Week 7&8

On the Tuesday of the 7^th week, I had the opportunity to join Dr. Spector’s team with Terence and Aaron to observe a mandible reconstruction surgery. A bone tumor, which was excised in the first stage of the surgery, was diagnosed on the right side of the patient’s lower jaw. To reconstruct the mandible, a piece of fibula flap without skin part is used to restore the defect. A CT-scan 3D printed skull of the patient had been made beforehand as a guidance to excise the tumor structure; and a template served as fibular guide was designed to cut the fibular in the precise location and angle to fit the defect. Because I had to shadowing Dr. Cross earlier that day to see patient, I came to the O.R. a couple hours late and missed the mandible remove part. When I entered the O.R., three teams of doctors including head and neck team, fibular team, and plastic surgery team were working on the patient simultaneously. There was a huge ear-to-ear cut on the patient’s neck and all the skin above had been lifted up to expose the mandible with clear margin for the bone resection. The fibula procedure took a while because the cuts and the holes for the implant need to follow exactly the size and the alignment of the guidance. But once it was removed, the fibula flab fit instantly and perfectly into the mandible. The last part of the surgery was operated with the aid of a microscope to reattach the vessels to neck tissue. Two veins and one artery of the similar sizes from the neck were chosen as the candidates. The arteries were attached by suturing end to end. The veins attachment, due to their smaller size, were performed by anchoring the ends of both veins on a small plastic rings with needles and then being clipped tightly to prevent leaking. The entire surgery took more than 8 hours to be finished. It is very amazing how the pre-designed guide and template help doctor perform the procedure precisely. The functional and aesthetic outcomes were incredible in comparison with those simile surgeries without patient personal guide.

On Thursday morning, I attend the TERR meeting in which a postdoc of Dr. Suzanne Maher presented his research work on stress distribution on knee models of patients with meniscus autograft transplantation. The study utilized MRI imaging technique to monitor the cartilage morphology and mechanical integrity change at the load of half body weight. Based on the MRI results, the decrease in T1ρ signals indicates the decreasing proteoglycan level which is in correlation with a decrease on the hydration level.  T2 value change was also in correlation with the water content and therefore it could be used as a double security on research results. The stress and stain distribution upon the same loading was also monitored by MRI and the results were compared to the data obtained by an intraoperative method. By comparing the results of two methods, the variation on contact surface area and peak stress values were found to be very similarly in each method, which indicated the potential for the MRI to serve as a surrogate non-invasive monitoring technology.

During the last few weeks of the program, I had started a research project in collaboration with Dr. Jason Spector to develop a substituent for current mainstream product in wrinkle smooth market—JUVÉDERM®. JUVÉDERM® is a FDA-approved injectable filler used by cosmetic and plastic surgeons to smooth facial wrinkles and volumize deeper folds. The major component of JUVÉDERM®, called hyaluronic acid (HA), is a family of naturally occurring linear polysaccharide that can be found in skin, connective, epithelial, and neural tissues. To achieve cheek augmentation, cross-linked HA hydrogels can absorb large amount of water and expand up to 1000 times of its own volume upon injection intradermally. Each injection cost at a price of over $500. The purpose of this project is to design and synthesis an effective JUVÉDERM® substitute that has similar/better characteristics but costs less.

In summary, a fantastic summer with awesome experience in hospital immersion is over. I have learned a lot of knowledge in orthopedic field as well as in vascular surgery and plastic surgery. Such experience will greatly benefit my future PhD career and I am looking forward to continue my collaboration with the doctor in the following years.

Weeks 7 and 8

Over the past two weeks I spent most of the time on my project. Making progress on the quantitative analysis part of the project that I’m in charge of. Interestingly, as you spend more time on projects and go deeper into the analysis you'll find it more challenging and the extent of the study increases as you find more results. Another thing to keep in mind is to eliminate inconsistencies in recorded cases arising for different reasons from imaging protocols, motion artifacts, image quality, scanner variability in each scan and etc. This can produce error and decrease confidence level in final results. I also spent good amount of time to perform preliminary analysis through anonymized patient’s diagnostics images with the help of my mentor and his assistants. Since I don’t have access to any database after I go back to Ithaca, it is important for me to collect as many cases as I can to process/analyze them later.  

Overall this was a great experience and an important stage in my life. It is my first time dealing with real world problems. Seeing patients, going through diagnostic images, and see how physicians make decisions based on knowledge and experience they have gained over the years and diagnostics provided by imaging modalities and other tests. Some  of the cases are patients with disease in advanced stages and patient’s life is in the hands of physicians. Interpretation/misinterpretation of the tests and results can either grantee the patient a few more months of survival or shorten and exacerbate his conditions.

One lesson learned from my immersion exposure was that although biomedical engineering is intertwined to medicine and engineers are there to build tools and devices that doctors need to improve diagnosis and decrease errors at different stages of treatment, still sounds like there is a disconnect between these two communities. Each community has its own expertise but when it comes to the point that how much knowledge and information they have from each other, there seems a huge gap. If filled, pace of technological advances in biomedical devices could increase because doctors will know what technologies are available in the market and engineers would have more information on what doctors need. Another important lesson was that the most successful people in this field are the ones who develop expertise in both sides. For instance, a radiologist/physician who knows all the technical details of the MR scanners and how they work can distinguish between an abnormality in patient's diagnostic image vs. any artifact or imperfection resulted from the system and not the patient.      

 I’m grateful to Cornell BME department and everyone involved to provide funding, housing, transportation, and making all the arrangements to make this summer memorable and valuable for future planning. I specially would like to thank my mentor Dr. Martin Prince whom I had the chance to serve for a few weeks, although short I got a chance to learn a lot.   

Week 8

This week was our last! I spent my time working on my poster and other items for immersion assignments. I also said my goodbyes and thank you's to the research team and Dr. Rodeo. This summer has been a great experience overall. I really appreciated the welcome from Dr. Rodeo and his team, and getting to see surgeries and also more clinical animal work. I think being in the OR and seeing patients has given me a new perspective on research later in my PhD. I understand better the line of defense used in treating PTOA and OA, and how research technology could be designed and better implemented. For example, I think working with intra-articular injectables would be an easy way to translate a technology because it is so frequently performed whereas something used in surgery may be much harder to get to that point and also maybe not as accessible to patients. I think I've also built up a good collaboration for the future. Dr. Rodeo agreed to serve as a thesis committee member,though I think it will have to be a "special"-type due to Cornell's graduate school rules, but it will be incredibly helpful and benefit research moving forward to have his clinical opinion and experience with research too.

Week 7

This week was full of interesting patients! A teenager came in who had a syndrome known as congenital indifference to pain and presented with a huge effusion in their knee. The indifference essentially means they had a huge pain tolerance and their body was not very good at communicating when too much activity was actually damaging, which was a large issue when they were younger. Turns out just from squatting at the fridge, they tore their meniscus and were experiencing clicking, clunking, and shifting of their leg. All of this caused a loss of the horn, OCD, marrow edema, and they also had some bone collapse but a stable cartilage surface. Another person came in with a need for an ACL revision surgery, and they had to use the quad tendon since they did not have the standard patellar tendon from prior surgery. This was a source I did not know about until then. I also learned about a new PRP-like treatment where alpha-2-macroglobulin is isolated and injected into the joint to stimulate healing.

In the OR this week, I observed an especially cool procedure in which the patient had lost power in their shoulder and was experiencing pain. From MRI, it looked like the joint capsule had degraded and the subscap of the shoulder was torn and degenerative. To repair this, a part of the pec muscle was transferred over to the subscap insertion to makeup for the muscle loss. Interestingly, the joint capsule was repaired by using an achilles tendon allograft. I had no idea how large a tendon it is! It was not a perfect replacement, but it facilitates the tendon gliding and prevents interaction with the bone.

Outside of clinical time, I also listened to a talk presented by Hongsheng, my research project advisor here, about his work (and mine this summer!). He discussed research methods for being able to apply load to patients' legs during MRI and how images obtained can be quantified to answer clinical questions.

The rest of the week, I worked on finalizing my project data and also discussing loose ends after I leave as this study will continue. I also did some reading in the library on new research ideas to bring back to Cornell.

Week 8: Communication is Key

Sometimes what you say is less important than how you say it; how you communicate information and transform it into knowledge.  Communication is critical in almost any discipline and medicine is no exception.  The communication between doctors and patients, communication between doctors and nurses or other healthcare professionals, even communication between one group of doctors and other doctors has the potential to be a determining factor in the success of a treatment or therapy.  Although I observed these types of communication throughout my time at New York Presbyterian Hospital, certain occurrences this past week specifically reminded me of the importance of communication in medicine.

My observations started with physician-patient communication during morning rounds.  It was the patient’s wife in particular who asked innumerable questions of the attending physician, holding him in the room, long past the few minutes usually spent with each patient on rounds.  The patient was experiencing a number of complex medical issues, and Interventional Radiology had been called in to perform only one procedure that amounted to a small part of the overall treatment plan.  However, as the attending physician explained the upcoming steps and options following the procedure that IR had already completed, it became clear that the patient and his wife were desperate to know what would happen in the future, how the disease would be treated, and what it meant for the patient’s life.  Unfortunately, the patient’s main team of physicians seemed to have not properly explained what the treatment plan would be, nor explained all the reasons behind the choices that had been made so far.  In this case it was not question of not the patient not understanding the information (the wife in particular was very well informed and asked intelligent questions) but rather the other physicians apparently had not taken the time to communicate with their patient or his family.

Communication with patients is not limited to before and after procedures.  While in many surgeries, the patient is anesthetized and completely unconscious, in IR the physicians often chose to perform the procedure with nothing but sedative and a local anesthetic, keeping the patient in a semi-awake (“twilight sleep”) status.  This practice reduces some of the risks associated with anesthesia, but it means that the patient is constantly aware and the physician must take care to communicate with the patient throughout the procedure, letting them know what is happening.  One patient I witnessed became upset upon feeling a constriction around her arm.  The constriction turned out to be a blood pressure cuff, a harmless and routine part of monitoring patient health during the procedure.  However, when a patient is nearly helpless, lying on the operating table, even something simple can be scary.  The experience emphasized the need to maintain a dialogue with the patient throughout the procedure. Even for simple things, if it is something the patient can feel, it is important that the patient be forewarned.

As I worked to complete my summer research project, I discovered an entirely different type of medical communication: recording results of medical studies in a way that could not only be understood by the other members of the research team, but by any physician in the same field.  In my own research I have frequently needed to express my work in a format that would be understandable to together researchers, even those outside my specific field.  The same concept applies to the medical-related research I have worked on this summer, but the audience is different (doctors instead of scientists and engineers).  In order to communicate my work effectively, I need to keep the experience and background of the audience in mind to ensure that my efforts to discover new medical information are able to advance medical knowledge in a way that would hopefully help patients.

Week 7 & 8:

            The last two weeks of the summer immersion were very research intensive. I finished modifying the pulse sequence and had it installed on a hospital scanner. I naively thought that the sequence would run without any problem, but unsurprisingly, I encountered bugs. After a few days of debugging, I got the pulse sequence running. After I confirmed that the sequence can collect data properly by scanning phantoms and volunteers, we decide to scan a few patients. The patient scans are more complicated than I expected, as I found myself bargaining with the tech (and my own morality) on how much data I can acquire and what is the quality of the data that I can acquire. On one hand, I want to acquire all the data I need at the highest quality, on the other hand, I feel bad for keeping the patient in the scanner longer.  Nevertheless, it was a good experience, and I learn to consider the patient’s condition when I write pulse sequence programs.

            The summer immersion has been a rewarding experience. Not only that I got to see some very interesting procedures that made me even more appreciating of the medical technologies, I also met many people that I will work with in the future and familiarized myself with the operating structure of the imaging centers in the hospital. Although this eight weeks program is ending soon, my summer immersion experience will continue, because I will be staying in the city. I will continue to immerse myself into this environment as I work toward my PhD degree for the next few years. 

Clinical Immersion - Week VIII

Epilogue.

After all the endless days of working and restless shadowing of doctors at HSS, my time as a clinical intern came to an end yesterday after a final presentation of my work to Dr. Potter. In preparation for the meeting I spent several days gathering data on image resolution for 468 pictures, resulting in 468 data points that had been categorized based on several parameters impacting resolution (GSI type, keV voltage or image filter, and use of a specialized image formats). The control for the pictures was the old GSI format used by GE on creating the MRI pictures, with all other experimental ones being studied due to their possible increase in resolution level. Creating a neat comparison among all the data points was perhaps the most critical step to making sure that the presentation went smoothly; to accomplish this, I decided to first compare the keV voltages and the use of the specialized filter (in this case, hydroxylapatite on water) among all three GSI types in order to visually how different was the resolution based on the parameters that a user can actually alter. After this was accomplished, I sorted the data once again based on GSI type, a parameter that a user can no longer alter. In this way, the presentation could make the most sense to Drs. Potter, Meyer, and Greditzer.
The data plots supported that careful consideration should be given more to the GSI type than to the use of any particular keV value. However, what was clearest was the fact that certain image formats were particularly advantageous for highlighting microfeatures in the femoral condyles, and possibly being much better at quantifying trabeculae in upcoming studies. The two image formats, work in progress and current standard, seem to be much better at acquiring features in an image (high acquisition value) and establishing a much higher resolution (high avg resolution level). While it was expected that these formats were going to do better, it was still great to see that the program could now quantify just how much better these formats were at capturing the distinct small features of the trabecular architecture present in the femoral condyles.
While much work is still needed before critical research on trabecular microarchitecture using MDCT can take place, the first step is ensuring that the Potter laboratory will move forward with their collaboration with Dr. van der Meulen. So far, I have been informed that my data will be taken into consideration for future research and that the program I made will be taken into consideration for the analysis of more pictures. It has also been suggested that a formal meeting should take place between Dr. Potter, Dr. van der Meulen and I in order to discuss possibly continuing this project as some sort of collaboration.

With regards to my last adventures, it seems that transition was the last theme: from city to beach escapades to a visit to the Museum of the City of New York/Museo del Barrio, the weekend highlighted how people affect their environment and vice versa. On Sunday I had the chance to visit Montauk with Lauren Hapach, a three hour trip taking us all the way to the tip of Long Island where sandy white beaches and multi-million dollar houses are. The stark contrast between the city and the beach were a surprise in their own right. Tuesday was devoted to Uptown Bounce, an event that allowed free admission to two museums on the Upper East Side, both of which featured exhibitions on activism in New York City, dating all the way back to the 1600s. The most informative was the Museo del Barrio's exposition on the Young Lords movement of the 60s and 70s that occurred not too far away from where the museum stands. Eerie snapshots of times past and present struggles on the way to transition. My last day on the city featured a vist to Soho and Prospect Park in Brooklyn before heading back to the Upper East Side.

The clinical immersion experience felt daunting at times and it, necessarily or not, placed me on awkward scenarios where I was left only with my intellect and plenty of time to define the problem and find the solution. While it was not necessarily what I had envisioned in mind (so much coding...), it did provide an insight into what the future will be like after I graduate from Cornell. By keeping an open mind, a problem can become a growing experience that can diversify in multiple ways. That would my advice for the incoming first years (in addition to having fun exploring the city)

Thanks for reading,
Victor Aguilar