Week 7-Mary Clare

My last week of Immersion Term was a bit more rushed than anticipated. I spent the first half of my week in Florida taking care of some unexpected family business. Due to these events I was not able to see cardiothoracic surgery. However while I was gone, the longer time point of my research project was running. The last two days of my immersion experience were spent trying to wrap up all the analysis for my study. This involved extracting, isolating, and analyzing RNA from my samples. Although our findings were interesting, I think there is still a lot of follow up work to be done before the study has conclusive findings.

Week 5-Marsha (Last Week)

            My last week of summer immersion was all about completing as many clinical rotations as possible. Monday: Cardiothoracic surgery. Tuesday: Lab. Wednesday: Emergency Department. Thursday: Medical Intensive Care Unit (MICU). Friday: Neonatal Intensive Care Unit (NICU). While each experience was unique, I think the emergency department will be one of the most memorable experiences of the summer.

            Since I had never been a patient in the emergency department, I didn’t know what to expect and in my mind was envisioning typical television dramas. Well, let me begin by saying real life is different than television. Over the course of the day there were two high alert patients where doctors, residents, and nurses rushed to the intake room. Aside from that, most patients did not have acute ailments. They came in because of some inexplicable feeling of discomfort—illness, digestive, or other, but were not in a life-threatening state. With the exception of the acute cases, the doctors and staff monitored patients at a calm pace, not frantically as I had anticipated.

            My memorable case was a sickle cell anemia patient. I learned about the challenge of pain management in sickle cell anemia from a physician’s perspective. Pain is one of the most common symptoms of sickle cell anemia and severe pain can be managed at the hospital using therapeutic drugs. In theory, every patient should be allowed to come into the hospital and receive unbiased treatment for their symptoms. Especially, in the case of sickle cell anemia where the pain is well documented and IV drug administration is the status quo. However, the situation becomes complicated because after a lifetime of morphine, Benadryl, and other drug administrations the line between patient and drug addict can become blurry. Should a physician be able to tell someone yes they can receive medication for their pain or no they cannot? How do you know if a patient is really telling the truth. After administering a combined pain treatment to a particular sickle cell patient, one of the attending physicians was explaining to me the challenges of treating these types of patients, and expressed that he really believed this patient was in pain. Two hours later, it was revealed the particular patient had been to the emergency department 28 times over the past 6^th months using different names and birthdays. When confronted by a social worker, they got up and left—of course having already received their treatment. This particular patient really highlighted the challenges that even the most experienced physicians face when trying to elucidate what is fact and what is fiction when talking to patients. It was also a good “last week” scenario because it showed the continued need to improve both diagnostics and treatments in medicine. We as a medical field are not doing a good job if our treatments turn patients into drug addicts.

            As a whole, summer immersion was without a doubt a once in a lifetime experience. Watching surgeries, rounds, and office visits I gained a better insight into how physicians think and the environment in which new medical advancements would be implemented. 

Darvin

In all, the summer immersion experience, though challenging at times, was incredibly unique and enriching. My medical vocabulary expanded by orders of magnitude, and I was given the privilege of seeing things that are usually exclusive to only medical students and clinicians. On top of it all, I had an interesting and useful project. I was partnered with Dr. John Kennedy, Foot and Ankle Surgeon at the hospital for special surgery.  Dr. Kennedy research interests are: osteochondral defects, cartilage regeneration using bioscaffolds, bone remodeling/fracture healing and platelet rich plasma (PRP) in Soft Tissue Injuries. Overall, I feel Dr. Kennedy was the perfect match, especially given that my thesis research involves cartilage biomechanics.

My summer project involved a long-term tissue database registry proposal, which will be submitted and reviewed by the New York clinical review panel. The conditions included in the registry will be any involving articular cartilage and soft tissue pathology of the ankle. Which includes but is not limited to, osteoarthritis of all grades, osteochondral lesions of the talus and distal tibia, degenerative joint disease, ankle arthrosis, joint and synovial inflammation, any pathology of the macro or micro environment of the joint or articular cartilage, ligamentous injuries and any associated tendinopathies. The registry aims to compile all data relevant to cartilage and soft tissue pathologies and treatments, biological state of the cartilage and related joint tissues, and the composition of biological adjuncts used to treat these pathologies and correlate this data to outcome data, mechanical studies, imaging studies, and already existing patient and surgical data currently collected in the Foot and Ankle Registry.  The data complied in this registry will allow many important research questions to be investigate that may impact clinical practice.

OVERALL, I  loved this experience. Thank you Cornell BME. 

Week 7 - Tara

It's pretty difficult to believe that summer immersion is already over. In some ways, I feel as though we just got started. This week happened to be very busy with different activities. I spent some time in the neurology group (as in the previous weeks) seeing patients with Dr. Gauthier. I also had to attend a couple of lab meetings and present my work over the last few weeks. This experience was nice as it solidified the background and purpose for the project in a general discussion with the post-docs and PI of the lab. Based on some primary data I was able to gather, the group will be optimizing the vaccine design going forward. I still have a few experiments to complete, and will stay back until the end of next week (8/2) to see them through to the end.

The highlight of my week came on Friday when I was able to view a cardiothoracic bypass surgery. This case in particular required an artificial bypass during the surgery in which Dr. Girardi was able to remove a section of the aortic arch and replace it with synthetic tubing. The best part about this experience was that I was able to stand very close to the patient and get an aerial view of the surgery being done from time to time. An open human heart on an operating table is something I will never forget. Furthermore, this surgery was interesting by watching the attending extensively suture the synthetic tube to the existing anatomy so that there would be no ruptures or tears. It was quite unlike any other the other surgical procedures I have previously seen, especially when observing the interplay between the artificial bypass and anesthesiological monitoring.

To sum up, it's been a really valuable experience and one of the best and most unique parts about being able to do a PhD at Cornell. I am sure some people have come away with knowledge about clinical practice, and others have caught a glimpse of the physical impact/contribution of their research in Ithaca in medicine today. In my case, I can say that there is an added level of meaning in that I have also discovered a new research interest that I will pursue in the course of completing my thesis. When I began Cornell, my primary interest was on developing therapeutic systems. However, after this summer, I realize I am more interested in better understanding the mechanisms of disease. Being able to see the practice of medicine (from the clinic to diagnosis to treatment to preventative measures) reinforced that enhancing current standard of therapies relies on a better understanding of the intricacies that trigger progressive disease. Furthermore, I have been able to see the diversity of patient's physiological response to the "same" disease. It is clear that some patients are asymptomatic, others have a severe and sudden onset, and others still fall under having a "spectrum" disease where their symptoms overlap with other pathologies. The question then arises, how do we go about treating the ever increasing complexity of disease that we see today and predict to have in the future? I would not have been able to see this research interest so clearly without having this clinical exposure firsthand. I am extremely grateful to have been able to participate in the immersion term.

Week 7 - Ashley

My last week of clinical immersion I decided to try the other departments I hadn't been to. My first experience was in the MICU (Medical Intensive Care Unit). Rounds started at 730 AM and our first patient was brought in for overuse of alcohol. She was unresponsive and on a ventilator since the night before she was admitted. The attending surgeon recommended keeping an eye on her until the team could get her fully awake. We saw many patients that day, but the one that grabbed my attention was a patient with a bacterial infection that was negatively affecting his whole immune system. The most intense part of the situation was that he could not speak English, and always pointed at his son to make his medical situations. There was still a communication barrier, but son was able to make the necessary decisions for his father because his father was giving him consent. 

I also decided to do an OB shift this week, and got an amazing experience in triage and in labor and delivery. The most exciting surgery I witnessed was a planned C-section. The surgery began with an epidural being placed, and the first cutting followed shortly after. The fascia was first removed to expose the uterus, and slowly the water broke and the baby's head followed. The umbilical cord was then clamped and cut. The baby was prepped and handed to the father standing nearby. The placenta was completely removed, and the uterus was then sewn back up. The procedure was relatively fast, safe, and completely memorable. This particular experience stands out from my entire experience. 

To sum up this summer, it was a completely unforgettable experience. I have met fascinating individuals that have taught me so much. I'm really thankful to have had the opportunity to meet and be mentored by excellent clinicians in their field. A special thanks to Dr. Lane for being a great mentor and allowing me to shadow him the entire summer.  

Week 6 - McCoy

This week I spent a great deal of my team reading up for my project, medical journals were a little difficult to get through in the beginning due to the various jargon, but now I think I have a much more firm grasp on reading them without actually having to look up the definition of every other word. This week we were able to sign up for MRI’s and have scans of body locations of our choice. Naturally, I chose to have my brain scanned and was able to see the result. There is something very meta about a brain wanting to see itself, though that’s a discussion probably best left for another time.

As far as clinical rounds and patients are concerned, this week I had more down time than previously due to the working on my project as well as being given some time to go and do things in the city that I should do before I have to go back to Ithaca. I did attend clinics still, however, and was able to see a few patients. One in particular sticks out as it was fairly emotional. A woman had been in a car accident and had gone to get a CT scan, though she felt fine after the crash. At the behest of her kids, she chose to go ahead and upgrade to an MRI scan; the results of the scan indicated that she had a malignant glioma deep within her brain even though she appeared to be asymptomatic. She is on chemotherapy regiment currently and the tumor has appeared to shrink slightly in size, though Dr. Boockvar has indicated that it will eventually become resistant and that it is inoperable with current technology. Still, the woman has been given several extra months, possibly years to her life purely because of a quick, seemingly unimportant decision. This is likely the most important story I will remember from my time in the immersion. 

Week 5 - McCoy

This week I had more down time to begin working on my project, which is more so of a literature search and review on the uses of ultrasound in chemotherapy delivery, particularly in seeing whether or not disruption of the blood-brain barrier would be possible or appropriate. Current limitations to using chemotherapies for brain cancers are their inability to pass through the blood-brain barrier and reach their therapeutic target. Additionally, I also followed a med student in Boockvar’s lab, Kartik Kesavabhotla, and saw how many of the med students practice for their eventual surgeries – on animals. It was actually a bit more interesting as I was able to be closer to the actual surgery and I could ask a lot more questions than I would normally be allowed to within a human surgery.

I spent some time again in clinicals with Dr. Boockvar, though much of the time was spent going through patient history, previous treatments, and other data that would be useful in his understanding of their cases. From this, I was able to pick up on key things that he uses in identifying different cases and his course of action for each of those. In particular, he seemed to be fairly accurate at diagnosing brain tumor types from their location and MRI appearance, something that he said he’s picked up on over his years of experience with them. He also told me about many of the basic therapies that are used for many of the gliomas, though due to their unique location and proximity to vital tissues, the list of possible therapies was very small. Additionally, he told me about many of the different nuances of surgery and thing he has to consider when he decides whether or not he wants to continue with surgery on a particular patient. 

Week 4 - McCoy

This week was shorter than the others due to the 4^th of July, but I still managed to follow Dr. Boockvar around during his clinical hours and was able to see him interact with patients and go through his internal diagnosing algorithm. These was the highlight of the week as I was better able to follow what he was doing as well as appreciate his contributions in not only being a primary physician, but also being a second opinion to many people. I was also able to see that, as is often the case in medicine, there is no clear cut solution to a specific problem. One particular patient suffered from a meningioma, and though it was benign in its growth, it was located near the speech center in her brain and would begin to affect its function if allowed to continue. The tumor had begun to respond to therapies, but due to its location within the brain, operation and removal were decided to be the last options. As this was one of a series of follow ups on the therapy, Dr. Boockvar remained optimistic about the treatment.

Following this, I was able to continue my clinical hours and see a more practical side of medicine, one that I see the nurses more so than doctors participating in. If anything became more obvious from my time within the hospital thus far, it’s the tedium of the day to day operations and the fact that the professionals there must want to actually help people. Their dedication towards good work and professionalism certainly makes the health field viable. 

Week 7 - Amanda

This last week was bitter-sweet. Even though I'm excited to leave the city (so many people, everywhere, all the time!) and get back to my normal research, it's a little sad leaving this opportunity behind. I made the most of it this last week, trying to work surgeries into my research. On Tuesday I went to a cardiothoracic surgery where the patient needed a mitral valve repair. Open heart surgery was particularly interesting to me, and I had been hoping to see the procedure this summer. In high school, my biology teacher had his class watch a recorded video on open heart surgery. Back then, I was afraid of blood and had to tell the teacher to keep an eye on my to make sure I didn't pass out. I managed to watch half of it (with frequent looking-away), but I didn't pass out. Seven years later, I was curious to see if this particular surgery bothered me. I can happily report that I was fine. In fact, I put on a face mask and stood next to the anesthesiologist by the patient's head, discussing and pointing out heart anatomy on the exposed heart while we waited for the surgeon to come from another surgery. The procedure itself was very fast. Once the surgeon appeared, he had the heart stopped with the patient on cardiopulmonary bypass and the heart opened within minutes of entering the room. He quickly assessed the mitral valve damage, and decided it could be repaired instead of replaced (which is ideal for the patient). In this case, the valve was prolapsed and ruptured, which means the main leaflet went past the normal stopping point, allowing blood from the left ventricle to shoot back into the left atrium. The surgeon sewed a biocompatible metal ring around the valve annulus, mechanically prohibiting the leaflet from going past the optimum stopping point. The surgeon sewed the heart back up, shocked it to get it beating again, and then made sure the valve was working (via doppler ultrasound) and the patient off bypass before leaving the room.

Although I thought watching open heart surgery, practically looking over the surgeon's shoulder, was great, I got an even better opportunity a few days later. I had set up a meeting with Dr. Scherr, a urologist that I'll be collaborating with for a new research project in my lab. I will be working with rat models of prostate cancer, developing instrumentation to optically detect nerves during a prostatectomy to aid the surgeon in avoiding nerve damage. However, I'm new to the field, so I asked him if he was doing any procedures that day that might help me understand the prostatectomy surgery. That afternoon he was performing one of these surgeries, so he invited me along. Dr. Scherr was one of the first surgeons to use the daVinci surgical system for minimally invasive procedures, which is ideal for a prostatectomy. All of the operating room staff were more than happy to explain the whole procedure as it progressed. They began by putting the patient under anesthesia, strapping him down, and tipping the bed so his head is much lower than the rest of his body, allowing the intestines and other organs to slide closer to the diaphragm and leaving room in the pelvic area for the surgery. They cut several small holes in the lower abdomen, placed about 5" apart, and slid cannulas in that served as ports for the daVinci instruments. They then wheeled the multi-armed robot over to the patient, and placed the tools on the arms, and guided the arms into the cannulas. This operating room had two control consoles for student teaching. The first part of the surgery consisted of clearing away the fat and tissue to expose the prostate, which was apparently easy enough for one of the newer residents to perform on his own. I sat in the other console, and had an opportunity to see the 3D display that allows the surgeon to gauge depth. It was incredible seeing exactly what the surgeon sees. I was surprised by the textures of the tissue, and noticed that some tissue could be cleared by "scooping" or swiping with a scalpel rather than direct cutting (mostly fat). I was very unfamiliar with the anatomy, as they kept on referring to small muscle groups in the pelvis and other landmarks that were relatively obscure/specialized, but I was able to understand most of the procedure. I'm excited to relate this surgery to the surgeries I'll be performing in rat models. Hopefully this will ground my research in an actual clinical basis.

Week 5 - Amanda

This week was primarily devoted to my research project. To test the hypothesis that scan position and level of hydration affects vein size in MRI patient images, I needed to scan several volunteers before the summer's end. The week before I learned how to operate the MRI scanners with Dr. Prince's help, and scanned a dehydrated volunteer and volunteered myself to be scanned. I wanted to experience the same level of dehydration and what it was like to be scanned in an MRI machine before I asked several volunteers to do the same. That was a wise choice, because then I was able to accurately describe the experience to my volunteers beforehand so they wouldn't be surprised or nervous by the new experience. This week was spent scanning volunteers in the clinic at night, after all the patients are done for the day and the scanners are available.

I've found my research on human subjects quite eye-opening. My thesis research is mostly focused on instrumentation and animal models of diseases, so the whole research "flavor" is quite different than the research I've done here. With my laser imaging experiments, I can loosely plan my experiment, try it, take notes on what worked and what didn't, and then try it again. However, with my human volunteers the goal is to optimize the experimental design as much as possible beforehand so that by the time they're involved, most of the details are taken care of and I can get them quickly through the experimental process. The last thing I want to do is miss something during the experiment and have to bring a volunteer back in to repeat a scan.

For me, it's been a fun challenge to learn how to proficiently use the MRI machine while simultaneously developing a professional bedside manner with the volunteers during the experiments. If my future research or career involves clinical device testing or interaction with human subjects, I imagine this experience will help me make that transition much quicker and I will know what to expect.

Week 6 - Amanda

After a week devoted to my research project, I spent this week on clinical rounds and seeing surgeries. I chose to go to the Medical ICU (MICU). None of the other immersion students had attended their rounds before, so I decided to be the first and was quite surprised by it. I rounded with Dr. Berlin, the attending physician. I had seen him weeks before in the ER, as he became the physician responsible for the older lady with pneumonia who came in unresponsive. There were several young residents on the rounding team, and Dr. Berlin was quite actively teaching them how to think like ICU doctors. Whenever the residents gave Dr. Berlin a "textbook" answer, he challenged them to look beyond the "right" answer, and to base most of their decisions on clinical symptoms. For example, if the patient appears to be doing better on the current treatment plan, perhaps it's a good idea to continue that treatment, rather than chasing down every possible symptom and potential pathology the patient might have. I found this viewpoint rather unique to the ICU, since their main goal is to get the patient out of their department. They focus on the immediate symptoms, and not necessarily the longterm health of the patient.

While many of the MICU cases were interesting, an interesting ethical questions came up during the rounds. A patient came in with serious metastatic cancer. He was in his late eighties, and had metastatic masses spread throughout his brain and multiple organs. He went into heart failure in the hospital department that he was receiving treatment in, and a doctor managed to revive him after extensive measures. During rounds, Dr. Berlin was very frank with his residents and voiced his opinion, which I'll try to summarize:

 According to him (and it was quite obvious from the patient's report), the patient was dying. Everyone reaches that point eventually where systems begin to fail, whether from cancer, cardiovascular disease, or just old age. Dr. Berlin was upset (for the sake of the family and the patient) that the attending doctor had revived the patient, but even more-so that procedures were still being performed on him. At what point do you decide that enough intervention has been performed? Imagine that you're a part of the patient's family, and a doctor comes to you and says, "He's in serious shape, but we'd like to try a few things. We can do an MRI to see how the cancer is progressing. We can also try to give him _____, a drug that will maybe improve _____. We can also try ____ procedure to see if we can fix _____." As a family member, what are you going to say? "No, let's not do a procedure that might save my family member's life?" By the doctor offering all these procedures, it gives the family hope that something can still be done, and they feel obligated to accept. You can perform procedure after procedure, but at a certain point, there's not much you can do. It's really the duty of the physician to realize when it's time to stop, and to tell the family that it's over. Spend the rest of the time making the patient comfortable, not doing useless procedures to treat symptoms.

For me, this was a point of realization. This was a responsibility that a doctor carries that I had never considered. How many doctors are recommending procedure after procedure, getting carried away by the details of the patient's care? I believe a responsible doctor would fully inform the patient's family of the big picture - what organ systems are failing, etc, etc - and put the procedures they're suggesting into perspective (this procedure may not help much. It may be better to just make the patient comfortable at this point). However, the ultimate choice lies with the patient and their family.

Week 7 - Julie

My immersion experience came to an end with a big cardiac week! I got to see different rounds, finish up my research project, and see a cardiac surgery. I attended rounds this week for the adult medical ICU (MICU), the cardiac ICU (CICU) and the cardiac critical care unit (CCU). It was interesting to see how similar the MICU and CICU were in terms of how they monitor patients. MICU receives all different types of diseases and medical conditions, most of whom are complex cases involving respiratory, hemodynamic and metabolism disorders. The CICU receives just as complex patients, but who have also just undergone heart surgery. They both still monitored ins and outs, urine analysis, cognitive function, and other basic stats on the patients whether they were a respiratory or cardiac case. I realized that this is very important not only for easy cross-talk between departments, but is necessary to understand the whole patient, and not just focus in on the main ailment. I also learned about the post-death procedures for the staff, such as the paper work, registering the death, a minute to minute dictation of the death, and deciding about autopsy and organ donation.

In the CCU, I learned about the different medications and regiments for post-cardiac arrest or cardiac failure patients. I learned about reading ultrasound, chest x-rays and EKG’s to determine the exact heart disease. It was good to see how much attention they pay to each patient, and that they stay in that critical care for a week after a serious heart condition. I learned that the heart failure team is its own division and is called in as a consult around the hospital. It was good to see the interplay between them and the CCU team and bounce ideas off of each other. I also got to see the patient who came in this Saturday with a heart attack, and who I followed through his stent placement. It was reassuring to see him doing well and being discharged after having no major incidents all week!

My summer research project came to a conclusion this week. I microtomed my samples, and stained them with H&E. Then I imaged them with light microscopy and compiled the photos. I quantitatively compared my samples versus the standard procedure in the lab. I wanted to know if seeding vascular cells in the bulk of the collagen would lead to the cells lining the lumen of our microvessel setup. This was compared to cells which were injected directly into the lumen, which a longer procedure and we were hoping to find a different and quicker technique. After quantitative analysis I determined that injecting the cells is best at obtaining cells lining them lumen. Therefore, although my technique is quicker, for now they will have to stay with injecting the cells directly. I began writing up my poster presentation of this research data and completed my HHMI fellowship grant, which is a step towards a collaboration between my lab in Ithaca and Dr. Spector’s lab here in NYC.

The cardiac surgery was very exciting to see because they have to stop the patient’s heart and then start it again, which is unreal. The surgery I observed was a mitral valve repair, because there was regurgitation of blood through this heart valve. I was able to see the real-time ultrasound that they take of the heart through the esophagus to visualize the regurgitation and decide on a repair strategy. Since there was a lag time between when the patient was ready and when the surgeon came in, the residents took the time to show me the anatomy of the heart and explain the procedure. We also learned about the function of the heart lung machine, and the anesthesiology monitoring systems. When the surgeon came, they threw what looked like an ice-slushy onto the heart to stop it, and immediately it shrunk down and stopped beating. This was a tense time since the patient’s life was being controlled not only by anesthesia, but also by the heart-lung machine technicians. They sewed in a ring above the valve to prevent regurgitation and I saw after the surgery the improvement using ultrasound. To start the heart again they perfused warm fluids through the heart and turned up the room temperature, and all at once the myocardiocytes began pulsing. It was really amazing to see the complexity of the surgery and how well the patient was able to survive through it.

My immersion experience has been really great, and is definitely something I will remember for the rest of my life. I feel much more connected to the health-care system in our country. I think this experience will help me approach my research in a more clinical aspect after seeing how necessary my work in atherosclerosis is, and how it could be helping patients right now.

Week 7 - Marie

This week was very exciting surgically: I was able to watch cardiothoracic surgery on Monday and gynecologic oncology surgery on Thursday. It's hard to believe these seven weeks are over, but I'm excited by everything I've seen and learned and have renewed motivation for my work in Ithaca.

Each of us had the opportunity to watch cardiothoracic surgery this week with Dr. Girardi. While this was the first "major" surgery I watch, I found it remarkably calm and uneventful. I saw a 70-year old man undergo a triple bypass, with veins for grafts taken from his upper right leg and mammary vein. It was difficult to see the procedure, as the opening is not that large and many people are actively working at the same time. However, for a portion of the surgery I was able to stand at the head of the patient (where the anesthesia team is) and from there I was able to see the last graft attached and the heart restarted. It was definitely one of the more inspiring things I saw this summer.

This week I again watched gynecologic oncology surgeries with Dr. Gupta. On Thursday I saw two surgeries for pelvic masses of unknown origins. The first patient, a woman in her 50s, was a patient I had previously seen in the office for her initial visit. This was great for me, as I was familiar with her history and the motivation behind her surgery. She was on hormone replacement therapy, and as a precaution, her general physician ordered a sonogram, which showed an ovarian/abdominal mass. As a result, she had an MRI which confirmed those findings, and was referred to Dr. Gupta. Her surgery began laparoscopically to remove the mass/her ovaries and fallopian tubes, determine whether it was malignant, and remove any other necessary tissues (uterus, appendix, colon, etc.) Inter-operative pathology confirmed that the mass was benign; however, her internal organs had a lot of adhesions, making it impossible for the surgery to continue laparoscopically. Consequently, she was opened up, which allowed the full abdominal cavity to be visualized.

The second pelvic mass removal surgery I saw was an older woman with a large (bocce ball-sized) mass, which was removed via laparotomy. Inter-operative pathology was performed on the frozen mass, which revealed that the mass was benign. I went with the sample up to pathology, which was interesting to see how a more "scientific" technique (pathology) affects active clinical/surgical practice. As the mass was benign, she did not need to have anything else removed, and was subsequently closed up.

Both of these patients were very fortunate to not have ovarian cancer, as it has very poor outcomes (5-year survival of <50%). It was very illuminating for me to realize that both of these women only learned of large abdominal masses through incidental imaging--underscoring the lack of early detection modalities for ovarian cancer. I'm looking forward to working with Dr. Gupta developing new ways of detecting ovarian cancer earlier, and as a result of this immersion term I have a much better understanding of the challenges associated with that goal.

Week 7-Jonathan

My mentor Dr. Bostrom was out of town most of this week. I spent one day in the OR observing him and one day in the OR observing Dr. Jerabeck. As I have mentioned in previous posts, Dr. Jerabeck utilizes robotic-assistant devices in his joint replacement surgeries. The goal of these devices is to ensure that the knee or hip implants are positioned in proper alignment. For proper alignment, the bone and cartilege in the original joint space needs to be cut away as perfect as possible. The robotic device ensures that you cut away the bone correctly and that your positioning of the implants are also correct.

I also spent time this week working on my final report for the summer immersion term. My summer research project was to investigate the literature for clinical studies about cementless fixation of knee replacements. Cementless knee replacements typically have higher revision rates than their cemented counterparts and are used much less frequently; however, in small comparative studies and in radiosteriographic studies, cementless knee replacements perform comparatively to cemented knees. New design components such as hydroxyapatite and trabecular metal coatings may improve clinical outcomes of cementless knee replacements to the point that they are more widely used.

I also gave a presentation to Dr. Bostrom's lab on Tuesday in which I showed them the imaging modality developed and used in my lab in Ithaca. Dr. Bostrom's lab is investigating changes in bone formation around a titanium implant following treatment with PTH (a bone growth agent used to treat osteoporosis). Our lab is able to perform high resolution 3D bone formation analyses and may be able to contribute to their upcoming study. They seemed very interested in my presentation and hopefully we can establish a collaboration with their lab.

Weeks 5 and 6- Jean C. Cruz

During the fifth and sixth weeks, as well as continuing to assist in different surgeries, we designed and started our summer project.

       During the fourth week I stopped shadowing Dr. Pua, who has been my principal mentor in respect to surgeries.  However I have contacted various doctors and professors who work in areas that are more similar and significant in respect to my thesis.  Among those doctors I would like to mention Dr. Chiang and Dr. Raj, both interested in the disease progression of Alzheimer.

     Once we have discussed our interests and knowledge in the areas, we have designed two experiments to complete during the following three weeks.  With Dr. Chiang we will be analyzing MRI and PET scan images of Alzheimer patients and determining the correlations between diverse factors that contribute to Alzheimer.  On the other hand, with Dr. Raj we will be designing a new biochemical diagram which will present all the proteins involved in the transportation of AB-plaques that will then be collaborated with different mathematical model through graph-theory algorithm.

        After realizing certain progression in both projects, I have opted to focus on the imaging analysis project during the fifth week.  We have started by analyzing

native-space MRI scan for each subject to define regions of interest, PET scans with flobetapir to label the AB-plaques in our regions of interest and have used the alterial spin labeling (ASL) in our MRI scan to measure the brain blood flow (BBF) in our patients. In addition we have been using the ADNI data base, which have certain extra information for every patient (inflammation biomarkers in the CSF, educational background, APOE and APP genetic info, etc.)  

Weeks 3 and 4- Jean C. Cruz

During the third and fourth week, in addition to starting to plan what will be my summer intern project, I have continued participating in diverse interventions and shadowing doctors in different departments.

      During the third week, I had the opportunity to shadow Dr. Howell in the emergency department.  I personally did not find it to be an exciting experience since during my time in the emergency department the cases attended were simple, less severe, and a bit repetitive.  However, one of the patients arrived with severe abdominal pain and bleeding.  This patient had undergone a sterilization operation to stop the bleeding, but the problem continued. After certain analysis, the patient was diagnosed with uterine fibroids and was transferred to radiology the next day. Once in the interventional radiology department, Dr. Schiffman was responsible of performing the uterus fiber embolization. 

What is UFE (uterine artery embolization)?

     It is an angiographic procedure used by interventional radiologist to embolize (block) the blood supply to the uterus. By limiting blood supply to the uterus, the fibroid will shrink and its symptoms subside, Figure 1.

Figure 1. Uterine artery embolization procedure

     Furthermore, I spent the fourth week shadowing Dr. Bishop in the Pediatric intensive care unit (PICU).  During our time together, we monitored the healing process of different patients that had undergone cardiac surgeries.  In addition to shadowing DR. Bishop, I had the opportunity to return to the interventional radiology and shadow Dr. Sista who was performing various installations and removals of inferior vena cava (IVC) filters.  An inferior vena cava filter (IVC filter) is a type of vascular filter, a medical device that is implanted by interventional radiologist or vascular surgeons into the inferior vena cava to presumably prevent life-threatening pulmonary emboli, Figure 2.  Also, Dr. Sista executed various thrombolysis and balloon angioplasty. 

Figure 2. Inferior vena cava filter