Week 3: Research, Surgery, and more Surgery

     This week, I ran real-time reverse transcription polymerase chain reaction (qRT-PCR) for the gene that encodes neuronatin, NNAT, with Lauren Havel in Dr. Mattel's lab. http://www.ncbi.nlm.nih.gov/pubmed/23328481. RT-PCR is used to clone expressed genes by reverse transcribing the RNA of interest into its DNA complement through the use of reverse transcriptase. The newly synthesized cDNA is amplified using traditional PCR. qRT-PCR sounds laborious and complicated; however, the process was actually quite simple and the machines did most of the work. Waiting between each step was the longest part. First, we made cDNA from the RNA of LM2 (lung metastatic cell line) untreated, LM2 scrambled, miR-708, LM2 wildtype (+ control), and MCF7 wildtype (- control). Then we amplified the cDNA using PCR to give us the normal fold expression of each RNA to be used with nanoparticles at a later time. Unfortunately, the particles will not be ready until the end of July so I have to find a different research project to do.

     Next, I visited with Dr. Alex Swistel in the OR and watch him perform surgery on four patients. Although Dr. Swistel is the lead surgeon, he has a team with him that helps him perform a successful surgery. He has the anesthesiologist, the techs that hand him instrument, the lead nurse, and the residents he teaches the surgery to. At the beginning of each surgery, the team would perform a Time Out lead by attending surgeon on consent immediately prior to incision. All team member must participate, all activities must stop respecting the zone of silence. Some of the patients were undergoing right breast lumpectomies with needle localizations and sentinel node biopsies with poss axillary dissection. The other patients were undergoing left breast excisional biopsies with needle localization. Dr. Swistel was very engaging during all surgeries and pointed out interesting skin marks, incisions, patient complications, and surgery techniques to me. He and the team was very funny and made me feel comfortable during the procedures. We even got into a conversation about one of the techs assisting in a parathyroidectomy under hypnosis with local anesthesia later on in the week! Unfortunately, the surgery was later cancelled.

     Then, I shadowed Dr. David Otterburn in the OR for a DIEP Flap, a type of breast reconstruction in which blood vessels called deep inferior epigastric perforators (DIEP), and the skin and fat connected to them are removed from the lower abdomen and transferred to the chest to reconstruct a breast after mastectomy without the sacrifice of any of the abdominal muscles. Surgeons do not take pectoral muscle or the nipple anymore and use body fate because it grows/shrinks with you and if it get infected you can use antibiotics. The surgery was a multi-step process that is usually a minimum of 8 hours. Dr. Otterburn was the attending surgeon but had a team of three residents help him complete the surgery. As a team, they cut out some of the third rib to get to the main artery in the chest, remove flap with the veins from lower abdomen to connect to the artery in the chest, close her abdomen up and stitch new belly buttion, put the flap in chest with connecting veins and arteries to construct the new breast, and use a laser with fluorescent dye to make sure blood vessels in flap were getting adequate flow. The surgery was long but I learned a lot from Dr. Otterburn and his team creating a very similar atmosphere as Dr. Swistel.

     All in all, I had a very exciting week that had a mix of research and plenty of surgery. I know for one thing though, I do not plan on getting surgery anytime soon. Although it was amazing to watch, surgery is so invasive and can have many complications. These past few weeks have taught me to really start checking my breasts and doing self-exams so I can detect any changes early. But, I do admire the sense of humors the doctors and patients maintain despite such unfavorable conditions. It pays off to have a positive attitude.

Week 3: It's like balancing on a tight-rope...

You could say this week had thrown me for a loop, diverging from the sense of normalcy and workflow I’ve been trying to develop during the past few weeks. Monday started off with the Plastics Conference/didactic lectures. Unfortunately we had missed a portion of the first presentation, on face lifts and other facial reconstructive procedures, on account of us being unable to get into the surgical associates wing due to our lack of card access. Luckily a fellow happened to be passing by, but am finding it frustrating how we are supposed to just figure out on our own how to gain card access/or figure out on our own how to setup these type of opportunities when we’re already handicapped by our general lack of awareness… then again, things could be worse (after hearing some of the experiences/difficulties of my peers). I digress… the talk mostly consisted of the presenter, a senior surgeon, giving their input/advice on the various surgical approaches/techniques for these types of procedures in a dialogue between other surgeons/interns/med students/etc. and a reliance of anecdotal evidence from decades of experience to support their preferences for those methods. Helps me understand why some physicians may be hesitant to adopt new technologies/methodologies to those already in existence/tried-and-true. Fortunately, the mentorship in NY Presbyterian in general appears to be more forward thinking. That surmised my clinical experience the first couple days, as Dr. Spector was either out of the city or busy handling administrative matters/not in clinic or surgery, sending us off to the lab to get ahead on our respective research projects.

Although I got the general gist of what was expected of me in lab, to forward our labs’ existing collaboration in whatever capacity I am able to here in NYC, the general vagueness and the limited time available to us over the immersion term makes establishing a solid game plan and obtaining the necessary materials (e.g. assays) and training (e.g. confocal LSM in Microscopy Core) a bit nerve wracking. Complicating our situation, this week had the rest of Spector lab scrambling to finish remaining experiments or get trained themselves as several of their senior students would be  leaving the lab in the coming week(s), and essentially a  changing of hands over lab projects/managerial responsibilities was taking place. Will likely be able to go into more detail in the coming weeks as I’m solidifying what I’m supposed to do/get rolling things rolling with experiments/etc.

Amongst the surgeries of the week, got to see the skin grafting/wound closure of two patients from the previous week. These were slightly more complicated cases due to the large surface area of tissue damage/degree of necrosis. For one female patient, Dr. Spector elected to move directly towards applying a split-thickness skin graft to her exposed calf after severals rounds of tissue debridement, whereas with the other case he had initially laid a foundation of Integra (skin substitute) the prior week before performing the same type of procedure. His course of action for the later had been due to the patient’s wound having regions of exposed bone. As such, the overlayed skin-graft, being avascular, would have a low chance of integration in these regions. The initial layer of Integra allows the development of a vascularized bed, as cells migrate into the ECM construct, which drastically improves the chances for the epidermal skin graft. The scoring of the skin graft serves to both increase the surface area coverage and prevent subcutaneous pooling of liquid between the graft-tissue interface.

Friday Dr. Spector was out again, however he was able to arrange for us to shadow Dr. Sharif Ellozy from the department of Vascular/Endovascular Surgery. One of the operations involved balloon angioplasty of occluded femoral vessels, stenosed due to calcific plaque development or failure of previously deployed stents due to re-stenosis of the surrounding vessel wall. After accessing the femoral artery via ultrasound assisted catheterization, Dr. Ellozy delicately manipulates the catheter/guide wire to snake his way through the vasculature, with the assistance of CT contrast imaging. Although there are surgical simulators to aide in training for these type of procedures, they are still in their infancy, with most surgeons obtaining experience through years of observation/hands on training. Recalling my undergraduate experience in researching the topic of simulators for central-line insertions, and then getting the chance to see how these procedures are performed in the OR close-up, it becomes blaringly apparent to me how inadequate they are in aiding in physician training and how there is a need for training tools which can actually be useful for in preparing for the actual procedure. I feel there may be somewhat of a disconnect between the companies which make these simulators to what actually goes on in the OR, and that they’d benefit substantially from this type of immersive experience… just saying…

Week 3: A little more lab time

This week was a slight change of pace, as Dr. Spector was out of town on Monday and Friday. Terence and I started Monday in plastic surgery conference, during which Dr. Hoffman presented face lift techniques and one of the residents discussed hand fracture management. The rest of the day was spent in lab, where I learned how to do paraffin embedding (now I really appreciate the work the histology core does) and also thawed some breast cancer cells.

Tuesday was also largely a lab day. I brainstormed some project ideas with Terence’s help, and we tried to troubleshoot some of the protocols that Spector Lab has had difficulties with, notably the set-up of a perfusion pump that is used for dynamic flow experiments. On a visit to Dr. Spector’s office (we thought to discuss experimental plans), we went on impromptu rounds and followed up with patients for about two hours. Dr. Spector discussed with one patient that they may have a condition called pyoderma gangrenosum, which causes ulcers on the skin after any sort of trauma or injury to the skin. He had been perplexed by when the patient had come in a week earlier, because at one week post-op the skin graft appeared to have been healing well. This had also occurred once before, on another skin graft that Dr. Spector did for them. Dr. Spector recommended no further treatment, and to just let the graft heal on its own, as the etiology is unclear.

In the OR on Wednesday, we saw an upper lip reconstruction, split thickness skin graft for a 30 cm x 30 cm wound (had previously seen debridement), and irrigation and debridement of a pseudoaneurysm near the groin. The psuedoaneurysm formed after the patient had percutaneous aortic valve replacement surgery, but femoral artery (where the catheter was inserted) was not fully closed. Blood leaked into the surrounding soft tissue (hematoma) until the pressure matched that inside the artery. Dr. Spector’s team made sure the artery was closed, and washed out the surrounding area of leaked blood.

Thursday morning we were in clinic, followed by more time in lab. Terence and I made a PDMS mold for some vascularized collagen constructs that I will be making for my experiments, and we went to lab meeting. Before the end of the day, Dr. Spector set us up to see endovascular surgery with Dr. Sharif Ellozy the following day, since he would be out of town.

We started with Dr. Ellozy at 7:30am on Friday morning, donning lead protective gear to watch as he cleared some vascular occlusions in a patient’s leg through the iliac artery of the contralateral leg via x-ray guidance. I was amazed to see how minimally invasive yet precise this technique was—through careful manipulation of specifically engineered wires inserted through a single catheter (single incision), Dr. Ellozy was able to skillfully perform angioplasty with paclitaxel-coated balloons-eluting polymer-coated tubes, effectively clearing blockage and preventing restenosis with one treatment!

Week 3

This week I was able to see several interesting cases with Dr. Bostrom. One patient was diagnosed with hip dysplasia when she was 18 months old. She came in complaining of hip pain, and her x-rays showed that her hips had essentially fused, resulting in very little range of motion. The fact that on both sides her femoral head is fused to the acetabulum will make her hip replacement surgeries more complicated. The femoral head will need to be removed without causing structural damage to the acetabulum.

Another interesting case I saw was a man with a hip replacement who had had multiple infections, multiple dislocations, and multiple revision surgeries. The doctors had chosen to leave his hip dislocated as the best case scenario, and his implant had created its own acetabulum above his native one.

On Thursday I went to the ARJR Grand Rounds in the morning. Two of the surgeons participated in a debate about the pros and cons of the anterior approach for a hip replacement versus the posterior approach. It was perfect timing for me because in the past week many patients had been asking Dr. Bostrom if he used the anterior approach because it was less painful, and they would recover so much faster. He would then explain to them that the data shows very little difference between the two approaches in the first few weeks, and essentially no difference at the six week time point. It was interesting to see how much the media can influence a patient's view on their healthcare, and even push them towards something with very little added benefit simply because it's "new".

Week 3: IDE, FDA, and PMA!

I continued to shadow the vascular surgery team in the OR during the third week of the Immersion term. This week, I had the opportunity to observe the endovascular repair of a thoracoabdominal aortic aneurysm (TAAA). TAAAs involve the descending thoracic aorta (above diaphragm), the abdominal aorta (below diaphragm), and multiple branches of the aorta including the superior mesenteric artery (SMA), celiac artery, and the renal arteries. The complexity of these procedures is such that the endograft used to repair the aorta is designed from pre-operational CT images for the patient's unique anatomy. This endograft was designed by Dr. Schneider, and sent to a company for fabrication. The endograft designed for this patient had two fenestrations (holes) for the right/left renal arteries and two branches for the SMA and celiac artery. Fenestrations were chosen for the renal arteries due to the patient's aorta being slightly too narrow for branches. In contrast, the SMA and celiac artery had sufficient room for the branches. The patient also had an iliac aneurysm, requiring the deployment of an endograft in the iliac arteries.

The surgery itself was significantly more complex and lengthy than any of the previous surgeries I have observed. The surgery required approximately 10 hours, and involved the deployment of multiple stents and endografts to repair a very large segment of this person's aorta. Fenestrations require nearly perfect alignment of the endograft with the renal arteries because poor alignment leads to partial occlusion of the renal arteries. Balloon-expandable iCast stents were deployed within each fenestration, while self-expanding viabahn stents were deployed within the each branch. Overall, the procedure was very impressive and integrated many of the strategies I've observed in previous procedures.

This patient is involved in an aortic aneurysm trial led by Dr. Schneider, which is covered by an investigational device exemption (IDE) from the FDA. The study's goal is to assess the feasibility and safety of endovascular repair of TAAA involving the mesenteric and renal arteries in patients at high risk for open surgery using standard or physician-specified branched and fenestrated grafts. As a biomedical engineer interested in medical device design, this aspect of the procedure was particularly interesting to me. Depending on the study outcome, I anticipate the clinical study data generated will be utilized in a pre-market approval (PMA) to the FDA in support of developing this endograft as a class III device.

Week 3: What's cabbage?

This week I finally started to get a sense of routine, still with some new twists thrown in.  Monday, I was in the Lung Cancer Screening Program where I continued to shadow the coordinator, Brooke, and smoking cessation counselor, Kate, while researching smoking cessation in the context of lung cancer screening programs.  Tuesday, I watched several lung and liver biopsies that were guided by CT scan.  As Dr. Pua described the cases for the day, he explained the process from injection of lidocaine into the chest cavity, "pleural bump," to piercing the tissue and positioning the needle (CT guides this) all the way to the retraction of sharp center of the needle to leave a sheath that would allow a core biopsy to be taken.  I learned that with lung biopsies, there can be a 10-15% chance of lung collapse, which would require a catheter in the chest cavity to establish a vacuum overnight, a possibility that does not sound appealing.  I watched as the first biopsy was performed on a woman to determine whether a anterior mediostinal mass in her chest was thymic cancer or lymphoma.  This diagnosis is important since lymphoma can be successfully treated systemically while thymic cancer is best treated with resection.  The next biopsy was a liver biopsy to look for possible conversions in a patient that has a history of follicular lymphoma.  Based on a prior PET/CT, which overlays results from both imaging modalities for optimal presentation of visual information, there was elevated metabolic activity in the liver, a sign of a potential tumor.  Ultrasound is generally the modality used to guide liver biopsies; however, there were too many ribs nearby the site of interest and thus, CT was used.  The next case for the day was a bone biopsy at the spine using a more robust biopsy needle specialized for brittle, hard bone.  I officially met some other members of Dr. Pua's team, the radiology technicians, nurses, and other doctors.  For each case, histology was called down and the biopsies were processed.  

After watching some biopsies, Dr. Pua recommended that I watch a particularly complicated blood clot removal performed by Dr. Sista.  The complications were twofold.  First, the patient had such a large volume of clotting caught in an inferior vena cava filter causing extreme edema in his right leg.  Second, TPA (tissue plasminogen activator) is usually administered after this procedure; however, this patient was recently in an accident where neural trauma, particularly hemorrhaging, was sustained.  After the description of the procedure, I donned an X-ray proof lead vest complete with neck guard and watched as a huge team set about getting a catheter into the patient's femoral artery(?)  I watched the remainder of this procedure from the control room since things were crowded around the patient so my view wasn't that good anyway.  All I needed was a view of the computer monitor to watch the X-ray guided procedure.  The novel part of this procedure was that a "flow retrieval" device was used to remove the clots.  Apparently, this was one of about 15 surgeries that have used this device thus far.  Later on Tuesday, I attended the Breast Tumor Board with Monet and Korie.  The case presented was of a 43 y/o female with bilateral breast masses with a history of breast mass excision 4 years ago.  A core needle biopsy had been performed, and a mammogram had been done.  The diagnosis was a benign fibroepithelial lesion with fascicular PASH.  The result of this diagnosis was a lumpectomy to remove the masses.  It was really great that I was familiar with the characterization of breast tumors from my Cancer for Engineers and Physicists course this spring.  The tumor was found to be ER/PR- HER2- Ki67 low index.  This LGASC (low grade adenosquamous cell carcinoma) is a rare variant of metaplastic carcinoma, which is indolent despite being triple negative.  

On Wednesday, I was back at the Lung Cancer Screening Program and got to watch a shared decision making visit conducted by Brooke.  The 71 year old woman was a 50-pack-year smoker but had quit 14 years ago.  I felt super uncomfortable and realized its the human interaction aspect of medicine that I can’t deal with very well.  When the patient is just a collection of chest scans or a body on a surgical table, I’m perfectly fine, but the moment they’re talking about moving their daughter to California this weekend or about how they quit smoking the year their daughter got married, I get way too wrapped up in the what if’s and imagining how a positive finding would affect her and her daughter.  I’m amazed at doctors who can maintain a cordial disposition with their patients and still function effectively as clinicians.  Anyhow, after that consultation, I went to Thoracic Tumor Board.  Things were definitely more lively at this tumor board than the one from Tuesday.  You could tell that certain clinicians had polar opposite opinions on what was best practice.  Instead of just one case being presented, in this meeting each doctor would call out patient IDs that they wanted the group’s opinion on.  

I shadowed in chest radiology again on Thursday.  There wasn’t as much as last week as far as interesting cancer cases go, but there was an emergency possible pulmonary embolism that needed a scan to diagnose.  There was an interesting case of patent ductus arteriosis (PDA), which is a persistent opening between two major blood vessels leading from the heart.  Normally this opening closes after birth, but sometimes it remains open leading to circulation issues.  I also learned how to identify dual lead pacemakers versus AICDs in CT scans.  

Friday took an unexpected turn since at the end of the day Thursday,  I got a call to see if I wanted to watch one of Dr. Salemi’s surgeries the following day.  Of course, I said yes.  So my Friday started earlier than any of my days in this program thus far with me meeting one of the fellows in cardiothoracic surgery, Dr. Huang, at 7:15am for rounds.  Again, I am not very good with observing doctor-patient interactions, maybe over the course of the summer, I’ll manage to improve.  The worst was a really far gone patient getting “bronched” to remove fluid in his lungs so his pneumonia wouldn’t worsen.  He seemed completely out of it probably due to the dyskenesia of his jaw, jerking from side to side, but in his eyes, there was still cognition.  The post-surgery suite wasn’t that bad until I heard the back-story on one of the patients that I gathered did not want placed on a ventilator or to undergo any major interventions for his ailments.  He simply wanted to be able to function to take care of his wife, who has end-stage cancer.  After the rounds were over, I learned about the surgery that I was here to shadow, CABG!  What is CABG you might ask?  (I know I sure did.)  CABG stands for coronary artery bypass grafting, which is used to treat people with coronary heart disease (CHD).  CHD is caused by plaque buildup in the coronary arteries and thus, actually ties into CRK lab interests.  This case, like the last surgery I watched had additional complications.  This man was obese, barely being contained on the operating table.  His heart function was in an extremely poor state with the left ventricle weakly contracting.  Last issue: normally, the saphenous vein is used for grafting but the patient had varicose veins so a cryogen from a cadaver was going to be used instead.  Dr. Huang told me that these veins are not ideal since they have a 5 year potency rate of ~50%.  I was shocked to see the painstaking process by which the heart was accessed after much cauterization to get through the ample volume of tissue to the sternum.  I was also really excited to see extracorporeal membrane oxygenation (ECMO), something I had learned about in undergraduate studies.  Of course, this was being used because the heart had been stopped using Cardioplegin, a drug that uses potassium to inhibit myocardial contractions.  While the heart was stopped, the cadaver in was attached to the appropriate bypass locations using sutures.  Things got a little rough in the middle of the surgery with the patient’s cardiac index reaching 1.2 so a balloon pump was brought in.  Dr. Huang and the entire team was super tense so I didn’t get to ask many questions but fortunately, for most of the key stages of the surgery, I had an excellent view hovering directly above the patient’s head.  All in all, there were no major complications and the patient’s heart showed immediate improvement after the bypass was completed.  

Week 2 & 3:

          I continued to shadow Dr. Weinsaft, spending time reading MR images in the image reading rooms. We also decide on a research project that I can work on. Since I will be staying in the city after summer immersion to work on in the MRI lab, we decide to take on a bigger project that will likely to take more than the rest of the summer immersion to complete. So I will be working on generating the QSM map of the heart. Aside from that, I observed a few cardiac catheterization for coronary angiography at the Cardiac Catheterization Laboratory. The purpose of coronary angiography is to check the condition of the coronary arteries, to look for substance build ups and ruptures. 

         The OR is divided into two sections, the operation section has the tables, catheterization tools, and the x-ray imaging equipment. The observation section has various monitors that a tech and utilize to support the physicians during the operation. I was told that the patients ought to remain conscious for the procedure, because during the procedure, the patient may be asked to adjust the position of his or her head minimize contact with the x-rays. During the procedure, a long, thin, and flexible catheter was inserted, from the groin, into the blood vessel. Once the catheter is in, the operator will slowly push the rest of the catheter into the blood vessel until the head of the catheter reaches the coronary arteries near the heart. While the operator carefully navigates the catheter through the blood vessel, real time x-rays images are being taken and displayed in a monitor. The operator and the techs all uses these image to guide the navigation of the catheter. Once the catheter reaches its target, special contrast materials that shows strong signal in the x-rays images are injected through the catheter into the coronary arteries, and x-ray images will be taken while the contrast materials are injected. The resulting contrast enhanced x-ray images was able to clearly show the fine structures of the coronary arteries. 

        The procedure was minimum invasive, though I wonder if the same test could be performed non-invasively with only the imaging methods alone.  

Week 3. Decided research topic

Even though I kept joining ICU rounds and meetings, it was not productive in the sense that I needed to catch up so many things to understand what's going on and I couldn't find my research topic out of it as well. So, I talked to my adviser about this. He agreed that it is unlikely to find a research topic and he thought joining ICU for one week was enough to "explore" life there. We decided not to join ICU rounds from now on. He set up me to take STAT program course with his research team from July 10th, and he will give me his stroke patients' data for me to be able to work on. I asked him again about shadowing neurology surgery, which, I hope, will happen soon.

Week 1 & 2. Life in ICU

For the first week, I couldn't meet my clinician, and I start to shadow my clinician from this week (week 2). I shadowed rounds and meetings in Intensive Care Unit (ICU) daily. Every morning, they talked about patients’ status and made decision about which medication they should use, how much dose, and whether the patient need additional surgery, etc. There are about 10 patients who usually have severe symptoms or just had their surgery. The doctors mainly checked the level of various materials in blood (Sodium, Hemoglobin, glucose, and etc) and also check various imaging results (mainly CT and MRI).

At the beginning (and I still am), I was overwhelmed by a lot of jargons and abbreviations that they used. So, I was standing there totally feeling idiot. It was just perfect combination of my lack of English and poor understanding in jargons. So, I decided to try one by one. From Tuesday, I tried to catch something (at least one thing) that I know from their conversation, and tried to understand one by one, or to ask questions about it. For example, I heard them talking about sodium level. I then thought why sodium level in blood is important in brain surgery patient. I made hypothesis that it would probably related to brain pressure, and sodium concentration gradient cause osmotic pressure. Sometimes, my hypothesis was correct like in this case. Sometimes, it was not. I thought the glucose level was important because brain tissue consumes glucose when it activates. I thought this was the reason why they check glucose level, which was not correct. The glucose level was monitored for checking if the patient has bacteria infection because bacteria usually consume glucose to proliferate themselves. Glucose consume by brain activation was not in the same scale as bacteria infection. Asking questions was also good conversation starter. In this way, I’ve been getting familiar with ICU. 

Week 3

I started off my week by visiting the MRI facility on 55th street. Since Dr. Prince was away this week I had the chance to talk with his assistants at the center. Thanks to Dr. Prince I was set up with my project and the people I need to contact regarding several aspects of the project. Having access to data I was able to start some initial analysis trying to figure out what type of data I'm working with (i.e. T1, T2, T1 weighted in MRI) and how they are generated. In addition, literature review on this topic helped me to understand what kind of analysis typically is performed on this type of data and what parameters are required to be included in the final report. I'm not sure how much details of the project can be posted on this blog but this topic is related to Dynamic Contrast-Enhanced MRI (DEC-MRI). There are some quantitative analysis as well as fitting and parameter derivation from modeling involved with this project. I was able to build some understanding and perform preliminary analysis on data. Hopefully talking with Dr. Prince after he comes back early next week will give me new directions on how to proceed on this project. There are some standard analysis that has been reported in any publication related to this topic but sounds like there is not a consensus on modeling and fitting methods in this community.

I also got a chance to go to a tumor board conference this week. These type of conferences are usually held early in the morning or late in the afternoon going through special cases within each community. The presented case in this conference was a 43-year-old female with 3 breast masses. She had excision for benign breast mass 4 years ago. Palpation and mammography results showed heterogeneous dense breast with partially obscured masses. In addition, ultrasound on these three masses showed one 4 centimeter vascular heterogeneous mass while the other two were mildly heterogeneous. Upon sonogram she was recommend for biopsy with 3 needle-cord biopsy.Two masses were identified as benign fibroepithelial lesions while the third one was described as fibroadenoma. Upon further diagnostics and histology analysis she was diagnosed with low grade adenosquamous carcinoma (LGASC). This is a rare case of  metaplastic carcinoma with triple negative (ER, PR,  HER2) and typically difficult to diagnose using imaging modalities. It usually co-exists with other type of lesions, locally aggressive and often recurrent. 

Week 3: To Each His (or Her) Own

7:30 am, morning rounds: port placements, PICC lines, drains, and biopsies with the occasional thrombolysis, stenting or tumor ablation thrown in for good measure. I have watched for three weeks the members of the interventional radiology (IR) division at New York Presbyterian Hospital discuss the same types of procedures for patient after patient.  After a while, one has to ask: why the repetition? Surely after years, or in the case of some of the attending physicians, decades of performing the same type of procedures they no longer need to discuss them.

            The problem with this seemingly logical conclusion is that no matter how many times a physician performs the same procedure each patient is different and each necessitates his or her own special considerations.  I witnessed a debate among the IR physicians this week about the best way to treat a particular patient with a thrombus.  One doctor was of the opinion that two days of anticoagulation (blood thinner medication) would be more effective than just a single day as was more standard.  All recognized that longer anticoagulation increased the risk of bleeding complications, but the physician in favor of longer anticoagulation believed that the risk was no longer particularly high for this patient despite a previous hematoma.  Upon hearing this conclusion, another physician responded “famous last words”.  He was clearly concerned that despite precautions taken against bleeding, the risk was too high.  In an otherwise perfectly healthy individual, the doctors would likely have easily agreed that two days of anticoagulation would be better, but the history of hematoma in this particular patient raised doubts.

            Besides history of previous disease, the age of a patient can drastically alter the way certain treatments are applied.  I watched a resident fellow put a peripherally inserted central catheter (PICC) into a 6 month old. This otherwise routine procedure became extremely complex due to the age of the patient. What is a small needle to an adult appears a deadly weapon next to such a young baby.  Wires and sheath’s had to be downsized, drugs diluted, and x-ray dose minimized.  Fellows and nurses from the neonatal department stood by to give advice.  Particularly complicated was the anesthesia.  Obviously, for one so young, general anesthesia rather than simple sedation was needed, yet even after the patient was completely asleep her continued movements necessitated the use of paralyzing drugs.  Although the main procedure lasted perhaps half an hour, the process of anesthetizing the patient and prepping her for the procedure took over an hour.

            Shadowing my mentor at the clinic, I saw that patient lifestyle also influences therapeutic decisions. For an athletic patient who made running, biking, and tennis a big part of his life, Dr. Sista considered a more aggressive treatment than he might otherwise in order to avoid the possibility of post-thrombotic symptoms that would interfere with this lifestyle.  When considering a particular treatment regime, he and others doctors carefully weigh a multitude of factors specific to that patient before deciding on the most optimal therapy.

            However, if the same patient sees two different physicians it is far from certain that they will receive the same treatment.  Much of medical decision-making is based on the physicians judgment, and just like their patients, every physician is different.  As a Ph.D. student, I have been trained to think objectively about everything.  Experiments must be carefully designed, decisions well supported by evidence and results reproducible.  At first the lack of uniformity and the unknown aspect of medicine jarred me.  Unfortunately, sufficient evidence is not always available for a fully scientific decision to be made.  Furthermore, clinicians do not have the option for waiting for more data; they have to make a decision when the patients need it. 

            The differences between clinicians and researchers became more obvious as I spoke to some of the visiting medical students.  As trainees in the medical field they seemed world’s ahead when it came to understanding medical procedures and diagnostic decisions, yet our roles completely reversed when it came to research.  As I worked on my summer research project I realized that the techniques that I took for granted and applied without thinking were foreign to them.  To each his own:  while the medical students delve into the complex world of clinical diagnosis, I will hopefully be researching new medical tools, techniques and therapies.  Perhaps together we can find cures for many human diseases. 

Clinical Immersion - Week III

It's that time of the week!

The past week has varied dramatically from reading papers to attending meetings to starting the long process of analyzing trabecular microarchitecture in femoral condyles. At the beginning of the week, I was tasked with getting acquainted with some of the work being undertaken on whole-body multi-row detector CT scanning (better known as MDCT) by reading a series of papers on current research into applying the technique to clinical situations that are very commonplace to HSS such as bone radiology. The premise behind this research is the fact that while key parameters of bone can be readily identified using common techniques in CT scanning, such as bone mineral density and morphology, the analysis does not often lead to proper diagnosis of chronic bone disorders such as osteoporosis. A version of CT known as μCT has the ability to more properly isolate and identify aberrations in bone morphology but it's not approved for use in actual patients given the harsh levels of radiation required to perform imaging. At the intersection we can find MDCT, which can produce mid-resolution images without harsh doses of radiation, leading to an enhanced acquisition of information during clinical imaging.

Given the promise of a better way to diagnose bone conditions in patients at HSS, the MRI Center has established a collaboration involving GE technicians from Schenectady, NY and scientists from Cornell University to implement a novel software algorithm to MDCT images, resulting in high quality with desired low levels of radiation. My task in this collaboration has been to analyze both normal and experimental MDCT images of femoral condyles of cadaveric specimens for trabecular microarchitecture using spectral analysis of decomposed images. Given the various specimens to analyze, this work is expected to take most of my remaining time at HSS given the shear amount of data that will be gathered. Even if most work is accomplished relatively quickly, there's already interest in going beyond trabecular microarchitecture towards other bone properties such as cortical bone porosity. It's the laboratory's hope that this research will eventually not only benefit clinical practices at HSS but also help update current protocols being employed by Cornell University for bone analysis, having a widespread impact from biomedical engineering to veterinary research.

This past week was also the MRI Center's monthly research update seminar, during which various members share updates about the current state from their research. This month saw the culmination of endless NIH grant and scientific paper submissions from most of the researchers, with most ultimately sharing really encouraging news. The meeting also illustrated the breadth of scientific inquiry taking place at the laboratory, going from arthritis and ACL injury to thumb cartilage and peripheral nervous system damage; each project is usually lead by a single person but the element of collaboration between all members becomes readily apparent. It was also insightful to see how each team member was able to bring their unique insight given their level of specialization (the team is comprised of people that either have a master's degree, doctoral degree, or professional degree in human or veterinary medicine).

With the first round of imaging done, I am already looking forward to meeting with Dr. Potter on Monday to discuss how to best approach the analysis of all the bone images available to the laboratory. Additionally, after finishing arrangements with orthopaedic surgeons at HSS, next week will be my first official week of surgeon shadowing, starting with Dr. Mathias Bostrom's clinical rounds of Wednesday and Thursday's surgeries (looks like an all day case). Outside lab life goes on, with this weekend having dedicated myself to exploring the borough of Brooklyn, arguably the hippest part of NYC. From Brooklyn Bridge to Williamsburg, the diversity of all the different neighborhoods blends into a rather nice spectacle for tourists and natives to take in. As the weekend comes to an end and the program nears its midpoint, I continue to feel invigorated to keep going forward in MRI research.

Restaurant of the week: Xi'an Famous Foods

This summer I am working with David Nanus, M.D.  Dr. Nanus is a board certified oncologist specializing in genitourinary cancers and the Mark W. Pasmantier Professor of Hematology and Oncology in Medicine.  He is involved in several clinical trials – one aimed at evaluating the genetic characteristics of individuals with prostate cancer and another evaluating the ability of multiphoton microscopy to distinguish between malignant and non-malignant bladder cells. 

At the beginning of the week I met with the Nanus lab group and we ordered lab supplies from the friendly neighborhood science store.  The first to arrive were syringes followed by 27 gauge needles and Microrenathane micro tubes. The micro tubes attached to syringe pumps and fastened onto inverted microscopes will be the workhorse of our experimental setup.  By functionalizing the inner micro tube lumen with different chemicals, adhesive interactions between malignant and non-malignant cells to chemically treated micro tubes can be observed. We hope to increase both the number and purity of malignant cells isolated from cancer patient blood samples, which can enable the development of effective personalized cancer therapies.

Week 3: Connecting the dots

After spending the first two weeks at the MRI facility and the Reading room, I was still unclear about the whole process starting from the MRI signal acquisition to its final analysis, including the image storage and processing. The Physics of MRI is well understood, but how it is accomplished, analyzed, and processed was not clear. Without them, science is just a philosophy! This week was mostly spent on unraveling these mysteries.

I came to know about the protocols which are used to scans patients. Depending on the kind of examination, protocols are decided by the doctors. The protocols contain the MRI sequences that needs to be observed. The technician sets the parameters (like voxel size, slice gap, signal averaging time, etc.) to obtain desired quality of image. However, the quality of images is also dependent on the patient's patience and cooperation. With troubled and troubling patients, it should not be taken for granted. At times, different machines and their age affect the image formation. MR signals acquired depend upon the response of the constituents of the analyzed part.

The reading room is where the image analysis is carried out. Patient's medical record is important for diagnosis. Previous examinations, if any, are required to compare the results. There are components of analysis: findings and interpretation. Findings is the narration of the observed images sequences, while interpretation provides conclusion to the findings for diagnosis. Results are not always black and white, and hence, careful wording in the report is required.

There are still a lot of mysteries to be revealed and will happen in due course of time. For example, how the images are stored and retrieved, how they are managed, and other procedures and process that are part of the whole system but are not known to any one person. Hopefully, by the end of the summer immersion, I will be able to draw a chart stating all the procedures.

This week also saw the beginning of my research project. I got access to some MR images. Now, I have to develop a denoising technique to improve the signal-to-noise ratio.

Week 3.

Week 3. 

On Monday, I saw lots of patients with Dr. Milsom in clinic. He examined two colorectal cancer patients who were just diagnosed. They came to plan for the therapy. Since nowadays, multidisciplinary approach is more favored way to cure cancer, patients get chemotherapy, radiation, surgery or all of them depending on their cancer type. In case of colon cancer, it is recommended to save the rectal muscle if possible but the patients had cancer right above the muscle area. So she will be treated with radiation first, to shrink tumor size and then will get a chemotherapy, and hopefully, Dr. Milsom will get rid of the cancer without damaging the muscle. On Tuesday, I started the day with morning conference. The topic was why the hospital need to move towards patient centered care system. I thought the surgeons do care their service quality as much as their professional technique, which was pretty impressive. The presenter, who studied how much faith patients show to their surgeon depending on their race. The results show patients who have college-level education, white, female have the highest trustiness on their surgeons. Interesting result was even after they got some serious complications after surgery, the faith didn’t much go away. One thing that came into my mind was if the study included the race of the surgeons as an important factor would make more reliable result, but it was interesting talk. Afterwards, I observed several cases. One patient had severe narrowing on rectal canal so he couldn’t move the bowl or even normally eat. Doctor operated on him to dilate the obstruction using balloon and he was able to enlarge the rectum a bit. But he definitely needed more permanent way to fix the problem and Dr. Milsom will remove the inflamed area and then reconstruct his path later. Another impressive patient was female patient who was diagnosed to colon cancer a week ago. When she visited his office, he examined her bottom with flexiscopy and took some suspicious sample for biopsy. Unfortunately, those tissues turned out into adenocarcinoma so she came to OR to remove the sigmoidal colon. Before resecting the colon, doctor tried to find the lymph nodes near the cancerous tissue to inhibit further metastasis or recurrence and was able to remove them with the colon. A day after, I saw her in rounding and she looked okay and promising. The thing that I realized in here is the attitude of the patient affects a lot on their recovery time. Most patients with positive attitude showed faster recovery time like her regardless of the procedure. 

On Thursday morning, I attended research meeting with his research team and heard about the progress on developing devices and other ongoing researches. Colon cancer shows much higher preference on mesenteric side than anti-mesenteric side but the underlying mechanism hasn’t discovered yet. So his research team tested the RNA sequence of tissue on both side but surprisingly there was no significant difference. It was really constructive to be involved in that discussion since I have observed similar phenomenon in the mouse model. When we make tumor model in the mouse, I saw huge tumor mess formed along with the mesenteric walls and even on the mesenchyme but rare in the back side of the small intestine. I haven’t thought about that seriously but now I got lots of inspiration on our tumor model as well. 

Today, there was huge case that Dr. Milsom and Dr. Samstein operate. The patient has recurrent colon cancer right above the rectal muscle and also has metastasized colony on liver. Dr. Milsom removed entire colon including some portion of rectum. Since the tumor found really close to the margin, he sent the sample to pathology lab and then went up to check result right away. It was amazing that they can get a histology result in 5 mins. When we do the histology in lab, it usually takes a couple of days but in the pathology lab, it was extremely faster. We confirmed that both margin was clean from tumor so thankfully we didn’t need more resection. Dr. Samstein started his operation on liver and I was able to watch it as well. It was the first time I observed liver surgery and it used quite different tools. He had to remove the entire left robe and a portion of right robe because we found huge metastasis on left robe and two isolated spot on right robe. It was hard, difficult, and long procedure but I hope she could recover soon and live rest of her life without cancer. 

Week 3: Choose Your Own Adventure

As I transitioned into my third week of Immersion, I was able to be connected through Dr. Kemi Babagbemi to work with Dr. Tessa Cigler, a medical oncologist in the Iris Cantor's Women's Health Center.  It was very insightful to see how the observations that I experienced in the Breast Imaging Center from radiology diagnosis that led to pathological results then flowed to the treatment phase of breast cancer after diagnosis.  Throughout every patient visit with Dr. Cigler, she discussed treatments, bone density determination through testing as well as corrective measures, updates, follow-ups, and comforted them with answers to all of their questions about treatment and the future.  Afterwards, she would perform a physical exam on her patients to gain a sense of their overall physical health. During the day, I also was able to attend a research meeting where the medical oncologists discussed patient studies in order to help impact breast cancer research.  On a white board in the meeting, they had a chart that listed molecular subtyping of the patients along with neo-adjuvant, adjuvant, metastasis, and treatments to follow patients to see what was working or changes that were made if patients presented with cancer progression.  It has been great for the past two weeks to get a holistic view of the journey of a breast cancer patient and be able to incorporate this experience as motivation to know that, in some way, my research is going to be focused in trying to take one step forward in the fight against breast cancer.

Throughout the week, apart from my usual business of reading radiology films, interacting with patients, and still learning more about the radiologists themselves and their day-to-day grind, I was able to observe Dr. Carolyn Eisen & Dr. Linda Kao at MRI facility at 416 E. 55th Street performing biopsies on patients.  From week 2, I learned about stereotactic and core biopsies, so I was curious why they needed an extra imaging modality for yet another biopsy.  MRI is used for an enhanced view of things not easily seen with the other modalities, such as mammogram or ultrasound.  It is performed on high risk patients, but mostly BRCA 1/2-positive patients where there is a small calcification or mass that can be seen under the MRI.  Cancer-like characteristics that they look for under MRI are things that take up the contrast and immediately flush it out or, if not enhanced, they look at the flow surrounding the area of concern. One particular moment where I was truly immersed in the case was when one of the patients had high blood pressure and Dr. Eisen did not feel comfortable with the patient undergoing the procedure. While we were being updated on her blood pressure,  I was having am interesting conversation with her and her blood pressure decreased slightly. Due to this, Dr. Eisen suggested that I continue to talk with her in hopes of reducing her bp further and proceeding with the biopsy. We had a great conversation over the course of 30 minutes and finally got it down for the biopsy. In that moment, I felt like I contributed a significant amount and actually had an impact in terms of helping the patient to get through her procedure and overcome her anxiety.

On the social aspect side of my life, I visited the Upper West Side to have dinner with my sister-in-law's mother and her wife. It was so great to connect with family and travel on the subway entirely by myself.  Further, I went on shopping escapades with Korie and Lauren which led us to journey to Jekyll & Hyde's Pub and Big Gay Ice Cream.  I am looking forward to the weekend.  I will be venture into the realm of catching up with some friends from undergrad who live in the city, travelling to Brooklyn to get my hair retwisted, as well as celebrate in the PRIDE events to commerorate the support for my family and friends who have recently gained a victory with the legalization of same-sex marriage nationwide.  All in all, it's been a pretty great week. I have fallen in love with the city because a pretty common theme in my experience thus far has shown me that around every corner in New York City, there is a new adventure :)

Week 3

On Monday, I observed Dr. Goodman as she met with patients. One patient I saw had a history of pseudogout and came in to see Dr. Goodman complaining of left knee pain.  He said that he had had similar pain in his right knee a few months ago and the corticosteroid injection that Dr. Goodman had given him for that worked great and he was hoping to do the same for the left knee.  Dr. Goodman examined him and his left knee was swollen so she aspirated about 5 cc of fluid and gave him the injection.  Based on the examination, Dr. Goodman was fairly confident that the patient's pain was due to osteoarthritis (his left leg had become slightly bowed indicating that there was a reduction in the joint space of the medial compartment), but she examined the aspirated fluid under a microscope to make sure that there weren't any inflammatory cells in the fluid which would be indicative of pseudogout.  The fluid was relatively translucent and no cells were seen upon inspection, so the steroid injection should alleviate this patient's symptoms.  Later that same day, another patient came in complaining of left knee pain who also had a history of gout.  Gout flares are highly sensitive to diet and other lifestyle factors and this patient had recently lost over 50 lbs in an effort to reduce the frequency and severity of his flares.  However, this patient had also recently stopped taking one of his gout prescriptions.  Dr. Goodman aspirated about 20 cc of fluid and gave him a steroid injection.  Even by eye, I could tell that his synovial fluid looked different than the previous patient's.  It was much more cloudy looking and when observed under the microscope, Dr. Goodman could observe various signs of inflammation.  Dr. Goodman concluded that this was another gout flare likely in response to the cessation of his medication and recommended that he begin taking that medication again.
At the Inflammatory Arthritis Conference on Monday, the case of a 23 year old patient was discussed.  This patient presented with a dissecting aorta, a condition where the inner layers of the aorta tear, which needed to be surgically repaired.  However, the attendings and fellows were not able to reach a consensus as to the best way to treat this individual.  Certain medications could mask his symptoms but could lead to further aortic dissection.  But if not treated, his aorta could still continue to dissect.  So there was a lot of debate as to how to treat this patient while also doing him no harm.  At this conference, certain insurance practices were also discussed.  Insurance companies only cover drug costs for certain indications even if the drug is known or suspected to have therapeutic effect for other indications.  While this may be how it works on paper, the doctors explained certain instances where the insurance companies really try to get patients approved.  For example, a doctor called the insurance company to try and get his patient, with ankylosing spondylitis, approved for a drug which was not indicated for that disease.  The insurance company representative "reminded" the doctor of all the different indications approved for the drug and asked him whether his patient had any of these other conditions.  As it turns out, this patient once had a psoriatic rash, an approved indication, and was therefore approved to get the drug.  So, I guess, insurance companies aren't all bad.
Tuesday began with a Combined Arthritis Program research meeting.  A number of abstracts were submitted by this group last week which seemed to represent the accomplishment of many goals.  Therefore, the purpose of this meeting was to identify new goals for the group.  Some of the proposed research areas included looking at pain in daily activities for patients with osteoarthritis versus rheumatoid arthritis and looking at 10 year outcomes for patients in the cohort who had received THR or TKR early in the study.  Another potential area was core decompression in patients with Lupus.  Core decompression is performed in patients with avascular necrosis.  During the procedure the necrotic tissue is cored (removed) and, sometimes, a bone graft is inserted.  However, it is known to the surgeons at HSS that this procedure tends to be unsuccessful in patients with Lupus and therefore the procedure is not performed on Lupus patients at HSS.  The reasons why the procedure is unsuccessful is not known and there is limited data to work with because the procedures are not longer performed at HSS.  However, the group members felt that this could be an area of study to make it more widely known that this procedure tends to fail in Lupus patients and to convince others in the field to stop performing the procedure on these patients.
At the CAP conference on Tuesday, the very sad case of a 40 year old patient was discussed.  This patient had been diagnosed with juvenile idiopathic arthritis at the age of 16 and within the past 5 years her arthritis had become so severe that most of her joints were fused and she had next to no mobility.  She could not bend any fingers besides her thumb; her hips, knees and ankles were so stiff that she could not maintain any position besides laying in bed; her neck was limited to maybe 5 degrees of motion; her shoulders and elbows were so stiff that the only way she could feed herself was by using an extended spoon.  She is completely bed bound and hasn't walked in almost 2 years but was at HSS this day in the hopes of finding a doctor who would help her to walk again. After the patient was examined and left the room, the first thing the doctors asked was how was she allowed to have gotten to this point?  They said that you don't see patients with cases this severe unless they are from a foreign country or they are extremely under educated.  But this woman was college educated, lived in NYC her entire life, and had a job as an administrator at a college until her disability become too severe.  This woman's situation could have been prevented if she had been receiving proper care.  Instead, it was explained that if she had 6 surgeries (bilateral ankle, bilateral knee, and bilateral hips) she had a 10% chance of standing again and a <1% chance of walking again.  It is more likely that her soft tissue is so damaged and muscles are so atrophied that even if all of her lower extremity joints are replaced, she still will not regain joint stability.  Rather than walking again, the surgeons explained that she could regain some independence by using a motorized wheelchair.  However, to get her into a seated position would likely require hinge replacements in her knees and possibly bilateral hip replacements as well.  One surgeon offered the extreme suggestion of bilateral amputation at the knee and bilateral hip replacement.  In that case, she may be able to use a wheelchair and it would be easier for her caregivers who are responsible for transferring her out of and into bed.  Another suggestion was to ignore her lower extremities and instead replace one or both elbows that way she could at least feed herself.  This was a really hard case to hear about because this woman could be fine and walking today if she had received proper care.
At Rheumatology Grand Rounds on Wednesday, the Director of the Roberts Center for Inflammatory Bowel Disease gave a talk on the state of steroid use for IBD treatment.  IBD and inflammatory arthritis are often treated with similar drugs because they are both inflammation based diseases. Like inflammatory arthritis, steroids are often one of the first choices for treatment of IBD.  However, also similar to inflammatory arthritis, other disease modifying drugs and biologics are gaining popularity.  The IBD community is learning from the experience of rheumatologists in the use of anti-TNF therapies.  However, despite all of the similarities between these diseases the differences should also be noted.  These diseases are genetically different and therefore respond differently to various drugs.  Unlike with arthritis, the microbiota of the gut play an increasingly important role in disease progression and treatment in IBD.  Also, these diseases tend to affect different populations.  For example, RA commonly presents after age 40 whereas IBD is more commonly diagnosed before age 30.  This can play a major difference in the drugs that can be used for treatment.  One of the more common RA drugs is methotrexate.  Methotrexate is widely used due to its mild side effects and known effectiveness.  However, methotrexate is a Category X drug, meaning that it has a strong potential to cause birth defects and therefore cannot be used during pregnancy and is avoided in patients who could become pregnant.  This is not a huge deterrent in the older aged patients with RA but means that methotrexate is rarely ever used in patients with IBD.  This presentation showed that while inflammatory arthritis and IBD have a number of similarities, their differences also need to be considered when debating treatments for either.
Thursday morning began with the Adult Reconstruction and Joint Replacement conference.   This session began with the discussion of a patient who had had both of his hips replaced and was now having a recurring infection and necessitated multiple revisions for one of his hips.  What was really troubling was that the culture from his first infection was positive for p. acne but all of the cultures for his following infections were negative.  This made it unclear how best to treat the patient and prevent any future infections.  Unfortunately, his case became so severe that his prosthetic had to be replaced, partly in fear that the infection would spread to the other hip.  There did not seem to be much consensus from the surgeons on how to best treat this patient.  This conference also included a slightly heated debate on the best approach to use for hip replacement surgery, an anterior or a posterior approach.  The scientific evidence seems to be a little inconclusive with some finding moderate short-term improvements in patient outcome with the anterior approach.  However, due to the lack of sufficient visualization with the anterior approach this technique often requires the use of fluoroscopy which is not always ideal for the patient or the personnel in the OR.  The posterior approach is the more common approach used at HSS, but that is partly because it has been around longer and the surgeons are thoroughly trained and experienced with it.  The anterior approach has more of a learning curve for the surgeon, but this learning curve could be minimized if the surgeons were introduced to the approach earlier in their careers (ie residency, fellowship),  Though the media has been hyping the anterior approach, the best approach for the patient is really that which their surgeon is most comfortable and confident with.
I also attended a meeting of the Tissue Engineering, Regeneration, and Repair (TERR) group.  At this meeting, one of the biologists was presenting her work in understanding cell signaling in the development and degeneration of intervertebral discs (IVDs) in the hopes of finding new treatment options for degenerative disc disease.  Her research focused on the Wnt, Shh, BMP, and TGF beta signaling pathways.  She has found that the Shh pathway is very important for the proper development of the nucleus pulposus (NP) of the disc and also that if the NP is ablated the integrity of the annulus fibrosus (AF) is diminished.  She has also found that the Wnt pathway is necessary for promotion of the Shh pathway.  With these findings, she has performed some initial in vitro studies to see if promoting the Wnt and Shh pathways in aged/degenerated discs can promote rejuvenation.  In these studies she has found that activation of the Wnt pathway not only activates the Shh pathway but also activates IVD cell differentiation and rejuvenation.  She has also found that disc rejuvenation is dependent on the type of serum used in the media.  Fetal bovine serum promotes rejuvenation, as does neonatal bovine serum to an extent, but adult bovine serum and serum free media do not.  Her work can be used to inform the development of new therapies but could also be used to inform how best to develop tissue-engineered IVDs.  It may be of interest to look into the Wnt and Shh signaling in the TE constructs developed in the Bonassar lab at Cornell.
Friday began with the Medical Staff Meeting.  This week, the meeting began with an update on the gradual implementation the the Epic electronic medical record system.  I have seen this system in use at the Geisinger Medical Center in Danville, PA.  This system seems to do a good job of integrating patient data across different departments and should have a great benefit for the clinical researchers here at HSS.  Currently, the clinical researchers have to sift through a number of different databases to collect information about patients in their studies, but Epic should allow all of this information to be found in a single place.  At this meeting, HSS's new Chief Scientific Officer presented on his short and long term goals for research at HSS.  Some of his short term goals focus on building more bridges between clinicians and scientists to promote translational research, bringing surgeons and clinicians into the conversation when recruiting new scientists, and also promoting basic research.  He said that one of the major areas of basic research to focus on was bone biology and mechanotransduction.  I was happy to hear that he called mechanotransduction a link between biology and engineering and said that he wanted to strengthen HSS's relationship with Cornell Ithaca, specifically with the BME department.  So hopefully that means more collaboration between BME and HSS!