Team:City of London UK/Human Practices
Silver Human Practices
After initially asking friends and family whether they had heard of Pre-Eclampsia, we quickly realised that awareness was not as wide-spread as it should be. In order to confirm this, we decided to construct a survey to gain a wider understanding of the general public’s awareness of Pre-Eclampsia.
After making the first draft of our survey, it was brought to our attention that there are certain ethical and social values that we must keep in mind, as Pre-Eclampsia can be a very personal topic for some people and it is very important for us to be respectful and not cause any harm to the participants.
This led us to speak to numerous people on the iGEM Ethics Committee, including the Committee Chair of Inclusivity and Diversity, so that we felt confident that our survey was appropriate, whilst keeping it unbiased. This was a very useful experience as they gave us many useful tips (sum of which can be seen on the Integrated Human Practices document) which helped us learn about how to conduct surveys that encompass values whilst providing us with reliable results.
We wanted to find out what information about Pre-Eclampsia already exists, so we looked at a survey from 2015 which includes responses from 1500 people in the US.[1] The results highlighted that despite many of the respondents having heard of Pre-Eclampsia, more than half did not know any associated symptoms and that Pre-Eclampsia can occur up to six weeks after delivery. This quickly showed us that education about this topic must become more wide-spread.
Despite this information already existing, our survey will mainly have participants from the UK, and therefore it will be interesting to see if there has been a comparative increase or decrease in awareness. As well as this, our main audience are 16-19 year olds who are supposedly the next generation to potentially become pregnant. Therefore, we thought our survey would be helpful in highlighting differences in education.
However, unfortunately the nearly 150 responses from 16-19 year olds made it evident that more education is needed.
Our project focuses on creating an effective yet affordable detection kit. Our focus on its affordability is as a result of extensive moral and social consideration: we want to ensure that our kit can reach the entirety of society, as well as both low and high income countries worldwide[2]. This is especially important to us as 99% of women who die from pregnancy related causes are in low and middle income countries. In engaging with healthcare, we believe that we have a responsibility not to contribute to health inequality, instead working to actively combat it. The aims of our project sit firmly alongside ‘The Millennium Development Goals’[3], which have placed maternal health at the core of the struggle against poverty and inequality, as a matter of human rights. We believe that its affordability allows for it to be implemented into routine use by the NHS, a comprehensive service, which is by definition available to all.
Through our varied research, public surveys and outreach work, we have found that general awareness of preeclampsia is low. Therefore a key aim of our project became raising awareness of preeclampsia so that the 4.6% of pregnant women affected worldwide[4], are more likely to recognise early signs and receive effective treatment. This work in increasing awareness of the condition has significant social benefits through ultimately preserving lives as more effective treatment can be accessed earlier following the onset of the disease. This is key as the Preeclampsia Foundation have concluded that 60% of maternal deaths due to preeclampsia are preventable[5]. Our project hopes to reduce the likelihood of lasting impacts for both the mother and developing fetus.
When designing our project we specifically wanted to make an early and accurate test for preeclampsia in order to reduce the severity of the symptoms as well as increase the chance of survival for the mother and baby. Preeclampsia concerns the partial transformation of spiral arteries, leading to more vasoconstriction and reduced placental perfusion[6]. With an early detection system followed by the use of mitigating treatments like labetalol/anticonvulsant medication and increased rest for the mother, our project aims to limit the danger and onset of hypertension, convulsions, and fetal hypoxia[7].
Following the construction of our biological circuits to detect upregulated miRNA during Preeclampsia, our next step was to confirm the viability of the project and therefore its social value to the world. In doing so, we contacted the Preeclampsia Foundation, explaining our project and its core principle. After liaising with the Managing Director at the Charity, Valerie Holloway, we received an official letter from the charity, which stresses that Preeclampsia is a ‘real-world problem’ caused by a combination of misdiagnoses and missed diagnoses, and recognises the potential of our project concept to improve healthcare outcomes and ‘certainly contribute to reducing mortality’.
Professor Thilaganathan
To ensure our project’s innovation, we interviewed Professor Basky Thilaganathan, Clinical Director of Fetal Medicine at St George’s Hospital. In doing so, Thilaganathan stressed the significance of an early detection tool, stating that it is ‘absolutely vital’, and that current methods ‘[rely] on a two-hundred-year-old instrument’ for detection. He also highlighted our RNA test’s potential economic benefits through preventative measures; early detection can reduce the number of Preeclampsia patients with several responses, which in turn would lower the costs required for treatment of these cases. Additionally, consulting Professor Thilaganathan advanced our understanding of Preeclampsia, as he highlighted a new-hypothesis which we were previously unaware of: the relation between pre-eclampsia and the heart, and how calcium, statins, metformin and aspirin, which are all used to treat pre-eclampsia, are all used to treat cardiovascular disease. In the 2020, Professor Thilaganathan, along with other Preeclampsia specialists, designed a programme which reduced the cases of Preeclampsia at St George’s by 25%[8]. It is for this reason that we consider him a credible source, from which we could accurately judge our project’s use in a clinical setting.
Professor Chappell
In our interview with Professor Lucy Chappell, NIHR research professor in obstetrics at King’s College London, we were able to explore the current methods of screening and detection whilst also analysing the benefits of our proposed system. Chappell introduced the importance of screening methods at 12 weeks, talking about the use of ‘clinical history such as body mass index and diseases like pre-existing hypertension’ and how if you have certain combinations of risk factors you are offered aspirin which ‘reduces the risk of getting preeclampsia by 50%’. She accentuated how the inherent problems with screening and detection methods is its sensitivity and specificity and therefore there needs to be a ‘trade-off’ between the two. When examining our proposed test, Chappell commented that whilst it would be ‘beneficial for developing countries’ one must remember that there is a ‘much lower incentive for the diagnostics companies to pursue’ these tests where they would ‘struggle’ to sell the tests for an economically suitable price. Additionally, Chappell found the And Switch useful as using both RNAs would ‘reduce false negatives’- an example of favouring specificity over sensitivity. Professor Lucy Chappell was the Honorary Research Director of the Action on Pre-eclampsia Charity and therefore is a reliable source of information on the issue of Pre-eclampsia.
Integrated Human Practices
Throughout our Project, we have relied on the help and advice of specialists and the public to help craft different aspects of our project - from the Design, to the Model, to Human Practices.
This page outlines interactions with different groups of people and individuals, and how their feedback was integrated into our project.
Design
Dr. Bae Wooli
Meetings with Dr Wooli helped the design team resolve some initial questions we had. In the meeting with Dr Wooli where we discussed using Anti miRNA instead of a normal toehold switch which we were using in our gen1 switches, he advised us to not use an anti miRNA design as he could not see how it would increase specificity.
Dr Wooli also advised us on ensuring the hybridisation domain length was more than 10 nucleotides long, so we increased the hybridisation domain of our AND gate switch, which previously had lower domain lengths for each trigger miRNA.
He also advised us to look at more than just the Minimum Free Energy (MFE) structure of our toehold switch-miRNA complex, but rather the 20 most likely secondary structures. We took this into consideration when writing the python script to design the gen2 toehold switches, by using probabilistic sampling, rather than just looking at the MFE structure.
Finally, he advised us against preparing our own cell lysate to use as a cell-free system in the lab, but to look into TXTL kits. We took this into account and ended up using a TXTL kit in the lab on his recommendation.
Professor Basky Thilaganathan
We were wary after we found out from Professor Basky that preeclampsia’s origin, despite this often being overlooked, lies within the heart as opposed to the placenta; this could mean the miRNAs which are upregulated in patients with Preeclampsia may not be present in high levels in patients with other heart problems. So we made sure to check on miRBase and a number of other miRNA databases that our microRNA biomarkers were not also upregulated in those conditions. Professor Basky also agreed that detecting a cocktail of miRNAs as opposed to just one, would allow us to create a more specific test. This inspired us to create our AND-gate switch.
Dr Alex Green
Dr Green is an expert in toehold switches, and synthetic biology in general. He advised us to base parts of our switches - notably the RBS - on his design for Zika virus detection, so we based all of our switches on these.
He agreed with Dr Wooli that we should not use our gen1 switch, as it would not increase specificity, but could in fact have the opposite effect by decreasing the length of the hybridisation domain, so we discarded these designs and he confirmed that our gen2 and gen3 switches should work.
We asked him about whether we could vary our linker regions from his design, as we had previously kept the amino acid sequence the same by only varying codons which limited our design capability. He told us that we could change the linker sequence and it wouldn’t have much effect on the switch’s performance, which allowed us to tweak our design algorithm for our gen2 switches, and gave us more freedom in designing our gen3 switch.
Furthermore, we asked him about how we could ensure our gen3 ‘AND-gate’ switch would unfold, and he suggested we look to vary the stem length. By doing this, we were able to ensure it unfolded properly on Nupack.
We later reached out to Dr Green about whether amplification would be necessary and he confirmed that in the real world, amplification might well be necessary. Based on his comments, we started researching an isothermal amplification strategy.
Dr Ciara O’Sullivan
After speaking with Professor Green about the necessity of amplification, we spoke to Dr O’Sullivan, a highly accredited biochemist working on amplification methods for nucleic acids among other projects.
We had decided that we’d like to isothermally amplify our miRNAs to ensure expensive equipment isn’t necessary for our test to be used, increasing its accessibility. We had noticed, however, that no other teams that had looked into toehold switches had researched amplification methods, let alone isothermal methods.
Dr O’Sullivan was impressed by our project and agreed with our assumption that the best way for us to amplify the miRNAs would be to first anneal two probes to them which would then be ligated together (this is called miRPA).We were looking for a method to amplify the miRNA, but she explained that there weren’t any currently researched methods which would result in amplified miRNA, but rather DNA based on an miRNA template. However, she told us that she thought single stranded DNA (ssDNA) would also be able to activate our toehold switch. Based on this advice, we looked into ways of getting the dsDNA from miRPA to become ssDNA, eventually settling on asymmetric RPA.
Hardware
Professor Lucy Chappell
Speaking to Professor Lucy Chappell, a research professor at King’s College London in Obstetrics, made us aware of how our project could have a great impact on third world countries. In our interview, she explained how by reducing the costs of the screening tool, our detection kit will be more appropriate in a global setting and could have a greater impact in these less economically developed countries, where access to even basic medical care is limited. With this in mind, we tried to make our hardware design as cost-effective as possible, by making it reusable and by developing our own luminometer. These changes, together with our removal of the automated liquid addition system, have significantly reduced the costs of our screening tool which we now hope will have a much wider impact across the globe.
Human Practices
KCL iGEM Team
Meeting with KCL helped us further consider how to avoid possible implications of our project as well as the ethical and data protection laws that need to be followed. They advised us to run our surveys by iGEM to ensure we remained ethical. Furthermore, they helped amend the phrasing of letters and surveys we were sending out to this end.
Anne Meyer
Anne Meyer, the committee chair of diversity and inclusivity from the Meyer Lab further, advised us on the importance of confidentiality with our data collection, and ways in which we can ensure this. We also discussed the importance of using gender inclusive language in our Survey with her. We decided, based on the discussion, to not talk about preeclampsia affecting ‘pregnant women’, but rather ‘pregnant patients’. And made sure to not make any type of analysis that could be perceived as a diagnosis.
John Grey & Tessa Alexanian
Contacting John Gray from the iGEM human practices committee also gave us advice on narrowing down distribution and designing scientifically valid surveys. He also informed us that our survey must be IRB approved. Furthermore, he advised us to try talking to clinicians about the condition. We took this feedback into consideration, and arranged to talk to Professor Lucy Chappell, Professor Basky Thilaganathan, and Dr Andew Shennan. We decided to prioritise increasing public awareness on preeclampsia with our human practices research for our project. Emailing Tessa Alexanian, a safety and security program officer with the iGEM foundation helped us gain insight into how to go about educating others on this. She proposed starting with existing research from preeclampsia related foundations based in the UK and other more specific regions. We then decided to consider what additional knowledge we were hoping to gain from our survey and designed our sampling strategy around that.
Dr Andew Shennan and Mrs J. Browne
Our interview with Dr Andrew Shennan made us realise the current lack of awareness of Preeclampsia and how tackling the prenatal disease requires public education as well as scientific solutions. This point was further reinforced when speaking with Mrs J. Brown, the current headmistress at City of London School for Girls and a previous patient of preeclampsia, who would have liked to have known more about preeclampsia before her pregnancy. Having heard a personal experience and also from a scientific expert, we were determined to raise the public’s awareness of the disease. In doing so, we created leaflets detailing what Preeclampsia is, and relevant medical information about the disease.
The Preeclampsia Foundation
Choosing our project was the culmination of months of deliberation as, even though we had several choices to select from, we were not sure which of these societal issues were real-world problems that could benefit from our solution. To decide, we reached out to several charities, amongst them Preeclampsia Foundation, who responded and reassured us that Preeclampsia is a ‘real world problem’ and that our project had the potential to make a huge impact and could ‘certainly contribute to reducing mortality’.
Refrences
- Pregnancy Evidence, Monitoring, Partnerships and Treatment. (2014). 2014 Preeclampsia Awareness Survey Highlights Need for Education [Online]. Available at: https://pre-empt.obgyn.ubc.ca/2014-preeclampsia-awareness-survey-highlights-need-education-1 [Accessed October 2021]
- World Health Organization. (2014). Maternal Mortality [Online]. Available at: https://apps.who.int/iris/bitstream/handle/10665/112318/WHO_RHR_14.06_eng.pdf [Accessed October 2021]
- United Nations (2018). Millennium Goals [Online]. Available at: https://www.un.org/millenniumgoals/ [Accessed October 2021]
- Edgardo Abalos, Cristina Cuesta, Ana L Grosso, Doris Chou, Lale Say. (2013). Global and regional estimates of preeclampsia and eclampsia: a systematic review [Online]. Available at: https://pubmed.ncbi.nlm.nih.gov/23746796/ [Accessed October 2021]
- Pre-eclampsia Foundation (2015). NEW RESEARCH: MAJORITY OF PREECLAMPSIA-RELATED MATERNAL DEATHS DEEMED PREVENTABLE [Online]. Available at: https://preeclampsia.org/the-news/Healthcare-practices/new-research-majority-of-preeclampsia-related-maternal-deaths-deemed-preventable [Accessed October 2021]
- Graham J Burton, Christopher W Redman, James M Roberts, Ashley Moffett. (2019). Pre-eclampsia: pathophysiology and clinical implications. BMJ 2019;366:l2381 [Online]. Available at: https://www.bmj.com/content/366/bmj.l2381 [Accessed October 2021]
- Mayo Clinic (2020). Preeclampsia [Online]. Available at: https://www.mayoclinic.org/diseases-conditions/preeclampsia/diagnosis-treatment/drc-20355751 [Accessed October 2021]
- St George's University Hospitals NHS (2020). Pre-eclampsia reduced by 25% at St George’s as rate increases elsewhere [Online]. Available at: https://www.stgeorges.nhs.uk/newsitem/pre-eclampsia-reduced-by-25-at-st-georges-as-rate-increases-elsewhere/ [Accessed October 2021]