By Lisa Brown
A former football player describes brain disease symptoms and angst
Tim Fox, the 62-year-old former New England Patriots safety, was describing to a room full of brain scientists at the Boston University School of Medicine (MED) the ferocious style of play that he’d been trained in from an early age, one that had led to countless head injuries during his 20-year college and pro career. “We were taught to use your head to tackle,” he said. “It was to be used as a weapon.”
Fox, who also played for the Los Angeles Rams and the San Diego Chargers, recalled two occasions as a Patriot when he was knocked unconscious, revived, and sent back on the field, where he was knocked unconscious again. “The doctor would come over and ask you, ‘What’s your birthday, what’s your phone number,’” he said. “Your buddy would be sitting next to you, he’d whisper in your ear, give you the answer, you give the answer to the doctor, and you’re back in the game.”
Some 50 scientists—from MED and School of Public Health (SPH), the Cleveland Clinic, the Banner Alzheimer’s Institute, the Mayo Clinic, Brigham and Women’s Hospital, and other major institutions around the country—gathered on the medical campus Wednesday to launch their landmark, seven-year, $16 million National Institutes of Health (NIH) and National Institute of Neurological Disorders and Stroke (NINDS)–funded study aimed at diagnosing CTE, a degenerative brain disease, during life. CTE, which is associated with repetitive brain trauma and characterized by changes in behavior, mood, and cognition—including the development of dementia—can currently be diagnosed only by postmortem examination of the brain. It has been found in professional football players, boxers, and other athletes with a history of repetitive brain injuries.
Robert Stern, the clinical core director of BU’s Alzheimer’s Disease & Chronic Traumatic Encephalopathy (CTE) Center, who is leading the study, introduced Fox at the meeting.
“I’d like to do anything in my power to help you folks get to the bottom of this,” Fox told the scientists. He said he has significant cognitive impairments—memory problems, difficulty with organizational tasks, severe mood changes—that he believes are clear symptoms of CTE. He said that he’d gotten lost driving to the meeting on the Medical Campus—“and I’ve lived here for 25 years.” As for his mood, he said, “my irritability factor has gone through the roof.”
The symptoms Fox described have been identified in people who were found, after death, to have had CTE. Does Fox have CTE? “We don’t know,” Stern said. And that, he said, is the point of the study: To develop ways of diagnosing CTE during life as well as to examine risk factors—repetitive hits to the head and genetics, among other things.
“We have to figure out why some people get this disease and some don’t,” Stern said.
He and his colleagues will study 240 people: 120 former NFL players (with and without CTE symptoms), 60 former college football players (with and without CTE symptoms), and 60 control subjects who have never played contact sports or experienced any type of brain trauma. Researchers will examine the participants at MED and three other centers: the Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, the Mayo Clinic in Scottsdale, Ariz., and the New York University Langone Medical Center in New York City. In addition to extensive clinical examinations, participants will undergo positron emission tomography (PET) imaging, MRI scans, blood work, and other tests with the potential to detect changes in the brain associated with CTE. Data will be shared with researchers worldwide.
Stern is one of four principal investigators on the study. The others, whom he introduced yesterday, are Martha Shenton, director of the Psychiatry Neuroimaging Laboratory and senior scientist at Brigham and Women’s Hospital; Jeffrey Cummings, director of the Cleveland Clinic Lou Ruvo Center for Brain Health; and Eric Reiman, executive director of the Banner Alzheimer’s Institute. Stern and others at the meeting emphasized the sweeping, multidisciplinary, multi-institution, collaborative nature of the research they are about to embark upon together. “We hear about this often as ‘the Stern study,’” Stern told his colleagues. “I can’t stand that, and I’ve been trying to do everything possible to undo that.”
Cummings, who is a physician, talked about the importance of early diagnosis. “How can we inform athletes, soldiers, other people involved in repetitive brain injury, about their future?” he said. However, he added: “This is not just about diagnosis. Eventually, this has to be about prevention and treatment.”
Cummings also sounded a cautionary note. “This is a very newsworthy study,” he said. “As representatives of the study, we all need to make sure we accurately represent what the study is and what it isn’t. This is not epidemiology. This is a convenient sample of people we’re able to recruit for the study. We cannot extrapolate from what we see to the entire population. The scientific process is key. This is about open, transparent interrogation. It’s about asking questions, finding answers, trying to set all our pre-inclinations aside.”
“This is funded by the public in order to help the public,” he added. “We want to protect athletes’ brain health and I believe everyone involved in athletics wants that. There is no advantage in having an athlete who is beaten up and can’t sustain a high level of performance. We want to protect against the effects of head injury wherever it occurs. We’re concerned about soldiers, traffic accidents, domestic abuse. This is a set of lessons that will have wide implications in society.”
Stern noted that the new study will build on the groundbreaking work of MED professor of neurology and pathology Ann McKee, director of the CTE Center and associate director of BU’s Alzheimer’s Disease Center (ADC), who first identified the telltale mark of CTE—tiny tangles of a protein called tau, clustered around blood vessels—in the dissected brain of a boxer who had been diagnosed with Alzheimer’s disease.
McKee, who oversees the ADC Neuropathology Core’s Brain Bank and has studied the brains of more than 200 people found to have CTE, gave the group an overview of her eight years of research into CTE. “We know this is a very biased sample,” she said. “You can’t take anything from these numbers in an absolute sense. But if this were a rare disease, there’s no way we could be this successful at brain collection. I couldn’t just go out and say, ‘I’m going to look at some strange, unusual disease and collect 200 cases in seven years.’ What this says is that this disease is much more common than we thought. Your study is going to show that.”
She showed a montage of the faces of dozens of athletes who have been found to have CTE over the years. “This is a study about people,” she said. “We do this because we are speaking for those people who can’t speak for themselves any longer. We tell their stories because people need to know.”
A Congressional investigation found last week that top NFL health officials had improperly pressured the NIH to remove Stern, who has been critical of the NFL, from the study. When the NIH refused, the NFL backed out of a signed agreement to pay for the study, according to the investigation by the House Committee on Energy and Commerce. Stern has declined to comment, saying he prefers to focus on the important science.
This BU Today story was written by Sara Rimer. She can be reached at email@example.com. Photos by Cydney Scott.
Evans Center for Implementation and Improvement Sciences
Department of Medicine
Pilot Grant Program
The Center for Implementation and Improvement Sciences (CIIS) seeks pilot projects that will improve the processes and outcomes of health care delivery, particularly in safety net settings.
Preference will be given to applicants that integrate implementation and improvement sciences; pilot funding is designed to foster multidisciplinary, collaborative, and innovative research. For more information about the pilot and how to apply visit: http://sites.bu.edu/ciis/center-organization/pilot-grant-program/
Application Deadline: July 15 at 11:59 p.m.
Funding Decision: Aug. 15, 2016
Earliest Start: Sept. 1, 2016
On May 24 the Department of Family Medicine hosted the Seventh Annual Lynne Stevens Memorial Lecture, delivered by Elaine Alpert, MD, MPH, a scholar in family violence, sexual assault, and human trafficking at the University of British Columbia (UBC) who consults internationally on education, policy, public health and prevention.
During the lecture Alpert described the scope, presentation, and health effects of human trafficking and outlined strategies for identification and response. She also discussed how to facilitate collaboration between health care and other sectors of society. She noted that as many as 88 percent of trafficking survivors reported encounters with health care providers while being trafficked in a variety of settings. Alpert explained that health providers’ barriers to effective care included insufficient prior education, lack of practical experience, not knowing how to respond, and no private space, insufficient time or reimbursement. She concluded that with knowledge of key principles for trauma-sensitive practice, effective inquiry can begin the process of intervention to help trafficking victims. After the lecture the audience discussed ways that providers can help patients share their struggles with being coerced or abused; the next critical step is knowing how to offer and refer the patient to appropriate assistance.
Alpert is the lead author of Intimate Partner Violence: the Clinician’s Guide to Identification, Assessment, Intervention and Prevention, and Human Trafficking: A Guidebook on Identification, Assessment, and Response in the Health Care Setting. She also offers online continuing medical education about domestic and sexual violence. She previously was a member of the medical campus community serving as an associate professor of Social and Behavioral Sciences at the School of Public Health and as an assistant dean at the School of Medicine. She subsequently moved to Canada with a Fulbright to develop and teach interprofessional courses in violence prevention and intervention at UBC where she served as the Director of the Interpersonal Violence Prevention Program and created the UBC Violence Intervention and Prevention Connector.
The annual event honors Lynne Stevens, LICSW, BCD (1946-2009), former director of the Responding to Violence Against Women Program and an assistant professor in the Department of Family Medicine. She was a clinician, activist and researcher who worked locally, nationally, and internationally, specializing in evaluation of the quality of care offered to women who were victims of violence.
March malfunction posed no public health threat
A malfunctioning network switch at BU’s National Emerging Infectious Diseases Laboratories (NEIDL) resulted in a shutdown of parts of the lab’s ventilation monitoring system for eight hours on March 21. The malfunction impeded the flow of air out of the Biosafety Level 3 (BSL-3) and Biosafety Level 4 (BSL-4) labs. The event, which was immediately reported to the Centers for Disease Control and Prevention (CDC) and the Boston Public Health Commission (BPHC), was detailed in a draft report by outside engineers Colorado-based Merrick & Company, whose final report is expected within the next several weeks. Once the event had been analyzed, BU also notified the National Institute of Allergy and Infectious Diseases.
The University has suspended BSL-3 research until the outside engineers review recommended remedial work to prevent future ventilation system malfunctions. Gloria Waters, BU’s vice president and associate provost for research, says the University will contact the CDC and the BPHC when the remedial work is complete. “We would want to hear back from them before we start to do research again,” she says.
Waters says the event did not pose a threat to public health because no research was under way, safety protocols were in place, and redundant safety systems continued to operate as intended. She says in both BSL-3 and BSL-4 labs, pathogens are exposed to air only within biosafety cabinets, which have their own filtration system, while a redundant filtration system operates in the rooms containing the cabinets.
NEIDL’s BSL-4 labs are not in use, says Waters, because they have not yet received final regulatory approval, and consequently there were no BSL-4 pathogens or research in those laboratories. (BSL-4 research requires the highest safety levels.) Even if research had been under way, Waters says, “The underlying safety systems, which include airtight seals around the doors, worked as intended, and the malfunction would not have created a public risk.”
Waters says the BSL-3 laboratories, which have been used primarily for tuberculosis research, were closed at the time of the event, and had been decontaminated after the most recent research. “Their pathogens were locked down in freezer storage units as required by safety protocols,” she says. The freezers were not affected by the ventilation system malfunction.
The draft engineering report, Waters, and Gary Nicksa, BU’s senior vice president for operations, gave the following details of the event:
The NEIDL’s ventilation, which is controlled by a Siemens Building Automation System (BAS), runs on a dedicated computer network linked to Siemens control panels that regulate airflow into and out of the NEIDL’s laboratories. At 8 p.m. on March 21, a fiber optic module on one of the network switches malfunctioned, cutting off monitoring of the BAS from the Medical Campus control center. The malfunction also triggered a “network broadcast storm,” a continuous stream of data that was sent to all devices on the BAS network, preventing the control panels from communicating properly and causing them to malfunction.
The ventilation system is designed to maintain “negative” air pressure in the BSL-3 and BSL-4 labs, so that any airborne contaminants stay in the labs until pulled by exhaust fans into HEPA filters that purify the air. On March 21, the BSL-3 and BSL-4 labs’ control panels were working properly until the network malfunction prevented exhaust fans from functioning.
With the exhaust fans off, air pressure in the labs increased. Local pressure monitors in BSL-3 rooms indicated that the pressure had become “positive,” indicating unfiltered air being pushed out of BSL-3 labs. Had research been under way, the local pressure monitors would have alerted researchers to finish work with any pathogens as quickly as possible, remove them from biosafety cabinets, the only place they are exposed to air, and safely store them.
The preliminary report by the outside engineers reported that at the same time, the BSL-4 rooms experienced momentary increases in positive air pressure, and the rooms’ internal containment system responded as designed, isolating the air supply. “The pressure monitors and all the controls for each room are contained on a dedicated room controller” the engineers reported. “The room controller was monitoring the room pressure and reacted to the fan failures by shutting HVAC isolation dampers serving the individual BSL-4 laboratories.” As a result, the BSL-4 laboratories remained airtight on March 21.
“Any pathogens would have been contained,” says Nicksa. “They would be vented and purified by a HEPA filter within the biosafety cabinet where researchers handle the pathogens and another pair in the lab’s exhaust system as an extra safety measure in the event any pathogens make their way from the biosafety cabinet into the lab space itself. We know that this system worked on March 21, and we know that it would have provided an additional margin of public safety had the laboratories been in use at the time.”
By 9:30 p.m., NEIDL safety, facility, and technology staffers had determined that a switch problem likely had shut down the monitoring system. An onsite mechanic physically monitored the air handling units and exhaust fans. At 11:58 p.m., with exhaust fans in the BSL-3 labs still inoperative, NEIDL staff replaced the malfunctioning network component.
By 4:45 a.m. on March 22, a little more than eight hours after the initial malfunction, all network services, BAS communications, and the labs’ air pressure control had returned to their proper operation.
BU asked Merrick & Company, which has offices globally and specializes in biocontainment labs like the NEIDL, to validate BU’s investigation and conduct an outside review of the event and the recommended remedial measures. The firm’s final report will be given to the CDC and the BPHC. According to the draft report, remediation may include, among other things: a hardwire interlock between exhaust and supply fans, to shut down the supplying air handling units anytime the exhaust system is not operating; a new protocol on BAS network switch uplinks to reduce the chance of a network broadcast storm; and increased network monitoring that will notify staff of similar events or to any unusual jump in network traffic.
“Boston is one of the few cities with well-defined BSL-3 and BSL-4 oversight,” Waters says, and BU complied with BPHC regulations requiring that the commission be notified. “We overreport because we want to be totally transparent. And we are satisfied that the redundant safety systems that are in place functioned as expected and that there was never any risk to public safety, which is the most important thing.”
Biosafety levels (BSLs), which range from BSL-1 (lowest risk) to BSL-4 (highest risk), are assigned based on primary risk criteria, including infectivity, severity of disease, and the nature of the work being conducted. Each level of containment describes appropriate laboratory practices, safety equipment, and policies for conducting research with a particular agent. The policies are in place to protect researchers, nonlaboratory occupants of the building, the public health, and the environment.
This is a BU Today story.
On Thursday, May 25, more than 100 faculty, staff, residents and students attended the 11th Annual John McCahan Medical Education Day on the BU Medical Campus, an interactive event that aims to showcase the wide variety of educational innovations and research activities taking place on campus.
Named after John McCahan, MD, former associate dean for Academic Affairs (1976–2006) and acting dean (2003–2005) at BUSM, the daylong event included five workshops and a poster session displaying nearly 40 abstracts.
This year’s theme, “Interactive Learning,” covered a variety of topics including team-based learning, peer-mentoring, professional development and other critical tools for teaching, learning and evaluation.
The keynote address, “Transforming the Large Enrollment Lecture Classroom into an Active Learning Zone,” was given by Colin Montpetit, assistant professor of biology at University of Ottawa and co-founder of the Ontario Consortium of Undergraduate Biology Educators, who shared his particular interest in producing a better quality, more engaging student experience without reducing enrollment numbers.
“We are pleased to offer BUMC educators a day of stimulating speakers and workshops for inspiration and sharing innovative ideas,” said Karen Antman, MD, BUSM Dean and Provost of the Medical Campus.
Parking and Transportation Services for Memorial Day observed on Monday, May 30
NO SHUTTLE SERVICES including the HealthNet service and Boston University Shuttle (BUS).
All parking facilities will be open.
- 610 Albany Street garage monthly parkers may park in the 710 Albany Street or Doctors Office Building (DOB) garages.
- All valid 610 Albany Street garage access will be programmed to work in the 710 Albany Street and DOB garages on Monday, May 30 only.
- Those who are not enrolled in the monthly parking program may park in 710 Albany Street and DOB garages for $7 on Monday, May 30 only.
- The MBTA is operating on a Sunday schedule, except the CT buses (CT1, CT3) which will not be operating.
- The Commuter Rail is operating on a Sunday schedule.
- For detailed information, please visit http://www.mbta.com/events/
Any questions? Please call TranSComm at 638-7473 or the Parking Office at 638-4915.
Boston University’s BioScience Academy has received nearly $100K to train unemployed and/or underemployed Massachusetts residents with additional skills for jobs in life sciences. This award is part of more than $2 million in grants from the Workforce Competitiveness Trust Fund (WCTF) that supports regional partnerships between businesses, educational institutions, community-based organizations and workforce development groups.
The program is designed to assist individuals with a STEM (Science, Technology, Engineering, and/or Math) or healthcare background enter the biotech/ life sciences field. Full tuition scholarships are available for eligible individuals.
The two-semester program, which begins in September and ends in May, includes classes in biomedical science and clinical research and an internship. Upon completion, graduates receive twelve Boston University credits and a Certificate in Applied Biotechnology. All classes are held at the Medical Campus. For more information go to http://www.bu.edu/biosci/
First Study to Prospectively Test the Effectiveness of a Teachable Moment
Parents who smoke are more likely to quit smoking after receiving motivational smoking cessation counseling following a “teachable moment” (TM) such as witnessing their child experience an asthma attack.
The study, which appears in the journal Addiction, also found that in-home counseling visits, including feedback on their child’s second hand smoke exposure (SHSe) and counseling phone calls improved the likelihood of smoking cessation and less SHSe.
Despite a reduction in overall smoking prevalence, parental smoking and pediatric SHSe remain high, particularly among minority and low income families with children with asthma. More than 40 percent of all children are exposed to SHSe, which increases the risk for asthma.
Led by Belinda Borrelli, PhD, professor of Health Policy & Health Services Research and Director of Behavioral Science Research at Boston University Goldman School of Dental Medicine (BUGSDM), the researchers compared parents who smoke and have a child with asthma to parents who smoke and have healthy children. They found parents of children with asthma who experienced a TM (child’s asthma exacerbation) and motivational smoking cessation counseling were more than twice as likely to quit smoking than those parents of healthy children who received identical counseling. In addition, among parents of children with asthma, those who received long-term in-home and telephone counseling were more than twice as likely to quit smoking versus parents who received short-term counseling. They also had children with an 81 percent lower risk of being hospitalized for asthma and were about half as likely to miss school due to asthma or have asthma symptoms.
According to Borrelli, interventions or counseling provided during a teachable moment does motivate smoking cessation. “Despite the fact that our sample had a high prevalence of risk factors that are typically associated with difficulty quitting smoking such as lower education, low income, single mothers, etc. we achieved quit rates that were two-five times greater than spontaneous quit rates,” she explained.
Borrelli believes that these results underscore the need to develop novel interventions to motivate cessation and augment risk perception among parents of healthy children, who had lower quit rates in the study.
Funding for this study was provided by a grant from the National Institutes of Health (National Heart, lung and Blood Institute).
Time constraints, professional boundaries, and a lack of training and shared electronic medical records are among the key reasons why oral health often is not integrated into pediatric primary care at federally qualified health centers, according to a new study led by a School of Public Health researcher.
The study, published in the journal Preventing Chronic Disease, looked at how children’s dental care was handled at six health clinics in Maryland and Massachusetts. It found no correlation between success at dental integration and factors such as clinic size, patient characteristics, geographic location, or budget. For example, the most under-resourced clinic was “the most highly integrated,” the authors said.
Instead, strong leadership with a commitment to cross-disciplinary collaboration was critical to ensuring that dental care was integrated into pediatric care, the study found. Recommendations that emerged from interviews with clinicians and staff include identifying oral health “champions,” forming an oral health committee, providing on-site workshops in oral health, and increasing funding for oral health at federal health centers.
The study found that administrators and staff at the clinics understood and supported the importance of oral health for young children. The US Preventive Services Task Force recommends that all children receive fluoride varnish starting at the age of six months or at the first tooth eruption. But, the authors noted, pediatric providers in health clinics often are the only source of oral health education for low-income children, and recent studies have confirmed gaps in oral care and referral rates for children on Medicaid assistance.
In clinics that did provide dental services, clinicians reported that “multiple clinic priorities” limited the amount of time available for cross-specialty communication. Co-location of pediatric and dental services in a clinic was not a guarantee that a child would be seen by a dentist, but instead was “only the initial step toward implementing interdisciplinary care,” the study found.
“There was general agreement that integration could happen only with leadership and vision at the top,” said the study’s lead author, Judith Bernstein, professor of community health sciences and of emergency medicine at the School of Medicine. “Upper-level administrators’ involvement was seen as critical in setting the tone for clinic priorities and empowering the staff.”
The study was sponsored by the Center for Research to Evaluate and Eliminate Dental Disparities (CREEDD) at the Henry M. Goldman School of Dental Medicine, under the leadership of Raul Garcia, chair of the Department of Health Policy & Health Services Research, and was done in collaboration with researchers from the University of Maryland School of Dentistry. Co-authors include Paul Geltman, a pediatrician with a joint appointment at SDM, and recent alumnae Christina Gebel and Ashley Walter.
Submitted by Lisa Chedekel
In an article in the American Journal of Preventive Medicine, Laura White, associate professor of biostatistics, and colleagues from the Slone Epidemiology Center at BU probed the association between ambient air pollution exposure and weight gain over 16 years among a large group of African American women in the long-running Black Women’s Health Study (BWHS). Levels of fine particulate matter, ozone, and nitrogen oxide were estimated at participants’ residential locations in 56 metro areas, and weight was tracked. The study adjusted for potential confounders, such as diet, neighborhood socioeconomic status, exercise, births, and smoking status.
The researchers found “no consistent pattern between weight change and pollutant exposure across BMI (body mass index) or SES (socioeconomic status) categories,” the study says. “The weight change associated with other exposures (such as different diet patterns and pregnancies) … was more substantial.”
The only statistically significant weight change detected was a loss of 0.50 kg over 16 years associated with each quartile increase in nitrogen dioxide. The authors said that finding may have emerged by chance or may reveal “underlying challenges in analyses of air pollution” where multiple environmental factors play a role.
Substantial research has been dedicated to understanding the reasons for the dramatic rise in obesity rates in the US in the past two decades. Animal studies and epidemiologic studies in children have suggested that air pollution might contribute to weight gain. In one such study, mice exposed to diesel exhaust prenatally were found to have greater weight gain in adulthood.
White and her co-authors noted that their models for particulate matter and nitrogen oxide levels relied on government monitoring sites, which tend to be located away from major roadways—meaning pollution exposures may have been underestimated.
Other BU authors on the study were: Lynn Rosenberg, associate director of the Slone Epidemiology Center and professor of epidemiology; Patricia Coogan, senior epidemiologist at Slone and research professor of epidemiology; and Jeffrey Yu, research data manager at Slone.
Submitted by Lisa Chedekel