOUD were prescribed buprenorphine, and 80% of these patients successfully received medication from a partner pharmacy, with an average time of 9.5 days between appointment request and prescription pick-up. The results of the project are encouraging. “Telehealth is absolutely feasible for initiating treatment for opioid use disorder,” Marcus asserts. He envisions a larger role for telehealth in the future with a greater emphasis on comprehensive and longitudinal patient care. One of the highlights of this project for him is making life-saving medication available to those in need. “With just some Department of Health paperwork and access to a phone, we can prescribe critical medication to these patients,” he says. The main concern at the moment is that the pre-COVID era barriers may return, hurting the clinic’s progress and the patients’ newly found ease of access to treatment. Sam hopes this is not the case after the team’s success with such a “simple way of marrying medicine and public health.”
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Telehealth is absolutely feasible for initiating treatment for opioid use disorder. – Marcus
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A
s the number of confirmed cases of COVID-19 continued to increase during the spring months of 2020, it became clear that the pandemic was here to stay. When the severity of the public health crisis limited syringe exchange services at Miami’s reputable Infectious Disease Elimination Act (IDEA) Exchange, volunteers serving at the exchange’s free student-run clinic were confronted with a formidable obstacle to continuing patient care. Run in collaboration with the Mitchell Wolfson Sr. Department of Community Service (DOCS), IDEA Exchange provides various harm reduction services that address Miami’s burden of blood-borne infection and has been the only syringe exchange in the state of Florida since its inception in 2016.
Along with the supportive care rendered to individuals who inject drugs, the student-run clinic also provides a valuable educational experience for the medical students who serve there. Both Marcus and Sam are positive about the role students can play in community service and projects like theirs. Marcus encourages students to practice compassion in their research and extracurricular activities, regardless of the specific field of interest. Sam also stresses the power of networking with faculty, students, and others: “in general, people really show up for you if you
During the COVID-19 Era: rescription escription via Telehealth
by Matt Drewes
show sincere passion for what you are working on.” He adds that what is perhaps most inspiring about his project with Marcus is how it was led and carried out by medical students. “Students shouldn’t underestimate their ability to create new ideas,” Sam declares positively. “When you see a need, grab the bull by the horns and see if you can do it yourself.” He also suggests that students who show dependability as they rise to the demands of a particular project will find success as they budget their time and contribute regularly. Setting boundaries about what you can get done each week is also important to avoid burnout.
MD Class of 2023
Honors: Article published November 17, 2020 in Harm Reduction Journal Mentor: Dr. Hansel E. Tookes III, MD, MPH Other Activities: DOCS IDEA Clinic Project Manager, Human Rights Clinic, DOCS Health Fairs Future Goals: Emergency Medicine
Students shouldn’t underestimate their ability to create new ideas. – Sam
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Marcus Castillo
For now, Marcus and Sam are looking forward to building on this experience. Both believe there are many more uses for telehealth beyond the medication prescription emphasized in their project. Mental health counseling and intimate partner violence screenings are some specifics that they mention. In fact, they have already been incorporating the latter into their telehealth work at the IDEA Clinic with the expectation that telehealth appointments are often more accessible than in-person clinic visits to victims of intimate partner violence. Sam’s and Marcus’ ability to adapt to the pandemic extends into their personal lives as well. As busy medical students, they recognize the need for balance and wellness. Sam has taken to honing his cooking skills in his free time. Marcus has also looked for physically distanced activities like paddle boarding and tennis. With creative individuals like these two among the student body and dedicated mentors like Dr. Tookes, UMMSM can be confident in meeting whatever future challenges await.
Sam Hinkes
MD/MPH Class of 2023 Honors: Article published November 17, 2020 in Harm Reduction Journal Mentor: Dr. Hansel E. Tookes III, MD, MPH Other Activities: DOCS IDEA Clinic Patient Relations Coordinator, MS2 Class Council, Doctor’s Note A Capella, MD/MPH Admissions Ambassador Future Goals: OBGYN
The Medical IBIS | 15
D
Practice Disparities in the Adolescent and Young Adult (AYA) Population with Extremity Sarcoma: A NCDB Analysis
Abdurrahman AlAwady (Abdo) MD Class of 2023
Mentor: Dr. Raphael Yechieli, MD Future Goals: Abdo is interested in radiation oncology and is looking forward to his third year of medical school to further explore his clinical interests. He will be presenting his research at the Eastern Atlantic Student Research Forum in February 2021.
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As a second year medical student at the University of Miami, Abdurrahman Al-Awady is interested in cancer therapy and addressing healthcare disparities. While describing his motives for this study, he states, “in order to address disparities, we must first identify them”. With his mentor, radiation oncologist Raphael Yechieli, MD, Abdurrahman and his colleagues worked to assess practice disparities of extremity soft tissue sarcoma between the young adult and older adult populations. Using the National Cancer Database (NCDB), the researchers assessed demographic variables including sex, race, ethnicity, insurance and socioeconomic status, and distance from cancer treatment centers; tumor characteristics such as anatomic site of the primary malignancy, histopathologic grade, tumor size, clinical stage, depth of tumor extension, and status of surgical margins; and therapeutic interventions including limb-sparing surgery, amputation, chemotherapy, or radiotherapy.
Sarcoma disproportionately affects adolescents and young adults, and further study is warranted to identify the clinical impact of practice disparities.
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by Jeffrey Brown
espite ongoing advancements in modern medicine and successes over acute and infectious disease states, with these advancements comes an unfortunate familiarity with death from chronic diseases like cancers. While it is common to know family or friends suffering with breast, colon, prostate, or lung cancer, far less well-known is the clinical entity of sarcoma: a malignancy derived from mesenchymal stem cells that comprises less than 1% of all cancers. Despite its low prevalence, the sarcoma subset of extremity soft tissue sarcomas (ESS) represents significant morbidity and mortality in the adolescent and young adult (AYA) population (ages 18-39). Unfortunately, this group is underrepresented in clinical research, and there remains ambiguity in the presenting characteristics and optimal therapeutic principles of soft tissue sarcoma.
Abdurrahman and his co-authors identified several discrepancies in clinical practice between older and younger sarcoma patients. They noted no difference in rates of amputation compared to limb-sparing surgery in the AYA cohort, and AYA patients were more likely to receive chemotherapy than older patients yet less likely to receive radiation. The authors noted that deep tumor extension and increased tumor size were associated with the use of radiotherapy, while clinically advanced stage II tumors and positive post-operative surgical margins were not associated with administration of radiation. Demographic considerations also affected use of radiotherapy. Living further than 10 miles from a radiation oncology center was associated with a decreased likelihood of receiving radiotherapy for all age groups. Non-black Hispanic AYA patients were less likely to receive radiation compared to patients of white race and non-Hispanic ethnicity, and AYA patients with private insurance were more likely to receive radiotherapy. In his retrospective NCDB analysis, Abdurrahman and his colleagues highlight therapeutic variability in AYA patients due to demographic and clinical factors. Sarcoma, including extremity soft tissue sarcoma, disproportionately affects the AYA population, and this study serves to further describe clinical characteristics and therapeutic distinctions between AYA and older adult populations.
Adipose to Androgens: The Interconnectedness of Medicine
by Juan Lizardi
Under the mentorship of Dr. Himanshu Arora, PhD and Dr. Ranjith Ramasamy, MD, Madhu decided to take a research year and joined a lab at the University of Miami Miller School of Medicine. The research group was interested in exploring the effects of leptin on Leydig Stem Cell (LSC) differentiation based on differing BMIs. Leydig cells are located in the testes and are responsible for the production of testosterone. Leptin, a molecule involved in energy homeostasis and metabolism, is produced mainly in white adipose tissue and has been shown to be a necessary factor in LSC differentiation. Additionally, varying amounts of white adipose tissue (or BMI) lead to differences in leptin production and regulation. The research team, therefore, hypothesized that treatment with leptin would have differing effects on LSC differentiation based on an individual’s BMI. LSCs were isolated from testicular biopsies of 12 men with testicular failure
who were categorized as having lean, normal, or obese BMIs. LSCs were treated with increasing doses of leptin for longer durations of time and characterized via flow cytometry and immunostaining. The team found that in samples from patients with normal BMI, low doses of leptin were associated with improved differentiation of LSCs to adult cells. However, this pattern was not seen in patients with lean or obese BMIs, suggesting a complex interplay between leptin regulation, BMI, and testosterone production. Madhu is excited about the implications these results may have on treating men with testosterone deficiency. This early research may be the foundation for novel therapeutic modalities to endogenously increase testosterone levels while avoiding unwanted side effects, such as infertility, associated with exogenous testosterone replacement therapy. As Madhu prepares to begin residency this June, she plans to continue her involvement in urology research. In addition, Madhu hopes to use the invaluable skills gained during her research year to explore her other diverse interests. When asked about balancing research, academics, and personal wellbeing, she emphasized, “It’s important to cultivate habits of things that relax or rejuvenate you and treasure them as ‘non-negotiables’. When you have so many things on your plate, it’s always nice to have those built-in systems to support you.”
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This early research may be the foundation for novel therapeutic modalities to endogenously increase testosterone levels while avoiding unwanted side effects, such as infertility, associated with exogenous testosterone replacement therapy.
Madhumita Parmar MD Class of 2021
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F
or her first 3 years of medical school, Madhu Parmar had envisioned a future in primary care. Her volunteer experience as Research and Quality Improvement Director in DOCS and her role teaching nutrition to middle school students in Wellness in the Schools helped her recognize the significance of preventative care on improving health outcomes. Unexpectedly, she fell in love with surgery during her third year and was ultimately drawn to pursue a career in urology for its unique blend of medicine, surgery, psychology, and lifestyle interventions.
Honors/Presentations: American Urological Association 2020 - Best Poster Award; American Society for Reproductive Medicine Conference 2020 Mentors: Dr. Himanshu Arora, PhD; Dr. Ranjith Ramasamy, MD Other Interests: Urology Interest Group, Doctor’s Note Acapella Group, Lifestyle Medicine Interest Group, DOCS: Research and Quality Improvement Director 2018-2019 Future Goals: Urology Residency
The Medical IBIS | 17
Assessment of the Unintende Crisis Standards of Care Res
T
he Covid-19 pandemic has highlighted the health disparities among populations. People of color are more likely to test positive for coronavirus. Factors such as race, ethnicity, and socioeconomic status influence someone’s health. In a healthcare setting, it is essential to work through implicit biases to offer the same level of health care to every patient. With the increasing threat of a ventilator shortage due to the pandemic, resource allocation became an urgent topic to be considered, and it begged the question: Can ventilators be assigned in a fair and equitable manner, or will vulnerable populations and minorities be harmed in the decision making process? In late May, Leah Colucci was invited to participate in a research study that sought to address the issue of the allocation of ventilators to Covid-19 patients in an unbiased way. Mentored by Dr. Gregory Holt, MD/PHD, and Dr. Hayley Gershenrgorn, MD, with the help of 6 other medical student supervisors (Andrew Rezk, Stefanie Delgado, Nayna Shah, Belen Gariji, Rahul Iyengar, Andy Lopez,), ethicists, and multiple volunteers, she worked to ensure vulnerable populations would get fair treatment if resource allocation were needed. The first step of the project was to create an algorithm, called the Priority Score. This score was calculated based on comorbidities and laboratory results, collected everyday at 5 am to ensure data consistency, from ICU Covid and non-Covid patients who needed a ventilator. The score was then used to determine who would get a ventilator in case there were not enough ventilators for every patient who needed it. The score prioritizes patients who would likely survive the disease, and have a good quality of life afterwards if ventilated. A sequential organ failure assessment was measured from lab work and used to assess how well the patients were doing internally, which impacted their survival chances. Comorbidities such as cancer, in which the patient had a lower survival rate regardless of Covid, would decrease the priority score. Diabetes and Hypertension were not counted as comorbidities on the Priority Score, due to the fact they affect disproportionately more minorities. If the score resulted in a tie, the decision was made based on the age of the patient, down to the day. The parameters of the algorithm were decided before the data collection began, with the help of the ethicists, to avoid future changes due to bias. After the data was collected, Leah and her team then retrospectively collected data on
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Leah C
MD/MS in Genomic M
Mentors: Dr. Gregory Holt, M Gershenrgorn, MD Other interests: Student G Future Goals: Leah is going i residency and plans to continue
Covid is a strong reminder that society can be unfair. This proje
18 | Spring 2021
ed Disparities Arising from a source Allocation Algorithm
Medicine Class of 2021
MD, PhD; Dr. Hailey
gender, race, ethnicity, and healthcare status. Those are factors that often contribute to the disparity in healthcare quality seen in America. The additional data was then compared to who would get ventilators each day to see if non-medical factors would affect the choice of ventilator allocation. The results showed that the Priority Score is unbiased towards minorities, and therefore fit to be used in a situation where resources are limited. As of yet, the score did not have to be used to allocate ventilators, since so far there were enough ventilators for all patients. Leah, who is in her last year at UMMSM and on her way to an Emergency Medicine residency, has a long history of working with vulnerable populations. Her mother works as a nurse in a rural area, and sees many patients who are immigrants and have little access to healthcare. This experience made her passionate about ensuring that everyone has access to equal care, against the biases and difficulties brought on by health inequalities and systemic racism in the US. With this project, she was able to help to show that a policy can be created to allocate resources in a way that is fair to all populations. She thinks the project could serve as inspiration for other hospitals, and even be used in future pandemics or situations when resource allocation is needed. As a future emergency medicine physician, she hopes to take things learned in this project and implement them in the future. For now, the project is completed. Since there is currently no need to prioritize patients, the algorithm does not need to be used. If the Priority Score were to be implemented, constant monitoring would be needed, to ensure that bias does not occur. If it comes to it, Leah says, she will gladly continue to work on the project. The COVID -19 pandemic has greatly affected everyone, and forced people to adapt to unprecedented situations. For Leah, this project came at the right time. As medical students were sent home and classes transitioned online, she felt she needed to do something to help in these difficult times, as much as she could. The project allowed her, and many other students, to participate in the combat of the pandemic from wherever they were, with some students in California waking up at 2 a.m. to help collect data.
Government Class President into an Emergency Medicine research
ect shows that resources can be allocated in an unbiased way.
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Colucci
by Julia Cavati de Abreu
The Medical IBIS | 19
The Psychosocial Burden on with HIV due to the COVID
T
he COVID-19 pandemic has shown far-reaching consequences that extend beyond Miami-Dade County’s hospital systems. As a consequence of long-term self-isolation, many people face new challenges with their mental health, social wellbeing, and financial security. In particular, research has shown that many marginalized groups, such as people of color or of low socioeconomic status backgrounds, experienced these tribulations to an even greater degree. Paola C. Martinez was interested in investigating the secondary effects caused by the pandemic and the psychosocial and financial implications for individuals living with HIV in Miami. This patient population represents some of the most high-risk individuals for COVID-19 due to associated comorbidities and includes a large demographic of racial and ethnic minorities, often of lower socioeconomic status. As one of the previous epicenters for the HIV epidemic in the 1980s, Miami represents a unique location to study the consequences of pandemic-level diseases. Dr. Deborah Jones, PhD and Maria Alcaide, MD, who first initiated a study examining the broad psychosocial effects of COVID-19 in the Miami public, became Paola’s mentors. While early research efforts largely focused on COVID-19’s impact on physical health in hospitalized patients, there was limited research focused on the psychosocial impacts on non-hospitalized patients. As part of her MPH field experience, Paola joined the team tackling this novel area of research as an opportunity to study individuals living with HIV. This was a patient population that Paola was familiar with as she previously conducted basic science research in NeuroAIDS during her undergraduate education. In her study, Paola assessed whether HIV-positive individuals experienced greater stress and anxiety associated with the COVID 19 lockdown and whether these mental health challenges were influenced by non-modifiable factors (age, race, and gender) or modifiable factors (job loss, medical care, and access to medication). She conducted phone interviews in English and Spanish with non-hospitalized, HIV-positive patients living in Miami, utilizing databases from institutions such as the Center for Aids Research (CFAR) and Center for HIV Research and Mental Health (CHARM). The subjects were stratified by age (greater than and less than 50 years old), racial identity, and gender. Subjects were offered $15 to respond to a phone-based questionnaire that asked their demographic information, history with COVID-19, medication regimens, disruption to resources, and psychosocial wellbeing. Interestingly, Paola’s findings pointed towards older age acting as a protective factor against the loss of employment, the loss of medical access, and the inability to afford medications. In addition, she identified a strong association between the subjects’ perceived stress and the incidence of depression and loneliness. Lastly, it was observed that white females older than 50, black females younger than 50, and black males older than 50 were more likely to experience depression than the individuals in their respective counterpart age groups. Paola’s findings from this project have important implications for approaching psychosocial dimensions in clinical care, as well as future directions for additional study. First, targeting levels of perceived stress may have helped patients’ loneliness and depression. Furthermore, cultural competence should be emphasized in clinical care as depressed patients from different backgrounds express themselves in unique ways. A lack of cultural competence may result in inequitable care for depressed patients of different races, ages, and genders.
20 | Spring 2021
n Individuals Living D-19 Pandemic
by Jason Greenfield
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Investigating the cross-section between infectious diseases, psychology, sociology, public health and a pandemic in real-time was a very rare opportunity. I am grateful to have worked with such a dynamic team and to have been able to conduct this research during a time when patient interaction was so limited by COVID-19.
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After presenting her research at the Annual Public Health Association Conference (APHA), Paola continued to examine her research to determine whether her findings could apply to other areas in the United States. As an immigrant herself, Paola understood firsthand the added challenges of navigating the US healthcare system and would like to work with immigrant and minority populations in the future. She is excited to continue performing research with this patient population and hopes that her findings will inform future practice for those living with HIV.
Paola C. Martinez MD/MPH Class of 2023
Honors: Oral presentation at the 2020 Annual Public Health Association Conference Mentors: Dr. Deborah Jones, PhD; Dr. Maria Alcaide, MD Other Interests: client navigation co-developer for the Human Rights Clinic, events coordinator for the American Medical Women’s Association (AMWA) and the American Women’s Surgeon Association (AWS), logistics coordinator of the Infectious Disease Interest Group Future Goals: Interested in a primary care specialty like OBGYN but is still keeping her options open.
The Medical IBIS | 21
Identifying a Novel Approach for Treating Uveal Melanoma by Apoorva Rangan
Cancer can be caused by two genetic mechanisms: the activation of proto-oncogenes and the inactivation of tumor suppressor genes. Current targeted cancer therapies are primarily focused on inhibiting mutant oncogenes and causing cell death. The Harbor lab sought to shift this paradigm by focusing on chemically restoring function of inactivated tumor suppressor genes, such as BAP1. The lab created a novel two-phase drug screen involving a cell-based rescue screen of transcriptional repression caused by BAP1 loss, followed by an in vivo screen to select for compounds with minimal toxicity in BAP1-deficient frog embryos. Working under the guidance of Dr. Jeffim N. Kuznetsoff, Andy played a key role in performing key experiments, which led to the identification of Quisinostat, a histone deacetylase (HDAC) inhibitor. Remarkably, this drug was able to block the growth of BAP1 mutant tumors in a mouse uveal melanoma model with minimal toxicity to the host.
Andy Lopez MD Class of 2022
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I had to think beyond the scope of what is found in a textbook.
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A
fter spending months in the anatomy lab during his first semester of medical school, Andy Lopez was excited to delve into the world of medical research. Inspired by a podcast on the applications of stem cell biology and his experience in molecular biology research, Andy joined Dr. J. William Harbor’s Ocular Oncology Laboratory at Bascom Palmer Eye Institute to investigate targeted approaches for treating uveal melanoma, the most common form of eye cancer in adults.
The lab’s novel approach culminated in a publication titled “Dual Screen for Efficacy and Toxicity Identifies HDAC Inhibitor with Distinctive Activity Spectrum for BAP1-Mutant Uveal Melanoma”, and a new collaboration with NewVac LLC, the owner of the drug. The University of Miami is partnering with NewVac LLC to initiate a multicentered clinical trial of quisinostat in adjuvant therapy setting for patients with uveal melanoma. Notably, the impact of this research extends beyond uveal melanoma as BAP1 loss is implicated in renal cell carcinoma, mesothelioma and cholangiocarcinoma. Additionally, the study provided a proof of principle and framework for future screens to identify novel therapeutics targeting other tumor suppressors, potentially changing the landscape of cancer therapeutics. Upon reflection of this experience, Andy notes how this opportunity strengthened his critical thinking and problemsolving skills as a researcher and future clinician. He remarks, “I had to think beyond the scope of what is found in a textbook.” When he’s not busy on the wards or conducting research, Andy likes to spend his time listening to music, meditating, and practicing guitar. As a third year, Andy now plans to specialize in Emergency Medicine, followed by a critical care fellowship. Nevertheless, Andy believes that the skills that he has gained through this experience will allow him to become a leader in the field of critical care research.
Honors: Dual Screen for Efficacy and Toxicity Identifies HDAC Inhibitor with Distinctive Activity Spectrum for BAP1-Mutant Uveal Melanoma (PMID: 3077485) Mentors: Dr. J. William Harbor, MD; Dr. Jeffim N. Kuznetsoff, PhD Other Interests: Former DOCS Station Manager, Academic Society Trainer, Former Logistics Director of MSA Future Goals: Emergency Medicine and Critical Care Fellowship
22 | Spring 2021
How Have You Adapted to the Changes Caused by the Pandemic?
connecting
“I have been able to spend a lot more time with my wife, who is a rockstar, my dog, and my friends, which has made balancing work and my personal life much more manageable.” - Justin Achua
“One good thing about the pandemic is that it helped me to connect with old friends and people I had not seen in years.” - Leah
Colucci
“I’ve learned to value my time more with my friends and family, especially those who live farther away.” - Paola
C. Martinez
“I am always online with my friends at home. We watch a movie together or play video games together.” - Antonio
Fontanella
“We need to go in to school .… a couple times a month now, and it’s … exhilarating every time. I come home so much happier.” - Adam
wellness
Burton
“It’s important to cultivate habits of things that relax or rejuvenate you and treasure them as ‘non-negotiables.’ When you have so many things on your plate, it’s always nice to have those built-in systems to support you.” - Madhumita
Parmar
“It is important to know how you relax and make sure you schedule that time, and sometimes it is also just talking about what you see in medicine...that is a part of wellness as well.” - Vedant Acharya “Getting involved with telehealth and spending more time outdoors have
hope
provided me with new ways to continue doing what’s most important to me.” - Marcus
Castillo
“Investing in my wellness has been critical, but since this has lasted longer than we all expected, I’ve focused on just two things: what I can do today and what I can do tomorrow.” - Sam
Hinkes
“Sticking with my hobbies, frequently checking on my mental health, and keeping clarity towards my goals is not only how I got through the pandemic, but also how I will continue to climb the perennial ladder that is medicine.” - Andy
Lopez
The Medical IBIS | 23