A football player making a tackle during a game. (© Joe/Fotolia)
What do football superstars Tom Brady, Drew Brees, Philip Rivers, and Adrian Peterson all have in common? Last year they wore helmets that provided the poorest protection against concussions in all the NFL.
"You're only as protected as well as the worst helmet that's out there."
A Dangerous Policy
Football helmets are rated on a one-star to five-star system based on how well they do the job of protecting the player. The league has allowed players to use their favorites, regardless of the star rating.
The Oxford-trained neuroscientist Ray Colello conducted a serious analysis of just how much the protection can vary between each level of star rating. Colello and his team of graduate students sifted through two seasons of game video to identify which players were wearing what helmets. There was "a really good correlation with position, but the correlation is much more significant based on age."
"The average player in the NFL is 26.6 years old, but the average age of a player wearing a one-star helmet is 34. And for anyone who knows football, that's ancient," the brain doc says. "Then for our two-star helmet, it's 32; and for a three-star helmet it's 29." Players were sticking with the helmets they were familiar with in college, despite the fact that equipment had improved considerably in recent years.
"You're only as protected as well as the worst helmet that's out there," Colello explains. Offering an auto analogy, he says, "It's like, if you run into the back of a Pinto, even if you are in a five-star Mercedes, that gas tank may still explode and you are still going to die."
It's one thing for a player to take a risk at scrambling his own brain; it's another matter to put a teammate or opponent at needless risk. Colello published his analysis early last year and the NFL moved quickly to ban the worst performing helmets, starting next season.
Some of the 14 players using the soon-to-be-banned helmets, like Drew Brees and Philip Rivers, made the switch to a five-star helmet at the start of training camp and stayed with it. Adrian Peterson wore a one-star helmet throughout the season.
Tom Brady tried but just couldn't get comfortable with a new bonnet and, after losing a few games, switched back to his old one in the middle of the season; he says he's going to ask the league to "grandfather in" his old helmet so he can continue to use it.
As for Colello, he's only just getting started. The brain doc has a much bigger vision for the future of football safety. He wants to prevent concussions from even occurring in the first place by creating an innovative new helmet that's unlike anything the league has ever seen.
Oxford-trained neuroscientist Ray Colello is on a mission to make football safer.
(Photo credit: VCU public affairs)
"A Force Field" of Protection
His inspiration was serendipitous; he was at home watching a football game on TV when Denver Bronco's receiver Wes Welker was hit, lay flat on the field with a concussion, and was carted off. As a commercial flickered on the screen, he ambled into the kitchen for another beer. "What those guys need is a force field protecting them," he thought to himself.
Like so many households, the refrigerator door was festooned with magnets holding his kids' school work in place. And in that eureka moment the idea popped into his head: "Maybe the repulsive force of magnets can put a break on an impact before it even occurs." Colello has spent the last few years trying to turn his concept into reality.
Newton's laws of physics – mass and speed – play out graphically in a concussion. The sudden stop of a helmet-to-helmet collision can shake the brain back and forth inside the skull like beans in a maraca. Dried beans stand up to the impact, making their distinctive musical sound; living brain tissue is much softer and not nearly so percussive. The resulting damage is a concussion.
The risk of that occurring is greater than you might think. Researchers using accelerometers inside helmets have determined that a typical college football player experiences about 600 helmet-to-helmet contacts during a season of practice and games. Each hit generates a split second peak g-force of 20 to 150 within the helmet and the odds of one causing a concussion increase sharply over 100 gs of force.
By comparison, astronauts typically experience a maximum sustained 3gs during lift off and most humans will black out around 9gs, which is why fighter pilots wear special pressure suits to counter the effects.
"It stretches the time line of impact quite dramatically. In fact in most instances, it doesn't even hit."
The NFL's fastest player, Chris Johnson, can run 19.3 mph. A collision at that speed "produces 120gs worth of force," Colello explains. "But if you can extend that time of impact by just 5 milliseconds (from 12 to 17msec) you'll shift that g-force down to 84. There is a very good chance that he won't suffer a concussion."
The neuroscientist dived into learning all he could about the physics magnets. It turns out that the most powerful commercially available magnet is an alloy made of neodymium, iron, and boron. The elements can be mixed and glued together in any shape and then an electric current is run through to make it magnetic; the direction of the current establishes the north-south poles.
A 1-pound neodymium magnet can repulse 600 times its own weight, even though the magnetic field extends less than an inch. That means it can push back a magnet inside another helmet but not affect the brain.
Crash Testing the Magnets
Colello couldn't wait to see if his idea panned out. With blessing from his wife to use their credit card, he purchased some neodymium magnets and jury-rigged experiments at home.
The reinforced plastics used in football helmets don't affect the magnetic field. And the small magnets stopped weights on gym equipment that were dropped from various heights. "It stretches the time line of impact quite dramatically. In fact in most instances, it doesn't even hit," says Colello. "We are dramatically shifting the curve" of impact.
Virginia Commonwealth University stepped in with a $50,000 innovation grant to support the next research steps. The professor ordered magnets custom-designed to fit the curvature of space inside the front and sides of existing football helmets. That makes it impossible to install them the wrong way, and ensures the magnets' poles will always repel and not attract. It adds about a pound and a half to the weight of the helmet.
a) The brain in a helmet. b) Placing the magnet. c) Measuring the impact of a helmet-to-helmet collision. d) How magnets reduce the force of impact.
(Courtesy Ray Colello)
Colello rented crash test dummy heads crammed with accelerometers and found that the magnets performed equally well at slowing collisions when fixed to a pendulum in a test that approximated a helmet and head hitting a similarly equipped helmet. It impressively reduced the force of contact.
The NFL was looking for outside-the-box thinking to prevent concussions. It was intrigued by Colello's approach and two years ago invited him to submit materials for review. To be fair to all entrants, the league proposed to subject all entries to the same standard crush test to see how well each performed in lessening impact. The only trouble was, Colello's approach was designed to avoid collisions, not lessen their impact. The test wouldn't have been a valid evaluation and he withdrew from consideration.
But Colello's work caught the attention of Stefan Duma, an engineering professor at Virginia Tech who developed the five-star rating system for football helmets.
"In theory it makes sense to use [the magnets] to slow down or reduce acceleration, that's logical," says Duma. He believes current helmet technology is nearing "the end of the physics barrier; you can only absorb so much energy in so much space," so the field is ripe for new approaches to improve helmet technology.
However, one of Duma's concerns is whether magnets "are feasible from a weight standpoint." Most helmets today weigh between two and four pounds, and a sufficiently powerful magnet might add too much weight. One possibility is using an electromagnet, which potentially could be lighter and more powerful, particularly if the power supply could be carried lower in the body, say in the shoulder pads.
Colello says his lab tests are promising enough that the concept needs to be tried out on the playing field. "We need to make enough helmets for two teams to play each other in a regulation-style game and measure the impact forces that are generated on each, and see if there is a significant reduction." He is waiting to hear from the National Institutes of Health on a grant proposal to take that next step toward dramatically reducing the risk of concussions in the NFL.
Just five milliseconds could do it.
Tardigrades can completely dehydrate and later rehydrate themselves, a survival trick that scientists are harnessing to preserve medicines in hot temperatures.
Formulating biologics to withstand drying and hot temperatures has been the holy grail for pharmaceutical researchers for decades. It’s a hard feat to manage. “Biologic pharmaceuticals are highly efficacious, but many are inherently unstable,” says Thomas Boothby, assistant professor of molecular biology at University of Wyoming. Therefore, during storage and shipping, they must be refrigerated at 2 to 8 degrees Celsius (35 to 46 degrees Fahrenheit). Some must be frozen, typically at -20 degrees Celsius, but sometimes as low -90 degrees Celsius as was the case with the Pfizer Covid vaccine.
For Covid, fewer than 73 percent of the global population received even one dose. The need for refrigerated or frozen handling was partially to blame.
The costly cold chain
The logistics network that ensures those temperature requirements are met from production to administration is called the cold chain. This cold chain network is often unreliable or entirely lacking in remote, rural areas in developing nations that have malfunctioning electrical grids. “Almost all routine vaccines require a cold chain,” says Christopher Fox, senior vice president of formulations at the Access to Advanced Health Institute. But when the power goes out, so does refrigeration, putting refrigerated or frozen medical products at risk. Consequently, the mRNA vaccines developed for Covid-19 and other conditions, as well as more traditional vaccines for cholera, tetanus and other diseases, often can’t be delivered to the most remote parts of the world.
To understand the scope of the challenge, consider this: In the U.S., more than 984 million doses of Covid-19 vaccine have been distributed so far. Each one needed refrigeration that, even in the U.S., proved challenging. Now extrapolate to all vaccines and the entire world. For Covid, fewer than 73 percent of the global population received even one dose. The need for refrigerated or frozen handling was partially to blame.
Globally, the cold chain packaging market is valued at over $15 billion and is expected to exceed $60 billion by 2033.
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Freeze-drying, also called lyophilization, which is common for many vaccines, isn’t always an option. Many freeze-dried vaccines still need refrigeration, and even medicines approved for storage at ambient temperatures break down in the heat of sub-Saharan Africa. “Even in a freeze-dried state, biologics often will undergo partial rehydration and dehydration, which can be extremely damaging,” Boothby explains.
The cold chain is also very expensive to maintain. The global pharmaceutical cold chain packaging market is valued at more than $15 billion, and is expected to exceed $60 billion by 2033, according to a report by Future Market Insights. This cost is only expected to grow. According to the consulting company Accenture, the number of medicines that require the cold chain are expected to grow by 48 percent, compared to only 21 percent for non-cold-chain therapies.
Tardigrades to the rescue
Tardigrades are only about a millimeter long – with four legs and claws, and they lumber around like bears, thus their nickname – but could provide a big solution. “Tardigrades are unique in the animal kingdom, in that they’re able to survive a vast array of environmental insults,” says Boothby, the Wyoming professor. “They can be dried out, frozen, heated past the boiling point of water and irradiated at levels that are thousands of times more than you or I could survive.” So, his team is gradually unlocking tardigrades’ survival secrets and applying them to biologic pharmaceuticals to make them withstand both extreme heat and desiccation without losing efficacy.
Boothby’s team is focusing on blood clotting factor VIII, which, as the name implies, causes blood to clot. Currently, Boothby is concentrating on the so-called cytoplasmic abundant heat soluble (CAHS) protein family, which is found only in tardigrades, protecting them when they dry out. “We showed we can desiccate a biologic (blood clotting factor VIII, a key clotting component) in the presence of tardigrade proteins,” he says—without losing any of its effectiveness.
The researchers mixed the tardigrade protein with the blood clotting factor and then dried and rehydrated that substance six times without damaging the latter. This suggests that biologics protected with tardigrade proteins can withstand real-world fluctuations in humidity.
Furthermore, Boothby’s team found that when the blood clotting factor was dried and stabilized with tardigrade proteins, it retained its efficacy at temperatures as high as 95 degrees Celsius. That’s over 200 degrees Fahrenheit, much hotter than the 58 degrees Celsius that the World Meteorological Organization lists as the hottest recorded air temperature on earth. In contrast, without the protein, the blood clotting factor degraded significantly. The team published their findings in the journal Nature in March.
Although tardigrades rarely live more than 2.5 years, they have survived in a desiccated state for up to two decades, according to Animal Diversity Web. This suggests that tardigrades’ CAHS protein can protect biologic pharmaceuticals nearly indefinitely without refrigeration or freezing, which makes it significantly easier to deliver them in locations where refrigeration is unreliable or doesn’t exist.
The tricks of the tardigrades
Besides the CAHS proteins, tardigrades rely on a type of sugar called trehalose and some other protectants. So, rather than drying up, their cells solidify into rigid, glass-like structures. As that happens, viscosity between cells increases, thereby slowing their biological functions so much that they all but stop.
Now Boothby is combining CAHS D, one of the proteins in the CAHS family, with trehalose. He found that CAHS D and trehalose each protected proteins through repeated drying and rehydrating cycles. They also work synergistically, which means that together they might stabilize biologics under a variety of dry storage conditions.
“We’re finding the protective effect is not just additive but actually is synergistic,” he says. “We’re keen to see if something like that also holds true with different protein combinations.” If so, combinations could possibly protect against a variety of conditions.
Commercialization outlook
Before any stabilization technology for biologics can be commercialized, it first must be approved by the appropriate regulators. In the U.S., that’s the U.S. Food and Drug Administration. Developing a new formulation would require clinical testing and vast numbers of participants. So existing vaccines and biologics likely won’t be re-formulated for dry storage. “Many were developed decades ago,” says Fox. “They‘re not going to be reformulated into thermo-stable vaccines overnight,” if ever, he predicts.
Extending stability outside the cold chain, even for a few days, can have profound health, environmental and economic benefits.
Instead, this technology is most likely to be used for the new products and formulations that are just being created. New and improved vaccines will be the first to benefit. Good candidates include the plethora of mRNA vaccines, as well as biologic pharmaceuticals for neglected diseases that affect parts of the world where reliable cold chain is difficult to maintain, Boothby says. Some examples include new, more effective vaccines for malaria and for pathogenic Escherichia coli, which causes diarrhea.
Tallying up the benefits
Extending stability outside the cold chain, even for a few days, can have profound health, environmental and economic benefits. For instance, MenAfriVac, a meningitis vaccine (without tardigrade proteins) developed for sub-Saharan Africa, can be stored at up to 40 degrees Celsius for four days before administration. “If you have a few days where you don’t need to maintain the cold chain, it’s easier to transport vaccines to remote areas,” Fox says, where refrigeration does not exist or is not reliable.
Better health is an obvious benefit. MenAfriVac reduced suspected meningitis cases by 57 percent in the overall population and more than 99 percent among vaccinated individuals.
Lower healthcare costs are another benefit. One study done in Togo found that the cold chain-related costs increased the per dose vaccine price up to 11-fold. The ability to ship the vaccines using the usual cold chain, but transporting them at ambient temperatures for the final few days cut the cost in half.
There are environmental benefits, too, such as reducing fuel consumption and greenhouse gas emissions. Cold chain transports consume 20 percent more fuel than non-cold chain shipping, due to refrigeration equipment, according to the International Trade Administration.
A study by researchers at Johns Hopkins University compared the greenhouse gas emissions of the new, oral Vaxart COVID-19 vaccine (which doesn’t require refrigeration) with four intramuscular vaccines (which require refrigeration or freezing). While the Vaxart vaccine is still in clinical trials, the study found that “up to 82.25 million kilograms of CO2 could be averted by using oral vaccines in the U.S. alone.” That is akin to taking 17,700 vehicles out of service for one year.
Although tardigrades’ protective proteins won’t be a component of biologic pharmaceutics for several years, scientists are proving that this approach is viable. They are hopeful that a day will come when vaccines and biologics can be delivered anywhere in the world without needing refrigerators or freezers en route.
Jamie Rettinger with his now fiance Amie Purnel-Davis, who helped him through the clinical trial.
Melanoma is the deadliest form of skin cancer. About 85,000 people are diagnosed with it each year in the U.S. and more than 8,000 die of the cancer when it spreads to other parts of the body, according to the Centers for Disease Control and Prevention (CDC).
There are two peaks in diagnosis of melanoma; one is in younger women ages 30-40 and often is tied to past use of tanning beds; the second is older men 60+ and is related to outdoor activity from farming to sports. Light-skinned people have a twenty-times greater risk of melanoma than do people with dark skin.
"When I graduated from medical school, in 2005, melanoma was a death sentence" --Diwakar Davar.
Jamie had a follow up PET scan about six months after his surgery. A suspicious spot on his lung led to a biopsy that came back positive for melanoma. The cancer had spread. Treatment with a monoclonal antibody (nivolumab/Opdivo®) didn't prove effective and he was referred to the UPMC Hillman Cancer Center in Pittsburgh, a four-hour drive from his home in western Ohio.
An alternative monoclonal antibody treatment brought on such bad side effects, diarrhea as often as 15 times a day, that it took more than a week of hospitalization to stabilize his condition. The only options left were experimental approaches in clinical trials.
Early research
"When I graduated from medical school, in 2005, melanoma was a death sentence" with a cure rate in the single digits, says Diwakar Davar, 39, an oncologist at UPMC Hillman Cancer Center who specializes in skin cancer. That began to change in 2010 with introduction of the first immunotherapies, monoclonal antibodies, to treat cancer. The antibodies attach to PD-1, a receptor on the surface of T cells of the immune system and on cancer cells. Antibody treatment boosted the melanoma cure rate to about 30 percent. The search was on to understand why some people responded to these drugs and others did not.
At the same time, there was a growing understanding of the role that bacteria in the gut, the gut microbiome, plays in helping to train and maintain the function of the body's various immune cells. Perhaps the bacteria also plays a role in shaping the immune response to cancer therapy.
One clue came from genetically identical mice. Animals ordered from different suppliers sometimes responded differently to the experiments being performed. That difference was traced to different compositions of their gut microbiome; transferring the microbiome from one animal to another in a process known as fecal transplant (FMT) could change their responses to disease or treatment.
When researchers looked at humans, they found that the patients who responded well to immunotherapies had a gut microbiome that looked like healthy normal folks, but patients who didn't respond had missing or reduced strains of bacteria.
Davar and his team knew that FMT had a very successful cure rate in treating the gut dysbiosis of Clostridioides difficile, a persistant intestinal infection, and they wondered if a fecal transplant from a patient who had responded well to cancer immunotherapy treatment might improve the cure rate of patients who did not originally respond to immunotherapies for melanoma.
The ABCDE of melanoma detection
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Clinical trial
"It was pretty weird, I was totally blasted away. Who had thought of this?" Jamie first thought when the hypothesis was explained to him. But Davar's explanation that the procedure might restore some of the beneficial bacterial his gut was lacking, convinced him to try. He quickly signed on in October 2018 to be the first person in the clinical trial.
Fecal donations go through the same safety procedures of screening for and inactivating diseases that are used in processing blood donations to make them safe for transfusion. The procedure itself uses a standard hollow colonoscope designed to screen for colon cancer and remove polyps. The transplant is inserted through the center of the flexible tube.
Most patients are sedated for procedures that use a colonoscope but Jamie doesn't respond to those drugs: "You can't knock me out. I was watching them on the TV going up my own butt. It was kind of unreal at that point," he says. "There were about twelve people in there watching because no one had seen this done before."
A test two weeks after the procedure showed that the FMT had engrafted and the once-missing bacteria were thriving in his gut. More importantly, his body was responding to another monoclonal antibody (pembrolizumab/Keytruda®) and signs of melanoma began to shrink. Every three months he made the four-hour drive from home to Pittsburgh for six rounds of treatment with the antibody drug.
"We were very, very lucky that the first patient had a great response," says Davar. "It allowed us to believe that even though we failed with the next six, we were on the right track. We just needed to tweak the [fecal] cocktail a little better" and enroll patients in the study who had less aggressive tumor growth and were likely to live long enough to complete the extensive rounds of therapy. Six of 15 patients responded positively in the pilot clinical trial that was published in the journal Science.
Davar believes they are beginning to understand the biological mechanisms of why some patients initially do not respond to immunotherapy but later can with a FMT. It is tied to the background level of inflammation produced by the interaction between the microbiome and the immune system. That paper is not yet published.
Surviving cancer
It has been almost a year since the last in his series of cancer treatments and Jamie has no measurable disease. He is cautiously optimistic that his cancer is not simply in remission but is gone for good. "I'm still scared every time I get my scans, because you don't know whether it is going to come back or not. And to realize that it is something that is totally out of my control."
"It was hard for me to regain trust" after being misdiagnosed and mistreated by several doctors he says. But his experience at Hillman helped to restore that trust "because they were interested in me, not just fixing the problem."
He is grateful for the support provided by family and friends over the last eight years. After a pause and a sigh, the ruggedly built 47-year-old says, "If everyone else was dead in my family, I probably wouldn't have been able to do it."
"I never hesitated to ask a question and I never hesitated to get a second opinion." But Jamie acknowledges the experience has made him more aware of the need for regular preventive medical care and a primary care physician. That person might have caught his melanoma at an earlier stage when it was easier to treat.
Davar continues to work on clinical studies to optimize this treatment approach. Perhaps down the road, screening the microbiome will be standard for melanoma and other cancers prior to using immunotherapies, and the FMT will be as simple as swallowing a handful of freeze-dried capsules off the shelf rather than through a colonoscopy. Earlier this year, the Food and Drug Administration approved the first oral fecal microbiota product for C. difficile, hopefully paving the way for more.
An older version of this hit article was first published on May 18, 2021