Saturday, June 30, 2012

Jocelyn Marshall Week 3

This week all the talk in the HSS Rheumatology Department was the Supreme Court's decision on Obamacare. Dr. Lockshin shared with me his experience as a young resident when Medicare and Medicaid were first enacted, it was an amazing story. I, being born only slightly over two decades ago, have no idea what it was like when there was no government support for healthcare.

This week I spent the majority of my week continuing to shadow Dr. Lockshin in his office visits. While I would say the normal visit is a followup just to see if someone's disease is active, this week I was able to see some patients in more devastating states than I had previously. For example, I saw a young girl with lupus nephritis, who is in complete renal failure, has to undergo blood transfusions because she is making no blood on her own, and to top it all off, now has a partially collapsed lung. But in spite of it all, she remains relatively upbeat and confident. She claimed that she is glad she is the one with the disease and not someone who can't handle it. She was very inspirational and extremely strong.
I also saw a woman who has sever rheumatoid arthritis whose joints in her hands and wrists are completely destroyed, and whose neck can no longer support her.

I have also discussed with Dr. Lockshin a lot about the board guidelines for care. He was telling me how the American Board of Rheumatology releases guidelines for treating the various diseases, but how it is hard to follow them to point with every patient. Every patient is different and many times the guidelines don't fit with the patient's needs or wants.

Next week I am looking forward to doing some ICU rounds and perhaps sitting in on  some surgeries. Though, it will most likely be a slower week due to the holiday.

Friday, June 29, 2012

Week 3 - Katie Hudson

On Monday I went on rounds with the physicians in the NICU at NYP. The rounds started at 9 and continued until about 12 because there were so many patients to see. I was impressed by the amount of attention given to each baby. Each nurse was assigned to only a couple babies and a doctor was also personally assigned to each baby even though all the physicians consulted on rounds. I have never seen so many tiny babies. Some had as little gestation time as 25 weeks where the normal gestation time for a full term baby is 40 weeks or more. I was told that treatment for neonates less than 30 weeks has improved significantly over the last 25 years and it is clear that technological advancements have helped significantly.
At first I was lost when the doctors started reviewing their babies’ numbers. What is the difference between an ‘indirect’ and direct? Is it true that these babies only eat about 90 calories a day? I didn’t have any idea what ‘normal’ was for a newborn or, in some cases, what the statistics meant at all. I started to pick up on certain words I recognized and slowly things started to make more sense. I also made a mental list of words or terms I did not know so I could look them up later.

From a purely engineering perspective, I was frustrated by the number of alarms going off at each bed. Most seemed unimportant judging by the doctors’ reactions but it seems like it takes immense amounts of conditioning to pick out which alarms are important for each baby. I think there may be a better way for the information on the monitors to be displayed and communicated. I will ask the doctors and nurses about the alarms the next time I go on rounds.

Monday afternoon I attended a surgery by Dr. Hartl. He was doing a decompression and he explained is approach and that he was going to be using the microscope which has a display. I’m starting to understand the real anatomy of the spine as seen during surgery, but I still need to watch more videos so I won’t be quite as lost. Without knowledge of what is supposed to be happening, surgeries can all start to look the same.
On Tuesday we had a research group meeting. I was assigned to work on data analysis for both Peter’s paper and our paper on annular repair.  I learned how to analyze the MR images that we get from the rat tails that we use in our experiments. I was surprised that it was difficult to get good data from the program associated with the MRI machine so I am in the process of writing a Matlab program that will allow us to analyze the raw data more easily and specifically in the way we need. The program cannot give us a listing of the relaxation times per voxel so I will process the DICOM images separately.

On Wednesday I visited patients with Dr. Hartl. This time we met not only with elderly patients, but with several younger patients as well including a trauma case. It made the experience much more real. I’m getting much better at recognizing the problem areas in the MRIs before Dr. Hartl tells me. Reading these images and localization of pain are the best ways to diagnose patients. We also went on rounds to visit patients still in the hospital after surgery. They are up and walking around very soon after they wake up.

Thursday and Friday I worked on my Matlab program and clarified some of my questions about the data. Dr. Hartl has left for Tanzinia so I will be focusing much more on my project next week.

Thursday, June 28, 2012

Weeks 1-2, CGregg


For my first two weeks working with Dr. Spector in plastic surgery has proved to be enlightening.  Starting the first day of immersion, I followed Dr. Spector during office visits, his usual Monday schedule.  Here is where I saw many post-operative patients including multiple limb reconstructions from accidents, several skin wounds, and a few unfortunate patients who were suffering from complications from previous operations.

On Tuesday of the first week I met plastic surgery residents and followed them on rounds starting at 6am.  This side of care was very different from the standard office visits that I experienced on Monday.  Many of these patients had just undergone major surgery and were still recovering.  Additionally, some patients had suffered serious complications which needed to be addressed.

Wednesday proved to be the most exciting day when I was allowed by Dr. Spector to be a part of my first surgery.  After first seeing a scar revision, I then retracted a patients abdomen for 6 hours while watching a hysterectomy, abdominal wall reconstruction for a hernia, and inspection of the intestines for visible signs of complications from severe Crohn's disease.

Dr. Spector was out of town for Thursday and Friday of the first week.  During this time I worked on my Specific Aims and Gantt chart for my research project.  Through Skype meetings with Dr. Butcher in Ithaca and research meetings with Dr. Spector, we established that I was going to attempt to build a vascular network from bioprinted scaffolds from the Butcher lab.


After the first week, the schedule with Dr. Spector has become fairly routine.  On Monday, I follow him during his office visits.  Some post operative cases that I saw this week were a rhinoplasty due to a deviated septum and multiple breast reconstructions for breast cancer survivors.  Dr. Spector has also taken the time to explain how he does every operation and why he makes the surgical decisions that he does.  From Dr. Spector's patience and teaching, I have begun to gain important insights into the world of clinical medicine.

The most exciting day this week was a foot reconstruction surgery from a free tissue flap obtained from the patient's thigh.  This patients was suffering from severe diabetes, suffered blindness from diabetic retinopathy, and was currently on dialysis for renal failure.  Traditionally, the tissue flap is harvested which includes the skin, muscle, and blood supply and then the blood vessels are micro-surgically connected to the recipient blood supply.  This allows for large tissue transfers and reconstructive surgery, in this case a patient who has lost part of the foot from a diabetic foot ulcer, for reconstruction.  Without this technique this patient would have had a foot amputation.  Due to the renal failure of the patient and the dialysis treatments, the calcium homeostasis of the body was out of balance and the blood vessels suffer from a large amount of calcium demosits which causes hardening of the vessels and furthers the vascular disease that the patient was already suffering from.  During the surgery I was able to feel a small part of artery in the patient and it was clear that the vessels were quite hard.

Lastly, during a small reconstructive surgery that I observed on Friday, an emergency trauma was rushed into the adjacent OR.  This patient had fallen off of a roof onto the head.  Dr. Spector lead me into the next OR where I could witness how a trauma situation was handled.  The room was complete chaos with multiple different surgeons and nurses all trying to assess the patient's state at once.  While most of the patient's body didn't look terribly bad, the head and face were entirely distorted and it was clear from hearing the surgeons speak that there was a lot of internal damage.  This was absolutely the saddest thing I have witnessed in the hospital thus far.

Wednesday, June 27, 2012

Joseph Miller Weeks 1-2

This post will recount my time in New York City during the first and second weeks of immersion term.

Week 1:
Things were a little more hectic for me since my relocation involved actually moving my whole apartment to the city and settling into the Lasdon graduate housing.  However, the move went semi-smooth and since one of my thesis advisors, Dr.Susan Pannullo, is acting as my clinician for the semester I was able to hit the ground running.  I work in the Neurological Surgery department with Susan, primarily focused on the application of radiation therapy to brain tumors.  On the very first day, I donned my resident attire and did patient rounds and already begun to see the immense application radiation therapy had beyond the treatment of tumors.  For instance, one patient had trigeminal neuralgia, a condition in which the trigenimal nerve experiences compression due to vessel pressure.  The symptoms involve a very sensitive face, numbness and an extremely painful sort of electric shock when eating, brushing ones teeth or even a breeze blows over the face.  Typically in young patients, a surgery will correct the problem, however, in older patients who wish to avoid invasive surgery, radiotherapy is an option.  The idea here is to essentially kill part of the trigeminal nerve while sparing the rest of the face's nervous system.  It has a 60% success rate, compared to the near 100% from surgery but again, it's non-invasive and surgery is always an option should the procedure not succeed.  The important part of this, from my perspective, is the realization that radiation therapy has other real applications in the clinic beyond tumor therapy.  It really opens up a world of questions about what other nervous system interventions can be achieved in this way.  It also reminds me of two-photon laser incisions, but where we've traded off the small incision points of 2p for a larger (mm) size from gamma therapy but you no longer have the penetration problem.  This was the highlight of this week but there were many other stories the rest of the week.  In general, I see all Dr.Pannullo's patients with her in the mornings and then in the afternoons, we do treatments and attend meetings regarding IRB's, Tumor board where other surgeons and radiologists discuss outstanding brain tumor cases, and other development projects.

Week 2:
This weeks highlight was definitely being involved in putting on a "halo" to one of the patients.  A halo is a titanium and carbon ring that must be physically bolted into a patients skull in order for a helmet that then rests on the halo to stay fixes with respect to the patient's brain.  This helmet then had a series of ports in which gamma rays are injected for therapy.  This is the most invasive, painful part of radiation therapy.  The patients tend to do well and generally forget the whole experience due to the drugs that accompany the procedure but it is painful for them and not a very graceful moment in the hospital room.  I discussed with Dr.Pannullo a number of things that could make this procedure better.  For example, currently it takes a number of people to screw the halo into place at the same time.  Usually, it's the doctor, maybe a nurse and a couple interns.  In our case, one of the interns fainted while holding the halo and went to the ground.  Dr.Pannullo reflected this happens almost every time with someone new.  Also, while Dr.Pannullo made some marks where the halo would be best fit, we missed the marks by quite some distance due to our inability to keep the halo level while tightening the screws.  It seemed to me a special chair built to hold the halo in place while still enabling the physician to have the degrees of freedom they need to adjust would make this whole procedure much less clumsy.   Also, medical school teaches a "two finger" rule for how much tension should be on the arbitrary assignment with no real meaning.  A halo with a torque measurement would be very simple to create and standardize the procedure.
I also spent some time with Susan in meetings regarding a new innovation center in which she is the director.  We saw some prototype facilities on 71st that will serve the innovation center well.  We speculated about making the halo prototypes in these facilities as a test.
Finally, I nailed down a project.  We want to assess a patient's response to therapy from computer algorithms in MRI.  Currently, a patient comes back for a follow up MRI 3-6 months post procedure for a look at the progress of the tumors.  Sometimes the tumors are larger, sometimes they are smaller.  In general, we prefer the tumors to be smaller but even this shrinkage is not a good indicator of remission. Sometimes the tumors are larger but this doesn't mean they are getting worst.  It could be that the tumor is inflamed and sort of balloons before shrinking away.  As a result, many patients hear sort of ambiguous news without really knowing if we should change therapy plans or not.  This is valuable time lost and figuring out some sort of biomarker or indication on an MRI could have significant impacts on patient care.  Currently, I'm doing research for a lead on what MRI could show to this end.


Another storm of clinical and research adventures filled the week. The most dramatic case, a free-flap autograft for a patient with a large diabetic foot ulcer, provided first-hand insights to the challenges posed by microvascular surgery and design criteria for tissue-engineered pre-vascularized constructs. However, more important than the project specifications, this week I learned to appreciate the value of reliability in the OR. Whereas in Ithaca, I might successfully fabricate a fully endothelialized microvessel in 1% of my attempts, Dr. Spector demands dramatically higher results before implementing any new technology in a procedure. This was most obvious in the suturing of the veins, which requires 12 microscopic pins to perfectly align with their receiving sockets. Any obstructions of the anastomosis could generate thrombosis and cause the flap to fail. Demonstration of robustness is an indispensable paradigm in surgery, especially micro-surgery.
This particular surgery was very informative for my summer research project, which may eventually include connecting tissue-engineered blood vessels to rat vasculature. Although I have produced such vessels in Ithaca, I never previously considered the problems of attaching these devices to the host circulatory system. Witnessing the strategies and technologies that currently exist for plumbing free-flaps illustrated the challenges associated with this obstacle. Meanwhile, attempts to generate TE thick tissues without addressing this step will be largely useless. As Dr. Spector repeatedly informs us, vasculature is critical for tissue survival. The interface between fully-biological surrogate vasculature and host vessels will be an interesting engineering problem, and like the free-flap operation, will require almost perfect reliability.
Meanwhile, I have had moderate success in my current project aim, which comprises the fabrication and implantation of micropatterned collagen scaffolds. This week I generated 12 discs which contained 0, 1, or multiple channels. Theoretically, the channels will facilitate cell invasion from the periphery toward the center of avascular wounds, such as exposed bone or synthetic hardware. Alone, even small openings on these areas would never heal due to lack of vasculature. Our constructs will hopefully facilitate the lateral invasion of cells and vessels from surrounding healthy tissue. Next week I will image the discs to see how well the fabrication technique was able to produce channels in the collagen.
It is amazing that another week has already gone by. I am starting to realize that, like the surgeon, each moment I have here at WCMC will be precious!


We took the proverbial plunge this week and landed elbow deep in a woman’s abdomen in the OR during a hernia operation and hysterectomy. The first few days with Dr. Spector redefined the phrase “summer immersion”; between operations, outpatient visits, clinical rounds, and laboratory research, this program should aptly be called “summer deluge.”
As an outsider to the hospital environment, the first noteworthy characteristic is the pace. In the first hour at the clinic we visited half a dozen post-op patients with conditions ranging from brain tumor resection to jaw reconstruction. Later, exhilarated and mildly exhausted from an action-packed day, we learned that it was a slow Monday for Dr. Spector and the team. This observation emphasized the most limited and valuable resource in the hospital: time. The profound ramifications of the importunate clock reveal an essential and enduring need for technologies that can accelerate, well, anything. Faster operations, faster imaging, faster healing, faster pre-op, faster post-op, faster treatment. For a surgeon, each minute of the day is an investment, and as engineers, we must develop technologies that afford high returns. Based on my first week, I expect there is very little demand for assays that will take several weeks to generate results, at least in this department.
The second most striking aspect of the week was the case diversity. Apart from their Latin etymology, every condition was remarkably unique in the pathology, severity, progression, and a hundred other metrics. Indeed, it would be wholly impossible to fully characterize any given patient. This reality highlights the importance of versatile therapies that treat fundamental diseases among a broad patient cohort. It also showed the inimitable role of the doctor in diagnosing and treating each particular case, again reinforcing the demand for each doctor’s time.
As I gain an understanding of clinical dynamics and patient care, I already notice an increasing awareness of my own aptitudes as an engineer to facilitate healthcare, as well as enhanced appreciation for collaboration between medical doctors and academic research. I anticipate a summer of exploring the significance of this synergy for a clarified perspective of the role of engineering in healthcare.

Tuesday, June 26, 2012

Week 2 - Katie Hudson

This week I began to focus more on my projects as Dr. Hartl was out of town for the majority of the week and my college, Peter Grunert, was more available.

On Monday I began working on my IRB. IRB stands for Internal Review Board and we must get permission from Weill Cornell’s review board before starting any experiments on humans. During fusion surgeries, Dr. Hartl often takes bone marrow to encourage the fusion of the two vertebrae. The extra marrow is usually discarded after the surgery. We would like to take this extra bone marrow and use it to create mesenchymal stem cells lines than we can use in our tissue engineering research. Taking this bone marrow, which is classified as surgical waste, requires IRB approval. Next Monday the new electronic system comes online, and I will submit it then.

Also on Monday, I read and edited a paper that Peter was writing in collaboration with my lab in Ithaca. This gave me a better idea of the experiments that were done prior to my arrival at Cornell and where we can go from here.

On Tuesday and Wednesday I worked on collecting papers for a review that Peter and Dr. Hartl would like to write on the different methods used to treat disc degeneration, including the potential of tissue engineering. Reading articles in order to write a review is one of the best ways to get acquainted with the literature in a certain area.

On Thursday, we all attended our weekly summer immersion meeting where we were introduced to Dr. Frayer. Dr. Frayer is an Associate Professor of Clinical Pediatrics at Weill Cornell Medical College and Associate Attending Pediatrician at New York-Presbyterian Hospital/Weill Cornell Medical Center and works closely with our summer immersion program. He suggested that we go on rounds in different areas and I expressed my interest in the NICU because it is so different from my field but it something I heard a great deal about while I was growing up.

On Friday Peter and I talked about different ways to represent his data in the paper I reviewed and what I should do while he is gone. He will be in Tanzania for 2 weeks as a part of a team teaching Tanzanian doctors about different spinal surgery techniques.

Monday, June 25, 2012

Kevin - Weeks 1-2

So, I have finally arrived in NYC, and before I knew it two weeks have gone by. I hope the rest of the summer doesn't fly by this fast, because overall I have been having a great time. I first got into Olin Hall on a Saturday, which was extremely convenient. I got extra time to sleep off the insanity that was the scurry to get everything set for the trip, and I had time to comfortably settle into my place. It definitely wasn't what I expected, but it was nice, and the surrounding area was very interesting. Plenty of randomness around to keep me entertained while I got ready for the program to start.

That Monday we had the introductory meeting, and then I finally got to meet my clinician. Dr. Shah is an oncologist who specializes in cancers of the GI tract, which I was particularly appreciative of since my research in Ithaca involves colorectal cancer. That first week I was introduced to the staff in the department, and I began doing clinical rotations with Dr. Shah and the other doctors. When I first began shadowing them, I was amazed at how they operated. Their thought processes seemed so fast; they just spouted off all these abbreviations for drugs and chemotherapy plans, along with pros and cons for each based on a few patient symptoms. It was a bit of a struggle to try and keep up with them. By the second week, after I had done some reading of my own and asked a few questions, I found my eyes a little less glazed over during conversations. So that was good. I was also impressed with their interactions with the patients outside of them. There were some patients who were coming to the clinic for the first time, and others who had been coming for years, and it was really interesting to see the bond that forms between the two of them. The patients who had been seeing the doctor for years would eventually switch to chatting about their outside life, and some of them seemed pretty close with the doctor. Sometimes it was really sad; occasionally a patient would come in who was obviously in a pretty bad condition, and the patient and/or his/her family would be so distraught. I wouldn't know what to say, but the doctors were always so calm about it. I guess you just learn what to say after doing this for decades. I for one didn't; I can't say I've dealt with very many situations like that. But sometimes it seems like they appreciate the conversation, if for no other reason to take their mind off things.

I've also been given a project to undertake, and it's pretty interesting. I'm supposed to work on a signaling network model for the angiogenesis pathway in gastric cancer. After I heard Dr. Shah going over the details I just thought thank goodness I took that systems biology class. I can actually sound like I know what I'm talking about. So know I just need to get down to brass tacks and read up on this pathway. I feel like I don't know nearly enough about the molecular biology involved to do anything useful yet. But it's all stuff I feel will be useful down the road, so it gives me more motivation to learn it. And...if I do work this out into something further than a summer project, I may get a reason to come back down her more often. Which would be wonderful. Because I seriously love this place. I feel like a boss in business attire with a hospital badge, taking lunch breaks to catch some of the Euro Cup here and there, then rolling back in to the clinic. I could definitely get used to this.

Frank He_Week 3

Friday mornings typically consist of Grand Rounds; a series of lectures, conferences, and group meetings that intend to inform the Orthopaedics staff of the current cases and educate the fellows on scientific topics that might prove useful in the clinic. These are excellent opportunities for me to really immerse myself into the type of discussions that doctors are having about their patients and how they are using newly discovered scientific knowledge in the clinical space. Overall I am very impressed by the basic science expertise of some of these doctors, especially the attending Patrick Boyland, who has given several lectures on bone metastasis already. I also really enjoy the team dynamic at these meetings; a casual professionalism that borders on a semi-collegial feel that encourages free-flowing exchanges between everyone in the group.

I've already been involved in several situations in which I have realized it is mutually beneficial for basic scientists and clinicians to interact. One particularly memorable moment was at the Pathology Conference last week, when we were looking at case studies of bone sarcomas. The doctors there were talking about how a second primary might arise elsewhere in the body, to which I asked if it were possible to tell to discriminate between a second primary and a tertiary metastasis. The lecturer just stared at me, kind of dumbstruck, obviously never had previously considered the possibility before. Finally one of the fellows responded: "it's just not clinically standard terminology." But I told them that it is a scientifically acceptable concept, and more than reasonable to anticipate sequential metastatic events since the cells are already primed to migrate from one site to another. The lesson here is that I've become increasingly aware of the fact that the practice of Medicine is in actuality very much conservative and it is extremely difficult to get doctors to adopt new scientific developments, especially if they haven't received formal scientific training. However, I can see why it is valuable to be more conservative, especially considering the scientific fraudulence that is disappointingly widespread in the global scientific community.

It is my hope that one day scientists and clinicians can really work side-by-side to tackle the issues lying forward, just like how engineers and biologists are starting to truly engage with one another in the newly emerging world of Biomedicine and Genomics.

Week 2 J. Zhang

This week I spent my time among the reading room, MRI scanning room, and my laboratory. In the reading room, I came across several interesting cases.
  • A patient came in, claiming back ache. CT shows a hyper-intensity spot in the intervertebral disc between T7 and T8. The intensity of the spot is much higher than the spine itself, which make us wonder what exactly in that spot. There is no sign of cancer or abnormality in the surrounding tissue. One possibility is trauma.
  • CT is also used to follow up surgical implants, mainly bone fixation. I personally think CT is superior in this area compared to MRI because of the imaging speed, the compatibility issue, and the strong contract between the fixation sites (hyper-intensity) and the surrounding soft tissue (hypo-intensity). The cases I saw were mostly spine fixation.
  • A stroke patient came in. First CT images showed obvious perfusions in the left brain. 90 minutes later, MRI was performed. Interestingly no obvious perfusion was shown on T2 FLAIR. Typically, T2FLAIR is sensitive to perfusion. Doctors believed it might be due to the fact that the local tissues were hyper-acute. Second CT, 18 hours after the first CT, showed further progression of the perfusion.  
  • On a patient’s MR images, a black hole was observed in the right ICA. Similar situation happened to another patient’s MR images a few weeks ago. It was suspected that the black hole was an artifact from the 3T MRI scanner. Patients were told to be re-scanned in the 1.5T scanner.  

In the MRI scanning room, I observed a cardiac MRI using cine imaging. It is a MRI technique used to take ‘real time’ sequential images for patient’s beating heart for functional evaluation. With the assistance of contracting agent, blood flow, heart valve movement, and muscle contractions can be seem in ‘real time’. During imaging, patients are told to hold their breath to avoid motion artifacts. Each cycle takes about 12 seconds. 12 imaging cycles are performed.
It is worth noticing that cine is not really ‘real time’. The scanner samples partial K-space during each heartbeat. The imaging cycle repeats until K-space is fully sampled. Then the entire sampling process restarts at a slightly different time point of the heartbeat in order to acquire next frame. Therefore, assumption has been made that heartbeats are almost identical through the time of sampling.

Week 1 J. Zhang

After the first meeting this Monday, I met my mentor, Ajay Gupta, Tuesday afternoon. He is a board-certified radiologist specializing in neuroradiology. Cooperating with my advisor, Dr. Wang, Ajay shows great interests in mapping oxygen extraction fraction and metabolic rates in brains using MRI techniques. After the meeting we attended a tumor board where doctors were gathered in a conference room to discuss and exchange opinions on difficult and atypical cases. Despite the difficulties in fully understanding the discussions, I did realize that MRI is heavily used in the field. More than 50% of the time MR images were showed and used to evaluate patients because of their non-invasive and yet informative nature. CT and PET are used as well. However, due to their invasive nature doctors took extra cautions when ordering CT and PET for their patients.

Then I spent the rest of the week in the CT and MRI reading room. I participated in image reading with doctors. While MRI technology is relatively mature, there is certainly room for improvement. For instant, image resolution could be higher. This is mainly due to the ‘slow’ nature of MRI. Higher resolution requires much longer scanning time (in the order from 30 minutes to 2 hours), which is impractical. Artifact can also be seemed quite frequently due to motions.

Alexey and I are given some contact information. Hopefully we can observe some surgery next week

Week 1 sidd

Along the edges of upper east Manhattan where the upper crust resides in vogue and where a cereal box is sold for a whopping 8$ are a set of hospitals where ground breaking clinical trials, research and surgeries are happening completely oblivious to the honking and cacophony of NYC traffic . Apart from getting my 6 mile run in central park every day, I have been running from pillar to post to get myself oriented to the huge hospital and my research project.  It was very different to step out the first day in a formal attire quite not the scenario in Ithaca as I was galavanting in my summer shorts ever since the sun started blazing. Dr. Yi Wang and Rebecca Cramer gave us a brief orientation after which all of us disbursed to meet our respective mentors.  I was matched with Dr. Joseph Osborne, MD from the department of nuclear medicine.  I couldn't meet him on Monday as he was in a conference at Florida. Instead I met with the research manager (Sagit Goldenberg) who is in-charge  of the project. I was thrilled to learn that I would be working on a clinical trial for prostate cancer diagnosis.  If I had to summarize the project in two lines: patients undergoing prostatectomy would be pre injected with radio labeled antibodies against prostate specific membrane antigen (PSMA) 5 days before the surgery. Surgically removed prostate tumor would then be imaged using positron emission tomography (PET) and multi-photon microscopy (MPM) to do a radio/path correlation to identify the foci of prostate cancer. Since the first patient is scheduled for the 20th of June, I spent the time helping a grad student (Kofi Deh) who works for Dr. Osborne. Since the imaging technique that would be eventually used for imaging ex vivo prostate tumor could be gleaned from the small animal imaging methods, I learnt how to use the PET scanner in the imaging facility at Weill Cornell Medical Center. He was imaging the mice with human tumor xenografts injected with prostate cancer cells LnCAP. I also happened to attend the meeting with experienced doctors that work on prostate cancer to discuss the course of the trial. On the whole the first week at Weill cornell has been super exciting. In the following week I am looking forward to the first patient participating in the trial and witnessing few prostatectomy  in the OR.   I also attended the Circulating Tumor Cell (CTC) seminar by Dr. Peter Kuhn and it was really exciting to know the several facets of mathematical modeling that could be applied for determining the probability of CTCs from a specific tumor type to metastasize to a particular secondary site.  I also happened to attend the group meeting of Dr. Neil Bander, a pioneer in the field of prostate cancer and got to learn the work that his lab does on prostate cancer circulating tumor cells and therapy. Apart from the clinical exposure that I would be gaining this summer it would be such a rewarding experience to meet with living legends and stalwarts in the field of cancer research and observing them in close quarters.  Well if you go to Disney land you don't spend the whole day with pirates of the Caribbean! On similar lines I think summer immersion is just not about being in the OR and watching cool surgeries. 

Sunday, June 24, 2012

Wk 2 - Spencer Park

Early this week, Dr. Bessey and I finally decided on a topic for my summer research project. When a person experiences a serious burn, their organs and tissues can undergo a hypovolemic shock, when a total volume of blood falls below normal level. This phenomenon deprives tissues of oxygen while also allowing build up of waste products. While many organs are affected, one of the most dangerous consequences is respiratory distress or failure. The patients experiencing lung failure require mechanical ventilators. According to a respiratory therapist, all adult patients with respiratory distress syndrome use airway pressure release ventilation (APRV), while infants and children use various different types (e.g. oscillators, etc). My project will involve looking through current as well as past patient records to determine the effect of the different modes of ventilation in patient recovery. I have thus far spoken to two respiratory therapists, who also showed me the different types of ventilators used in the ICUs and the mechanism through which they work. I am waiting to be cleared for the use of Eclipsis, which contains all the patient data I will need for my work. I expect to be able to access them by sometime next week.

            I watched a few surgeries this week, many of which were routine skin grafts. It seems most of the skin grafting surgeries are very similar. I think I will try to see contact other surgeons to see if I can watch some other types of surgeries as well. One of the other surgeries was on a patient’s foot. He had diabetes and edema on his feet. He also had ulcers on the bottom of his feet, which had bad infections. I also noticed other open wounds on his legs, which Dr. Bessey explained was due to poor circulation caused by diabetes. He was also having trouble breathing and his kidneys were doing very poorly. Before treating the ulcers, Dr. Bessey first got deep tissue and bone biopsies. This procedure was interesting because I realized that in the midst of the cutting-edge technology, some surgical procedures were still very rudimentary. In order to get bone samples, Dr. Bessey cut into the ulcer and used a device that looked very similar to pliers to break off a piece of bone. This surgery also involved the first allografting that I have seen. Because the patient was in such critical condition, Dr. Bessey decided against autografting. The donor skin pieces were kept in a liquid nitrogen tank before being taken out to create pores on them. The rest of the procedure was exactly the same as the other autografts I’ve seen.

            At the clinic this week, I saw many of the patients that had just been released from the burn ICU last week. They were coming back for follow-ups to check the grafts were being taken well. Among them was a patient that seemed to have gotten dependent on the painkillers. She demanded to be given oxycodone and when Dr. Bessey suggested using milder painkillers, she became very angry.  It was interesting to see clinicians dealing with such situations outside of treating patients. Another patient came in with some serious gout and what he claimed was ‘a rock growing on his toe’. Indeed, he had a crystal as big as a nickel growing out of his third toe. After sterilizing the foot, Dr. Bessey removed the crystal and sent it off to a lab for analysis. Dr. Bessey didn’t know at the time if the crystal was due to the high concentration of uric acid in the blood associated with gout, or it was something else.

            Similar to last week, I attended rounds with Dr. Bessey, Dr. Yurt, and Dr. Gallagher. I also attended a research presentation and a multi-disciplinary meeting.

Saturday, June 23, 2012

Week 2 -- Bunyarit

For second week, I reobserve Dr. Tewari's surgeries and saw the da Vinci Surgical System in action. Dr. Tewari employed this system to perform robotic-assisted prostatectomies. For this week, I had a chance to explore robotic-assisted prostatectomies closer than previous week. I saw the surgeries from the beginning till the conclusion of the surgery. Before the surgery began, the patient was anesthesized. Thereafter physician assistants marked about 5 small incision points on the patient's stomach, and the robotic arms and endoscope were then inserted into the body. The physician assistants emptied the patient’s bladder by inserting a small tube to drain urine out of the body. After that, three assistants stood by the patient to guide, move the robotic arms, and prepare necessary elements for the robot, whereas Dr. Tewari sat at a console and remotely controlled the movement of robotic arms like playing video game but it is the game of life. Amazingly, the endoscope view provided clearer three-dimensional picture than human eyes did; consequently, the robotic surgery made him to pay close attention to details that open surgery cannot offer. For this surgery, Dr. Tewari would like to remove the patient’s prostate gland, but spared the nerves around the prostate gland in order to maintain bladder and sexual function of the patient, and the crystal-clear picture provided by the enndoscope is an important element for nerve sparing technique. At the conclusion of the process, the holes used for inserting robotic arms were repaired and anastomosed, and the patient stayed in hospital for 2-3 days.

I attended the weekly meeting of Dr. Tewari’s group, and there my project started to be defined. My research project is to investigate the effect of suprapubic tube on continence of patients after robotic-assisted prostatectomy. The motivation of this project predicates on the fact that after the surgery, patients are incontinence, which is the inability to control their urination. For this reason, the patients have to be inserted by small tube in order to empty their bladder. The tube will be inside the patients about 1-2 weeks, and then removed out. After the tubes are removed, the patients have to use pads. The number of pads employed by the patients will be representing their continence or incontinence. The further detail of the project will be discussed in the third week.

Funmi: Weeks 1-2

For my summer immersion term, I am working with Dr. Mathias Bostrom at the Hospital for Special Surgery (HSS). Dr. Bostrom specializes in hip and knee replacements, which is very clinically related to the work I'm going to be doing in Ithaca (Dr. van der Meulen's lab), so I was really excited to get started this summer. These past two weeks consisted of meeting a lot of the clinicians and researchers at HSS, learning new techniques, absorbing as much information as I can, and shadowing Dr. Bostrom while he saw patients. I have come to develop a deep appreciation for the work done at HSS. In what I would describe as an incredibly unique setting, HSS consists of engineers, biologists, surgeons, and pathologists working together to treat various orthopedic medical problems. For example, within the hospital itself, there are engineers working to develop better implants for joint replacement, surgeons who are conducting the implant surgeries in patients who need them, and biologists and pathologists who are investigating ways to treat arthritis in order to prevent joint deterioration. The entire process comes full circle, as clinical fellows have the opportunity to work with the engineers in examining implants that have failed, investigating why such implants failed, and brainstorming what can be done in an engineering sense to prevent such failures.

It's really fascinating how at some point, particularly in biomedical engineering, the engineering tends to divert from medicine, however this is certainly not the case at HSS. To that point, I had the opportunity to see some of Dr. Bostrom's patients this week, and it gave me a whole new perspective on orthopedic research. I was able to see a range of patients, from those who had just received a hip or knee implant and were pain-free for the first time in years, to those who had been living with pain and would have to receive an implant soon. Most of these patients were older with arthritis in their hip and/or knee joints. It was amazing to hear that hip implants could last a patient upwards of 20 to 30 years, and it made me appreciate how successful the interaction between engineering and orthopedic medicine has been in the past decade. It has been an informative two weeks and I look forward to the next five weeks here, as I continue to shadow Dr. Bostrom and conduct a clinically relevant small project in the field.

Frank He_Weeks 1-2

For my BME Immersion Experience I have chosen to work with Dr. John Healey, the head of the Orthopaedics Services Unit at Memorial Sloan Kettering Cancer Center. He is the world leader in treating bone sarcomas and incorporates both clinical and research components into his career agenda. How his unit perform these surgeries is that they excise the tumor from the bone, partially remove any other bone that was affected or seemingly affected by the cancer, and then finally replace the mechanically unstable areas with a prosthetic device, which could be as extensive as a synthetic metal knee joint or just a frozen allograft to stabilize the femur, or some combination of the aforementioned devices (the possibilities for replacement are seemingly endless. remarkable).

My first two weeks have given me exposure to some of these surgeries. The first case that I observed as a man who was unable to bend his knee after previously having a sarcoma removed from his bone and an implant inserted to replace the bone. Since current MRI imaging techniques are unable to resolve tissue surrounding metal prosthetics, Dr. Healy and his colleagues have to diagnosis mid-surgery the next course of action. As an Engineer, I feel that this an area where improved technology can drastically affect the efficiency and outcome of an already very invasive procedure. For this particular case, they quickly uncovered a mass of fibrotic tissue growing around the implant, and then systematically worked to remove as much of the inflamed growth as much as they could. Dr. Healey's team is a well-oiled machine; this entire procedure was performed in just over three hours.

I was also able to witness the excision of a bone sarcoma last week. After a very methodical four hours, the surgeons were able to remove a huge mass of soft tissue about the size of a sea abalone from the patient. I gasped in awe as Dr. Healey walked towards me with this somewhat demonic slice of human life in hand. But calm and collected as always, he finished up the procedure by tying the specimen up and putting into a container for pathological analysis and cryo-storage.

Friday, June 22, 2012

Week 2 - Anne

My clinical mentor, Dr. Prince, was away this week, so I observed a number of surgeries in other departments.

On Monday, I went with Pao to a robotic prostatectomy performed by Dr. Tewari. The patient was a middle-aged man with prostate cancer, and we arrived just as he was being put under anesthesia. The da Vinci robot for the surgery was really cool - it was over 6 feet tall and had four arms that entered the patient through small incisions on his abdomen. Dr. Tewari sat in an alcove of the OR, and his hand movements were mimicked by the robotic hands. He wears 3D glasses and his . We wore 3D glasses and were able to observe the entire surgery on a large TV in the OR. The prostate was removed whole and the urethra was reconnected to the bladder. Then the robotic arms were removed from the patient and the incisions were sewn back up. It was a relatively quick surgery, about 4.5 hours from start to finish.

I went with Chelsea and Peter to see a reconstructive surgery performed by plastic surgeon Dr. Spector. The patient was a middle-aged woman with Type II diabetes, and she had lost her eyesight in both eyes and had a large foot ulcer on her right foot. It had literally eaten away about 1/3 of her foot. The surgery involved taking a piece of healthy tissue from her thigh, including the blood vessels and muscle, and using it to cover the ulcer and encourage rejuvenation of the remaining foot tissue. One team worked on recovering the piece of tissue from her leg while Dr. Spector located the veins and artery near the woman's ankle to which the healthy tissue would be sutured and the ulcer area was prepped. Using a microscope, he sutured the veins and arteries of the healthy tissue. The thigh incision was sewed up, and the tissue transplant was trimmed to fit the woman's foot and sewed into place. It was an all-day surgery that hopefully saved the woman from having her foot amputated.

Yesterday I went with Sidd and Fredrik to observe two urology surgeries. The first was an elderly man who had come in for a prostatectomy for prostate cancer. Unfortunately the cancer had spread to his bladder, so the surgeon was going to use part of the right colon to make a new bladder. When they opened him up (it was a very invasive surgery), they discovered that the radiation treatment had left a quarter-sized hole in his rectum, so they had to remove that as well. I certainly hope all of the cancer was removed so he doesn't have to have more surgery.

The second patient was a younger man (early 40s) with a golf-ball-sized tumor on one kidney and a number of large kidney stones. The surgery involved dumping two buckets of ice into the patient's side to give the surgeon more time (about an hour) to operate while keeping the kidney's function intact. The surgeon removed only part of the kidney as the patient was unable to live with just the second kidney, and spent a good 20 minutes picking out several dozen kidney stones, one as large as a peanut.

Being in the OR has been an amazing experience and I am really glad I have been able to see up close what it is like to undergo a surgery for a life-threatening disease. I would really like to see the follow-up for these patients. Next week I will return to the MRI reading room on Monday with Dr. Prince and learn more about my research project!

JMarshall Weeks 1-2

This summer I am working with Dr. Michael Lockshin in the Rheumatology department at the Hospital for Special Surgery. Dr. Lockshin specializes in lupus and specifically lupus pregnancies. The HSS is in fact developing a lupus center where several attending physicians will be available for pregnancy counseling. For the past two weeks, I have been following Dr. Lockshin on his office visits. I have seen a wide range of patients all with some sort of autoimmune disease. The two major diseases that I have encountered so far are lupus and rheumatoid arthritis. It is interesting because these diseases, as well as Sjogren's syndrome and antiphospholipid syndrome are all extremely closely related differing only on the predominant antibodies found in the patients' blood samples and the main manifestations of the diseases. However, during my short time here I have noticed that even within the individual diseases the way they manifest in each patient differs quite significantly. For example, I saw a few patients where their main symptoms were merely rashes, while others had siginificant joint pains and deep tissue involvement. Also, the rheumatology department deals with a number of cases that can't. E specifically diagnosed but are definitely autoimmune in nature. In addition to office visits, I have attended a number of meetings and conferences within the department. As an engineer, one thing I have noticed is that with these diseases not enough is known for a cure or for therapies that work across the board. While some of the newer therapies now work to treat the disease mechanism, the majority of the therapies and drugs used treat symptoms and downstream effects of disease rather than the cause. Because of this, there is not one cocktail of drugs that works for every patient. Also, these diseases are known to go into remission for long periods of time but the. Can suddenly flare with no warning. Dr. Locks him describes his field as those able to work the most with uncertainty and I am starting to agree with him.

Week 1 - Anne

My experience in NYC so far has been great. My assigned mentor is Dr. Martin Prince in radiology. He focuses mostly MRIs of the body/torso. During my first week, I spent two days shadowing him in the reading room, where he reads cases from the previous day with fellows. His office is located at the imaging facility on 55th Street, but he also reads cases at Columbia's hospital and at the main hospital.

He has a project in mind for me that involves using the MRI scanner to scan myself and a few of the fellows. He was out of the country beginning Wednesday and I'm not sure of all the details yet, but in the meantime, I read the safety training information online at, a website that Dr. Prince created along with several graduate students in BME. Dr. Prince works closely with the graduate students in Dr. Wang's lab, who are based at the 55th Street facility. In their research, they often use the MRI scanners at the 55th Street facility and the main hospital after hours and on weekends, so I plan to watch one of them to learn more about how to run an MRI.

I also attended a bioethics lecture and our first round-table meeting with Dr. Wang. It was neat to hear about the wide variety of experiences everyone in the program is having. While Dr. Prince is gone, I plan to use observe some surgeries in other departments.

Thursday, June 21, 2012

Wk 1 Spencer Park

On Tuesday morning, I met with Dr. Bessey. He is a surgeon at the Burn Center along with Dr. Yurt and Dr. Gallagher. We talked about my research for a while before deciding that the topic of ‘wound healing’ should be my focus for the summer. He got me involved immediately by showing me all the patients and introducing me to the staff members.

I helped some of the nurses and technicians in the ‘tank’, where the burn wounds were scrubbed and cleaned to remove dead skin, puss, and other debris. Though I helped out briefly with infants, I’ve been working with adult patients mostly. Since all patients go through tank sessions, I got to observe all the patients and their progress in recovery. I saw many interesting cases and I’ll share a few here. I met two patients who had 2nd degree burns on their feet. Their injury would not have been so serious but they have diabetes and didn’t feel their feet burning. Dr. Bessey explained that diabetes leads to poor circulation, as well as microvascular disorders, so their wounds do not heal very quickly, if at all, which then increases the chances of infection. I saw several minor patients, one of whom was a 4-month-old little girl. She had 2nd degree burns on the lower parts of her body, with some parts that experienced 3rd degree burns. There was a distinct line separating the burn and normal tissues, which Dr. Bessey said in many cases is due to being intentionally dipped into hot water. The mother has previous conditions of mental illness. Either way, the girl had to be wrapped with creamy bandage lined with silver sulfadiazine, a topical antibacterial cream that inhibits the growth of bacteria and yeast. People sometimes use silver nitrate solution instead. She will need surgery on the 3rd degree burns since they don’t heal on their own.

Final patient was a new admission, who had burns so bad that all the attendings and residents came to see him. According to him, he fell asleep while smoking a cigarette and dropped it on his T-shirt. He said the fire was in direct contact with his skin for 2-3 minutes before he was able to take the shirt off. He has a history of alcoholism and smokes a pack of cigarettes a day. He experienced direct flame burns on his left side and the inside of his left arm. Dr. Bessey explained that the ‘cherry red’ parts are worse burns than the pink, while the white patches indicate complete skin burn. The patient didn’t feel anything when we touched the white patches because the burn had damaged his pain receptors.  We scrubbed off much of the debris, cleaned him off of soot (from the smoke) and dressed him with silver sulfadiazine and ace bandages. He was shaking from pain even with a lot of medicine.

Today I observed Dr. Bessey performing surgeries in the OR. The patient experienced burns on his entire back and the inside of his right arm, where he was feeling the most pain. The back was healing well, showing signs of pigmentation (purple dots). His arm, on the other hand, seemed to be healing much more slowly, if healing at all. Dr. Bessey and his surgical technician used what looked like a large vegetable peeler to take thin skin sections from the patient’s thigh. The skin was then perforated to look like a Band-Aid. Blood oozing from the injury site can prevent skin autografts from attaching. Therefore, perforations must be made to allow the blood to leave. Stapling the skin onto the injury site and wrapping up the arm completed the skin autograft.

Dr. Bessey is also introducing me to the multidisciplinary aspect of patient care. In a meeting that takes place weekly, doctors, nurses, technicians and social workers all met to discuss each of the patients and their needs for quick recovery from their injury or surgery. They discussed whether the patients needed physical therapy, social workers, etc. I realized there is much more to working at a hospital than diagnosis and treatment.

Went on rounds on M, T, W, F with different attendings each day, listened to the research presentation on hypertrophic wound healing on Wednesday morning, weekly meeting with Dr. Wang on Thursday, and the bioethics meeting on Thursday morning. I also observed Dr. Bessey in his clinic session on Thursday afternoon.