Saturday, July 31, 2010

Katie - week 7

This week was the last one for 2010 summer immersion. My overall experience was very positive. I really enjoyed being able to see a variety of procedures, surgeries, and clinics. Although I was paired with one particular doctor, I think the experience was enhanced by being able to shadow other doctors as well. My research at Cornell in the van der Meulen lab deals with bone adaptation to mechanical loads, and so this summer I wanted to learn as much as I could about bone in a clinical setting as possible. To achieve this experience, I was able to attend a Metabolic Bone Disease Clinic, the Clinic for Skeletal Dysplasia, view orthopedic surgeries including total hip and knee replacements, shadow doctors during patient clinic hours, attend grand rounds, attend a number of lectures about bone topics, and be part of a research project evaluating wear in total knee implants. Also, I was able to spend a day in the ER and had the opportunity to view a cardio thoracic surgery. These seven weeks really flew by, and I know that I gained a lot of valuable experiences and information.

This week was my last visit to the Center for Skeletal Dysplasia with Dr. Raggio. There were fewer patients seen during the day than usual. One of the patients was a ~30-year-old woman who has been living with osteogenesis imperfecta (OI) Type I. Because she was a new patient, she did not feel comfortable with students coming into the room during the examination. However, I was able to see her for a few minutes and learned more about her during the patient conference afterwards. She actually leads a fairly normal life, and her stature at 4’ 10” is right around the level to not even be considered a little person. She is a great success story for OI. Her reason for contacting the center was just to make sure that she is doing everything she can to lead a healthy, normal life. Her fractures have been few and far in between, with the last occurring over a decade ago. Dr. Raggio wanted to have some x-rays and blood work done to take a look at her bones and to measure her calcium and vitamin D levels, just to keep her in check. Since I went to the center for three straight weeks, it was definitely one of my favorite experiences during summer immersion. I think the team involved really does care about the patients they treat, and it makes all the difference.

My project also took up a lot of time this week. I wanted to be sure that I had all the data and information necessary to move forward with the statistics. Earlier, I had begun to run some preliminary statistics on the scores for each region of the knee implants for both the med student’s and my grades. Also, I did a lot of background reading on the wear ratings for implants to get a good idea of the big picture. My statistics background is decent, but I have not gone much beyond t-tests and ANOVAs before, and so this week I also met with one of the research engineers to learn about the statistics she had ran previously on a similar study. It gave great insight to how I want to tell the story of this study.

This week we had our last summer immersion meeting and a farewell dinner. The dinner was wonderful, and it was a great way to end these seven weeks! When I get back to Ithaca, I will begin to write my paper for this class to put all my clinical experiences and research project together.

Week 6 - Ruiz

This week was full of in-depth discussion and editing sessions with Dr. Grant regarding my project. Following a couple iterations of revision, I am currently working on a final draft of my analysis of injectable derma l fillers and my proposed integration of nanotechnology and biomedical engineering with that field. Dr. Grant is very interested in my BME-perspective, and hopefully I can bring new engineering ideas to the table. In our talks Dr. Grant suggested that I mention some alternative therapies briefly in the introduction, such as laser resurfacing and chemical dermabrasion. After doing some background reading, I found that laser resurfacing uses a focused laser to ablate the upper layer of skin in an attempt to remove surface wrinkles, and chemical dermabrasion is a “controlled burning” off skin. It seems that these measures are very brute-force and that any small mistake can leave permanent damage. I also noticed some trends related to dermal fillers – for instance, with increased viscosity the dermal fillers become harder to inject and more painful for the patient. (The more viscous substances displace more tissue and evoke more of a pain response as a result) I also learned that normal facial movement has the potential to push dermal filler substances inward and reduce their ability to correct facial wrinkles. Additionally, I came across several papers which I would like to investigate further and incorporate into my final draft. Some of these interesting articles involve percutaneous collagen induction therapy, in vivo chondrogenesis of mesenchymal stem cells in a photopolymerized hydrogel, and biosynthetic materials used for wound healing and guided tissue regeneration applications.

Also for this week I went to the NICU (neonatal intensive care unit) for two days to go on rounds with the residents and observe the treatment protocols for the babies under observation there. It was very interesting how technical and precise all the residents must be with regards to the medication administered to each baby - every volume and concentration must be carefully documented and increased/decreased in small increments to adjust each baby’s vitals at a gradual and safe pace. Many of the babies were premature, and as such they are more at risk for serious complications following birth. One baby was one of twins, and it had had a partially resected ileum. The post-operative course involved close monitoring for infection and keeping the baby on a ventilator until it showed better vital signs. The residents also said that they would be warming up the baby slowly – but they had to be very careful because if they warm up the baby too fast it may cause coagulation complications and brain reperfusion problems. A variety of instruments and devices were used to monitor and treat the babies, and there was a lot of information to keep track of for each patient. Although each baby requires different procedures and treatments, there were a few common treatments applied across several patients: phototherapy to combat hyperbilirubinemia, constant positive air pressure (CPAP) for breathing, incubation in highly controlled chambers, and total parenteral nutrition (TPN). One of the most interesting things about these baby patients is that they cannot communicate as adult patients do – they can only cry and that gives us minimal insight. Instead, doctors must rely exclusively on diagnostic measurements such as ECGs, stool samples, x-rays, feeding patterns, and increases in weight. From these readouts, physicians are able to diagnose and successfully treat the babies in the NICU.

I also attended more office procedures (i.e. scar removal/modification, botox injections, nipple reconstruction, steroid injections for wounds that are not healing properly, etc.) and I was able to observe several follow-up consults for patients who underwent surgeries in the first few weeks of my summer immersion experience. It was really great to see the follow-up patients so that I could get an idea of how well they were healing and what kind of rules/restrictions they had to deal with. For instance, the fleur de lis abdominoplasty patient is healing well, but she had to use drains for 2 weeks to remove excess fluid collecting in her abdomen as a result of the body’s healing processes. For her second post-op meeting with Dr. Grant, she was finally allowed to have them removed, which made her extremely happy. The C-section patient is also healing well, and her scar is barely visible now! I am impressed at how fast patients can heal, especially after learning how invasive these surgeries can be.

Week 7 - Jen Richards

This last week was primarily focused on analyzing the data from my experiments and wrapping up my research project as a whole. I got some interesting preliminary data, measuring the stiffness of fat and muscle. I think the device will be very useful to doctors removing cancerous tissue in the future, although it still needs some work.

On that same note, I did see a surgery with Dr. Simmons, who works primarily with invasive breast cancer. I observed a breast resection and lymph node biopsy. What was interesting was that the lymph node tissue sample as sent to pathology, and we immediately got a response that the tissue was benign. This meant that the rest of the lymph nodes could remain. The breast resection was interesting, especially as it relates to my research project. The cancerous mass was removed, and then the edges around the mass, known as the "margins" were also removed for testing, in case the cancer had spread. This is exactly what the device is meant for, to test the margins for tissue stiffness (cancerous tissue is stiffer than healthy), so that tissue is not needlessly removed. All in all a very interesting surgery.

This was a very educational and exciting experience. I would like to thank everyone who put the time and effort to make this possible, as well as my mentor, Dr. Spector, for sponsoring me for this summer.

Week 7 - Carissa

This last week I spent most of my time on my research project, but I did get into the operating room one last time. I watched as Dr. Giardi and his team replaced a man's aortic heart valve and froze parts of his heart to get rid of the source of his arrhythmia. I was amazed to see that the heart valve they removed was so fragile and shapeless. They implanted a bovine biovalve attached to a synthetic graft to replace parts of the aorta that they had to remove with the valve tissue. The whole procedure was the most intense I have witnessed during my stay here. For the most part, I've shadowed plastic surgeons up until this point, and now I have come to the conclusion that they are somewhat a breed of their own. Cardiothoracic surgeons don't explain much, or really use any extra words at all. Fortunately the lady running the Cell Saver (to send lost blood back to the patient) and the OR nurse were kind enough to explain what was happening throughout the procedure. Hopefully the patient will go home and recover fully.

My research project has been going very well for the past few weeks, and I am excited to say that it has resulted in a collaboration between Dr. Spector's lab and my academic advisor Mike King at Cornell's campus in Ithaca. The next few weeks I will be focussing entirely on getting the next phase of the project off the ground and I will be submitting an abstract for a surgery conference in California to present the work. I couldn't think of a better way to end the summer. It has been a great experience over all. I've learned a lot, and it was a good time to connect basic research in a lab to clinical applications that doctors actually use to treat or diagnose patients. It gives a bit of a different perspective as I go back to my regular work in Ithaca.

Week 7 - Jenny Puetzer

Wow, seven weeks sure can fly by quick! It is hard to believe that summer immersion has already come to an end after looking forward to it for over a year. This was such a great opportunity to see and learn so much in the medical field that I never thought would be possible without an M.D. beside my name.

This week I was able to wrap up my summer immersion term with a trip to the cardiac thoracic department to see a triple coronary artery bypass, also called a CABG. This surgery was extremely different from any of the other surgeries I saw this summer and was a great opportunity to see a lot more technology used in the medicine field. I was able to see an echo preformed and the patient placed on bypass (the heart-lung machine). The patient had three clogged arteries so a vein was taken from the upper right thigh of the patient and divided into two sections to bypass two of the clogs, while the third clog was bypassed by using a mammary artery. It was very interesting to see how quickly and minimally invasively the PA was able to remove the vein from the thigh and prepare it for the bypass. During the surgery I was able to stand at the head of the patient and look down into the chest cavity as the surgeons worked. It was amazing to see the heart working in person. We have spent so many years now as biomedical engineers learning about the heart and all that it does, and then to get the chance to see it in action is just amazing. Additionally it was very impressive how quickly the surgeons were able to perform the bypass. The patient was only on the bypass machine for 32 minutes.

This week I was also able to take a tour of the biomechanics research facility at HSS. This will be very helpful if in the coming years I find I need certain equipment to perform my research.

What I feel I have gained most from summer immersion is motivation for the rest of my career. You can read statistics on how many people are effect, and how injuries affect patients lives over and over again from journal articles but it doesn’t really sink in until you get to experience firsthand these statistics in real life. My research in undergrad and graduate school has and will focus around the orthopedic field. Obviously, this field does not have the high life threatening problems as does the cardiac and cancer fields, so it is easy to lose motivation or feel your research will only help the super athletes. However, through seeing patients and observing surgeries this summer, I have begun to wrap my head around just how many people are plagued by orthopedic problems that have no solution other then total replacement, which only then lasts 10 years max. There is a real need for multiple solutions so that these people can live without pain every day of their lives. I am confident these past few weeks on summer immersion will stay with me the rest of my career and fuel my research.

Friday, July 30, 2010

Week 7

Week 7

This week has been focused mainly on finishing my research project. I am working on quantifying the binding of a single chain version of a monoclonal antibody. Thus far I have had trouble conjugating the single chain and this week I am attempting a new technique.
During my last week I attempted to block the binding of a fluorescently labeled monoclonal J591 antibody with the single chain version of J591. The experiments produced promising results however, they must be modified and repeated to verify that the single chain is binding and thus prevent the fluorescently labeled monoclonal antibody from binding to the cell surface PSMA.
As far as clinical work, I have wrapped up the summer with my physician in the area of urology. During the summer I watched in the office diagnostics as well as surgical procedures. The physician I worked with, Dr. Te, specializes in laser prostate surgeries. In the office he usually determines the extent to which there is blockage from the enlargement of a patients prostate or if the enlargement is related to malignant tumor growth.
I learned quite a bit about the stages and degree to which the enlargement of the prostate affects the quality of life of the patients treated by Dr. Te. In addition to the decisions that the doctor is required to make and the information used to guide those decisions.
After this summer I plan on continuing my work on the project that I was working on over the summer and keep my physician up to date with the information. I also hope to continue to collaborate with Dr. Te on future projects.
-S. Parker

Thursday, July 29, 2010

A Future Uncertain

Immersion term is rapidly coming to a close, but has provided me and my fellow biomedical engineers with much insight on how to reconcile the worlds of clinical practice and cutting-edge research. My experience here has provided a look into the daily routines of all kinds of clinicians and shown me how different their work can be compared to mine, even though the end goal is the same: to develop and advance new medical technologies to improve human health. Probably the most valuable thing I've learned here is how doctors are trained to think. Biomedical engineers are trained to focus in on the details of their work and use that knowledge to make hypothesis about specific outputs. In comparison, doctors are trained to observe multiple more generalized factors simultaneously in order to make effective diagnoses.

I will most likely continue work on my Immersion term project after I leave Manhattan, as most of it can be done remotely. If I am lucky, the work may turn into a publication down the road and will also help keep me connected with physicians at the Weill Cornell Medical College.

Urological Impressions episode 5&6 - The ER strikes back

Hi everyone! This will be the first post of mine that encompasses two weeks that I had missed of blogging specifically the week of Jul 11 and the week after. So much has happened these past two weeks yet so little time to describe it all... but for those of you (you know who you are) that read these posts I will submit my abstract of my experiences.

So one of the more interesting things that occurred was attempting to shadow a clinician in the NYP ER (emergency room) Center located to the right of the hospital's main entrance. Initially when I went on Jul 12th I had no idea which doctor I was supposed to shadow, but after some wrangling I met up with Dr. Jeremy D. Sperling the Assistant Director of Emergency Medicine Residency Program. He gave us an indepth tour of the ER including all the sub-facilities such as the Urgent Care Ward, the Pediatrics Ward, Pysch Ward, the diagnostic triages and even where they store the ambulances. It was a very impassioned tour where Dr. Sperling regaled us stories from the ER and discussed the ramifications of the ER policies (in the ER they are required under law to never turn away a patient even if they don't have insurance or payment). Unfortunately we only got a tour and didn't quite shadow on that day, we tried again a week later but could not find Dr. Sperling.

I also saw some more surgical procedures such as a free fibular flap microvascular jaw reconstruction involving removing a part of the fibula from the leg to form the new portion of the jaw bone being replaced. This patient previously had a jaw reconstruction surgery using his iliac crest (a pelvic area bone) after they removed a mouth tumor but the iliac crest fractured and did not vascularize. So they altered the fibula along with its attached vasculature to form the new jaw, they were also testing a new device that allows them to monitor the blood flow of the vascular anastomosis' post-op. Unfortunately for the excited Dr. Spector (Plastic surgeon) and the company sale rep. the device was malfunctioning but it was interesting nonetheless to see how technology makes its way into the operating room. The jaw reconstruction surgery was headed by two teams of doctors working in tandem: Dr. Spector of Plastic Surgery and Dr. Kutler an Otolaryngologist (Head and Neck doctor). I also saw an adult autopsy with Dr. Khani and Dr. Minick of surgical pathology of a 68 yr old male.

In other news I also had a MRI scan of my brain and attended a Grand Rounds session on the fibrosis of renal transplants by Dr. Thangamani Muthukumar. I also ordered some Sodium Oxalate for my experiments in the lab which arrived on Jul 23rd. Hopefully I can get some real research done before my final week is over and I just noticed that the spacing and font in this post has suddenly changed so....

See you all next week!

Wednesday, July 28, 2010

Week 6: XLIF - The final fronteir

This week, was composed mainly of research, learning about histology, and spending time in the E.R.

In the E.R., I met up with Dr. Lemery, who gave me a tour of the various units that constituted the emergency room. We also discussed various pieces of technology he thought could be improved in the E.R., as well as finding ways to optimize patient flow in the E.R.. I was then paired with Dr. Heath, as senior resident, to shadow for most of the day. Most of the cases were fairly standard; bumps and bruises sustained through falls. However, I did meet a fairly chatty Nazi concentration camp survivor, who refused to believe a fall would do him in. Additionally, I saw a woman who presented with back pain that had all the signs I've come to recognize as a spinal stenosis in her cervical/thoracic spine. However, she was adamant the pain was related to an infection. I was struck by how multi-talented E.R. doctors have to be in terms of interacting with patients across various barriers (i.e physical and emotional state of the patient upon arrival, language) and having knowledge of all the various maladies they might encounter in the E.R..

This week, I spent some time in Dr. Stephen Doty's laboratory in HSS. Dr. Doty's lab specializes in the evaluation of bone, cartilage, and other connective tissue by means of histology and immunohistochemistry. A particular research interest of Dr. Doty's is to find a way to quantitatively evaluate histological samples. In Dr. Doty's laboratory, I spent some of my time familiarizing myself with various histological instruments, such as the microtome, and various common stains for these types of tissues, such as Alcian Blue, Picosirius Red for collagen, and the standard Hematoxcylin and Eosin. I also learned what the intervertebral disc and end plates of the vertebrae would look like under each of these stains. Dr. Doty is truly a master of histology, and I hope to use his expertise in my research at Cornell.

Most of the rest of this week focused on my research project. After extensive searching and refining, I finally narrowed down the 12 patients I could use for data, and began to compile as many demographics as possible. Already, there are some statistical differences in terms of pain pre- and post-op. Additionally, I have narrowed down 8 more patients that could be added, but may need to be called to gather additional data. I also began to write the abstract for SMISS, although it is becoming apparent that there may not be enough time for me to write this abstract or work on a paper for these findings. Dr. Hartl suggested that another fellow might collaborate with me while I am in Ithaca to get both these things done.

Looking ahead to the next week, I plan on getting back into the O.R. to see a few more cases, finish up what data collection I can, and learning how to use MRI and CT to look at Cobb angles in patients. Already, it has been quite a summer, and I look forward to wrapping up next week.

Tuesday, July 27, 2010

Week 6 - Zavrel

This past week I mostly spent working on my research project, which involves the design and construction of an electromechanical device to strengthen the genioglossus muscle so as to keep the upper airway from collapsing during sleep. When the upper airway collapses, cessation in breathing occurs. This in turn prompts the person to awaken momentarily. A person with severe obstructive sleep apnea may experience upwards of 30 or 40 such arousals an hour. These breathing episodes serve to disrupt a person’s sleep, leaving the person feeling groggy and lethargic the following day. Most of the device is finished. The major issue I foresee is making it user-friendly, not just for the patient but for the doctor. I still have to incorporate some feedback (visual or auditory or both) mechanisms. I also have to get the USB data logger to work and connect the device to a DAQ emulator. In this manner, data can be saved to a portable drive for later retrieval and analysis or displayed in real time. The choice will depend on the setting in which it is used, i.e. in the lab or in the patient’s home. I need to be able to read from the external drive in addition to writing to it so as to customize the training regime. The idea is that with time, the person’s upper airway becomes stronger, so initial baseline values need to be measured and stored. These baseline values need to be incorporated in the return of feedback, mostly as a consequence of limited resolution.

This past week I also met with my Ithaca PI’s collaborator here at Weill. Dr. Joseph Scandura works in the hematology and oncology departments, specializing in blood cancers like leukemia and lymphoma. He received his undergraduate training in electrical engineering and was surprisingly adroit when it came to engineering matters. He proposed a particularly elegant and novel way in which to implement PCR within channel-confined droplets. I hope to follow up his suggestion upon return to Ithaca as to my knowledge it represents a completely original solution to an important problem.

Katie - week 6

This past week was very busy for me with a variety of activities. For the second week in a row, I attended the Center for Skeletal Dysplasia with Dr. Raggio at HSS. Here is where we get to meet with patients who have a type of skeletal dysplasia, most often osteogenesis imperfecta or achondrogenesis (most common form of dwarfism). After meeting with patients all morning, there is a patient conference, where the whole team, including the orthopedic surgeon, social worker, nutritionist, and genetic counselor, gets together to discuss the progress and status of each patient. One of the most interesting things that happened this week was a patient who was diagnosed with Robinow syndrome a very young age. However, now that he is 18 years old, Dr. Raggio's team is unconvinced that this is his diagnosis, and they will want to keep meeting with him to figure out what type of skeletal dysplasia he truly has. We also met with another patient how has Type I osteogenesis imperfecta and a number of allergies, but who has not been following her doctor's protocols. She is supposed to be cutting out certain foods for weeks at a time so that she can hone in on what foods to which she is actually allergic, but the 13-year-old female is having big compliance issues. The Center for Skeletal Dysplasia is always interesting because the cases vary greatly, and I enjoy the team approach to these complicated patients.

Also this week, I had the opportunity to shadow Dr. Bostrom, an orthopedic surgeon, for a day as he met with patients for follow-ups, infections, and for new visits. During this particular day, he was "triple booked" with 4 pages of patients he was supposed to visit within 10 hours, so it was a very hectic day. I was able to see a lot of different cases, though. Some patients were recovering from a knee or hip replacement very well, while others were having pain issues, and one had a horrible infection. Others were getting advice on whether they were a candidate for a total knee or hip replacement. Furthermore, some were doing very well post-op according to Dr. Bostrom, but the patient was unhappy with their abilities at this certain point in time. One of the highlights from my day with him was meeting a famous actress and patient of Dr. Bostrom. Because of his reputation, he has quite a few patients who are famous.

Also this week I shadowed Dr. Bostrom in the OR for an entire day. I saw a hip revision, a knee revision, and a total hip replacement. The second two surgeries I was actually allowed to scrub in on, and so I had a perfect view of the entire process! Seeing the total hip replacement up close was by far the coolest thing I have done on immersion term so far. I was so shocked at how fast the whole process was. Dr. Bostrom's part was done in about 45 minutes! He has to rotate the hip so that the joint pops out, saw off the femoral head, drill a hole into the cancellous bone of the femur, fit a post, drill the acetabular cup, hammer in the metal cup, snap on the plastic cup, pop the hip back in, then sew up. It was incredible to see it all in action and to see all of the drills and saws that are used in orthopedics.

This week I also finished analyzing the retrieved knee implants. The next step in my project will be running statistics on everything to reveal our findings. I will be meeting with one of the research engineers to discuss the best strategy for this analysis.

Monday, July 26, 2010

Week 6 Yue

Another exciting week! The first three days were packed with literature search and lab work. After talking to Dr. Nanus and Dr. Gakhar, we have decided to integrate the characterization of MDA-Pca-2b prostate cancer cell rolling into the study by performing a series of experiments varying shear rate and E-selectin concentration. Since our lab is specialized in this type of experiment, Dr. Nanus will be sending us frozen MDA-Pca-2b cell along with prostate patient samples to perform buffy coat spiking experiments. We also tested several other prostate cancer cell lines such as DU145 and LNCap. Interestingly, although these cells express E-selectin ligand, they do not roll on the functionalized E-selectin surface. This is most likely due to the distribution of the ligand on the cell membrane.

On Thursday, I observed a kidney transplant surgery (that I’ve been waiting for weeks). The recipient is a 14 yr old boy diagnosed with Focal Segmental Glomerulosclerosis (FSGS), a major cause of nephrotic syndrome in children and adolescents. He has an identical twin brother who had a transplant surgery last year. The patient suffers from chronic renal insufficiency at stage (CKD5), a progressive loss of renal function over a period of months or years. Patient’s mom, a 44 yr old healthy female, is the donor. Dr. Del Pizzo, who has vast experience in the laparoscopic and robotic treatment of kidney and adrenal tumors, kidney sparing surgery, and living kidney donation, successfully harvested the kidney. Single-incision laparoscopic kidney removal was performed, which offers minimal risk and quick recovery and allows the kidney to be taken out easily. Upon removal, the kidney was submerged in ice-cold saline solution, cleaned (blood and excess fat) and placed on the lower right of the patient’s abdomen and surgically connected to nearby blood vessels.

On Friday, Matt and I shadowed Dr. Sperling at the Emergency Department. I will be writing about my experience later next week since I would lie to go back to the ED and observe more cases.

Week 6 - Jenny Puetzer

This week I spent a day shadowing in the emergency department. I spent two years as a volunteer emergency medicine technician (EMT), so it was interesting to see what goes on in the ER after the EMTs and paramedics leave and how the doctors use what they are told from the EMTs. I was paired up with a first year resident who had only been practicing for a month. I think this made the experience much more interesting since it was like I was learning with her. It was definitely a slower day then if I was paired with a more experienced resident, but I was able to actually help her with certain things and see the whole process of diagnosing a patient all the way through. The most interesting patient we had was a 61 year old man who came in as a trauma one because he had fallen and we were told had a laceration on his head. As soon as he rolled in to the ER a team of doctors went to work on getting all his information and doing a quick examination. We found that he did not have a laceration on his head, just a very large hematoma. He had a cut up back, bruised hip and possibly broken collar bone also. As soon as the examination was over, the resident and I took him down for a CT and X-rays. We got to stand in the room as he got the CT and X-rays done and got the results instantaneously. He luckily had no damage to his skull, neck, or hips, but did have a broken collar bone. While we were at X-ray the patient’s breathing became very labored and loud. This raised the concern that he may have a collapsed lung. We rushed him back to the ER for more examination and to rule out the collapsed lung. The patient wasn’t completely coherent so it was very difficult to get accurate information from him, however we learned that he has COPD and he claimed to have just gotten diagnosed two weeks ago with pneumonia. This eased the doctor’s mind about his breathing and they let him rest some more in hopes of it improving. However, a little bit later his blood pressure dropped extremely low. At first it was believed this was because of the morphine, so fluids were pumped. However, with time his blood pressure rose slightly and then crashed again. The patient continued to look worse and worse throughout the day. The doctors were afraid they had missed a bleed somewhere in his abdomen so the resident and I rushed him down to CT again for a full body scan. No bleeds were found leaving the doctors perplexed on what could be the cause. By the end of the day a friend of the family came to visit and we learned that he had actually just gotten out of the hospital 3 days earlier after a 5 month stay and had a whole host of things wrong with him. The patient was admitted for the night and continued observation. This was a very interesting case to work on and see how the doctors worked through all of his aliments to try and diagnosis him. It was also very interesting to see all the CT and X-rays results first hand.

Aside from shadowing in the ER, the rest of the week was more of the normal schedule of seeing patients with Dr. Rodeo, grand rounds for arthroscopy, and many orthopedic surgeries. I think one of my favorite things to do while here for the summer is to see patients with Dr. Rodeo. It is very interesting seeing firsthand how orthopedic problems affect so many people from the super athletes to the degenerative disease aged patients. It is also very touching to see how many younger patients, under the age of 20, have very serious orthopedic problems needing surgeries that will only delay the inevitable total knee replacement. Seeing these patients and what they must deal with on a day to day basis will help to motivate me the rest of my career and I really appreciate the opportunity.

Like a needle in a haystack

Predictive models are only effective if their predictions are useful, or in this case, correct most of the time. The past week was dedicated to evaluating the predictive capacity of our discriminant function developed last week. To do this, we ran our test set of data through the function to obtain a predicted MDI classification for each case in the test set. At first glance, our model appeared to work well, having predicted about the expected number of patients with higher MDIs versus lower MDIs. The next step was to compare the predicted MDI scores to the actual values in the test set. It was here that we ran into a problem: the MDI scores of the patients in the test set were missing. Either the patients had never returned for their follow up, or their appointment for evaluation had not yet taken place. To get around this we did the next best thing; we took a look at their charts to see if there was any mention that the patient was developmentally delayed, and classified them accordingly. Using this method of classification, our model only made a correct prediction about half of the time. This meant it was time to take a step back and re-evaluate which variables to use when we create our discriminant function. To do this, we've decided to cast a large net and create a cross-correlation matrix of all the variables we have access to in the training set. The idea is that we will then pick out the variables that have a high correlation with MDI score and then use those in our discriminant analysis. More number crunching to come next week!

Week 6 - Jen

This week I saw another interesting application for a muscle flap in surgery. The patient had an esophageal fistula (an abnormal connection between the epithelium around the esophagus) due to the radiation treatment he had received earlier. This was removed by Dr. Kutler, an otolaryngologist (head and neck surgeon), which left a hole in the throat that Dr. Spector proceeded to close. This called for a muscle flap, using the patient's pectoralis muscle. The muscle was literally released from the chest and then flipped over to cover the throat. The wound in the chest was closed, and a skin flap from the patient's leg covered the muscle flap. This was a very interesting surgery that led me to wonder just how these surgeries are developed in the first place. Who would have thought the pectoralis muscle would be a good flap for the throat??

In addition to this surgery, I spoke with an oncologist, Dr. Simmons, who specializes in removal of invasive breast cancer. This meeting was very informative, as I learned about cancer and talked with her a bit about my project, which hopefully will in the future be able to test cancerous tissue. I will be observing one of her surgeries next Wednesday, which will give me a different perspective of cancer-removal surgery.

The remainder of my week was spent on my project, testing the stiffness of different tissue, calibrating the device, and retesting. I am working on the analysis of this data, mostly analyzing stiffness differences in muscle and fat. Eventually this device could test different tissue (both diseased and healthy), but for my immersion project, I am simply doing a proof-of-concept on the device, to ensure that it works properly. So far I have been getting good results!

Week 6--Weiwei

This week I mainly spent time doing my project: analysing the Lower Extremity Duplex (LED) data to evaluate the predictivity of future stenosis by continuous LED monitoring.

I wrote n draft, which includes some brief reasoning, methodology and some figure results.

Summer Immersion Week 6

This week I spent much more time wrapping up my summer project, but I also got to have a few interesting clinical experiences.

This week I got to see the DaVinci surgical robot in action with Dr. Scherr in urology. Coming from an electrical engineering background the robotic system itself was quite impressive. It was clear to me that the size of the instruments and the magnification the device gives the surgeon allows for greater flexibility during the surgery. Though I wonder how difficult it is for the surgeon to control the robot during a delicate procedure; for example, how well can the surgeon control how much force they apply to their instruments while performing the procedure? Towards the end of the procedure while the surgeons were tying their final sutures I got the chance to actually see what the surgeons see through the console of the DaVinci system. Though I could not touch any of the controls on the console, from peering through the viewer of the console it was clear that the binocular vision that the system provides for the surgeon does give the surgeon a three dimensional impression of the environment where the tools are in the body. The only issue that I could see that the surgeons might have had during the procedure was that obtaining this view required that the endoscope that provided this view remained dry, which is difficult in the environment in which the endoscope must be placed to obtain the proper view of the surgical area.

To wrap up my project I am currently still working on using the simulation that I created this past week to work with real data from an MRI scan. Completing this is my goal for next week along with presenting what I find to the researchers that I have been working with over the summer and Dr. Gauthier.

Sunday, July 25, 2010

Week6-Jiahe Li

This week, I spent most of my time on research. Previously, the postdoc whom I have been working with since last month cultured colon cancer stem cells and normal colon cancer cells in 3-D culture. The advantage of 3-D culture over traditional 2-D lies in that the former mimics in vivo microenvironment more than the latter. As a first trial, early this week I sectioned normal colon cancer cells fixed by parrafin(wax) into slices of 7mm, fixed them and then did H&E staining. The initial success prompted me to section more speciman in order to do immunofluorescence staining which is more target-specific.

Besides, I attended a seminar on cancer stem cell given by EMD company. Since I have been working on colon cancer stem cells this summer, I found tremedous guidance from this seminar which pointed out three main directions within cancer stem cell research: 1. single cell study;2. How niche contributes to CSC. 3. response of CSC to chemotherapy.

Lastly, I also attended my first lab meeting here. One of labmates gave a wonderful talk on her work in the past few months. Previously, by using aCGH array, she identified increased copy of certain region in certain cancer cell lines which turned out to be a cluster of microRNA. microRNA is a hairpin RNA with a length of ~20bp. By binding to 3'UTR of mRNA in mamalians cells, they can downregulate target gene expression. Since increased copy number is associated with higher expression of certain microRNA which led to downregulated target gene expression, she is seeking to study if the effect can be reversed by using specific antisense RNA which binds to microRNA.

Overall, this week I feel fully immersed in research study from which I learnt new technique as well as new knowledge.

Week Six -- Mitch

This week I focused more on my research than clinical shadowing. I did shadow in Echo though. I watched a few trans-esophageal echo-cardiograms, and one stress echo. TEE is a relatively quick and non-risky procedure. The transducer is inserted into the esophagus where it can get a clearer ultrasound of the heart, than if it was on top of the chest. I found it very interesting how clear the pictures were, compared to regular ultrasound. In addition, the doctors can tell a lot from the images, including if there is a thrombus in the heart. This seems to be one of the biggest applications of TEE -- because patients going for cardio-versions need to be thrombus free, to reduce the risk of stroke. I was surprised by the fact that there only seemed to be one TEE procedure room, even though they are very busy and also have to do consults in different services. In addition, I was surprised by the fact that they read the echos right after they take them, unlike MRI or CT, where the image is taken by a technician and the doctors read the images later in the day.

Working on my research, I continued to help my mentor prepare for a clinical trail of the use of the new GE t1 mapping tool in cardiac amyloidosis. This week we got the mapping software from GE and I worked to install it, learn it, and run it on some cases. I also ran a few scans using phantoms with known t1 values, to evaluate the consistency of the reconstruction tool. It works fairly well, but does have some variability. I will cover this in my final report for the class. In addition, I went to pathology this week to see slides from a positive amyloid case, that we had done an MRI on, and then the patient got a biopsy. It was really neat to see the amyloid under the microscope, and how it affects the myocardium.

Week 6 - Julian Palacios

This week I worked on a patient database about outcome of kidney transplants. I have to look through the notes written by the doctors after each follow up of the patient. These notes are usually unorganized and difficult to understand (and badly written because the doctors write fast and abbreviate the sentences as much as possible), and each doctor has his own style and each gives varying degrees of information. The number of acronyms is astonishing and I have to work my way through them.  Many are simply phone notes, usually to check how the patient is doing at home, and very often the patient is currently being taken care of in another institution which complicates the acquisition of information. Looking through the notes you see interesting things. For example, it was shocking to me to find out that one patient who was undergoing a routine kidney biopsy had his colon pierced by the surgeon which led to a removal of part of the colon and a 4 month hospitalization!
A highlight of the week was to attend grand rounds on an interesting subject: fibrosis as a cause of organ failure. There I learnt that doctors think (but aren´t sure) that collagen produced by fibroblasts that come from endothelial cells through an epithelial-mesenchymal transition cause the fibrosis that damages organs.  To me it seems very clear that this is a wound healing response and that stopping it might help the body to regenerate a little bit better but the underlying cause of allograft rejection is still an immune response which is what doctors such focus on controlling.

Saturday, July 24, 2010

Week 6

This week I was able to observe surgeries and work on my project. I observed surgeries that Dr. Farmer performed and I will be working with Dr. Abjorson and Hani Ghazi on a research project. The research project is with the Biomechanics Department at HSS.

The surgery that called my attention was a lumbar posterior fusion on a 46 years old patient. This surgery was performed because the previous surgery did not fused and the x-ray showed that it was not healing Dr. Farmer took the screws that were loose and the procedure had to used several x-rays to determined if the new screws were placed on the write position.

Also, I was able to work with Dr. Abjerson and Hani. This lab is interested on the development of a new strategy for a better integration of bone-implant interface. This consists in the use of a chemical surface treatment results in a self-assembled monolayer of phosphonate molecules (SAMP). At the same time, I worked a subproject helping determined the best position of infrared cameras to determine the displacement of a spine due to constant load.

Friday, July 23, 2010

Week 6 (more research)- Carissa

This week I've spent quite a bit of time in Dr. Spector's research lab. Most of the projects in progress in the lab involve understanding blood flow through tissue and using it to improve tissue viability after trauma or ischemia. I was able to watch one of the technicians work on rat microsurgery. She teaches a class for doctors to learn how to reconnect blood vessels during surgery under a microscope. I also learned how tissue sections are prepared for histology and how the images are analyzed and interpreted. A lot of the techniques they use on mice and rats in the lab are exactly the same as the techniques I have witnessed in the operating room, and it's interesting to see how doctors base research off of their tried-and-true techniques in hopes of discovering something that revolutionizes their field of medicine and the way they treat patients. I think this is where students like me can actually contribute a fresh perspective on how to solve some of the problems doctors currently face in their daily practice. For my remaining time here I will continue to work on my research project in Dr. Spector's lab. Hopefully by the end of the summer we will have learned a little more about how ischemia reprofusion injury affects the immune system of patients who have experienced transplants, heart attacks, etc.

Week 6 - Parker

Research Project: Prostate Cancer Antibody

This week I have been spending the majority of my time on my research project. I am working on quantifying the internalization of the J591 antibody in LnCap cells, a prostate cancer cell line. The antibody I am testing is actually a single chain version of the monoclonal antibody. I have been having some issues with labeling the antibody using the amines, this is due to the size of the single chain. There are a lot fewer amines for the fluorophore to conjugate to. However, the antibody has a his-tag located at the n-terminal end of the protein that could be exploited to label the antibody.

We are now attempting to label the single chain using a new conjugation method that binds the fluorophore to the his-tag instead of the amines. We hope that this will allow for enough conjugation to reduce the noise we are seeing with the current method. In addition, we hope that the single chain will have results comparable to what we are seeing with the monoclonal antibody staining. Thus far we have been unsuccessful in comparing the two due to the poor conjugation we are seeing with the single chain.

The significance of this work is in the unique targeting and production of a targeting agent. The single chain will be easier to make than the monoclonal antibody and could possibly allow for mass production of a targeting agent for prostate cancer therapies.

S. Parker

Thursday, July 22, 2010

Week 5 - Zavrel

During this week I gained more exposure to the clinical setting and made progress with my research project.

I was able to observe cardiothoracic surgery with Dr. Leonard Girardi attending. The operation was an aortic valve replacement on a man in his 50s. While waiting outside the OR, I met two sales representatives from Edwards Lifesciences, the company that manufactures the heart valve replacements. They were on hand to field questions posed by the surgeon on the proper selection of valve replacement. If the chosen valve is too small, the pressure gradient across the valve will be too great, leading to device fatigue and premature failure. One of the sales reps. explained that the goal is to achieve a gradient as close to that associated with the natural valve as possible. The sales reps showed me a chart that indexed the cross sectional area of the valve against the BMI of the patient. This convenient chart was color coded (green corresponding to a safe match, yellow to a satisfactory match, red to a severe mismatch). Larger patients need correspondingly larger valves. Given that the pressure inside a channel exhibits a fourth power dependence on channel diameter, even minute increases in the diameter of a valve can result in substantially lower pressures and hence less likelihood of failure. The sales reps. were very knowledgeable and were able to provide a play-by-play of what was occurring during the surgery. I learned many things from my first time in the OR. For instance, I knew that the surgeons siphoned off blood from the thoracic cavity so as to facilitate surgery but I did not know that the patient’s blood was stored and then reintroduced afterward. I assumed that banked blood was used and that the patient’s blood was disposed of for reasons of contamination. One of the sales reps. pointed out the cell saver device that stored the patient’s blood and then reintroduced it. Also, they pointed out that to prevent clogging of the tubes that carry the blood to the cell saver, a blood-thinning anticoagulant agent (heparin) is administered. Upon completion of the surgery, the effects of the heparin had to be countered. Room temperature was raised when the surgery was over and the surgeons were attempting to restart the patient’s heart. I was impressed with the size of the staff on hand – nearly 20 people. The atmosphere was like that of mission control with the surgeons calling out for readings or barking out orders and the support staff flatly intoning dial readings or confirming compliance with the order.

Later in the week I was able to spend time in the emergency room (ER). Dr. Dean Straff gave me a tour. Afterward, I followed one of the senior residents on rounds and saw several cases. Dr. Straff explained that the ER sees everything from the mundane to the unprecedented. Anyone who shows up at the ER will be seen, regardless of how minor their complaint really is. Upon arrival, patients are triaged – the severity of each case is assessed and the patient is relocated accordingly. The ER is organized into three areas: A, B, C bays. Section A is nearest the ambulance drop off so usually houses the most severe cases. Among the cases I observed, several stood out.

1. An elderly man who had been the victim of a brutal physical assault late last year and suffered a stroke soon afterward was admitted from his nursing home due to a feeding tube coming loose and an infection taking hold. The gentleman was in a vegetative-like state, moving his eyes and moaning in response to discomfort but otherwise unable to communicate. X-rays of his chest looked foggy so pneumonia was discerned and antibiotics prescribed.

2. Girl in her mid-20s with a family history of heart disorders (father had heart attack at young age, brother had heart defect, etc.) was admitted complaining of severe chest pains, the intensity of which changed with position. The senior resident was inclined to believe this was pericarditis, an inflammation of the sac that surrounds the heart, which is caused by a viral infection. The girl remembered having a cold a month earlier. Ordering a CT scan was one possible way to confirm this, but the senior resident cautioned against it unless it proved absolutely necessary, as the radiation dose is equivalent to about 200 x-rays – an amount inadvisable to be administered to a young woman due to the sensitive nature of the breasts and ovaries to radiation.

3. A middle-aged man presented with an abscess on his ankle. He had earlier broken his ankle and had it mended but had developed an infection. The senior resident lanced the abscess and drained it of pus, taking a culture sample for analysis. She explained that if the situation were dire, the patient would be put directly put on a general antibiotic, but because the situation was not life-threatening, they had the luxury of sending a sample to the lab for analysis to identify the specific bacteria so as to prescribe a more narrowly-focused antibiotic.

Also, a new mobile computer system was unveiled to the ER staff. This cart-mounted computer terminal was touted as being able to obtain digital signatures on consent forms and discharge papers from bedridden patients. The mobile terminal also featured an RFID reader which granted access upon swiping an ID badge, saving precious seconds that might otherwise be spent keying in a password or trying to recall a password from memory. A senior staff member at the ER was absolutely beside himself with excitement, going on at great length as to how this represented the paradigm that all emergency rooms in the nation were going to emulate in the coming years. He claimed it would free up very expensive hospital beds and result in faster turn-around time, more important than ever with cutbacks to government-supported insurance programs like Medicare and Medicaid.

The electronics needed for my research project finally arrived. I was able to verify the operation of the load cells. One observation was that the load cells exhibited a non-zero voltage output in their non-stressed state. So, I may have to account for this DC offset in the final design of the device.

My other project involves interfacing a microcontroller to a commercial sleep monitor known as a Zeo Personal Sleep Coach. The device isn’t intended as a research tool, but owing to its many features and relatively low cost, it is ideal for use in clinical studies of long duration outside the lab, i.e. at a person’s home. As the device is intended to operate as a consumer device, it isn’t terribly amenable to alteration. Consequently, I spent a good amount of time exchanging emails with technical support from the company.

Lastly, I was given a Zeo of my own to explore. The Zeo consists of a headband with a sensor that monitors brain wave activity and streams sleep stage data wirelessly to a base station for storage and display. Data can be uploaded to the company website for analysis.

Wednesday, July 21, 2010

Research - part 2

This week, I continued reviewing fluid dynamics text books and reading papers about modeling flow in a parallel plate flow chamber in order to begin analyzing a design modification for chambers used to study stem cell differentiation under shear stress. I learned that I should not have taken photographs of the chambers I am working with since they are not commercially available, and I switched to documenting an earlier model of the chambers. After speaking with researchers, I have a better understanding of which aspects of the design make it difficult to use, and I hope to address these concerns by proposing a new design that could expand the scope of the research being done with these chambers.

Toward the end of the week, I began working on a simplified bioreactor design based on a paper published in Science a few weeks ago. The original paper used a decellularized lung as a scaffold on which to grow cells from a mouse that served as a transplant recipient. Due to time constraints, I will not be able to test the bioreactor with decellularized/recellularized lungs from mice, but I will be able to test it with the intact tissue under cyclic stretch. If successful, this bioreactor could be used for further genetic studies and provide a system for expanded work on stem cell differentiation under stress.

In just a few days, I have been exposed to more animal research than ever before. I have been fortunate to learn more about features of mouse anatomy as well as healing responses that are absent in humans. This knowledge will likely be useful as I progress in my PhD research.

The week ended with literature searches, a brief study of anatomy, and the realization that very few people are capable of threading a catheter into the pulmonary vein of a mouse's heart.

Week Five: Research, Research, Research

The main focus of this week was Research. The week started with a research presentation at a morning Spine conference in the Neurosurgery department. Dr. Vamsi Vijay Nagineni presented the clinical findings of Dr. Hartl's surgeries with actifuse. We then discussed the demographic data I had begun to add to the revision case database; however, as of right now, no trends can be readily seen. We then took a look at the XLIF patient data I had collected. Although at first glance, only 8 patients could be included in our study design, Dr. Hartl is optimistic that this may be enough for an abstract and poster presentation at the Society for Minimally Invasive Spine Surgery (SMISS) conference. The first parameters to be calculated would be VAS leg pain and back pain scores pre-op, post op, and in follow up, which I learned were a staple when evaluating data of this sort. Additionally, I would later have to contact Dr. Gebhard to determine how to measure angle of correction with MRI scans, as another set of data. I set about performing these calculations this week, as well as double checking the database for patients I may have missed. Additionally, I looked into the SMISS conference abstract information, and set about writing the abstract when not analyzing data.

On tuesday afternoon, I attended my first Spine Case Conference. In these conferences, the doctors, residents, and fellows from neurosurgery attend to discuss interesting patient cases and get second opinions about treatment routes. Vendors, social workers, physical therapists, and radiology staff also attend these conferences to lend their expertise to the diagnoses. The case conference really demonstrated the interdisciplinary nature of treatment at NYP, a concept espoused by biomedical engineering at Cornell as well.

Besides research, I also attended the first of a two part tutorial on MRI. The class was organized by Mitch Cooper and Dr. Michelle Ann Cerilles of Dr. Yi Wand's imaging lab. The curriculum is set up into 12 exercises and in this first session, we performed exercises 1 -3. These included learning how perform a phantom scan as a calibration tool for the MRI, learning about MRI safety and how to prepare a patient to receive an MRI, and performing MRI scans of the knee. These lessons can be found at; however, performing them in person was much more valuable then just reading through the exercises. We were also introduced to MRI terminology and were taught how to differentiate between tissues in the MRI scan, at least in the knee. The second lesson, schedule for next week, will include MRI imaging of the brain and abdomen.

Looking ahead, there are only two weeks left and so much more to do. My research project takes up a good deal of my time, but next week will be a busy one. Dr. Frayer has helped to set up shadowing in the ER and a chance to see an open heart surgery. The second MRI class should also be quite interesting. I look forward to the chance to squeeze in as much as I can out of what is left of immersion term, and maybe get an abstract as well.

Tuesday, July 20, 2010

Week 5 -Yue

Research Project:
I spent most of my week working on my research project. Dr. Gakhar and I have successfully narrowed our prostate cancer cell line candidates from five to two (PC3 and MDA-PCa-2b) since they both highly express E-selectin ligand and exert my favorite “rolling” motion on functionalized E-selectin surfaces, which would allow us to capture them under flow condition. We then optimized the antibody concentration (anti-PSMA and anti-EpCAM) so that once the E-selectin on the surface stops the cancer cells temporarily during the flow and causes them to roll (due to weak adhesion between the ligand-receptor interaction), the antibodies coated on the surface could capture (form firm adhesion with) the cells of interest. I’m very happy to see that the project is moving forward and I hope to finish as much as I can while I’m here.

Bilateral Maxillary Le Fort I Osteotomy, sagittal split osteotomies, anterior mandibular horizontal osteotomy/Genioplasty
On Thursday, I observed a very interesting cosmetic facial surgery performed by Drs. Neugarten and Sachs. Dr. Neugarten’s previous case got delayed so the surgery was pushed to 4pm although originally scheduled at 1pm. While I was waiting, I was introduced to two of the residents that were involved in this case and the circulating nurse, Natalie. The patient had incorrectly positioned jaw, which affects her chewing, function, speech, long-term oral health, and appearance. Prior to the initiation of treatment, she received a thorough examination with facial measurements, photographs, x-rays, and dental impressions. The doctors then personalized the course of treatment for her based on the results of the examination and consultations. Natalie encouraged me to hold the patient’s hand while general anesthesia was given to her, which is supposed to provide some level of comfort for the patient.
Procedures performed:
Maxillary Le Fort I Osteotomy involves separating the maxilla and the palate from the skull above the roots of the upper teeth through an incision inside the upper lip. It is performed to straighten or realign the upper jaw, often to bring the middle of the face forward.
Sagittal Split Osteotomy: back of the jaw is split bilaterally in the region of wisdom teeth, which allows the lower jaw to be pushed back with adequate bone contact for healing.

I look forward to spending next Friday in the ER and making progress on my research project in the coming week.

Summer Immersion Week 5

During this week I was able to make some progress with my summer project and experience another area of the hospital outside of neurology.

During this week I was able to observe a cardiothoracic surgery with Dr. Girardi. The procedure was for an aortic valve replacement. A few years ago I took a course in tissue engineering and one unit of the course was about medical grafts, including heart valves. With this background I was able to better appreciate the nature of the material that was being grafted in place of the native heart valve that was no longer functioning. The procedure itself was invasive, it required an open sternotomy and that the patient go on bypass as the new valve was put in place. One aspect of the procedure that I found very surprising was that during the actual valve replacement, the coronary arteries of the heart are not perfused by the bypass machine. This means that throughout the procedure the muscle of the heart is not circulated with oxygenated blood. From speaking with the anesthesiologist in the OR it would seem that this is due to a plumbing issue. The location of the system to deliver oxygenated blood back to the body cannot reach the coronary arteries near the near the heart off of the aorta. Dr. Girardi was performing the procedure with one of him fellows and while suturing the new valve in place he mentioned that the tension and location of the sutures was particularly important for preventing leaks and other healing issues with the valve. Though I am not a materials science person I would think that there would be a need here for reliable means of attaching the valve that does not leak and can interface with the native tissue of the heart well.

On my project, I have been able to present the mouse data that I spoke about in my last entry. I was also able to show some meaningful trends in the data as well. With this part of the project complete I have moved on to implementing a simulation for the next kind of fitting algorithm that is going to be used for the data to recover information about the underlying composition of the voxels in the image.

I look forward to finally seeing some good results from my project and exploring the hospital more next week.

Monday, July 19, 2010

Pathological Immersion, Week 5

I spent the majority of week 5 working on my summer project with Drs. Shin and D'alfonso (resident) in Surgical Pathology. Because I worked on the project so much this week, it seems appropriate to discuss it more completely. The study we are conducting is retroactive (as is most clinical pathology research) in that we have filtered cases from the past fifteen years based on certain criteria. There were three basic criteria that needed to be fulfilled for a case to be included in our study: 1) the patient had a needle core biopsy (NCB) in which either lobular carcinoma in situ (LCIS) or ductal carcinoma in situ (DCIS) was identified; 2) there were no invasive/infiltrative or worse-graded components to the lesion; 3) the patient had a subsequent lumpectomy or mastectomy of the same region as the NCB. To clarify, epithelial cells in breast tissue make up either ducts or lobules, which are basally lined by a basement membrane of various extracellular proteins and a layer of myoepithelial cells. An in situ carcinoma exhibits cytologic and architectural abnormalities, but the suspicious epithelial cells are confined within a basement membrane. Cancerous lesions can arise from both the ducts and lobules, and cells derived from each structure retain certain traits and profiles of gene/protein expression that allow scientists and clinicians to identify them. For example, a lesion of LCIS can grow and spread into ducts, but to the trained eyes of a pathologist, these tumor cells will appear distinctly lobular. This distinction is critical because patient care is determined by the nature, severity, and source of a tumor, and patients with LCIS are treated differently than patients with DCIS, regardless of where the in situ carcinoma has spread. The goal of our study is to evaluate the predictive capacity of LCIS and DCIS diagnosed from a NCB, which is currently the least invasive and most widely-used method to biopsy suspicious breast tissue. We are using indicators such as nuclear grade of the in situ carcinoma and association with other benign lesions to determine the likelihood that the cancer will "upgrade" (see tumor grading, Week 4). This and next week, we are reviewing the slides that I collected from the warehouse, recording the above indicators as well as many others. We will then use the pathology reports from the excisions (lumpectomies and mastectomies) to see how these biopsied lesions ultimately behaved.

This week I also began to envision a Reinhart-King/Shin collaborative side-project that I can work on when I return to Ithaca in August. My experience with the clinical aspects of breast cancer has inspired a lot of research ideas that I'm excited to pursue.

Week 5 - Ruiz

This week I went to a guest lecture conference that was held for the new incoming plastic surgery residents. This week an attending physician from the Memorial Sloan-Kettering clinic came and gave a lecture on mandible reconstruction. I was really impressed with the depth of knowledge that a doctor needs for just this one type of procedure! The guest lecturer gave us a very thorough review, starting with an explanation of the main considerations – function, form, composition, etc. – which must be taken into account when planning this operation. He especially stressed knowing everything there is to know about the gold standard flap used for mandible reconstruction: the fibula flap. He showed us many detailed images showing us the critical anatomy of the fibula, and explained that the greatest advantage to using this flap is that it has a segmented blood supply. This unique characteristic essentially means that the fibula is a flap that can be shaped and optimized for many types of mandible reconstructions. We then went through a number of case examples in which he called upon the residents to help him plan out mandible reconstruction surgeries for each patient in each case. I really enjoyed the discussion and debate surrounding different real-world cases, in addition to connecting our anatomy knowledge of the flaps and the mandible with the reconstruction goals of the procedure.

I was also able to attend patient rounds and office patient consults with Dr. Grant. This week a diverse array of patients were seen. Some had just had a nasal reconstruction operation, some were coming in for office procedures (i.e. liposuction or facial augmentation using injectable dermal fillers), and others came for first-time consults about eyelid alteration surgeries and breast implant procedures. I am still very surprised by how expensive plastic surgery is! For instance, one Asian teenager came in wanting eyelid surgery, and she was told that having the operation to “create” more Caucasian-looking eyelids would cost about $4000. Another patient came in seeking facial augmentation to remove her wrinkles. Dr. Grant told her that he would need to use 2-3 tubes of dermal filler – with each tube costing about $750. I understand that these procedures help the patients feel better about themselves and happier in general, but I wonder how these prices got to be so high…

Another interesting aspect of my week was shadowing in the ER with Dr. Sperling. He gave me a full tour of the Emergency Department and explained the triage process and how patients were sequestered into different wings of the ER. I then paired up with one of the ER attendings to observe how they treated and diagnosed incoming patients to the ER. I never really realized how much problem-solving is involved with ER diagnostics! One of the attending physicians told me that “we always assume that the patient has a very serious/dangerous condition until proven otherwise.” In narrowing down the possible conditions, a lot of the discussion, lab tests, and diagnostics in the ER are used as forms of evidence that the ER doctors must then gather, organize, interpret, and integrate into one final diagnosis. This was a very different (but equally interesting) kind of clinic compared to the plastic surgery patient consults that I’ve observed with Dr. Grant!

In my spare time this week I have been working hard analyzing the literature and current perspectives on injectable dermal fillers for my research project. In the middle of the week I drafted up an outline for my review/ analysis and discussed the pros and cons of it with Dr. Grant. I have come up with a few theories on how nanotechnology and biomedical engineering can enhance the field of dermal fillers, and in the next week I plan to flesh out these ideas, back them up with current research findings, and hopefully finish a more polished rough draft of my review.

Katie - week 5

This week was filled with a variety of activities, which kept the days very interesting. I had the opportunity to attend the center for skeletal dysplasia, led by Dr. Raggio on the 3rd floor of HSS. Here, they see patients with a variety of skeletal dysplasias, including osteogenesis imperfecta and achondrogenesis (the two most popular that are dealt with at this center). It is a fun environment that involves a large number of people. Throughout the day, each patient meets with some or all of the following, depending on their needs: orthopedic surgeon, social worker, nutritionalist, geneticist, and genetic counselor. The team works really well together, and it is obvious how much they care for each of the patients. As those with OI or Achon have to deal with the disabilities and issues their entire lives, the doctors usual develop very long-term relationships with them.

As my research at Cornell relates to mechanical sensitivity of bone and the pathways involved in bone development and maintenance, I am intrigued by all things related to bone. Recently, I had read a novel where the main character had osteogenesis imperfecta, and so I was ecstatic to be able to see patients in real life. OI is characterized by small stature, bowed bones, and low bone mineral density, usually due to a mutation in the gene that codes for collagen type I. There are many types of OI (at least 8), and the research is still growing, as type VIII was just identified earlier this year. Some of the types are fatal, while others only mildly inhibit growth. One of the most interesting things I saw with OI patients was that one child had a bone density score of -8.5! This means that her bone density is 8.5 standard deviations below the normal for her age and gender. To be considered osteoporotic, one's bone density must be -2.5 or lower, and so this -8.5 is tremendous. Dr. Raggio says it might be one of the lowest if not the lowest bond density score she has ever seen. This causes a huge increase in fracture risk, and so great precautions must be taken to protect the skeleton through diet, and to try and strengthen the bones while at the same time not overworking them.

Achondroplasia is the most common form of dwarfism, and is charactized by an enlarged forehead, short stature, trident hands, among other symptoms. It is caused by an autosomal dominant mutation in the gene coding for fibroblast growth factor receptor, which results in problems with cartilage growth plate differentiation and deficient endochondral growth.

Also this week, I was able to shadow Dr. Sperling in the ER, an experience I was really looking forward to. To start off the day, Dr. Sperling gave us a quick tour of the whole ER department. We got to see where patients came in and how they decided the severity of the symptoms. Some patients are sent over to Urgent Care, while others stay in the ER department, with some accelerated due to severity (i.e. chest pains). It was interesting to get a quick overview of the infrastructure. During the day, I did not get to see any sever trauma cases (good news for the patients) but was able to shadow doctors on a number of different cases. One case was a woman who comes in twice a week to get her bandage on a wound replaced and is probably addicted to pain medication. I was impressed with the way the doctors handled her with such a professional and kind manner. Dr. Sperling explained to me that, by law, they must treat everyone who walks in the doors, and I admire them for treating everyone with respect.

One interesting case I saw was a woman who began suffering from a seizure all of a sudden. I was surprised at the disorganization of the process. From watching medical drama on television, I was made to think that any time a crisis arises, it is handled in a hectic but completely efficient way. In this instance, the janitor was the one who alerted the doctors to the seizure, and the nurses were flustered because at first they could not get a straight answer as to the patient's name so that they could administer the correct medicine, and then they were unsure if the patient already had an IV intact. Luckily, they were able to act quick enough to get the seizure under control.

Also this week, I made significant progress on my knee implant retrieval study. I have now analyzed all 38 of the implants, both articular and backside surfaces, ten areas on each surface, 7 modes of wear for each area. Next, I will be getting the data from the mobile bearing implants to which we are comparing our implants so that we can begin to compare the results. I am very interested to see the results of hours spent looking through a dissecting microscope!

Week 5 - Jenny Puetzer

This week I changed things up a little bit and went to neo-natal rounds. It was a great change of pace to see all the cute babies, but then very sad at the same time to see how sick some of them were. There was one baby that was 4 months old already but still smaller than most newborns. It was very interesting to see all the doctors and fellows work together on rounds to determine what should be the next step for each neonatal and interesting to see a different take on the patient-doctor relationship.

This week I also went to grand rounds for arthroscopy. They had a very interesting presentation on what causes deaths most often in total hip and knee replacements. This was especially interesting since deaths are so uncommon in these procedures and definitely not something that we would get the chance to witness during our short stay at the hospital. Apparently, death, as we would expect, was more prevalent 10 years ago and beyond. This causes a problem with research studies that examine this issue since the orthopedic field has developed so much in the last ten years it is important research studies take this into account. The conclusion from the presentation and research was that pulmonary embolisms(PE) which used to be the number one cause of deaths in total hip and knee replacements was now third on the list for causes of death. This means the field has done very well at decreasing the risk of PE, but that now the field needs to focus on other causes such as blood loss or the use of tourniquets.

One improvement in the orthopedic field over the past few decades which has allowed for a decrease in the risks of surgery is arthroscopic surgery. I have had the chance this past week and all weeks I have been here so far to see countless arthroscopic surgeries. I find these surgeries very interesting because of the vast amount of different types of surgeries they are able to do, while still keeping the surgery very minimally invasive. Some surgeries I have seen so far with arthroscopy include arthritis clean up, menisctomy, torn cartilage removal, exploratory to find a cause, removal of mechanical issues in the knee, rotator cuff repairs, tendon repairs, reattachment of the biceps, and countless more. It is great to see how this improvement in technology has helped so many people. In the past all of these surgeries would require the person’s knee or shoulder to be completely opened up leading to increased risk of infection, longer surgery times, and longer recovery times. But now these patients are able to have 2 or 3 small incisions, an hour or less surgery with local anesthesia, and shorten recovery time, which in some cases means back to everyday activity after just one day. This is truly a great asset to the orthopedic field, and many other fields for that matter. It makes me wonder what improvements we will make in the coming decade to make this already optimized field even better. It will be truly amazing to see.

Sunday, July 18, 2010

Week 5 - Jen

This past week was interesting, for several reasons. Firstly, I saw my second jaw reconstruction. Much like last week's case, the patient was getting a fibullar flap transferred to his jaw. Unlike last week, the reason for this replacement was due to the failure of a graft he had received one year ago. The graft had died, which meant they were now trying for a fibullar flap. This jaw reconstruction was also more extensive, needing two pieces of bone from the fibula, shaped and oriented in such a way as would match his jaw. What I also found interesting was the presence of a sales rep in the OR, representing a new device that Dr. Spector was trying. It was a insertable Doppler after the blood vessels had been anastomosed together, to determine if blood flowed through the newly joined vessel. Although the device did not actually work (and Dr. Spector was disappointed), the presence of the sales rep was important so that Dr. Spector could be sure of protocols and use of the device during surgery. I also had a nice conversation with the OR nurses, and they were giving me plenty of suggestions of things to invent to make their lives easier (of course they said to remember them when I made millions off these ideas)

On a different note, my research project is finally getting off the ground. I have the tissue device here, and I am ready to start testing the mechanical properties of different tissue. Now if I can only get the last step of the IRB finished...having doctors sign some forms! Well, meetings have been set up for next week, so hopefully everything will be cleared and ready to go!

Looking forward to next week, and seeing what kind of data I can get!

Week 5

This week I was able to learn more about more patients’ pathologies and more surgeries.
There were two patients that called my attention. One of them had a fusion on her neck and back approximately two years ago. However, she was experiencing a lot of pain on her joints. Dr. Farmer said to her that probably she has arthritis. The other patient was a male who had a motor accident in 1982, from that day he experienced a lot of pain on his back. However, in 2007 he fell down and his left arm and left leg were in pain. From that day he has been using a wheel chair to move. He can walk but he loses balance very quickly. His MRI showed he had a compression on his neck. Dr. Farmer said he will operate, but does not guarantee his condition will improve due to his pathology severity.

The surgery called my attention was the posterior and anterior lumbar fusions were performed on two different patients. Each operation lasted for at least 9 hours. The first operation was performed on a 46 years old male patient. On this surgery the x-rays shows that the screw did not heal. Therefore, after the screws were placed, Dr. Farmer had to take several x-rays to determine if the old screw was removed and if the new screws were placed in the right verterbra. The second posterior and anterior fusion was performed on an 81 year old patient. On this procedure an allograph was used as well as the technology produced by Stryker ®. Dr. Farmer used Spine Navigation Software from Stryker ®, an image-based technology that utilizes scans of the patient’s anatomy and instruments that are tracked by the Navegation System’s camera. This navigation system guided Dr. Farmer to place a more precise screw placement.

Mitch -- Week Five

Wow, what an amazing week. This week I spent some of my time shadowing in the CCICU for patients with severe heart problems. A lot of the patients on this floor, due to their heart problem, are very sick, and have afflictions with other parts of their body too. While some patients recover 100% and are able to leave soon, for a lot of the patients, some of what the doctors have to do is decide how to take care of the patient's problems in a long term manner.

In addition to the CCICU, I spent one day shadowing in the ER with Dr. Jeremy Sperling. There were no extremely urgent cases, but it was very interesting to see how the flow of the ER worked. There are three main departments that patients are sent to after being triaged -- the main ER for patients with larger problems, urgent care for small cuts and burns, etc and then a pediatric ER for children. I talked to Dr. Sperling specifically about Heart Attacks coming into the ER, since I am interested in Cardiac problems for the summer since it pertains to my research. He said that other then a STEMI, it is hard sometimes to distinguish what chest pain is coming from and if it really is a heart attack, or just something like indigestion. Currently, they use a lot of tests, including checking triponin levels, but that can take hours. There is one study that is going on that uses CT to rule out heart attack, but there is only one radiologist that runs it, and it is only avaliable 9-5 Monday through Friday. Dr. Sperling said that if MRI was better developed though, that they would use that on almost every patient with chest pain, to diagnose heart attacks quickly. This was good to hear, since that is exactly my research, and it was really cool to see that there is already a specific need for it!

The third interesting part of my week was being able to watch an open heart surgery. The patient had an atrial mixoma that had to be removed. Fortunately, it turned out that the mixoma was benign. It was interesting to see how the doctors first sawed through the ribs, then worked their way into the heart. Once they were ready to cut open the atria to take out the tumor, they put the patient on the heart and lung machine which takes care of lung and heart functions during the surgery. They then opened the heart, took the tumor out, revived the patient from the heart and lung machine, and then closed up the chest. It was really interesting to see the amount of people that work together in this surgery -- the surgeons, nurses, anesthesiologists, and heart/lung machine techs. It really was a once in a lifetime chance to watch this surgery, and I was very fortunate to be able to see it.

Friday, July 16, 2010

Week 5 - Carissa

This week I've spent quite a bit of time working in the lab on my research project. During my time here, I am working with Dr. Spector's lab on a project aimed at better understanding how ischemia-reprofusion affects the body's immune system. Ischemia means that blood flow is stopped. Reprofusion is when blood flow starts again. Ischemia-reprofusion injury is tissue damage resulting from the cessation of blood flow through a tissue. If an hour or two pass before blood flow begins again, then reactive oxygen combined with many other harmful factors will cause damage that create a self-destructive response in the body. This problem is always a concern when blood flow stops and restarts (patients who have experienced the loss and reconnection of an appendage to the body, heart attacks, strokes, surgery , transplants, etc.) All of these patients would benefit from the development of a better way to control ischemia related tissue damage. My time this week has been spent studying the effect of one possible drug remedy on immune system cells to see if it has any measurable effect on some of their surface proteins.

The highlight of my week, however, was the day I was able to meet with a man I had seen undergo surgery just 3 weeks earlier. His procedure involved the removal of part of the epiglotis, or back part of his tongue, where he had a golf-ball sized tumor. Dr. Kutler was able to remove the tumor without disrupting blood flow in the rest of his tongue, so Dr. Spector was able to sew his tongue back together so he might still have a chance to talk and swallow with the help of a speech therapist. This man took wonderful care of himself, and in his follow up appointment I watch as Dr. Spector removed the stitches from his neck and lips, listening to the man talk about how his recovery has been going thus far. It was wonderful to see that a man of his age (70+) was able to heal so well and recover so quickly from such a drastic procedure. He could talk (although a little hard to decipher at times) and swallow a little water (though he will still use a feeding tube to eat or drink for at least 4 more weeks). The sad part of the story is that pathology indicated that the tumor had very thin margins, meaning they don't know if all the cancer cells were cut out of the patient's tongue. After he recovers for a few more months, doctors will probably put this man on radiation or chemotherapy courses to try to get rid of the remaining malignant cells. Hopefully it works. Only time will tell, but for now the man has a few more years left with his tongue intact with a life that's at least a little closer to normal.

Weiwei-Week 5

This week I observed three cases.
The first one is called the "exicision of left axillary mass". The female patient had an over-grow of her left axillary and it pushed the nerves and caused pain. The possibility of malignant growth was eliminated because of previous diagnoses.
The second one is called laparoscopic cholecystectomy. The patient had a large piece of gall-stone in his gallbladder. So the gallbladder was removed by endoscopic techniques. Actually it was not easy to seperate the gallbladder from the liver, and there were some small hidden arteries which needed to be blocked before excision. After the surgery I had a chance to actually touch the gallbladder and I feel a solid sphere stone with a diameter of about 1cm in the bottom of the gallbladder.
The third one is a colorectal surgery. The patient had a colon cancer. She received several rounds of radiotherapy and chemotherapy. The patient's condition was good, seems no metastasis was discovered before the surgery. The malignant part of the colon was excised, the edges of the tumor sample were dissected and sent to pathology labs to check for possible metastasis. The tumor was not in proliferative form, but ulcerative form instead. That's why I coundn't see the big tumor mass, but just the irregular inner surface of the colon.

Getting down to what matters

This fifth week of Immersion Term saw the lift-off of my summer project with Dr. William Frayer, which involves some statistical analysis of data on patients from the neonatal ICU. It was a very productive week; on Monday we only had a rough idea of what needed to be done, but by Friday we had obtained a copy of SAS (very expensive statistical analysis software made by SAS Inc.), I had learned the required syntax, and we had started generating some meaningful statistics. In doing so I had expanded my own knowledge of statistical techniques. Now for some fun details...

The first goal of the project is to determine which patient factors have a strong correlation with low mental developmental index (MDI, measured at approximately 1 year of age) in low birth weight babies. The second goal is to use these factors to create a discriminant function that will allow physicians to make predictions about the MDI of their patients. A discriminant function is a linear function that sums the products of each independent variable with its correlation coefficient (a value determined though canonical correlation analysis). The discriminant function can be created from any data set containing a categorical dependent variable (the variable you want to make a prediction about) and several independent variables (the predictors). This set is called the training set. To validate the function, a second data set with the same variables (the test set) is needed. The test set is then run through the discriminant function, the predictions made by the function are compared to the actual dependent variables in the test set, and the frequency of Type I and Type II errors (false positives and false negatives respectively) can be determined. Having low error frequencies means that the discriminant function is a good predictor of the dependent variable.

This type of analysis may sound complicated, but luckily it only takes about 4 lines of code in SAS to complete. I can't imagine how long it would take by hand! Next week will most likely involve fine-tuning our analysis and maybe even some validation if we're lucky. Stay tuned...

Week 5- Parker

Urology Surgery Women

This week I was able to observe surgeries that were preformed on women with incontinence issues as well as support issues with their bladder and rectum. These patients have bladders and/or rectums that are collapsing into their vagina. This is extremely uncomfortable for the patient. Issues with bladder support also add to incontinence issues.

The cause of these conditions is associated with child bearing. Child bearing results in additional pressure on the bladder and giving birth also stretches the muscles of the vagina and can weaken the structure in place to support the bladder and the rectum.

The surgical procedure that is used to correct these issues involves the use of polypropylene meshes as well as slings. The meshes are inserted in between the bladder and the vagina and support the bladder preventing it causing collapsing in the vagina walls. The sling is used to support the urethra tube. It is inserted into the abdomen of the patient just above the vagina and sits below the tube supporting it, similar to the mesh. The rectum impedance is repaired by joining the muscles between the vagina and rectum together with sutures to prevent further disruption of the vagina. The vagina is then tightened with sutures to repair the stretching that has occurred. The surgeon uses a two-finger width allowance when tightening the muscles.

S. Parker

Monday, July 12, 2010

Mancuso: Summer Immersion Week IV

My fourth week in Pathology advanced pretty regularly. With the holiday weekend no one I've been shadowing was around on Monday and so I only stayed around long enough to read a few papers and feed my cells. Tuesday came around and was a bit rushed because Neuropathology was essentially trying to fit two days into one. The experience was likely the busiest so far and was quite enjoyable. We started off in the morning reviewing cases with a resident which she wasn't sure about and then looked at a few frozen samples as they came up from surgery. We also had a few brain dissections to do at brain cutting, and then more samples to prepare and look at before a cancer board meeting. On Wednesday I finally managed to place the order for the last remaining reagent for my experiments as well as prepared some other materials around the laboratory for the beginning of my experiments.

Thursday morning I was able to follow Mingchee and observe the Da Vinci robot for the first time. I was actually really excited for this opportunity and it didn't let me down. Sure, most of the surgery takes place out of sight and can only be seen on screen, but there's something oddly satisfying about watching robots do our work. I was particularly interested in how it could ever be possible to automate the surgery, and was completely surprised by the appearance of an out of place artery on the patient. The surgeon mentioned it a few times, and joked about how the loss of it could produce erectile dysfunction problems, but was very careful to leave it intact and had to altar some of his approach to the surgery to do that. The head surgeon also had to take over for the younger doctor at points around the artery to make sure it came out okay.

While the presence of the artery seemed strange, the complications didn't seem too large. I'm interested in how often complications like that arise, and how many different things can change per procedure. It seems to me if we'd really like to have universal health care eventually we'll need to make procedures easy enough that less educated personal can perform them. Robots seem a huge step in that direction and the idea of automating the entire procedure doesn't seem to foreign to me.

In terms of my research project from this point on I'm pretty much just waiting for my materials to all arrive, and hoping to make some rapid progress after that. I have one early experiment to try with both positive and negative controls as well as a second set of experiments if the first goes successfully. Briefly, the first set is completely research based and uses only materials found in a research laboratory. If the experiments go successfully I can try them on actual clinical samples which the group has access to in the second set of experiments.

Overall this week has been successful in terms of both research and clinical work. Further, Dr. Frayer has set up for us to visit the ER in the next few weeks, which I really look forward too.

Week 4 Yue

Week 4

Thanks to Dr. Frayer and Dr. Abramson, I had the opportunity to visit the Ophthalmic Oncology Center at the Memorial Sloan-Kettering Cancer Center (MSKCC) and observe 20 Retinoblastoma cases in one day, given that the disease is extremely rare (~350 new cases of retinoblastoma diagnosed in the U.S. each calendar year). Dr. Abramson sees 15-25 retinoblastoma patients one day each week, including both established and new patients. On a given clinic day, about 2/3 of the patients are seen under general anesthesia, giving the physicians an opportunity to both observe the progression of the disease as well as treat the tumors immediately when necessary. I was introduced to a room full of people including a pediatric anesthesia team, pediatric neutrooncologists, genetic counselors, pediatric nurses (who specialize in anesthesia recovery for children), fellows, residents, and pre-med students.

Retinoblastoma is the most common primary intraocular malignancy of childhood, and the 7th most common pediatric cancer in the U.S. (Leukemia being the most common secondary intraocular cancer). The average age at diagnosis for retinoblastoma in the US is 18 month of age and the incidence of retinoblastoma is the same in boys and girls. Among RB patients, 30% of them have bilateral RB (both eyes are affected). Interestingly, only 10% of patients have a previous family history of RB. For sporadic retinoblastoma cases, leukocoria (white pupil) is the most common presenting sign, followed by esotropia and exotropia.

One of the young patients was previously diagnosed and treated in Korea. He was given three cycles of invasive chemotherapy which possibly would affect brain development later on and require bone marrow transplant after. His parents heard about Dr. Abramson and decided to travel all the way to the US, hoping to find a better (less invasive cure). Dr. Abramson detected tumor masses in both eyes and suggested intra-arterial chemotherapy (IAC), which has minimal systemic effects. IAC sends chemotherapy directly into a tumor through a catheter placed in the artery. The goal of IAC is to concentrate the drug inside the tumor and minimize the exposure to healthy tissues. I was able to observe the IAC procedure performed by Dr. Pierre Gobin the next day on this patient. I look forward to seeing this patient tomorrow for his follow-up visit.

CT scan of Retinoblastoma


Laser Therapy (Dr. Abramson)

For more information on Retinoblastoma and current treatments, you can visit Dr. Abramson’s website: www.

Highlights of the rest of my week:
-Patients consultation with Dr. Nanus
-Splenectomy on a patient with Myelofibrosis
Myelofibrosis is a disorder in which bone marrow is replaced by fibrous tissue. It produces severe and painful splenomegaly. A splenectomy does not cure myelofibrosis but may be performed to relieve pain caused by the swelling of the spleen. In this case, splenectomy was performed to give the patient, a 29-year-old male a better life quality. The spleen removed by the surgeons turned out to be ~25 cm in length and ~15 cm in thickness compared to the less than 13 cm in length and less than 5cm in thickness criteria for normal spleens.
-Research Project
More blood spiking experiments to optimize the capture efficiency.