Friday, July 07, 2006

2nd week course report

07/03/2006 Monday
•This morning, first we come to the M014 to see the patients. Dr Kent( the chief of vascular surgery) is there, actually he is in charge of clinical room today. Dr K just came to help him to check some patients. He checked one patient who lost his right leg. The wound recovered well and it is supposed to be healed in 2 weeks. Then a patient speaking Spanish visited. A young girl helped her to communicate with Dr K. Normally a translator is needed for such a case.

Today a new fellow started her study at Hospital. Dr K told me that normally there are 4 fellow at Cornell and Columbia medical school, each place has two. After 6 month, they will exchange. So the Dr Russell Lam moved to Columbia today.

At 11 am, Dr K gave a presentation about DVT( deep Vein Thrombosis) at the Uris Auditorium. Two baseball superstars (Paul Blair and Phil Niekro) came to share their the experience about DVT. Blair's song died of DVT at 29. Niekro suggested that everyone should be sreious of DVT and hospital should offer the normal check for DVT. Dr K introduced the DVT and some simple knowledge about DVT that could be easily understood by the public.

For more information about DVT, please visit Here I also posted some information related to DVT.
What is DVT?
Deep Vein Thrombosis is a condition resulting from the formation of a blood clot thrombus inside a deep vein, commonly located in the calf or thigh. DVT occurs when the blood clot either partially or completely blocks the flow of blood in the vein.

See How DVT Occurs
Deep veins are surrounded by powerful muscles that contract to help bring blood back to the heart. The quick and efficient return of blood to the heart using these muscles is an essential part of the circulatory process.
When the rhythm of circulation of the blood slows down due to illness, injury, or immobility, there is a tendency for blood to accumulate or "pool." A static pool of blood offers an ideal environment for clot formation and poses a potential risk for DVT

This afternoon, I observed a DVT surgery, due to the shortage of the clothes preventing X-ray irradiation, I wait outside for a while. It seems that a lot of the OR rooms in the 3rd floor have X-ray instrument. The following is a piture of the Angio machine(SIEMENS AXIOM -ARTIS)
After getting into the room, a balloon was first applied, from the x-ray image, we could find that the blood could flow in the target vessel after the treatment of balloon, however, the vessel is not wide as the normal vessel. Dr K told me that if the stent should be used in this case.
Then a stent was delivered and expanded to the place, the fellow did not do it well and finally Dr K finished it by himself. Normally, the attending surgeons would supervise the fellow/resident and operate by themselves when some difficulties met.

The patient is an old Russian Lady, around 85. She could not communicate with the doctors and nurses. She only knows Russian. During the operation, it seemed that she felt pain and try to move her arms and legs, which brought trouble to the doctors. Finally we found a doctor who could speak Russian to make her calm down. Some drugs were injected to help her relieve from the pain.

Now let's have good holiday

BTW, my food was stolen in 9th floor last weekend, everyone should be careful of their food

07/05/2006 Wensday

Today I watched 2 vascular surgery at OR10.
The 1st one is for blood clots cleaning.At the beginning, the X-ray showed that the blood could not pass the vessel. A balloon was delivered and expanded. After the balloon was removed, they found a lot clots are still in the vessel. Then a wire with special top( like a brush) was used to clean the blood clots, the cleaning repeated several times. After that, the X-ray image showed that the blood could come through the vessel again.

For second patient, she was implanted with a stent one year ago, now her stent was covered abnormal tissue and serverly blocked the blood flow, this is the second time after her surgery. From the X-ray image, we could see that the stent was composed by 3 short stents and small indentation could be observed.
A new set was applied, at the end of guide wire, there is a special set like a cutter, it could cut the tissue, then compress it and store it, after the wire was taken from the body, the tissue could be cleaned. The fibrous tissue looks like yellow/white.
This new cleaning precedure was repeated for around 8 times. Dr K and the fellow was the first time to use this set. A nurse who has used it before stood beside and explain some detail to them. Anyway, it's not hard to learn it.

Afternoon, after the second surgery, Dr K asked me whether I want to watch a amputation surgery, I told him that I wanted to watch at that time. The patient, an old man, could not let the blood flow through the vessel of the leg.(I could not remember it's right or left leg.) Before the surgery got started, his two daughters, come into the room to visit him and try to encourage him, however, one daughter could not control her feeling and burst into tears. Their tearful feeling made me very sad. The fellow doctor said” it’s really a disaster”. Dr K left and he will not supervise this operation. Finally I left because I do not want to see the disaster. At that time, I felt the importance of tissue engineering, the patients need it so that they could have the chance to live as a normal person, without any disability.

In the first week, I saw two patients came to visit Dr K to have a check after amputation. They looked normal. So I believe that this patient would be face it and live with a positive attitude.

07/06/2006 Thursday

Dr K met me in the office and we discussed the clinical research project.
We are interested in the stent fracture and the stent with drugs for the vessel in the lower extremity. For the stent fracture, it happens frequently and it brings big trouble to the patients. So we want to know what caused the fracture and how could we precisely detect the fracture. For cornary artery, the stent coated with drugs has been proved to be with great success. However, the lower extremity vessel, auch as SFA( superficial fermoral artery), the clinical results showed not difference compared to the bare stent.

07/07/2006 Friday

This morning, Dr K did his clinical examination in the M014 (two days per week, normally Tuesday and Friday) We watched around 14 patients in the morning and early afternoon.

From 2 pm, Dr K operated two EVLT procedure for an old lady and middle age lady.

What is EVLT, EVLT by Diomed is the leading laser treatment for varicose veins. It is the first choice of when it comes to a minimally invasive alternative to painful surgery.
The EVLT procedure is simple and effective. It takes less than an hour in a doctor’s office to eliminate varicose veins and get patients back to their everyday activities right away. With a success rate of up to 98% and minimal side effects, EVLT is the new gold standard in varicose vein treatment.

The ELVeS™ Procedure

1, Drape and prepare the patient
2, Administer local anesthesia to the treatment site.
3, Create a small incision through the skin behind the knee and into the vein, using ultrasound guidance.
4, Insert catheter into greater saphenous vein.
5, Insert laser fiber, using ultrasound guidance and the laser’s aiming beam.
6, ELVeS™ laser treatment: Emit laser light to seal the vein while slowly withdrawing fiber.
7,Check with ultrasound to determine success of the procedure.

EP are you with me?

As this is my first post, let me first introduce myself. My name is Uche Kanu. Thats about all you need to know about me. In fact, I will refrain from mentioning anything more about my peronal self in this particular blog. Why you ask? Well, for starters thats not the point of this blog. Maybe if I want the world to know about me I'll start a personal blog. But from here on out, its all EP (electrophysiology) related. Ok good, now that we have the introductions out of the way...

As you all know by now, all 1st year PhD students in Biomedical Engineering (and a few others) embarked on a 6 week odyssey into the bowels of the clinical world at the internationally-renown Weill Cornell Medical Hospital. We each have clinical mentors that were kind enough to show us a glimmer of what they do. My chosen area was Electophysiology and Dr. Kenneth Stein (Cardiac Electrophysiologist, Associate Professor of Medicine at the Weill Medical Center of Cornell University and Associate Director of Clinical Cardiac Electrophysiology at The New York Presbyterian Hospital – Weill Cornell Medical Center) was gracious enough to take me under his guidance for these precious few weeks. I must admit, I was not fully prepared for what I was about to experience just moments after I had met Dr. Stein for the first time. Shortly after taking a brief tour of the Cardiology unit of the Hospital, I was standing an arms length away from a patient undergoing an ICD (implantable cardioverter defibrillator) replacement. Here I was, thinking I was going to be slowly 'immersed' into the flow of things, standing basically on top of a patient undergoing a rather intricate and serious medical operation that could potentially safe this persons life. Just amazing really. Oh, and by the way, by the time the day was out, I also was able to witness a pacemaker implantation. I quickly reassessed my expectations, and realized how lucky I was to be taking part in this BME immersion experience.

So you may be now asking yourself, 'well, what goes on during a typical ICD or pacemaker procedure?' Well, if you would be patient for a little bit longer, I was just about to give a basic overview... :) (just kidding). Without going into too much detail (both because there isn't enough blog space / I really don't know that much) both procedures start basically the same. A small pocket of space is created in the left or right upper chest area, under the skin and muscle, where the device (about the size of PDA) will reside. The ICD is a little bit bigger, but both are relatively small. As this is my first post, I'll keep the details of the underlying cardiac electrophysiology for a later time. For now, I'll just say that the mechanical function of the heart is directly dependent upon the propagation of electric impulses that spontaneously originate in a special area of the heart (thats the SA node for all you uber-nerds/trivia wizards). Abnormalities with the electrical propagation can thus cause abnormalities with heart function, and bluntly put, its a bit harder to operate on a day to day basis with a messed up heart. Unfortunately, problems with the electrical origination and propagation are common. Fortunately, there are some extremely clever people that devised ways to treat these ailments, and there exist some very talented doctors capable of implementing these solutions.

Pacemakers aim to take over the function of the SA node, causing the heart to beat at a new cycle length, and ICDs can do a little bit more including the capability to deliver a massive 'shock' to the heart in the presence of very erratic electrical activity, causing a potentially lethal scenario to revert back to a normal 'thump-thump, thump-thump' of the heart. Whew, even my so called brief overview took up a few lines. After creating the incision, but well before the implantation of the device, a series of catheters, capable of both recording and stimulation electrical activity, are inserted through a nearby vein (at the moment I don't know which one, my bad) into various positions of the heart. A series of pacing protocols are initiated to fully probe and understand the functionality of the particular heart. Often times many other tests not particularly necessary to the particular procedure are done. As a fellow doctor told me "It's like taking a car to the shop and having a new battery put in. Since the mechanic already has the hood of the car open he/she is going to test the engine, the oil, and a bunch of other stuff to make sure these other things are in working order as well" (not a direct quote, by the point of the quote I hope was clear). After the doctor is satisfied, the actual device is hooked up and additional tests are run to ensure everything is in working order. These devices are fully programmable, and the doctor will take time in order to change all the settings to best fit the patient. Then the Doc sews the patient back up, and everything is hunky-dory, easy huh....well, there's a whole lot more...

But you know what, I have already rambled on for quite some time. Even though I have sooooo many wonderful things to say, and even though I am soooooo good at writing captivating and fun blogs that readers simply cannot stop reading, I think I will stop for now just to let all that I have said really set-in. No really, go now and reflect on what I just told you all...its really genius if you think of it. Ok, I've gone mad, I know...its Friday so maybe now I will explore the great city that is New York...maybe meet some people crazier than myself!!! (I really don't like calling people crazy though, its dismissive in a way) Anyways, stay tuned for a more detailed and comprehensive account about EP. And for whomever understood the reference that is the title of this lovely little piece...kudos. And for those that want a face to go with the blog...looking at the first group picture posted by Jan, I'm the one in the first row on the leftmost side with the big head and blue shirt. And for those who want me to stop talking, I will.

Today I looked at the x-rays and CT images for the shoulder implant I'm working on for Dr Wright. I'm still very excited about a reverse shoulder since it makes so much sense to me as an engineer. The radiology file had x-rays from 1982 when the patient fractured her proximal humerus, as well as CT scans from 1987 and 2004. It will be interesting to learn more about CT and x-rays since improvement over the years was apparent. In the post-operative x-rays of this year, the new joint seemed to have depth, instead of a blinding white spot.
Yesterday I was introduced to a study being done by a surgeon here to develop a new surgical technique. It's part of a pilot study being done with cadavers to hopefully persuade a company to finance a larger scale study. They used fluoroscopy to check their work, which is a low intensity, portable x-ray machine for use during surgery.
Last week at one of the rounds, I saw a presentation on the uses of the Ilizarov frame, which is used often in bone lengthening procedures. Since then, I've heard it mentioned several times, including at physical therapy where a patient had one, and pediatrics rounds. It's also called a Taylor Frame. It is used to correct lenght changes, angle changes, soft tissue problems, and problem fractures.

Clinical side of life

So after a week of running around HSS trying to brake our way through the bureaucracy, I finally got to experience the clinical fun most of my classmates have already been enjoying. Not that I didn't enjoy my blood test, PPD test, and extra introductions and quizzes, but I am glad to finally be off and running. I am working with Dr. Hollis Potter who specialized in MRI of the musculoskeletal system. So far it has been an exciting experience as I have watched the morning readings of the MRI and have been quizzed by both Dr. Potter and the fellows on anatomy and MRI basics. For a short explanation of MRI refer to Evans July 6, 2006 post "Week #1: What is conrast-enhanced MRA". He has some helpful links and a short blurb on MRI.

Dr. Potter spends her mornings reading the MRI images for patients, which is quite impressive. She looks at the images and within seconds sees the patients problem. I guess this is to be expected from the #1 doctor in America on muskuloskelatal MRI. While reading these images she is also teaching her fellows quizzing them on the anatomy and MRI principles. She has taken her time to teach some basic principles of MRI as well. I also spent some time with her 11 month fellow Dr. Sebastian Fong who began to teach me the anatomy of the hip and shoulder. He loves to ask questions and quiz me which is exciting as I learn the anatomy of these joints. I already feel I have learned quite a bit. I now know what muscles make up the rotator cuff (teres major, infraspinatus, supraspinatus, and subscapulus), the location of the rotator interval inbetween the supraspinatus and subscapulus where the bicep passes through, the lateral placement of the fibula in the knee, and many other new pieces of knowledge about anatomy. I have picked up small bits of anatomy in my research but it has been very limited since I have never taken a dedicated course. So far I have been able to grasp quite a bit of anatomy and obtain a more complete understanding of the main orthopedic joints.

In addition to just learning about the anatomy, I have learned how to pick out many of these structures in MRI images and begin to see how the pathology is diagnosed. I now know that you start by looking at the fat suppressed images to look for edema in the joints before continuing on to the other images. The most exciting experience was when they put up a knee on Thursday and Dr. Potter had to step out of the room. I took the time to examine the MRI and was able to recognize that the ACL looked abnormal. I was excited to see if that was true and when Dr. Potter came back in and examined the MRI's she called it. Of course no one asked me but I was patting myself on the back in my head. I have already learned a ton in just two days with Dr. Potter and am excited to learn more.

In addition to the time with Dr. Potter, Dr. Wright has assigned a case study on an explanted hip implant. I requested the medical records yesterday and should be receiving them today. On Monday and Tuesday I will have the pleasure of entering the OR and will report on that next week. So stay tuned.

July 4th 1st 2006, who said engineers don't have fun?

So we all know that all work and no play makes jack (or in this case Grad students) a dull boy. I was hoping that someone would post some July 4th pictures to show the world we do more than just work. Unfortunately I was busy "working" July 4th so I wasn't able to take any pictures of the Macy's Fireworks in NYC. Thankfully on Long Island they do fireworks over the weekend and I was able to snap some pics of a private firework show just off the North Shore by Grucci, a Long Island based fireworks manufacturer.

Enjoy the pictures and have a Happy Independence Day!

Thursday, July 06, 2006

Week #1: What is Contrast-Enhanced MRA?

This is my report for the first of six weeks in the Cornell Weill Medical College Summer Immersion program. My advisor, Dr. Prince, has a dual appointment at Cornell University and Columbia University and is also the Chief of MRI at New York Hospital. Possibly his most noticeable contribution to science and the medical field is the development of contrast-enhanced Magnetic Resonance Angiography (MRA), which will be the subject of my post.

It would be very time consuming to first introduce Magnetic Resonance Imaging (MRI) and then explain contrast-enhanced MRA so I'll leave that to the experts.
If the sites above aren't enough to explain MRI then you'd be better off with a book on MRI. I would suggest Dr. Prince's book due out in August 2006 (MRI From Picture to Proton). It may be a little expensive but it is by far the best reference on MRI and is the equivalent to the Dummy's Guide series of books.

Abbreviated Introduction to MRI
MRI as you should know by now stands for Magnetic Resonance Imaging. Now you might be asking yourself what magnetic resonance is and how can it be imaged. Lets break down the word MR: Resonance is a condition in which the frequency of an external force matches the natural frequency of the object it is acting upon and Magnetic refers to the presence of a magnetic field which induces the resonance. You might need to brush up on some E&M Physics to fully understand the concept of resonance. This magnetic resonance applies to certain atomic nuclei in your body such as 1H and 13C. For more information on nuclear magnetic resonance read this.

Nuclei that exhibit magnetic resonance are often referred to as nuclear spins and are normally oriented randomly. When these nuclei are placed in a strong magnetic field, they align with the applied field in their equilibrium state. The image below is a good example of this.

The MRI machine is a giant magnet that causes all of the 1H nuclei in your body to align along the applied field. Essentially, an image is acquired by applying a slightly different and smaller magnetic field to your nuclei that perturbs the alignment and determining how long it takes the nuclei to relax back to their original magnetization along B0. Of course there are many variations on this principle that allow for the large array of different images that can be taken in MRI machine.

Contrast-Enhanced MRA
MRA or Magnetic Resonance Angiography is a specific method of MRI that is utilized for imaging blood vessels. MRA is very useful for diagnosing problems with a patient's circulation, in particular vessel stenosis and/or aneurysm. This is an example of an MRA:

(Image taken from Wikipedia)

MRA is generally used to evaluate arteries in neck/brain, the thoracic and abdominal aorta, the renal arteries, and the legs (also referred to as run-off). A majority of the cases that I have seen in my first week have been patients with stenoses of the renal arteries and multiple stenoses of arteries in the leg (internal/external iliac, superficial femoral artery (SFA), popliteal, anterior tibial, peroneal, etc.) Problems with the vasculature are enhanced by Contrast-Enhanced MRA, which uses a contrast agent that accentuates the blood vessels - in particular the arteries - because of the paramagnetism of the contrast agent.

The most common and widely used contrast agent is Gadolinium (Gd); a rare earth element in the transition group IIIb of the periodic table. Gadolinium is abundant throughout the Earth's crust making it widely available but not necessarily cheap. The electron shell structure (eight unpaired electrons in the outermost shell) of Gd is what imparts its special paramagnetic properties. The paramagnetism of Gd in the body enhances the signal and thus intensity of the image depending where it is found in the body.

T1, the time it takes for longitudinal relaxation of the nuclear spin to return to equilibrium is affected by Gd as predicted by the following equation:

1/T1 = 1/1200 + (R1 * [Gd]) Eq. 1

R1 is the T1 value for the Gadolinium chelate, [Gd] is the concentration of gadolinium in the blood, and 1200 is the T1 value for blood (in msec) without gadolinium. Gadolinium by itself is toxic and can cause heavy metal poisoning, but is safe for use in humans when bound to a chelator. The chelator does not affect the paramagnetism of gadlinium.

Contrast-Enhanced MRA uses a small (30-60 mL) bolus injection of Gd which is then followed by acquiring a series of images that track the flow of Gd through the body. The technician operating the machine will acquire a series of images at different times in the same location. This allows for a time-lapsed movie of the contrast agent flowing through the vasculature. However, timing of images and location is vital to ensuring that adequate detail is obtained from the Contrast MRA. For more information on contrast-enhanced MRA read this article. A sample of a MRA that has been imaged over time to show the change is contrast in the arteries can be found here.

One of the aspects of contrast-enhanced imaging is in some procedures the patient is required to hold their breath in order to reduce motion artifacts in subsequent images. The biggest problem with breath-holding is that the process of inhale-exhale-hold takes a significant amount of time that makes the scanning procedure long and uncomfortable for the patient and technician. All breath-hold imaging is done during expiration because it is easier to hold one's breath when the lungs are deflated.

The problem is that people can hold their breath longer during inspiration but the motion in images caused by holding your breath during inspiration is too great to make imaging effective. The MRI technician observes the respiratory phases through a small elastic belt located on their chest just below the xiphoid process (small cartilaginous protrusion from bottom of rib cage).

One school of thought is that if people were enabled to hold their breath for longer the imaging procedure could be sped up and time and money saved in the process. Increasing breath-holding can be accomplished several ways, the most straightforward way is to administer the patient a hyperoxic gas. Hyperoxic gas is simply air that has an excess of oxygen; typical room air has ~20% Oxygen but by increasing the O2 level to 40%, studies have shown that people can hold their breath longer than under normoxic conditions.

My project for this summer will be to design, develop, and test a device that is MR compatible and will administer hyperoxic gas to the patient. One of the biggest concerns is making the device simple enough that it can be setup in a matter of seconds.

MRA is certainly not as simple as it looks and there are a lot of variations in the procedure that I am not yet familiar with. As I learn and work on my project, I will be posting about my progress here.

Wednesday, July 05, 2006

The first week went by in a rush. I went with Robbie and Alicia to Occupational Health at Hospital for Special Surgery to complete the required physical, drug test, and blood test (titers) for employees and volunteers at that hospital. This also included an orientation packet that showed more of the business side of the hospital--wear business attire, report suggested improvements, safety, etc. HSS's policies and procedures to reduce infection have given their operating rooms one of the lowest, perhaps the lowest infection rate in the country and world.
Since one of the aims of HSS is to advance the science of orthopedic surgery, they use the IRB approval process all the time. I will get to help with a study that has exempt status, and I've started a project that has standing approval from the IRB to allow summer students to examine a failed implant as a case study.
The failed implant I have is a total shoulder replacement that was about 20 years old. The operative notes indicate that it was replaced by a reverse total shoulder replacement. This URL gives more information:
As I understand the information, the difference in using a reverse prosthetic is that the socket in a typical replacement is rather shallow, and given the wide range of shoulder motion, the tendency of the humerous to slide on the glenoid socket causes wear. In fact, traditional shoulder designs use a different, larger radius to form the socket than for the ball so that sliding can take place. The reverse prosthetic is able to align better and the powerful deltoid muscles do not promote sliding since the surfaces align with the direction of force much better.

Monday, July 03, 2006

1st Week Report
Peripheral Neuropathy Center

I am working at the Peripheral Neuropathy Center of Cornell-NYPH, basically this is a clinic where 3 doctors treat patients with different problems in the nervous system. They do research aswell if sometime is left. The main tool that they use are nerve conduction studies, electromyography, and related special studies such as neuromuscular transmission studies.
The doctor who I am working with is Dr. Sander, the director of the center.

A normal Day

All days are similar because we do the same tests over and over. We have from 4 to 6 patients coming daily and each test is about 1-2 hours long. Even the tests are the same the results varie, sometimes difficults in getting the signals may come along. Also, the muscles that we are recording from are differents depending of the problem of the patients. So I learn something new each time and the doctors can answer my questions while they are preforming the test.

Eventhought the fact that this are not complicated and apparatosus procedures as syrguryes, interpreting the obtained results could be challenging and not obvious.

A brief Summary of things that I did on the first week.

- Tour of the biomechanics laboratories at HSS. (monday)

- Getting the basics about the test that are performed on the neuropathology center through the observation of patients (tuesday, we,thursday, friday)

- Reading about collision studies, Dr. Sander is making research on this theme. (thursday, friday)

I have been working with and observing Dr. Wong, who specializes in cardiac catheterization procedures. During my first week, I spent most of my time watching Dr. Wong and others perform angiography and related procedures.

Day 1: Dr. Morin, a fellow who works with Dr. Wong, went over some basic cardiac anatomy with me, and explained how to look for vessel blockages in angiograms. His patient, an 81 year old female, came in complaining of shortness of breath. Angiography, a procedure in which a contrast enhancing dye is injected into the blood stream and observed with x-rays, revealed a blockage in the left anterior descending (LAD) artery. Intravascular ultrasound (IVUS) was used to determine the extent of the blockage. Since the blockage was greater than 70%, Dr. Wong chose to use a stent to open up the artery. The surgery was unconventional, but impressive, and succeeded in reducing the blockage.

Another patient, a 79 year old male, already had a graft and a balloon in his heart. After angiography, the doctors decided against further surgery.

Day 2: The first patient I observed on day 2 already had bypass surgery, in which a vein was moved from the leg to a very high point on the aorta. This was necessary because the vein would have two output points. The doctors decided against further surgery.

The next patient had two blocked vessels, but only one of them was blocked enough to make surgery absolutely necessary. This was confirmed with angiography and IVUS. Dr. Wong spoke to the patient and his son, and recommended fixing both vessels. The patient, however, refused the optional surgery, and the doctors only stented one vessel.

The final patient I saw had already had bypass surgery, pacemaker devices on both chambers, and grafts. The grafts were in excellent condition, and working quite well. However, the angiogram showed lesions in the native circumflex. The doctors inserted a stent, but the procedure was challenging since the vessel was highly calcified.

Day 3:
A 61 year old female had blockages in the LAD and the first diagonal of the LAD. Both were stented. During this procedure a nurse explained to me the advantages of modern cypher stents, which contain a drug that reduces clotting, preventing the need for recurring surgeries.

Day 4:
One patient had an angiogram for diagnosis, but no surgery was necessary. I spent the remainder of the day studying heart anatomy, so that I may be able to follow the procedures better.

Sunday, July 02, 2006

Course Report for the 1st Week

First I have to say that everything happened in the NYPH is very interesting. And I have no doubt that it would be a wonderful course and we could learn a lot

1st Day,Monday, 06/26/2006

At 9.00 am , Dr Wang met all of us in the lobby of Olin Hall(not the Olin Hall in Ithaca). After the short orientation, he brought us to the security department of the hospital to get the ID so that we could come into the hospital at any time.

Last friday I made the appointment with Dr Karwowski through the email. Today I arrived at P710A at 12:30pm. His secretary, Rachel( another rachel) told me that he will be back soon. Dr Karwowski met me in his office at 1:30pm. At first he was not very clear about this course, but he came to be interested and know some details of the course after my some introduction. I also gave him a copy of Dr Wang's proposal for this summer course(2005) so that he could get more ideas from it.

After the meeting, he gave me some documents about the stents, bloon and UV laster medical system for the vascular surgery so that I could understand some modern techinques applied in the vascular surgery. After that, he tried to find the scrubs for me so that I could go with him into the operation room( OR) to watch the surgery operation. But at that time, he could not find more, then he just showed me around for visiting the patients after surgery. It's the follow up after the surgery. I remembered that he gave some evaluations for a patent whose forearm was cut. Now I am still confused because his major working part is the legs and feet, not arms.

At 5pm, we are given the first lecture about bioethics by the professor(she has a very long name and I could not remember it).

At night, I read some of documents and I found the currently technique of stent is very advanced.(I would describe it in the later part, maybe next week) So clinical practice course allow the students to touch the most advanced biomedical techniques, which is one of the great importance of this course

Tuesday, 06/27/2006
Today's work is seeing patients in the examination rooms(ER, not emergencey room).( M014)
Totally there are 11 patients visited from 12:00 pm to 4.00pm. No small surgery was done in this afternoon. Sometimes the small surgery( need not X-ray) could be finished in the ER.He may do some surgery after 5pm because he told me that I could go with him to OR to watch the surgery operation. So dotcor's life is really busy and sometimes they have to work very early and leave in the night.
The follwoing is some information of the patients observed today.

Patient one is an old man. His two fingers of the foot are injured. One recovered well and would be totally fine soon; another one is still swell, in a big shape. Dr K told him that he need to be watched in future. X-ray examination is suggested.

Patient 2 is an very old lady( around 85). Her case is AAA( refer to my previous post(2nd one)). She is in great danger because the diameter of AAA is 7cm and the rupture could happen at a great chance. Open surgery(graft replacement) is suggested. However, the chance of dying is very high because of her high age. She may have the chance to lose the walking ability after surgery. So Dr K told her son the possible dangers and let him decide. A stress test is suggested before the surgery by Dr K.
The lady could undersood everything discussed by us.

Patient 3 is an old lady. Three of her foot fingers lost and the wound condition is not good. Dr K aksed the nurse to send her to the emergency room immedicately because the infection of her would is severely.

Patient 4 is an old lady. She has a SFA stent ( would be explained in future) in her leg.

I noticed that sometimes the doctor would be very busy and he could not have time to write all the patients information as record. So they would use a recorder to record the patients' information by voice.

Wendesday, 06/28/2006

For Dr K, today is surgery operation day. It seems that each attending surgeon will have the fixed OR room, several doctors share one room. Dr Karwowski's room is OR10. Today's fellow is Dr Steffney. It's her last day of fellow in NYPH. After this week, she will go to California to work as an attending doctor. It's seems that she does not like to leave. I guess that she likes everything here and Dr Karwowski taught her well. Dr Karwowski hope that she would be one of the smartest people in the world.

Thursday, 06/29/2006
Today is also for surgery operation.
Today's fellow is Dr Lam. He is a talkive fellow.

Friday, 06/30/2006

Today is to see the patients. There are 10 patients visited from 9 am to 12:00 pm.
From 2.00 pm to 4:00 pm, a surgery was operated in the clinical room.
Why not in OR? Because this operation need not X-ray machine.
Cool Laser(wave length: 810nm) system and Ultrasound machine were utilized to remove the blood clots in the patient's blood vessel in the leg.

5:00 pm we took the last bioethics course about FDA. Dr Wang had a discussion with everyone for the course progress .
Thank's Rachel for the pizza, pasta and salad.

Then it's the time to enjoy the great weekend. The follwoing is some picture of OR

By Jun

Vascular Surgery

Hello, Everyone

Now it's my 1st post for the clinical practice.

According to my 1st week's observation, the doctors in the vascular surgery division are mainly dealing with blood vessels(arteries and veins) of human body, not including the the blood vessels around the heart, whcih belongs to the cardiothoracic surgery department. And I found that the major part of the visiting patients have the problems in the part of Lower Extremity(leg anf foot). Besides the lower extermity part, some of the patients may have the disease of Aneurysm. One major example is Abdominal Aortic Aneurysm(AAA).

The follwoing information and figures about AAA are from

What is abdominal aortic aneurysm (AAA)?

The aorta is the largest artery in your body,and it carries blood away from your heart. When aorta reaches your abdomen, it is called the abdominal aorta. Just below the abdomen, the aorta splits into two branches that carry blood into each leg.
When a weak area of the abdominal aorta expands or bulges, it is called an abdominal aortic aneurysm (AAA). The pressure from blood flowing through your abdominal aorta can cause a weakened part of the aorta to bulge, much like a balloon. A normal aorta is about 1 inch (or about 2 centimeters) in diameter. However, an AAA can stretch the aorta beyond its safety margin. Aneurysms are a health risk because they can burst, or rupture. A ruptured aneurysm can cause severe internal bleeding, which can lead to shock or even death.

The leading thought is that the aneurysm may be caused by inflammation in the aorta, which may cause its wall to break down. Some researchers believe that this inflammation can be associated with atherosclerosis (also called hardening of the arteries) or risk factors that contribute to atherosclerosis, such as high blood pressure (hypertension). In atherosclerosis fatty deposits, called plaque, build up in an artery. Over time, this buildup causes the artery to narrow, stiffen and possibly weaken.Besides atherosclerosis, other factors that can increase your risk of AAA include:

Being a man older than 60 years

Having an immediate relative, such as a mother or brother, who has had AAA

Having high blood pressure

Your risk of developing AAA increases as you age. AAA is more common in men than in women.
What tests will I need?
Abdominal aortic aneurysms are most often found when a physician is performing an imaging test, such as an ultrasound, for another condition. If your physician suspects that you may have AAA, he or she may recommend one of the following tests:

Abdominal ultrasound

Computed tomography (CT) scan

Magnetic resonance imaging (MRI)
How is an abdominal aortic aneurysm treated?
Watchful waiting
Your physician may recommend "watchful waiting," which means that you will be monitored every 6 months for signs of changes in the aneurysm. Your physician may schedule you for regular CT scans or ultrasounds to watch the aneurysm. This method is usually used for aneurysms that are smaller than about 2 inches (or 5.0 or 5.5 centimeters). If you also have high blood pressure, your physician may prescribe blood pressure medication to lower your blood pressure and lower the pressure on the weakened area of the aneurysm. If you smoke, obtain help to stop smoking. An aneurysm will not "go away" by itself. It is extremely important to continue to follow up with your physician as directed because the aneurysm may enlarge to a dangerous size over time and could eventually burst.
Open Surgical aneurysm repair

A vascular surgeon may recommend that you have a surgical procedure called open aneurysm repair if your aneurysm is causing symptoms or is larger than about 2 inches (or 5.0 to 5.5 centimeters), or is enlarging under observation. During an open aneurysm repair, also known as surgical aneurysm repair, your surgeon makes an incision in your abdomen and replaces the weakened part of your aorta with a tube-like replacement called an aortic graft. This graft is made of strong man-made material, such as plastic, in the size and shape of the healthy aorta. The strong tube takes the place of the weakened section in your aorta and allows your blood to pass easily through it. Following the surgery, you may stay in the hospital for 5 to 10 days. You may also require 2 to 3 months for a complete recovery. More than 90 percent of open aneurysm repairs are successful for the long term.
Endovascular stent graft
Instead of open aneurysm repair, your vascular surgeon may consider a newer procedure called an endovascular stent graft. Endovascular means that the treatment is performed inside your body using long, thin tubes called catheters that are threaded through your blood vessels. This procedure is less invasive, meaning that your surgeon will need to make only small incisions in your groin area through which to thread the catheters. During the procedure, your surgeon will use live x-ray pictures on a video screen to guide a fabric and metal tube, called an endovascular stent graft (or endograft), to the site of the aneurysm. Like the graft in open surgery, the endovascular stent graft also strengthens the aorta. Your recovery time for endovascular stent graft is usually shorter than the open surgery, and your hospital stay may be reduced to 2 to 3 days. However, this procedure requires more frequent imaging procedures after placement to be sure the graft continues to function properly, and is more likely to require periodic maintenance than the open procedure. In addition, you may not be suitable to have this procedure, since not all patients are candidates for endovascular repair because of the extent of the aneurysm, its relationship to the renal (kidney) arteries, or other issues. While the endovascular stent graft may be a good option for some patients, in some other cases, open aneurysm repair may still be the best way to cure AAA. Your vascular surgeon will help you decide what is the best method of treatment for your particular situation.

Just a couple of pictures from the first week: Times Square and the BME 2006 Immersion Group Photo
So this first week in NYC has been an adventure, to say the least, and when they say "This is the city that never sleeps," they sure do mean it. NYC is always moving, and you'll hardly get to experience some quite time unless you're in the hospital working on MRI imaging, but even then there is the quite buzz of electronics in the background.

To begin, the ride out to NYC on the campus to campus bus was very comfy and nice. Plush leather chairs, a snack bar in the back, XFM satellite music, and wireless internet (although spotty at times) still made the whole commute much better than taking any other bus line to the city. On top of that being dropped off at the medical school right next to the dorms where we were going to be living at couldn't have been any easier. The dorm rooms are a bit bigger than I was expecting, with a shared bathroom, and a communal kitchen area next to the elevators. Air conditioned as well, since its such a must during the summer! There are lots of good cheap and fast places to eat just a few streets away and all the grocery shopping/drug stores are within walking distance, so its really convient to get lunch and take care of errands.

My first day began with obtaining my ID so that I could actually get into the medical school and shortly thereafter I met with my clinician Dr. Jonathan Weinsaft at a seminar on MRI Contrast Enhancers for cardiac imaging. Contrast enhancers as the name implies, add contrast to the MRI image which allows for a differentiation between different tissue types (i.e. cardiac muscle vs. cholesterol occlusions) in real time. After our meeting, I then was given a reading list and a few authors who's research I should look up to gain more knowledge in the area of cardiac MRI imaging. On my second day, I met with Dr. Weinsaft again and we proceeded to discuss what my project would be for the following 6 weeks. But before we began, he actually gave me a white lab coat with the hospitals logo embellished on the left shoulder and told me that by wearing that around the hospital, it would allow me to have much greater freedom and access to parts of the hospital that I would normally have problems getting into (and to tell you the truth it has, although you get into a little trouble when people confuse you as a real doctor!). As for the details concerning my project, I am going to be comparing MRI images of healthy patients versus patients that have heart disease, specifically those with high blood pressure and left ventricular hypertrophy (a medical condition in which the left ventricle increases in size, muscle wall thickness, and results in a lower amount of blood being pumped out also known as the ejection fraction). The main goal is to see if a correlation can be determined between the healthy and diseased patients in aiding as a diagnostic took upon cardiac MRI.

After our meeting and gaining more literature to read, I was lead to the "Cath lab" or catheterization lab, where I observed three explortative angiograms in real life. It was really amazing to see how the heart functions in real time and how the whole procedure can be used to detect healthy vessels from those that are diseased.

On the third day, I met the current medical residents for 8am rounds in 4 North, the cardiology section of the medical hospital. After hearing briefs about the patients currently in the hospital, we then toured the floor and met the actual patients and listened to how they were doing and what they wanted/what was going to happen next in treating their conditions. After rounds which lasted about 2 hrs, I went back to the Cath lab and observed another 2 catheterizations this time being able to see one patient have 3 stents put in to help alleviate their clogged vessels. I met later with Dr. Weinsaft and was given an introduction into reading MRI images and how to diagnose the patients condition.

The fourth day began with rounds again at 8am in 4 North, followed by starting the initial stages of my research by compiling a list of patients that have had both a cardiac MRI along with a cardiac ultrasound (echocardiography). Afterwards I took the patient confendiatility exam that is part of the requirement of our week long ethics course. Following these two things, I met up again with Dr. Weinsaft and proceeded to learn more about cardiac imaging, but this time by reading SPECT (single photon emission computed tomography) images. SPECT is a CT image that is generated by the emission of photons from a radioactive tracer element that is metabolized in the heart due to its high energy demand. This offered another oppotrunity to see how the diagnosis of cardiac disease is done.

My fifth day again began with rounds in 4 North, followed by heading to the 2nd floor in to the nuclear cardiology wing of the building where I saw the actual imaging of the SPECT images I was reading yesterday. The day wrapped up with readings of the SPECT images along with being assigned to the resident that I am going to be working with for the following weeks on my project.

In addition to all the work that has been happening in the hospital, I still have been able to get out to see parts of the city. Have been to Times Square three times already, went to the ESPN Zone which is also in Times Square, and cheered for Portugal while being surrounded by a sea of England fans which were not to happy with our win. Have been to the meatpacking district to see the night life and clubs that are there, have been to the NYU campus and surrounding area, explored Bryant Park (which is a great place to visit when its warm and sunny outside), and have found many a good place to eat within the local vicinity of the dorm and hospital area. All this is possible to the subway system which keeps the city connected and running 24/7 and also the massive amounts of taxi's that can be found all over.

With that a week has passed already and only 5 more to go... its going to be over sooner than we know it!

Jan Kostecki

Ben Hawkins: Week 1

Monday morning I met with Dr. William Frayer, physician in the Neonatal Intensive Care Unit (NICU). Our meeting lasted a few hours while we discussed a range of topics; from pastimes to research interests. We discussed the research project, started during the last immersion term, and how I would continue in their work to model neonatal lung function. Due to his vacation schedule, Dr. Frayer has been out since our meeting, and will return this coming Wednesday. He introduced me to, amond others, Dr. Steven Pon, attending physician in the Pediatric ICU (PICU). I have since been attending rounds with Dr. Pon and his fellow(s) and residents; all of whom have been exceedingly helpful aiding my understanding of conditions and treatments of patients under his care. Several patients with trisomey 21, Down Syndrome, require cardiac reconstruction. In many cases, this is an open heart proceedure, which is complicated by the trisomy 21, as well as other associated conditions. In some of these cases the chest is left open for a number of days due to these complications. This was my most astounding realization thus far.

I took notice of a number of bedside testing aparati. ISTAT is a bedside testing device where a blood sample is placed in a disposable cartridge. This cartridge is analyte specific (blood gases, pH, electrolytes, troponin, or others) and is inserted into the handheald or bedside analysis system. Results are available in minutes. Development and use of these, and similar, systems are my primary interest.

In addition to bedside labs, I observed a number of ultrasound procedures to view heart defects. I plan to expand on the nature of these conditions and the the function of devices in future postings.