Mike Mitchell's 2nd Week: "Use it or lose it!"

The phrase "use it or lose it" is used in many different ways; in terms of our own bodies, the phrase can have tremendous implications. Research has shown the more we use our brains (i.e. reading, learning, studying), the more dendrites will extend from our nerve cell membranes. These dendrites form a network that is the "hardware" of our intelligence; when we do not use this network, we will "lose" these dendrites, and thus our brainpower! The same principles apply to many other parts of the body, including our bones, muscles, and even our reproductive organs!

How does this apply to our circulatory system, and how are these principles used to our advantage in surgery?

I was fortunate to be able to watch Dr. Karwowski and his team perform a lower limb bypass surgery, the first "invasive" vascular surgery that I saw. When you think "bypass" in vascular surgery, it is essentially redirecting blood flow from one artery or vein to another. The surgery focused on the arteries shown below:

The patient had a large thrombus within their left iliac artery, blocking the artery by 95%. The thrombus formed on a polymer graft with the iliac artery; while this graft's intention was to help improve the blood flow, it ended up being an ideal site for the formation of a thrombus. Since the blockage was near the groin, the patient had poor circulation throughout the whole leg and foot, causing foot and leg ulcers. The circulation was so poor that the patient was at risk of losing his left leg. Again, "use it or lose it"; if the circulatory system within that leg was not used properly, it would become dysfunctional. Without proper nutrient distribution throughout the leg, it might have been lost.

What approaches could be used to restore blood flow through the patient's leg?

Unfortunately, the thrombus could not be removed without destroying the artery. Other arteries within the leg were not viable replacement options, as the patient had atherosclerotic plaques within the arteries. The approach used by Dr. Karwowski was something that caught me by surprise; he wanted to take a vein from the left leg and use it as an artery. How would this work? The following things were flowing through my head.

- Veins have valves to prevent backflow of blood, while arteries do not.

- The vein being used was not the same diameter as the artery being used.

- The endothelial cells that comprise that vein are very different from those within the artery.

How was this going to work out?

The result was fascinating; since the veins have valves that are one-directional, he simply "flipped" the vein over. Such a technique would make the vein like an artery; the valves would always stay open, allowing arterial blood flow. Could these very different cells handle the new blood flow, and could they compensate for the difference in diameter? Dr. Karwowski told me that the cells would "arteriolize"; in response to the new blood flow patterns, the cells forming this vein will actually engineer the vessel to become more like an artery. The surgery ended up being a success; the vein was able to handle the new blood flow patterns, and normal circulation returned to the patient's left leg.

However, it is worth noting that a bypass is one of the last options that are desired in vascular surgery. The scar left was tremendous; a deep incision was made within the patient's leg, from his groin to his knee. The patient had a recovery period of 6 weeks within the hospital ahead, and the such a large wound poses a huge risk of infection.

It was also interesting to note that Dr. Karwowski said this bypass would only last for 5-7 years. While such a vein can arteriolize, it will not last forever. There are only so many blood vessels within the body that can be used for a bypass; better solutions are needed for such problems.

On the research side of things, Dr. Karwowski stated that the creation of an engineered blood vessel (currently being worked on at Yale: http://www.technologyreview.com/biotech/19693/) is the "Holy Grail" of vascular surgery. While such a solution currently seems far away, it is an area of great need that can use more funding and researchers. Future Cornell BMEs, take note!

I will finish off with a few food and karaoke suggestions:

Patsy's Pizzeria: Look no further for great pizza; located on 69th and 2nd avenue, Patsy's provides a very unique, coal-oven baked pizza made with fresh ingredients. It stands out from the rest of the pizzerias on the upper east side.

For Pete's Sake: Located right around the block from Olin Hall, Pete's has free, awesome karaoke on Thursday nights! It is becoming a Thursday tradition for Cornell BME students.

I hope to do better next time!
-Mike

As fast as a growing baby

After diving deep into the heads of various patients last week, I took advantage of an opportunity to experience a very unique part of New York Presbyterian Hospital: the neonatal intensive care unit (NICU). The NICU is where newborn (often premature) babies are brought to receive treatment for conditions that result from spending less time in the womb. Babies that are born prematurely can face a host of developmental problems and have very specialized needs that—if not addressed properly—can lead to significant complications down the road. As such, most of the treatment in the NICU addresses the deficiencies (nutritional or environmental) of its newborn patients.

I started each day this past week going on rounds with a team headed by Dr. Anne-Lise Yohay, an Assistant Attending Physician in newborn medicine at NYP. Although the specific needs of each baby differed between cases, there were several common treatments used: constant positive air pressure (CPAP) for breathing, total parenteral nutrition (TPN), incubation, phototherapy to combat hyperbilirubinemia (jaundice), etc. One unique aspect of the NICU are its patients. Their communication abilities are limited to crying, which forces physicians to heavily rely on diagnostic readouts including but not limited to: stool analysis, x-rays, ECGs, feeding/sleeping patterns, and weight. From these readouts, physicians are able to diagnose and successfully treat patients.

In addition to spending time in the NICU this week, the rudiments of my research project have begun to emerge. More details to come, but it will involve a good amount of statistical analysis...exciting!

Pathological Immersion, Week 2

During the second week of Summer Immersion, I shadowed Dr. Shin and her residents in Pathology, as well as Dr. Drotman in the Women’s Imaging Center (Radiology); I also continued to work on my research project and got a much more hands-on experience than I would have liked (see below for more details!).

The primary role of Radiology in breast cancer medicine is to screen patients to identify both consistencies and inconsistencies in patients’ scans. The focus is on classifying features observed through X-ray, MRI, and ultrasound screening to provide recommendations for the future. Such observations and recommendations include: no findings, standard 12-month follow up; somewhat suspicious findings, 6-month follow up; suspicious findings, perform biopsy and determine course of action from pathology; biopsy-proven cancer, discuss options with surgical and medical oncology. Shadowing Dr. Drotman, I learned a great deal about gross tissue structure and was encouraged to learn about the clinically-relevant link among breast tissue stiffness, calcification, and cancer as this connection represents the crux of my research in the Reinhart-King lab. During my visit, a patient underwent a stereotactic, X-ray-guided needle core biopsy because calcifications were identified on her mammogram, and were not successfully removed by a previous biopsy. I was surprised to see that low-dose X-rays were used not only to identify the region of interest, but also to position the biopsy needle and confirm the presence of the suspicious calcifications in the biopsied tissue. My experience in Radiology gave me a better understanding of the full progression of cancer diagnosis, from screening and biopsy in Radiology to analysis of biopsy tissue in Pathology. Next week, I will shadow a medical oncologist who specializes in breast cancer.

I continued to observe the sign-out service in Pathology, where I worked with residents to identify features at both the cellular and tissue scales that are characteristic of certain types of breast cancer. On Thursday, I experienced a moment of controlled chaos in the Pathology department when “frozen section” work quickly piled up. Imagine the “front line” of the Pathology department: there is a single resident who spends all day in the specimen receiving area. This doctor is responsible for receiving non-urgent tissue specimens from biopsies and surgeries all over the hospital. He or she catalogs them and performs a number of different procedures depending on the specimen. In addition to this near-constant influx of specimens, runners bring small canisters of tissue (ranging from red-speckled gauze that appears to contain no more than a drop of blood to entire excised organs) to Pathology to be “frozen sectioned”. Essentially, what this means is that there is a patient undergoing surgery, and the surgeon wants to confirm the identity of an excised region before continuing the surgery. One memorable example was the case of a patient having a benign goiter removed; the surgeon excised tissue and sent two pieces of gauze, each containing a speck of tissue (one was from the thyroid and the other was possibly parathyroid, which they did not want to remove), up to pathology. The resident began processing the samples by embedding them in a snap-freezing gel, slicing the now-solid blocks into 4 micron sections, and submerging the slides in a series of about fifteen chemical baths to fix and stain the tissue. The whole process from beginning to end takes the average (frantic) resident no more than three minutes to complete, but, as it turned out, even that wasn’t fast enough. In a matter of minutes, there were five other frozen section samples waiting (and thus, five other surgeries that were temporarily suspended until pathology called the operating room with the identity of the specimen). After a number of pages and loudspeaker announcements, a small army of 5 residents stormed into the already-cramped room, ready to help (I retreated to a corner to get out of the way). Back to the goiter surgery... The slides were stained and ready to look at under the microscope. By now, I had seen a fair amount of tissue under the microscope, so I can tell you that this tissue looked rather unremarkable. Nonetheless, another resident appeared in the room, and, knowing nothing of the case or surgery, peered into the microscope and confidently explained that the tissue was definitely parathyroid and not thyroid. Apparently, the cell morphology and presence of a unique crystalline substance were the give-away. One by one, the other residents offered their input on the identities of tissues from neurosurgeries, plastics procedures, and more. Fifteen minutes later, all of the frozen sections were done, the ORs were all notified, and the receiving room emptied.

I began the next stage of my research project this week, which required me to collect more than 1000 slides from the hospital archives. This task is typically reserved for lab techs, but because of the volume of slides I needed, I was volunteered to go. I jumped into the back of Joe's van - behind the car seat, between the tricycle and Dora the Explorer - to drive up the FDR to a non-descript warehouse building in the Bronx. I spent about 3 hours in the 100-degree, windowless, fanless warehouse pulling dusty slides from 10-year old cases. I came back to tell the residents of my journey, and they laughed, conceding that they didn't know it was that bad (as they redacted any previous wishes to go see The Warehouse). Although this experience was entirely unpleasant, it gave me an appreciation for the work of the Pathology lab techs, and I look forward to reviewing the slides that I gathered.

Week Two: Hit the Spine Running...

The week started with a meeting between Dr. Hartl and I to set up a project for the remaining 6 weeks of the summer immersion. We decided upon a retrospective studies to look at. In the first study, I would look at the outcome/results of patients who had degenerative scoliosis and stenosis in the spine and were treated with a new technique called the Extreme Lateral Interbody Fusion, or XLIF technique. XLIF is a minimally invasive spine repair technique, that is characterized by approaching the spine from the patients side through small incisions so as not to disrupt the back muscles, as when the spine is approached posteriorly, or the abdominal muscles and organs, as when the spine is approached anteriorly. As the XLIF is quite new, compared to traditional approaches, it is important to ensure that patients who have this procedure maintain the same degree of health as those who get more traditional procedures to alleviate scoliosis and stenosis. In addition to this, Dr. Hartl would also like to look back at revision surgeries and complication rates for surgeries he has also done.

This week was also my first week in the clinic, and there was no lack of interesting cases. The first patient we saw had had a successful spine surgery, however, the incision, which was about 1 to 2 inches wide, had never closed and was fairly deep. The solution was more or less to stuff the wound with iodine and gauze, and watch it for signs of infection. Eventually, the wound will heal. I was later told that this kind of case happened very rarely in people. The next case was even more interesting. A patient with severe osteogenesis imperfecta (OI) presented with tingling and numbness in the tongue and jaw area that was causing him to slur his speech. Now, OI is a genetic bone disorder that causes defective connection tissue, or the inability to create connective tissues, due to collagen deficiency. In this patient's case, he legs had been severely stunted, he was prone to fractures, and his spine was severely malformed. Dr. Hartl consulted with other physicians to determine what exactly was the cause of the tingling and to determine how best to perform surgery on the patient without further damaging his spine. After the consultation, Dr. Hartl and the other surgeons decided to contact more physcians at HSS to get further consultation on the case. The other cases I was able to see this week were more routine, however, it was interesting to see how much a slight disc herniation could impact the various patients' lives. Additionally, Dr. Hartl let me read MRI and CT scans to determine if I could figure out what was wrong with each patient before he diagnosed them. The most striking case was a man who had breast cancer, a rarity in men, that had metastasized and was impinging on nerves near the base of his brain. Dr. Hartl had removed the tumor and the patient was in good condition. When the patient saw Dr. Hartl again, all he could do was cry and thank him.

I also got to go into the O.R. this week with Dr. Hartl and see various spine surgeries. I very quickly learned that a routine, simple surgery, such as a laminectomy and decompression, was actually at least a 2 - 3 hours, if not more when prep time and anesthesia are considered. Additionally, all surgeries were performed with X-ray and flouroscopy, so lead vests, kilts, and thryroid gaurds were worn for most of the duration of the surgery. During the course of the routine surgery, the discectomy was more or less the shortest part of the surgery, which was surprising. Cutting through muscle tissue took a long time, however, Dr. Hartl is committed to preserving as much tissue as possible (a staple of minimially invasive surgery), so it was not surprising. Additionally, I had not realized that the spinous processes had to be removed in order to get to the disc and cut it away. I actually brooched this subject with Dr. Hartl, and learned that it was the only way to get to most herniations when using a posterior approach, even if it leaves the spine more exposed in those areas. Additionally, it was interesting to see that even in the O.R., the attending physcian is just as much teacher as he/she is surgeon. Dr. Hartl routinely pointed out tips and tricks he'd learned in practice to the resident surgeon to make the surgery easier on and more beneficial to the surgeon and patient.

In the cases that required spinal fixation with rods and screws, it was interesting to se ehow the dynamic of the operating room changed. The O.R. became full to bursting, requiring not only the usual staff, but also a doctor tracking EMG in various muscle groups effected by the nerves Dr. Hartl was drilling near, as well as vendors from the company that created the equipment. The vendors were quite knowledgeable about how to use the product, and even what surgery would be most appropriate for each case. I was also introduced to a device known as the Brain Lab. Using Brain Lab, the surgeon first takes a 3-D X-ray scan of the patient and that data is imported to the Brain lab software. Then using cameras and special utensils, the physician can have an image of the screw he plans to implant super-imposed on the 3-D scans to ensure the screw is going exactly where it is supposed to. All surgeries were performed with a posterior approach, and I hope to see an XLIF before the immersion term ends.

On saturday, I got to get an MRI of my right knee through Dr. Yi Wang's laboratory. It was even more interesting because a radiologist was on staff to guide me through the MRI. It was my first experience, and I learned alot about how functional MRI for all joint spaces. It was also nice to see that besides a few deformities from an accident I had in high school, my knee was in pretty good shape!

I look forward to next week, both seeing more patients and more interesting surgery cases. I also plan on making a larger dent in gathering data for my research project, and that will be the focus of my week.

Week 2 - Palacios

Last week ended with an extraction of a uterus which had such a big tumor that the woman seemed to have a 4 month old baby. The tumor was benign and this type of tumor in the uterus is called Uterine Fibroids. The procedure was the first that I have seen with the da Vinci robot, which is a very big and impressive machine. Amazingly, they did not begin to extract the uterus until four hours into the operation. This was because the woman had had all her kids by C-Section. As a consequence of all the C-sections, she had a lot of scar tissue that had glued together  parts of the uterus to the abdominal walls and the fact that she had not given birth to any of her kids the natural way also did not help when extracting the uterus through the vagina.
Surprisingly, as in most surgeries that I´ve seen, sometimes the surgeon was not completely sure of what he was seeing. This was shocking to me because I would expect that the surgeons would know where everything in the body is and how it looks. Also surprising to me was that the surgeons often don´t have a plan of what they are going to do, they just deal with things as they come along, and even the place of the initial cut into the skin is where ever the surgeon (or most often the resident student) decides at that moment. The extraction of the uterus was going to be done through the vagina and the surgeons were not sure if the uterus was going to fit through the vagina, but they tried to to it anyway.  Even after four hours of intense procedure the surgeons were able to make jokes all the time.
I learnt that we are not allowed to film inside the operating room, unless the patient has given her consent in a sheet of paper.
This is a picture of the actual machine being pushed into place. The robotic arms are covered in plastic to avoid possible contamination.

The rest of the week I spent in the lab of Dr. Suthanthiran, where I am learning about the diagnosis of acute rejection after kidney transplants, mainly by measuring the expression of appropriate messenger RNA in urine and blood samples of kidney transplant patients. I always wanted to learn about immunology and this is a great opportunity for me to do so, and for me it is a surprise that hospitals have such big laboratories where they do groundbreaking research.

Week 2 - Bailey Cooper

Monday morning began with a bypass scheduled for a 69 year old male suffering from an aneurysm near his left knee. An angiograph was used to image the flow of blood through the aneurysm and to pin point the section of the femoral artery that needed to be bypassed. Since a first attempt, with the catheter placed just above the aneurysm, only provided images of the upper portion of the affected area, the catheter had to be guided into the aneurysm in order to allow the dye to progress further down the artery in order to obtain an image of the end of the affected area. After a clear image of the femoral artery was obtained, the surgical team began isolating a superficial vein from the patient's leg in hopes of grafting it to the artery instead of using a synthetic material. Unfortunately, after hours of painstakingly isolating the vein and securing all of the branches originating from it, the team found that it was not healthy enough to use, and a PTFE (a.k.a. Gore-Tex) graft had to be used instead.

The vein had been affected by thrombophlebitis (vascular inflammation resulting from blood clots), and after removing an occluded portion from the middle, there was still a ridge of scar tissue within the vein that could not be removed while maintaining the necessary length. From an engineering perspective, the PTFE graft was quite interesting since it contained a membrane that allowed it to leak like a sieve when flushed with water but prevented blood from leaving the tube. The PTFE graft was further designed to promote the growth of endothelial cells along its interior lining and coated with heparin to prevent blood clots from forming along the inner surface post-op. (The patient was already on Coumadin due to an angioplasty on this right leg one week prior, so clotting inside the graft was not expected to be an issue.)

Since this was a large artery, the PTFE graft was suitable, but blood clotting issues still prevent PTFE from being effective when bypassing smaller arteries. A new nanocomposite material developed at University College of London aims to solve this problem, and it is scheduled to enter clinical trials later this year. The new material is based on Silsesquioxane and has shown remarkable properties in the earlier tests (prevention of the coagulation cascade, etc.), so I will be interested to see how the clinical studies go.

I was surprised that over an hour of sewing was required in order to secure each of the graft to the artery and to over-sew the corresponding end of the artery containing the aneurism. This has led me to contemplate other materials that could be used to attach the graft to the artery more quickly while providing a reliable seal. I was in the OR for 10 hours, but the surgical team was easily there for over 12 hours. Anything that could be done to save time on such a procedure while reducing the risk of leaks would certainly be welcome.

On a lighter note, I would like to find a way to prevent back pressure from building up when the surgeons are irrigating the graft so those in the OR do not risk being sprayed by the fluid. Oh well, at least I now know how to respond when I am hit with fluids in the middle of an operation. The surgery was a success, and patient has been recovering nicely so far.

During my time in the clinic, I was able to meet many patients and observe a variety of cases, but the one that stood out most in mind was the case of a middle aged man who was no longer able to walk after the successful removal of a malignant tumor 6 weeks ago at Sloan-Kettering left him with a painful blood clot that will now be difficult to treat. It is unclear if his body will be able to resolve the clot on its own or will require surgery, and it is unclear what level of activity the patient will eventually be able to resume. A few weeks ago this man was surfing, running, and generally leading a very active life. Now he is unable to lower his legs without swelling or walk without pain. Ideally, the clot would have been treated 6 weeks ago when it was fresh, but at this point the clot fairly old, so the method of treatment will be different. Further information from the patient's hematologist will need to be considered when deciding the most appropriate course of action. I plan to learn more about the treatment options once the results of his blood work come back.

During a conversation on research, Dr. Bush mentioned a physician-scientist whose work is of great interest to me, and whom Dr. Bush suggested I contact. After a few rounds of e-mails and a forwarding a CV, I was fortunate to be able to meet and discuss my research interests with the PI (who is an investigator with the Howard Hughes Medical Institute and a professor with the Weill Medical College of Cornell University) as well as one of leading researchers in the lab. (Over 15 members of the lab have and MD and/or PhD.) They drew my attention to several recent publications connected to my dissertation topic and offered their perspective on the direction in which the field is progressing - with suggestions on potential modifications to my research. All of this was incredibly helpful, and I eagerly look forward to learning more during my 4 week stent in their lab. We are in the process of establishing a collaboration between their lab and the lab of my mentor, Dr. Putnam. Dr. Bush is also keen to collaborate with them, so this could provide a very nice opportunity to start multiple inter- and intra-campus projects.

The upcoming week holds a couple of key lectures, an opportunity to learn more about a number of projects (both in vivo and in vitro) in the lab, and of course, more time for clinical and surgical observation. There is never a dull moment here, and I am looking forward to what next week has in store.

Katie - week 2

Hello readers! This second week of summer immersion gave me experience meeting with patients and helped to further define my research project. On Monday, I had the opportunity to meet with Joe Lipman, the director of device development in biomechanics at HSS. Since my summer project is going to be focusing on total joint replacement, I wanted to understand an engineer's perspective. He helps to design custom made implants for the knee and hip. At the meeting, I was able to hold actual knee and hip replacement parts and saw the software that he uses to design the implants. Most often, one of the common manufactured implants will suffice for a patient's case, but in very complicated situations other design considerations are made.

After meeting with a fellow engineer, I set up a meeting with Dr. Wright to help guide me in my literature reading. He gave me a lot of guidance, and so I have been reading up on chapters about design considerations for the knee. I have learned how to define a load-sharing implant and a load-transferring implant. Also, it was interesting to learn the different designs that are available for total knee replacements. Some are very constrained, for when the collateral ligaments cannot be saved. These structures act more like hinges. Other designs, where the ligaments can remain intact, are less constrained. Through the literature review, I also saw variations in stem vs. no stem, cement vs. no cement, thickness of the metal cap, and many others.

Throughout the week I continued to attend many meetings - the biomechanics meeting, Dr. Bostrom's lab meeting, Dr. Boskey's lab meeting, grand rounds for arthroplasty, and TERR. From these meetings, I have been making connections with residents and post docs to get some experience with different lab techniques, such as learning RT-PCR, immunohistochemistry, and histomorphometry. Furthermore, I met a few new doctors to widen my clinical experience. Hopefully next week I will be attending a spine clinic and viewing a couple different surgeries.

On Friday, I went to Dr. Padgett's weekly meeting with Dr. Wright and the biomechanics lab, where he further identified the type of project I will be working on. With a medical student, I will be comparing the wear and tear of mobile bearing knee implants to non-mobile bearing knee implants. I hope to find out more about this next week. Also, I am interested in seeing the lab simulations that are done to replicate joint wear in the body to demonstrate the effectiveness of new designs.

Also on Friday I accompanied Dr. Padgett for five hours of visiting patients. It was a really neat experience, and I was really surprised that none of the patients minded having a few extra people in the room. During this time, he met with a total of twelve patients. Some were new consults, some had just received a total knee or hip replacement a few months ago, and some were years out from their surgeries. I was surprised to see a couple patients who had bilateral hip replacements! It is the wonder of modern medicine - these patients (at least the ones I saw) were able to walk normally without a cane. And some of the patients with just a single hip or knee replacement were quite active. One woman was a ballet choreographer.

Next week I hope to see a few surgeries, visit more patients, and learn more about the mobile bearing knee implants and how they will be compared to the standard knee replacements.

Week 2 - Carissa

This week was a bit of an eye opener. I was able to follow Dr. Spector during patient appointments for an entire day on Monday. Most patients came in for post-op check-ups to see how they were recovering after reconstructive surgery. Of course there were a few patients who came in for elective surgeries, but I was surprised how much plastic surgeons affect the outcome of patients healing from serious burns, broken bones, or unhappy encounters with cars or buses. There was one woman who did a remarkable job of keeping an upbeat attitude after multiple reconstructive surgeries after nearly losing her leg after getting hit by a NYC bus. Fortunately orthopedic and plastic surgeons have been able to use metal plates, muscle flaps, and skin grafts to save her leg so far. It was amazing to see how modern medicine has been able to do so much to help her keep the leg she would have otherwise lost.

Surgery this week was a very intense schedule. All told, we spent 3 solid days in the operating room observing many different types of procedures. The surgery that sticks out the most in my mind was a procedure where a woman had a broken leg, and her fall had caused the creation of a dead section of skin right below her knee. Her tibia was expose, so a regular skin graft couldn't be used to cover the wound. Instead, Dr. Gayle took the medial portion of the patient's gastroc muscle and moved it across her tibia to cover the wound, while leaving it connected to the blood vessels at the base of the calf. Once the muscle was sewn in place, then a skin graft was used to cover the rest of the wound. To let fluids and air in and out of the wound, the surgeon performed "in situ pie crusting" which is just poking holes in the graft to let it breathe... like a pie. The patient is expected to heal well, and I hope to see her next week during a follow-up appointment.

Week 2 Yue

Week 2 started after a solid weekend of sightseeing and yummy Chinese food (still can’t believe we went to Chinatown on both Saturday and Sunday…).
Project & Lab Meetings
I attended two lab meetings this week, with Dr. Nanus’s group on Monday and a joint one with Dr. Avi’s lab. A post-doc student from Cornell (Ithaca) joined us on Monday to record/study the technologies that are involved in research collaboration between Cornell Ithaca Campus and Weill Cornell Medical College, which makes the scientific discussion rather interesting. I realized that there exist distinct differences between basic research and translational/clinical research. For example, in the King lab, we flow approximately 1 million cancer cells through the functionalized microtubes and we focus on characterizing cell rolling behavior and optimizing the capture efficiency. In the Nanus lab, we are using 200 cells instead since that is a more physiologically relevant number for circulating tumor cells. The main goal is to capture all the 200 circulating tumor cells on the surface.
We modified the surface chemistry to increase cell adhesion using three prostate cell lines and we expect to have patient samples next week to test our new syringe pump.
Case Study:
I also attended a genitourinary clinical conference with case presentations on Monday. Dr. Nanus, Dr. Tagawa and a few other attending physicians reviewed the most recent cases. One patient was diagnosed with bladder cancer since MRI and CT scans revealed the tumor mass and Hematoxylin–eosin staining of the bladder tumor specimen showed 95% small cell pattern carcinoma. This is a rare case since less than 1% of bladder cancers are small-cell carcinomas. Chemotherapy for these cancers is similar to that used for small-cell carcinoma of the lung. After discussion, the doctors decided to treat the patient with combined radiation and chemotherapy followed by surgery. I was surprised that I actually learned a lot of medical knowledge from this two-hour long case presentation thanks to all the extremely experienced physicians and pathologists.
Surgery:
I can’t recall how many times I said to my self “This is so cool…” this week in the OR (I had to try really hard to keep this thought to myself).
Right Hemithyroidectomy
The patient is a 63 yr-old male with a 1.7 cm cancerous right thyroid nodule. Thyroid nodules are solid or fluid-filled lumps that form within the thyroid, a small gland located at the base of the neck. Most of the time, thyroid nodules are noncancerous and do not cause symptoms. In this case, the patient’s thyroid nodule has become large enough to press on his windpipe, making it uncomfortable to swallow.
Laparoscopic adrenalectomy (Dr. Del Pizzo)
Laparoscopic surgery refers to the technique in which a surgeon operates within the abdominal cavity with small telescopes and long instruments instead of making a large incision with conventional instruments. A 5cm large adrenal tumor mass was detected in the patient, which resides really close to the vena cava. The chief resident who was operating expected a long surgery due to the potential risk although he successfully took out the tumor within two hours using ultracision harmonic scalpels. I was fortunate to have a visiting medical student from Vanderbilt Medical School explaining the procedure in details for me. He also recommended a website (MDconsult.com) to learn medical terminologies and common disease symptoms.
Robot Assisted Prostatectomy (Dr. Douglas Scherr)
With Dr. Scherr’s permission, I observed my second robot assisted surgery with the da Vinci surgical system. Thanks to Dr. Nanus, I learned the basics of prostate cancer prognosis evaluation systems: Gleason Score and PSA Test. Prostate-specific antigen (PSA) is a protein produced by cells of the prostate gland. The PSA test measures the level of PSA in the blood. The Gleason Grading system is used to help evaluate the prognosis of men with prostate cancer. As for Gleason Score, pathologist assigns a grade to the most common tumor pattern, and a second grade to the next most common tumor pattern. The Gleason grade ranges from 1 to 5, with 5 having the worst prognosis. The Gleason score ranges from 2 to 10, with 10 having the worst prognosis. The patient, a 57 year-old male, had a Gleason score of 6 and PSA of 8.4 with no family history of prostate cancer and was perfectly healthy otherwise. Interestingly, CT/MRI scans did not detect any tumor mass. The enlarged prostate (5X4 cm2, compared to its normal walnut size) was removed followed by anastomosis on the urethra and bladders. The da Vinci surgical system is known for faster recovery and less bleeding when compared with the conventional open surgeries.

Week 2 - Ruiz

Unforeseen challenges in a left popliteal artery aneurysm repair

With the permission of Dr. Bush, one of the Cornell surgeons, I was able to observe a highly invasive aneurysm repair procedure in the lower left leg of a patient. From the very beginning I knew that this surgery was markedly different than the surgeries I had viewed last week. The patient was male, in his 70s, and had previously undergone a popliteal bypass in his right leg – which, unfortunately, had resulted in skin and vasculature failure in his upper right thigh, leaving a deep recession/cavity in that area. This man had other complicating factors as well – he was allergic to penicillin, had some form of sleep apnea, and he had extremely small arteries that may have been weakened (from the previous bypass) and partially thrombosed (due to age and lifestyle habits). While the sleep apnea made him hard to intubate, the real problem surfaced when the anesthesiologist tried to put in a central line in his arm. After multiple sticks by the residents and the anesthesiologists, a trained technician was called in to perform real-time Ultrasonic Doppler flow detection to help locate the small and deeply recessed arteries. Finally, after simultaneously scanning the arm of the patient with Ultrasonic Doppler while another anesthesiologist stuck the arm with a needle, they were able to get the central line in! What should have been a routine procedure turned out to be quite complicated, and I was impressed at how quickly the problem was solved when incorporating the real-time ultrasound technology.

Even so, I had some questions brewing in my head after watching the 90minute-long process. Why is the Ultrasonic Doppler a last resort? From what I understand it is fairly non-invasive, and it could have saved a lot of time and trouble had they pulled out the device immediately after the patient was put under. I was also wondering why the Doppler device was built into a wand sort of format, with the detecting probe at the head. I noticed that the technician had trouble keeping the wand/head in the correct plane to monitor blood flow in the arteries. I wonder how the device could be modified to either 1) facilitate proper orientation (and stabilization after proper orientation is found) for blood flow detection, and 2) enable the device to orient itself without the manual manipulation of the technician.

That said, the aneurysm repair was more complicated than I thought it would be. Two angiograms had to be performed so that Dr. Bush could verify that there was still blood flow in the leg below the site of the aneurysm. If there had been stagnant flow, the surgery would have been called off. It turned out that even getting the proper image from the angiogram was a challenge. The first angiogram did not prove successful because the injected dye could not reach down far enough to image the area below the aneurysm site. Thus, an injecting catheter had to be threaded down into the aneurysm (literally, which is quite dangerous if the aneurysm breaks up and causes clotting elsewhere in the body) so enough dye could be injected into the entirety of the vessel for proper imaging. I don’t believe there was any way to get around it since the angiogram was essential for planning the next steps in the surgery. I do wonder though: is there a better way to provide enough imaging dye for the angiogram without risking breaking or rupturing the aneurysm? Perhaps the intrinsic flow properties of the dye could be modified, or the image-taking protocol for the angiogram could be changed.

Bone-anchored hearing aid (first stage implant) with cartilage graft ear reconstruction

Dr. Grant was able to introduce me to fellow Columbia surgeons and residents in Plastic Surgery, and through some of them I was able to see a really interesting surgery at the Children’s Hospital. This surgery was two-part: part 1 involved the first stage of a hearing aid implant procedure, and part 2 involved harvesting cartilage from the rib of the same child to use for reconstructing an ear for this child. From what I understand, this child had been born with a malformed right ear which had no cochlea. This invasive procedure was delayed until the child reached 12 years of age because during the child’s early development there was no telling how the cartilage-grafted ear would respond or adapt to the growing child.

Overall, this dual-part procedure was extreme in a couple of ways. The first stage ear implant required that screws be drilled into the child’s skull. A very small incision was made on the right posterior region of the head, and after the muscles and tissue were pulled/cut away to expose the skull, a drill (yes, it even looked somewhat like a power tool) was used to insert two ear implant screw attachments into the skull. Surgeries of this kind are difficult to perform on children because child skulls are not as hard and are not as thick as adult skulls – thus, it is hard to stabilize the screws in the skull for the long-term. An impressive detail in this surgery was the tool used for drilling into the skull – it actually was programmed to stop on its own when it passed through the entire skull layer. It is critical to stop the drill before it breaks through the basal layer of the skull and starts to pierce and damage the brain tissue. The cranial drill was a great solution to the problem of surgeons not being able to predict exactly when they would break through the skull layer. I did noticed that the surgeons had trouble keeping the drill perpendicular to the skull surface though – perhaps other skull surface sensors and device positioning mechanisms could be incorporated into this cranial drill to make it even more efficient.

The other extreme part of this surgery was the harvesting of cartilage from the lower rib region of the child. I was shocked that the surgical tools being used were quite large and forceful. (Apparently harvesting cartilage is not as easy as cutting through muscle or tissue!) I quickly learned that cutting out cartilage involves methodical slicing at the proper angle and with precision so as not to take too much or too little out of the rib section. Unfortunately I was not able to see the entire ear reconstruction procedure, but I did see the early stage of the cartilage re-structuring. I am very impressed how the surgeon (Dr. Wu) could start with a mere piece of cartilage and build a full new ear for the child! I only wonder though, could a synthetic ear have been tissue engineered for this child? I am not sure if tissue engineering has reached a stage through which this can be done, but I do believe that a fully tissue engineered cartilage ear construct would have saved a lot of pain and stress during recovery for the child because the cartilage-rib-harvesting is more painful and takes longer to recover from than the new skull screw implants.

Additional noteworthy surgeries and meetings

I was able to see a diverse set of surgeries this week. In addition to the aneurysm repair and the ear reconstruction, I observed: a primary elected caesarean section, nipple-sparing mastectomy, bilateral breast reduction, and a unilateral second-stage breast augmentation. All were performed on different female patients of different ages ranging from 29 to early 60s. It was interesting to see how the patient’s age and physical health would impact what strategies Dr. Grant would employ in the surgery.

I also had the unique chance to meet with consulting representatives from a company named Allergan. The two representatives were observing a few of Dr. Grant’s surgeries to see how the Allergan products (i.e. synthetic breast implants and expanders) were being implemented for different patients in a hospital environment. It was great talking to them because I was able to ask them questions about how they chose particular implant designs and materials over others and how they distributed their product to different client hospitals with different needs. Additionally, the Allergan reps were questioning Dr. Grant and his plastic surgery residents to see what current issues they had with the Allergan products, and to inquire how the products could be made better or more customizable for different patients. This encounter further proved to me that there are many close-knit ties between technology/industry (i.e. marketing, development, and engineering of medical products and devices) and the clinic/hospital application of said technology. Crossover is essential in this type of relationship, especially since feedback from both sides can directly improve patient care and satisfaction for hundreds of patients all over the world.

Week 2 - Jen Richards

This week was packed full of interesting surgeries, but the week first started with patient rounds on Monday. This was a different experience than I have had previously, and I was exposed to a range of emotions and situations surrounding each patient. I watched as one concerned mother asked normal questions like, "Are you the one to do the surgery?" and "What do you think is our best option?". Another patient had been hit by a bus one year previously, and had gone through an exhaustive amount of surgeries. This patient was extremely brave, but understandably wished for an end to surgery. It is good to connect people to their various ailments, and remember that surgeries are done on people with specific concerns.

As I said previously, the middle of the week was full of interesting surgeries, some of which displayed extreme amounts of creativity and skill on the part of the surgery. Tuesday I watched a glossectomy, or removal of cancer of the tongue. Initially the patient was prepped to have a full muscle transfer; once the tongue was removed, an arm muscle would replace it in the mouth. However, because the ear, nose and throat surgeon was so successful at removing the cancer without removing unnecessary parts of the tongue, they were able to save the tongue and sew it up. It'll be about a week until we know if the patient will be able to keep his tongue. Another interesting surgery was a face lift of a man with paralysis of the right side of his face. Normally I think of face lifts as purely cosmetic, but in this patient's case, it was for purely reconstructive purposes, as that side of his face sagged lower than the healthy side. One interesting aspect of this case was the insertion of a gold weighted plate into the eyelid to help the patient close his eye. This was inserted so skillfully that I had trouble seeing where the initial incision was. Also, the surgeons used the biomaterial 'Alloderm' to lift the skin of the face, an aspect that I found extremely interesting.

All in all this was a good week, and a bit of an eye-opener as to doctor-patient relations and the truly extraordinary work that can be done in an operating room.

Mancuso: Summer Immersion Week II

During my second week of summer immersion I continued shadowing doctors in Molecular Pathology and Surgical Pathology. So far the experience has been very satisfying. One of my most surprising discoveries has been how huge the knowledge gap between engineers and doctors is. Most of surgical pathology seems to revolve around histology slides in simple brightfield illumination. While it is certainly a useful and well understood technique it feels dated from the sort of technologies used in Biomedical Research.

With Dr. Lavi from Surgical Neuropathology I've continued seeing histology samples from different patients. The samples come in two different types; samples fixed in formalehyde which are then stained and sectioned and samples which are frozen and sectioned to help surgeons make quick decisions. I'm always surprised to see just how many samples are some form of cancer; I know the statistics for it are high but actually seeing it is so much different.

One of the most interesting set of opportunities I've had this week was the chance to observe both a full body pathological autopsy and a brain autopsy. While I've dissected my share of animals during my education I've never seen a human body opened like that and was amazed by what I saw. Everything looked very similar to I what I expected from books and the size and color of different organs amazed me. It was definitely a little more unnerving to see a human opened up then an animal, but the excitement for the chance to learn kept me focused.

During the brain autopsy I had more of a chance to ask questions because it was preceeding at a slower speed and the doctors were looking for specific parts of the brain. The patient had suffered from amyotrophic lateral sclerosis (ALS), or Lou Gehrig's disease, which progressed rapidly and eventually caused his death. The autopsy was being conducted to confirm the diagnosis and figure out exactly what had happened. ALS is a degenerative motor neuron disease in which the patient loses the use of their voluntary muscles. In general it can effect either or both the upper and lower motor neurons and in rare cases some other areas. During the autopsy we looked at both sets of motor neurons and took samples for later observation.We then fully sectioned the brain and upper spine and looked for other anomalies. All together we took around 20 samples to send to histology for staining which I'm hoping to get a chance to look at next week.

Along with Dr. Cesarman I've continued my research on Kaposi's Sarcoma causing Herpes Virus (KSHV) and the detection of it. A set of articles, starting with two papers from Chad Mirkin's group in 1995 and 1996 began a body of work around using transition metal nanoparticles for the aggregation and detection of different analytes. With Dr. Cesarman I'm trying to use some of this technology to create a system for the detection of KSHV DNA which would be operable with little infrastructure or equipment. Briefly, viral DNA would be used to crosslink nanoparticles and form an aggregate with different optical properties. In the presence of enough viral DNA a visible change in solution color could serve as an indication of positive detection. Over the course of this week I learned a little about how current detection can be carried out using PCR, Gel electrophoresis, and a number of other techniques. Further, I identified a nucleotide sequence which should be detectable using the a similar system and studied most of the chemistry I'll need.

This week has proven just as exciting as the previous has and I'm excited for all of the opportuniutes that are arising. Next week I hope to see another brain autopsy and the slides from this weeks. Further, I hope to continue my research project and order the reagents and parts neccesary. I've also began spending some time in the Neonatal ICU which I'd like to continue next week. It's fascinating to see how all sorts of technology and measurements can be used to get information from patients otherwise unable to communicate.

Week Two - Jenny Puetzer

My second week of immersion consisted primarily of seeing patients with Dr. Rodeo. I find seeing patients very interesting because it allows me to meet the patient to hear about the pain that is bothering them, observe the MRI and X-rays to see what is bothering them, and finally hear what can be done to help them. It allows me to see cases that demonstrate the need for research in the orthopedic field and cases where the research that is going on has completely changed the patient’s life.

One case I saw this week really touched me and demonstrated the need for the research I do, which is tissue engineering menisci. The patient was a 23 year old female who had already had an ACL repair and meniscus transplant starting back in 2003. She is now a graduate student in college and has difficulty sitting in class with her knee bent and pain in all her everyday activities. Arthritis has already taken over one side of her knee (most likely due to the meniscal transplant) and she is looking for some way to improve her pain. Dr. Rodeo suggested injections of hyaluronic acid, a molecule which provides a little bit of lubrication for 3 to 6 month at a time to reduce pain in arthritis patients. He adds this is all they can do to delay the inevitable total knee replacement which only last for about 10 years now. A tissue engineered meniscus may have delayed this breakdown of her knee or a tissue engineered repair for cartilage may relieve her pain if they were around as an option of treatment. This case, along with multiple juvenile sports injuries and arthritics cases, really demonstrated the need for further research in the orthopedic field. There is still so much we cannot do to help patient that experience pain every day of their life.

Another case I saw this week was very exciting because it demonstrated how research is touching patient’s lives. A female in her early twenties came in for a check-up 9 months after her ground breaking surgery. So far HSS has only preformed two of these surgeries and her surgery was the first one. She had a large lesion of missing cartilage on the back of her knee cap, most likely due to some sports injury early in her life. Since cartilage can’t grow back, she was pretty much stuck with constant pain for the rest of her life. However, she underwent a new procedure which consisted of taking juvenile cartilage from patients that are younger than 13 years of age. They cut this cartilage up into small pieces and then place them in the lesion on the back of her knee cap and secure them in the lesion with a fibrous capsule. Then since the cartilage is from young patients the cells are very active and have a good chance of growing new cartilage in the lesion. Just nine months after her surgery she has new cartilage growth as seen on her MRI scans and a remarkable change in the amount of pain she has day to day. Her knee is not completely repaired yet, but it’s definitely on its way.

Aside from seeing patients, I also went to a few meetings, including grand rounds, and saw two surgeries. Grand rounds was interesting because it was all about treating ankle injuries and debates on immobilization and taping. The two surgeries I saw were both arthroscopic with one on the knee and one on the shoulder. It’s very interesting to see the anatomy so clearly of the knee and shoulder during these procedures and to see all the tools they use to repair them.

Next week I look forward to starting my research project and exploring other areas of the hospital.

Summer Immersion Week 2

This week was certainly just as enlightening as the first week. This week I got to see more patients with Dr. Gauthier and observe neurosurgeries with Dr. Kaplitt and Dr. Greenfield.

With Dr. Gauthier I got to see a new side of multiple sclerosis (MS). There is a wide range of responses that people can have to the same disease. Since MS is a chronic disease many of the patients that come to Dr. Gauthier’s office have had the disease for a very long time. The exact form of the disease varies for each patient; patients can feel subtly different effects during a relapse of MS which may or may not be reflected in the MRI scans showing where new lesions form in the CNS (central nervous system). But rarely for some patients the nature of the disease seems to become less predictable; the disease can become aggressive and lesions appear in the MRI that are not usually typical of MS. Dr. Gauthier has had such patients before that have required likewise more aggressive treatment, such as the same chemotherapy treatments that are given to cancer patients since these treatments aggressively suppress the immune system. In cases with such drastic changes from the usual form of the disease it is also necessary to look for diseases that can sometimes mimic MS like symptoms. It is with this kind of case that I could see how doctors investigate diseases that have no specific test to confirm whether or not the disease is present, like MS; which seems to be something like solving a medical mystery. Dr. Gauthier described this process as looking for the typical markers of disease which ranged from getting a spinal tap and blood tests to more MRI images. This new information allows doctors to rule out other diseases like certain infections that can have neurological symptoms to other autoimmune diseases of the nervous system.

With Dr. Kaplitt and Dr. Greenfield I was certainly dazzled by the technology present in neurological surgery. Dr. Kaplitt does, among other types of surgery, work with deep brain stimulators and spinal stimulators for various maladies. In these such cases Dr. Kaplitt would implant an electrode array to stimulate a specific part of the nervous system to alleviate the patient’s symptoms. Though I have not yet seen either type of device implanted within a patient I did observe how some of the electronic components, the battery pack, are replaced and readjusted for the patient. This was my first experience with technology that is physically implanted within a patient; even though it was still surgery it seemed relatively simple and quick for the surgeon to perform. After the surgery the newly implanted components were adjusted wirelessly. The second surgery I observed with Dr. Greenfield was much more complicated. It was a craniotomy for a suboccipital tumor resection; the removal of a tumor from the back of the brain. Without advances in imaging technology there is simply no way that I could see that this operation could have been performed. Not only were MRI images integral to detecting the tumor and planning the surgery, but the same images were also central to the tracking technology that essentially tracked the position of a surgical probe that was in the brain of the patient during the surgery, this technology was called BrainLAB. From my stand point there seemed to be a few critical questions during the surgery; identifying tumor tissue from normal healthy tissue and knowing when the entire tumor has been removed. Answers to these questions were aided by the BrainLAB technology. The position of the surgical probe within the brain was mapped, with BrainLAB, to the MRI scans of the patient before the procedure which allowed the surgeons to get an estimate of how far they have gone into the tumor and what might remain during the procedure. The whole procedure was completed in about 5 hours through which I also learned a lot about the anatomy of the brain.

It has been an interesting week and I look forward to next weeks’ adventures.

Week 2 - Parker

Neonatal ICU

This week I was able to shadow the doctors and residents during neonatal ICU rounds, as well as observe the diagnostics and treatments preformed there. The NICU at WCMC is divided into two separate teams that are responsible for a certain babies in the unit. I went on rounds with a team lead by the attending, Dr. Yohay, who was accompanied by a fellow and the NICU residents. Each resident on the team in the NICU is assigned to three to four of the babies that the team is responsible for. Before the rounds begin the residents print out a summary of the each of their patients up-to-date statuses. During rounds the attending and fellow lead the residents around the NICU and the residents go over the information they have for that morning for each baby and the team decides on the plan of the day for each baby.

The residents and doctor discuss the weight gain, fluids intake, residuals, any incidences, etc. for each patient to determine the care needed for that day. Some patients require special testing for heart problems or other developmental defects, which is also taken into consideration during the rounds.

It was interesting that the NICU works on a day-to-day basis. The doctor does not even begin to consider the longer-term future until the patient is stable. This is different from the work in my main area, urology, with older patients. The doctor is able to predict the outcome of the treatments preformed and usually has to only follow up with patients. The NICU is special in that each day the babies are there is uncertain and the main goal is to allow the babies to dictate how well they will do and when they will be released.

-S. Parker

Week 2---Weiwei

This week I observed three vascular surgeries. One of them made me understand that clinical surgery sometime is not predictive. In that case, the patient had 50~99% stenosis in his left popliteal artery (POP). The surgery was planned to use angioplasty to open the POP in order to recover the normal blood circulation in patient's lower left leg. However, during the surgery, the angiograph showed very complicated local geometry of the POP together with an enlarged section of calcified vessel in front of the clotting. The local blood vessel was so narrow that the catheter couldn't pass through. Doctors finally decided to stop the angioplasty and was going to plan another open surgery in several weeks--setting up a bypass. Though it was a minimal-invasive surgery and the patient was only local anesthetic, such unsuccessful experience demonstrated the risk in vascular surgeries.

This week I started my project: using the ultrasound data to analyse the progress of blood flow velocity after placing the stent. The incentive is, there may be a trend that the stent will cause the blood flow velocity change at specific location (in the location of the stent, upstream or downstram) after time. I am gonna selective choose about 20 patients with continueous Low Ext Duplex data after placing a stent, build up my own database and try to analyse the trend based on the data.

BME summer immersion 2010 week 2

In the second week of summer immersion, I became more familiar with the fundamentals of sleep, sleep disorders, and sleep medicine. I also developed a greater appreciation for the importance of sleep medicine, both to the individual as well as to society at large. A not insubstantial portion of my week was given over to conducting background reading on sleep and sleep disorders so that I would make better sense of what I encountered in the clinical setting. In order to identify sleep disorders, assess their severity, and prescribe efficacious treatment, the ability to read and interpret electroencephalographic (EEG), electrocardiographic (EKG), and electromyographic (EMG) waveforms is essential. Toward this end, I have been familiarizing myself with the considerable existing body of knowledge on the subject.

I was able to be present during several “hookups” of patients for nighttime recordings. I was also able to sit in on consultations between my advisor and patients. I was impressed by the meticulous nature of these consultations and the exacting way in which medical history, family history, and lifestyle details were teased out of the patient in an effort to ensure proper treatment. One individual with severe sleep apnea was prescribed a CPAP device to alleviate the frequency of breathing cessations (and associated arousals that disrupt sleep). The device will not only make this individual – who was feeling torpid and lethargic throughout the day – feel refreshed and invigorated, but may also serve to lower his high blood pressure, a possible consequence of the labored nature of breathing during obstructive episodes.

A refinement of my probable research topic also emerged. Dovetailing nicely with my undergraduate education in electrical engineering in general and my interest in biomedical instrumentation in particular, my advisor and I agreed that design and construction of a novel sensor would represent an important contribution to the existing bevy of sensors. Several possibilities emerged including an incontinence sensor to detect bed wetting and concomitant interface of it with the commercial system currently in place, an accelerometer-based periodic leg movement sensor, or most likely, a new implementation of elastomeric plethysmography, a technique used to noninvasively track thoracic (chest) and abdominal contractions and expansions while breathing. The latter is essential for accurate diagnosis of several important medical conditions including paradoxical breathing in which the chest and abdomen contract and expand in an antagonistic manner as well as discriminating between central and obstructive sleep apnea. A project involving the design of a novel device to diminish the severity of sleep apnea is also emerging in collaboration with Dr. Arthur J. Spielman of the Center for Sleep Medicine.

Mike Mitchell's 1st Week: Not Quite Like "Scrubs"

Welcome Back!

The first week was a very hectic one; between moving in, seeing patients, viewing surgeries, researching potential projects, and exploring NYC, there was very little time for sleep (I can sleep when I get back to Ithaca...just don't tell my advisor that!). I will do my best to recap here; if you are curious as to why the following sections are color-coded, simply view my last blog entry (Mike Mitchell's Summer Immersion: Introduction) for a quick overview!

I will forever be known to the first year medical students as "the poor kid who moved in during a monsoon," as I moved in a day later than most of my colleagues during the middle of a torrential downpour. Luckily, they were all kind enough to help me move into Olin Hall, our residence for the summer. Housing expenses are zero for our time here, and most of us either share a dorm-sized room and living room with a roommate, or have a single room and share a bathroom with another individual. The rooms are already furnished as well; just make sure to become buddies with IT so you can get the internet up and running! A full basketball court, cardio and weight training machines, along with free weights are conveniently available within the residence.

Dr. Yi Wang introduced us to the program on our first day, and helped us get into contact with our clinicians. Mitch Cooper also helped us obtain IDs, an absolute staple when entering any building room within Weill Cornell and New York Presbyterian Hospital. I would also recommend using these first few days to become acquainted with New York Presbyterian and Weill Cornell. The hospital is absolutely massive and most of the buildings are interconnected; in order to attend meetings on time, it is essential to know your way around. Clinicians are extremely busy, and being late for one meeting could mean that you will not have another chance to meet with them for a few days or more!

Speaking of clinicians, I was able to meet with my own mentor for the summer: Dr. John Karwowski, Chief of Vascular Surgery. We barely had time to shake hands and introduce ourselves to one another, as surgery was about to begin.

The two main surgeries I viewed this week involved minimally invasive interventions for vascular disease. Vascular disease affects the blood vessels within your body, either in terms of hard plaques on the vessel walls (they are typically calcified; think of having an almost bone-like material on your vessel wall), blood clots (typically clumps of platelets called a thrombus that can stop your blood from flowing normally; the normal function of platelets are to heal wounds/tears on our blood vessels), and other blood flow abnormalities. Since blood flow is essential for nutrients and oxygen to be distributed through the body, not enough blood flow can make it very difficult for parts of the body to survive.

The two cases involved:

(1) A thrombus formation in the inferior vena cava (aka IVC, a large vein the provides blood to the right atrium of the heart);

(2) A patient with foot ulcers (wounds due to vascular complications; and absolute haven for infections), due to inadequate blood flow to his lower body (caused by plaques within the vessels).

Two different devices were used in these cases; for the first, an IVC filter (seen below, courtesy of Gunther Tulip Inc.) was used, and in the second a balloon catheter was utilized (see video from MIT for more details: http://web.mit.edu/invent/www/ima/fogarty_video.html). For the first case, the IVC filter was used to allow blood to flow through the vessel, while maintaining the thrombus within that spot. In the second case, a small balloon was inflated within a vessel to expand a stent (a very small metal cage used to push plaque aside to allow adequate blood flow to resume) within the plaque filled artery.


In both cases, blood flow was obstructed in some shape or form from the body. However, two very different devices were used.

Why were these different devices employed? What key differences could there be between plaques and thrombi, and what effects can they have on our health? What would happen if the thrombus were to move?

Observing Dr. Karwowski in surgery was simply amazing; the IVC surgery took an astounding 50 minutes to complete (I have had Biology 101 labs that have taken longer!), while the other surgery took about 3-4 hours to complete. Both were a complete success, although it is unclear in the second surgery if adequate blood flow would improve the foot ulcers. Other measures may need to be taken; unfortunately a foot amputation might be in store for the patient if the infection continues to spread.

I will touch up on seeing patients, along with my potential research projects within my next entry. For now, enjoy some food suggestions around Manhattan!

Quality Places to Eat:

ZaZa Restaurant: Excellent lobster ravioli, sweet outdoor seating in their garden in the back!

Bamboo Sushi: Super fresh sushi, a minute walk from Olin Hall, and great lunch specials!



Not So Quality:

O'Flanagan's: Great bar, sweet karaoke, but I would avoid the overpriced, average bar food.


I will try to do a better job next time!

-Mike

Urological Impressions episode 2 - The daVinci Wars

Hi everyone, it's been another week down at the OR (operating room) and meeting patients with my mentor Dr. Douglas Scherr of Urology. This week has not been as hectic as it was when I first arrived, probably because I have gotten adjusted to the scenery of the hospital. Anyways to prevent the unfortunate readers of this blog from being bored to death reading long entries every week, I will keep this one (and hopefully the coming ones) short and straight to the point highlighting the events that I found particularly interesting or relevant.

This week I was finally able to view the da Vinci Surgical System, which I shall refer to as the daVinci, which is a large robot composed of two parts: one parts resembles a large spider with many arms and a second part which looks like a small cube. The part with the arms contain the surgical instruments and tools that are controlled remotely by the medical doctor from the small cube. What I found interesting was that after the cameras and arms are inserted into the patient, a 3-D projection of what the cameras see is projected into the cube allowing the doctor to have depth perception. The daVinci allows excellent control and responsiveness to the doctor utilizing it as well as a magnified view of the inside of the patient. I would also like to mention that the procedures involving daVinci is minimally invasive which allows faster healing for the patients in comparison to open surgery. I watched a robotic radical prostatectomy using the daVinci which removed a benign prostate tumor from a patient about the size of a mandarin orange (compared to healthy walnut size) after which they performed anastomosis (reconnection) on the urethra and bladders. Another surgery I've seen was a robotic radical cystectomy on a male with T2 bladder cancer where his bladder, distal ureter, seminal vesicles and prostate were removed via daVinci. Afterwards they created a neobladder or fake bladder from a section of the ileum which they modified into an elliptical shape, which was then reconnected to the urethra and ureters.

In other news I attended a Grand Rounds on Mon. where a doctor presented some case studies involving urodynamics. In the Grand Rounds the doctors would show some real patient cases and then question the residents on what their diagnosis would be given the information. I watched a cystography where the doctors put their patient under general anethesia and removed a bladder tumor from the inside with a resectascope. I've also watched an interesting case where a patient was under a CT scan and the doctors discovered, to their shock, that she was missing a large portion of her right ureter which would require surgery on her part.

As for my research, my mentor still needs to get in contact with my research advisor back at Ithaca before we can make more progress. In the mean time I looked up information involving calcification and stone formation in the bladder; I've discovered that GAG's naturally inhibit stone formation and that heparin coated materials also do a similar job. For now I plan to do some more literature search on my own and hope to make progress on this potential project very soon.

Stay tuned for episode 3 of Urological Impressions next week...

Week 2 -- Mitch Cooper

Week two was an interesting week for me. I started my first week of rotating through all of the services in the radiology department. This week I was based in Nuclear Cardiology with Dr. Frank Wong and his Fellows Helena and Hasan. Nuclear Cardiology is particularly interesting to me, because it is close to my research topic of myocardial perfusion with MRI. Nuclear cardiology though looks at cardiac perfusion through using a radio-isotope tracer that is injected through intervenously and then imaged using a SPECT machine (i.e. gamma camera). To see perfusion two sets of images are taken -- one set before exercise when the patient is at rest. The other set is taken after the patient runs on a treadmill until their peak heart rate (220-age) is achieved, they are then injected with a tracer, and imaged later. The advantage over stress MRI, is that 1. the patient is doing real stress, where symptoms can be re-created with a doctor present, and 2. there is not a need to have the patient be stressed during imaging. In some cases though, as with in-patients, they do need to artificially stress the heart using drugs like adenosine, lexascan, or dobutamine. These can be problematic though for patients with COPD/asthma, since bronchiospasms can occur.

I also found it very interesting to watch the doctors communicate with patients. The doctors have great skill in being able to sympathize with the patient, and make an instant connection with them. This skill is very important in situations such as with the stress test, because it is important for the doctor to be able to push the patient to keep exercising to maintain peak heart rate. I never had realized before the skill that doctors have in relating to the patients, and how important it is to patient care and treatment.

Experiencing nuclear cardiology this week was very useful. Next week I hope to go on to watch echo-cardiograms, then hopefully cardiac characterization the following week. I find this very useful for my future research. Since I research cardiac MRI, it is very helpful to see what other modalities are out there, what they are used for, and what their advantages/disadvantages are compared to MRI.

Mike Mitchell's Summer Immersion: Introduction

Hello Everyone!

After going almost two weeks with internet access, IT has finally been gracious enough to grant me internet access. While that may sound excruciating to some, New York City and Weill Cornell certainly find many different ways to fill every second of the day. Plus, the secretary at IT, Maria, rewarded me with absolutely amazing candy for being a patient soul. A win-win situation, I tell you.

Now onto blogging; I hope to make this blog both easy to read and useful for:

(1) My colleagues in Ithaca who have participated in the program in the past, faculty included;

(2) My future colleagues who will be entering Cornell Biomedical Engineering in the fall of 2010, so they can have some tangible sense of the program and make the most of their 7 weeks from the get-go;

(3) Any individual who is interested in vascular surgery, my field of focus here at Weill.

In order to make this blog "one-stop shopping" for everyone, I will attempt to color code my blog based on interest area:

-Parts of my blog labeled BLUE will focus on items that are of particular interest to the future summer immersion classes, including day-to-day living, how to communicate with doctors in different field areas, etc.

-Parts labeled GREEN (New York Presbyterian scrub colors!) will focus mainly on vascular surgery, but also diseases that I find of interest in the body, along with other areas of the hospital that peak my curiosity.

-Last but not least, suggestions for anything food/sightseeing/music/FUN will be labeled in CORNELL RED.

Since a lot has happened in the hospital in the first week alone, I will attempt a broad sweep of the immersion experience each week. I will pose questions throughout my blog; either questions I may have had for my clinician, or questions that could spark interest in you, the reader. From there, you are certainly more than welcome to comment on these areas, and we can begin discussions based on the reader's interest in the field. Many of these questions will not have right or wrong answers, so any thoughts or criticisms you provide may prove to be constructive ones! That should be about it for logistics; I hope you enjoy my blog!

-Mike

Week 1 - Jen Richards

The first week of summer immersion in New York City seemed to fly by as I met my mentor, observed surgeries, and had bio-ethics training, all in one week! When I arrived in New York, New York, I first had to get settled into Olin Hall, located just across the street from the hospital. After being oriented and getting hospital ID's, I was ready to meet my surgeon mentor. I am shadowing Dr. Jason Spector, a plastic surgeon specializing in reconstruction and microsurgery. He is actually mentoring not just myself, but another BME student, Carissa Ball. Dr. Spector is extremely knowledgeable and is interested in teaching, which bodes well for the rest of the summer!

Tuesday I found myself dressed in scrubs and waiting in the operating room (OR) for the first time. I was excited and nervous at the same time. I really wanted to see this surgery, but I didn't want to be a distraction in any way. I soon found out that as long as I did not touch anything sterile, I could watch all I wanted. The OR was not the serious place I thought it would be. Although Dr. Spector, the residents and nurses working in the OR were focused on their work, there was a relaxed atmosphere with music playing in the background.

The first surgery I observed was a pressure sore located on the buttock of a paraplegic man. I was surprised to discover that pressure sores can occur within 2 hours of a constant pressure of only 30 mmHg! The necrotic tissue reached to the patient's pelvic bone, which meant the wound had to be fully opened, the necrotic tissue removed, and then sewn up again. Very interesting was that the surgeon used a biodegradable suture made of PGA/PLA for the inner tissue sutures, and a strong nylon suture for the outer stitching that will need removing later. The second surgery of the day was a preparation for a skin flap on a very severe burn patient. This patient has severe diabetes and did not realize the serious extent of his burns. The burns on his ankles extended all the way to the bone. Dr. Spector cleared the infected tissue away, and then cut a skin flap from the back of the patient's calf. A side note: what's the difference between a skin graft and a skin flap? Well, a skin graft is just a piece of tissue that is not vascularized in any way - so the wound must have it's own blood supply. However, a skin flap comes with its own vascularization, so it can be lain over an area that does not have its own blood supply. A little something I learned. The skin flap was simply opened then sewn up again (it will be left for a week so that the blood vessels have a chance to dilate).

The next day I spent in the OR with another plastic surgeon, Dr. Schwarz. The first surgery was treating a patient with carpel tunnel and trigger finger. This was a much simpler surgery, one that could completely cut off the blood supply to the hand without causing lasting harm. One tendon in the wrist was separated so as to give more room in the carpel tunnel, which will relieve pain. Also, the A-1 pulley in the trigger finger was released so that it would no longer click and pull when the patient moved it. The second surgery was a breast implant in a woman who had had a mastectomy. This patient insisted on saline implants because she had read about the dangers of silicone. Although the doctor tried to explain about the newer silicone implants, the patient would not be swayed. I learned that the patient's wishes are always taken into account in these surgeries.

All in all, the first week was a great success, and I am looking very much forward to the weeks to come!

June 14-18, Katie Povirk

This first week in NYC I got settled in at the Hospital for Special Surgery. We were required to obtain an extra ID badge, fill out forms to be cleared for the OR, and to meet with the director of Biomechanics, Dr. Wright. My PhD advisor, Dr. van der Meulen, is on sabbatical this year in NYC, so I was also able to meet all the people who are collaborators with her and who are people I might work with in the future.

On Tuesday, I was able to meet with Dr. Padgett, my mentor for the summer. He performs many total and partial arthroplasties of the hip, knee, and shoulder. During our meeting, he presented me with a particular patient's chart and x-ray scans, which were severely misaligned due to a growth plate abnormality. His right knee was in dire need for a complete makeover, as the joint appeared rotated probably at least 30 degrees. After we briefly talked discussed the case, we walked over to a patient room and actually met with the patient for his follow-up visit, a year after surgery! I was able to see Dr. Padgett compare the old and new x-rays, examine the patient's mobility, and discuss his pain levels and problems. It was really interesting to learn how Dr. Padgett worked with the patient, his wife, and an engineer to design an implant that perfectly fit his needs. Afterward, Dr. Padgett showed me the patient's "pain level" charts, which showed great improvement from before surgery to after. He really made an impact on the patient's quality of life, who before surgery would not want to even walk down the driveway to the mailbox. We briefly discussed my summer project. Dr. Padgett directed me to Joe Lipman, the director of device development at HSS and also an engineer. For my summer project, Dr. Padgett wants me to learn about custom made implants, and present a particular patient's case in detail, with my inputs.

Also this week I attended the required bioethics training, which covered many of the topics we had to read for the CITI training. Also, I attended a number of lab meetings, including Dr. Boskey's lab meeting, Dr. Bostrom's lab meeting, and the TERR meeting, all of which gave me an idea of the particular research projects that are being conducted in these groups.

On Thursday, I attended grand rounds for total arthroplasty. A fellow presented some recent cases, and the attendings, fellows, and residents present discussed the outcomes. Throughout the meeting, Dr. Bostrom (who was leading), would challenge residents to answer specific questions about the chosen course of action. It was very interesting to learn about how bone scans after a total arthroplasty can indicate where the device is probably loose. This area shows up as "hot" on the scan, and can be a very non-invasive method for diagnosing problems with implants. It was also interesting to hear how doctors handle patient cases differently, such as the difference in material for hip implants with age. Some doctors use metal on metal in as young as 45 years of age, whereas some believed that was too young. Later, we had a presentation that discussed how patients at higher volume centers have better outcomes, and the reasons behind this were speculated and examined through data presentation.

From Thursday afternoon to evening, I was invited to go sailing with Dr. Bostrom's group for their yearly event at the Larchmont Sailing club. We sailed for over 4 hours in the afternoon and had a very formal and fancy dinner later in a private room at the club. It was fun to spend more time with the people in the lab and get to know Dr. Bostrom better.

Lastly, on Friday I also attended another lab meeting, usually held by Dr. Padgett but this week was held by Dr. Wright. He went around the table and discussed issues each person was having, and touched base with their progress. I learned that the lab has quite a few projects going on, from spine fusions, hip and knee simulators, and new mobile bearing hip replacement projects. I was interested to learn that the lab often has cadaveric samples to work with, which is of great advantage. Often a sheep or cow is used for a spinal sample, but they do not experience the same loads as quadrapods such as humans do, and so the outcomes are never exactly the same.