Upstate Health, fall 2012
The consumer health publication from Upstate Medical University, Syracuse's academic medical center.
Health UPSTATE UPSTATE MEDICAL UNIVERSITY Fall 2012 emergency responders the baby boomer CONNECTION hepatitisC always on call HOW TO PREVENT FALLS distracted driver? triathlon Preserving fertility THE LURE OF THE bath salts before cancer treatment CONTENTS Health 4 5 8 10 12 "Magical hands" lead to stroke recovery Would you donate a kidney? New sensor could improve diabetes care Adventures with Alzheimer's Advice Contents for your emergency supply kits Medical scans -- should you worry about radiation? 14 15 Community Partners in Health participation Physician team responds to disasters Food 17 18 19 20 Strawberry, Chicken and Fennel Salad 8 types of vitamin D deficient people In every issue 6 10 Lessons from Upstate Advice for Caregivers from Caregivers Questions & Answers In the Know The Upstate Ethicist 16 20 22 23 24 Good Job Calorie Burn Good Read The Humorist Science is Art is Science Leisure Why Kristina Sherman loves gardening The Lure of triathlon "It's a little bit like `CSI' mixed with `House'." �ALEXANDER GARRARD, PAGE 16 11 12 14 ON THE COVER: JEREMY JOSLIN MD OF THE PHYSICIAN RESPONSE TEAM. SEE STORY ON PAGE 15. PHOTO BY ROBERT MESCAVAGE Good for You 2 U P S TAT E H E A LT H 4 Concussion facts Driving without distractions 9 hepC 11 11 Hepatitis C test Electronic medical records 18 Making decisions 20 Boot "Kamp" fall 2012 w w w. u p st ate . e d u ould you donate one of your kidneys to a family member? A friend? A co-worker? Meet five people (p. 5) whose lives were improved and likely extended because of kidney transplants made possible by living donors, right here at Upstate. This is but one of the thought-provoking subjects presented in this issue of Upstate Health. Should research include people with developmental disabilities? (p. 14) Do the precise images provided by a computerized tomography scan outweigh the dangers of radiation exposure? (p. 12) Why is the Baby Boom generation at risk for hepatitis C? (p. 7) The pages of this issue, hopefully, will get you thinking. They will also introduce you to the Upstate expert whom CNN turned to for coverage of "bath salts" (p. 16) and tell you why Joel Potash MD recommends reading Cutting for Stone, (p. 22.) You will also learn that it is impossible to drive safely while texting (p. 6), that electronic medical records are valuable for patients (p. 9) and that Upstate scientists are involved in important research into how the heart develops (p. 24.) Enjoy your Health! W WHAT'S UP AT UPSTATE by the numbers 80 pints of blood donated by Gary Kittell, a physical plant administrator. That's 10 gallons since 1966, when he started donating as a student at the University of Vermont in Burlington. "It's easy for me to do, and it's a very positive give back to the community," he says. Connect with us We've gone mobile! Download Upstate's new app, which is free, at upstate.edu/app. Use it on your smartphone to find directions to important Upstate locations, to learn more about your Upstate doctor or for one-touch dialing to Upstate Connect. You can read Upstate Health via the UPSTATE APP, or stay current with Upstate's social media and news channels. You can even submit suggestions for new features on the app. If email is your thing, subscribe to What's Up at Upstate the "What's Up at Upstate" blog at upstate.edu/whatsup. A box in the right column will ask for your email address. Find us on Facebook by searching for "Upstate Medical University" and the "Upstate Golisano Children's Hospital." On Twitter, we are @upstatehealth, @upstategolisano and @upstatenews. 50 7 New York State designated centers at Upstate, including AIDS, Burn, Diabetes, Poison, Sexual Assault Forensic Examiner, Stroke and Trauma. Your health For appointments or referrals to the health care providers on these pages, or for questions about health topics, contact a registered nurse at Upstate Connect at 315-464-8668 or 1-800-464-8668, day or night. years Eugene Kaplan MD has been practicing psychiatry at Upstate. He graduated medical school here in 1957, then completed an internship at Albert Einstein College of Medicine before returning to Upstate for his residency and eventual career. Health PUBLISHER Wanda Thompson PhD Senior Vice President for Operations EXECUTIVE EDITOR Melanie Rich Director, Marketing & University Communications EDITOR-IN-CHIEF DESIGNER Amber Smith Susan Keeter PHOTOGRAPHY & ILLUSTRATION Susan Kahn, Robert Mescavage, Susan Keeter, Debbie Rexine, Chuck Wainwright, William Mueller, Dan Cameron Fall 2012 For more information, visit us online at www.upstate.edu or phone us at 315-464-4836. For corrections, suggestions and submissions, contact Amber Smith at 315-464-4822 or email@example.com ADDITIONAL COPIES: 315-464-4836. Upstate Health offices are located at 250 Harrison St., Syracuse, NY 13202 Upstate Health is published by the Office of Marketing and University Communications. Upstate Medical University in Syracuse, NY, is an academic medical center with four colleges � Medicine, Nursing, Health Professions and Graduate Studies � as well as an extensive clinical health care system that includes Upstate University Hospital's downtown and community campuses, the Upstate Golisano Children's Hospital and numerous satellite sites. Affiliated with the State University of New York, Upstate is Onondaga County's largest employer. 4 fall 2012 types of cancer (prostate, lung and bronchus, breast and colo-rectal) that represent more than half of all cancers diagnosed in 13 counties within Upstate's service area. Knowing changes everything.SM U P S TAT E H E A LT H 3 HEALTH Six important facts about concussions 1. A concussion is a traumatic brain injury, usually with minimal consequences if it is handled properly. Symptoms may include confusion, disorientation, memory loss, slowed reaction times and extreme emotional reactions. 2. A loss of consciousness is not necessary for a diagnosis of concussion. In fact, 90 percent of concussions do not involve a loss of consciousness. 3. Neuroimaging (including CT and MRI scans) cannot reveal whether a person has had a concussion, however computerized tomography scans or magnetic resonance imaging is often used to rule out more serious bleeding in the brain. PATIENTS first Stroke survivor Ronald Eckert with his wife, Patricia, in the work out room of their Manlius home. 4. Repeated blows to the head are dangerous. "If you have another injury before you're fully recovered from the first concussion, and you start stacking them up, we know that can have very significant consequences," says Brian Rieger PhD, director of Upstate's Concussion Management Program which now has offices in Upstate's Institute for Human Performance, 505 Irving Ave., Syracuse. He says chronic traumatic encephalopathy, from repeated head injuries, used to be called "Boxer's Dementia," but now is seen in football players and hockey players. In addition, rates of dementia and depression are significantly higher among retired football players than the general population, and head injuries are thought to be responsible. 5. Management of concussions is straightforward: Remove the person from risk of re-injury, and limit his or her physical and mental exertion during a three-week recovery period. 6. The best treatment for concussion is sleep and rest. Current medical advice says that it is not dangerous to allow a child to sleep after a head injury, once they have been medically evaluated. Stroke patient grateful for full recovery R onald Eckert was running mundane errands on a dreary Friday. What's amazing is that Eckert was able to do the errands at all. blood vessel and advanced a device called the Solitaire� stent to the clot. He captured the clot and removed it with the stent from the body through the catheter. All Eckert remembers is suddenly being able to feel his right arm again. Later in the day, nurses evaluated him by asking what day it was, and what he had done for a living. He knew the day, and he could describe his work, but he couldn't find the words "heating, ventilation and air conditioning." He felt confused. He spent the night in the intensive care unit. The next day, he was clear-headed and could answer the questions on his evaluation. He underwent tests of his heart, of the arteries in his neck, of the veins in his legs. He got up and walked. When he was alone and quiet in his hospital bed, Eckert reflected on what he went through. Everything happened so fast, much of it seemed a blur. Before he left the hospital, he asked to see the doctor who removed the clot from his brain. Swarnkar arrived. "You have magical hands," Eckert told him. Then he did something he came close to losing the ability to do that Friday, April 13. He extended his right hand to shake the doctor's. G He suffered a stroke two weeks prior. Not only did he survive, his recovery was quick, and he has no lasting damage. Friday, April 13 was like any other day. Eckert got up and had coffee with his wife, and then they worked out together while watching "Good Morning America." Eckert finished on the treadmill and went to the basement to do his pushups and sit ups. "I got up, and I fell on the floor," he remembers. His glasses fell from his face. He called his wife to come get them. His right side was limp. She took one look at Eckert and ran upstairs to call 911. He was upset she did not retrieve his glasses. Eckert remembers riding in the ambulance. He kept pulling his right arm on top of his torso. It kept falling to the side. Over and over, he put his arm back on his torso. Eckert did not know it at the time, but he was having an ischemic stroke, meaning a clot was blocking a blood vessel in his brain. At Upstate, he underwent a sophisticated clot-retrieval procedure. Amar Swarnkar MD, an interventional neuroradiologist, threaded a catheter through a 4 U P S TAT E H E A LT H fall 2012 w w w. u p st ate . e d u HEALTH Five inspiring kidney donations From a wife to her husband The Rev. Dr. David Tanyhill's loss of kidney function was diagnosed after he told his doctor that his daily five-mile jogs had become too difficult. Diabetes and high blood pressure had caused damage, and he was put on the transplant list. He had near matches with several cadaver kidneys; four relatives and a friend were tested but could not donate. After these options failed, his wife, Laura, insisted that she be tested. She was a match. "I am forever grateful to my loving wife," says Tanyhill. "She gave me the gift of life." Good to know NEW SENSOR COULD IMPROVE DIABETES CARE ome Central New Yorkers with and without diabetes participated in a study of a painfree glucose sensor that's in development, called Biologue�. The device, the size of a round pill box, would eliminate the repeated finger sticks that are required to test blood sugars multiple times a day in people with type 1 or type 2 diabetes. Biologue is an electrochemical biosensor that measures glucose within the interstitial fluid just below the surface of the skin. It transmits that data wirelessly to a hand-held monitor. It has not yet been approved by the Food and Drug Administration, but initial results are encouraging, says Ruth Weinstock MD, PhD, medical director of the Joslin Diabetes Center at Upstate and the lead investigator for the study, paid for in part by the National Institutes of Health. The company that makes Biologue, Ultradian Diagnostics in Rensselaer, wants to make it smaller and flexible, like a Band-Aid, which could be worn for days without recalibration. To do that, the company is collaborating with the Smart System Technology and Commercialization Center in Canandaigua, a microsystems lab that specializes in micro electromechanical systems, or MEMS. Upstate conducted the first testing of this device in humans. Weinstock was impressed with the accuracy of the sensor, compared with continuous glucose monitoring devices already on the market. "We believe this new technology could greatly benefit patients with diabetes and move us forward in the development of the artificial pancreas." The pancreas is the organ that produces the hormone insulin, which helps the body manage blood sugar. S From a friend to her friend's son "I'll never forget the day Tyler's mom told me his kidneys were failing, says Rita Walldroff of Lafargeville. "It was not a quick decision, but after his family members were not matches, I started the process of testing to become a kidney donor for Tyler." Tyler Reome, now 18, started dialysis on his 14th birthday and remembers, "I felt better the very first day with my new kidney." Reome's kidney problems surfaced during adolescence, with symptoms of muscle and bone weakness, dry skin, bad breath, nausea and fatigue. From a daughter-in-law to "Dad" Joe Corapi of Syracuse had scar tissue in his kidneys. His daughter-in-law, Michelle Corapi, remembers: "We all started donor testing as soon as we learned Dad needed a kidney. High blood pressure ruled out my husband, but my sister-in-law and I were matches." When Corapi's condition worsened, Michelle was the best choice as a donor. Today, both family members are doing well. Corapi reports that he is able to play golf, enjoy his family and that he "feels good every day." From a grandma to her grandson Hunter Cardinale, 9, was born with underdeveloped kidneys. He was on daily dialysis -- and the organ donor list-- since age 7. Hunter's grandmother, Sandy Rice, donated her kidney to him on Dec. 1. Both recovered well, but his grandmother knew the risks. "No matter what had happened," says Rice, "by giving him my kidney, I knew I had done everything to help him and give him more time." Today, Hunter is a busy 5th grader at Cato-Meridian Middle School who enjoys playing with Sonic, the hedgehog. From one firefighter to another George Turner of Antwerp was on dialysis after losing his kidneys to polycystic kidney disease. At a volunteer firefighters' awards dinner, Erin Dulmage asked him about dialysis and how to get tested as a kidney donor. "The day she told me she was a match, we just sat and cried," says Turner. Two years after donating her kidney, Dulmage gave birth to her son, Jakob, now 3. Turner is adopting a son of his own. "Erin gave me the gift of life," he says. "Now I'm giving the gift of a good life to a child." G Transplant surgeons Amy Friedman MD and Dilip Kittur MD performed these kidney removals and transplants. For information on becoming a donor, talk with the person in need and then contact the Upstate Transplant Program at 315.464.5413. Knowing changes everything.SM fall 2012 U P S TAT E H E A LT H 5 HEALTH Lessons FROM UPSTATE HERE IS ANOTHER BAD SIDE EFFECT OF SNORTING COCAINE side from creating an addiction, snorting cocaine can kill a person through heart attack, stroke, kidney failure � and an underappreciated condition called pneumomediastinum, a condition in which air leaks into the space in the chest between the lungs. Brian Kloss DO, an instructor in emergency medicine at Upstate, wrote in the "International Journal of Emergency Medicine" about a man in his 20s who came to Upstate University Hospital's Emergency Department complaining of constant chest pain behind his breastbone that worsened when he moved or inhaled. The man admitted drinking a pint of gin and snorting 7 grams of cocaine prior to his arrival. Pneumomediastinum can occur when a person smokes cocaine. Only a few cases, including the one at Upstate, have been reported from snorting the drug forcefully while bearing down to maximize the drug's absorption. Kloss wrote about the case to alert emergency physicians to consider pneumomediastinum in patients similar to his patient, who was treated successfully with pain medicine and bed rest after undergoing tests to make sure his respiratory tract and esophagus were not perforated. Kloss says people using cocaine should also be aware that the drug is often cut with levamisole, a chemotherapy agent that wipes out the body's immune system and leads to death of skin tissue. The effects can be reversed if a person discontinues cocaine, he says, but that can be difficult since the drug is so addictive. A Trauma coordinator Steve Adkisson RN hopes to prevent injury through Upstate's "Let's Not Meet by Accident" classes for high school students. Electronic distractions: a deadly epidemic C entral New York leads the state in traffic-related fatalities among 16- to 19-year-olds because of what Upstate trauma coordinator Steve Adkisson RN calls a modern plague of the highways. injuries and deaths involving pedestrians wearing headphones. Adkisson says in his decades as a trauma nurse, he's learned one thing: "You can't save people from themselves. You can treat the symptoms all day long, but you can't change behaviors unless people want to change behaviors." G NO, YOU CANNOT Linda Spear PhD and her TEXT team conduct research late TALK AND SAFELY at OR night and early inDRIVE the morning within a one-block area of Binghamton haseven eight bars. They interview � Talking on a cell that phone, hands-free, young adults been drinking but are not sesaps the who brainhave of 39 percent of the energy verely putting them to through a series of cogit impaired, would normally devote driving. nitive and motor tests and breath tests and asking them Using a with cell phone your reaction time to � follow up onlinedelays surveys. as much as having a blood alcohol concentration of .08, the legal limit for drunk driving. "The level of distractions in the car are just unprecedented," he says, citing electronic devices as the biggest distracters. "It's killing more people than drunk driving ever did." A survey commissioned by tire manufacturer, Bridgestone Americas, shows that many young drivers are in denial about their habits behind the wheel. "This age group simply does not believe they are at risk," Angela Patterson told the National Press Club in the spring. She manages the Teens Drive Smart program for Bridgestone. Distractions can be manual, visual or cognitive. Sending or receiving texts is considered most dangerous because it involves all three, simultaneously. Distracted walkers are also at risk. A study in "Injury Prevention" in January documented an increase in the number of � Drivers using a hand-held device are four times as likely to get into a crash serious enough to cause injury. � Texting drivers are 23 times more likely to get into a crash. � Sending or receiving a text takes a driver's eyes off the road an average of 4.6 seconds, the equivalent of driving the length of a football field at 55 mph, blindfolded. Source: American Trauma Society 6 U P S TAT E H E A LT H fall 2012 w w w. u p st ate . e d u HEALTH Everything you need to know about hepatitis C arlier this year, the Centers for Disease Control and Prevention recommended every Baby Boomer � people born between 1945 and 1965 � be tested for hepatitis C. David Paar MD, medical director of the Designated AIDS Center at Upstate, and social worker Kelley Flood, the center's assistant director, explain: � This group of people is at risk. A lot of things in our country happened as the Baby Boomers reached adolescence. We had our sexual revolution. People started experimenting with drugs. I have patients who I know today are professional and responsible, but they experimented with intravenous drugs. Intranasal cocaine is thought to transmit hepatitis C if you're using the same instrument to take the cocaine intranasally. And then, the more sex partners you have also increases the risk of hepatitis C infection. It was the cultural changes that occurred in our country, plus blood transfusions, that make this a concern to this generation. � When one has hepatitis C infection, you're basically asymptomatic for the first 10 to 20 years, so you don't know it. You wouldn't go to your doctor because you're feeling bad. So the thing to do is to screen asymptomatic people with a simple blood test. � The individual wants to know about his or her status, but the country does as well. We're anticipating over the next 50 years, billions of dollars is going to be spent on taking care of people with cirrhosis and who need liver transplantation. So this is also a public health concern. � In the United States and most of the developed world, about 30 percent of people who have HIV (human immunodeficiency virus, which causes AIDS) also have hepatitis C, and that's because the diseases are spread similarly. We see both HIV and hepatitis C patients in our clinic, co-infected. � When somebody comes in contact with hepatitis C, about 20 percent of people will fight it off, and 80 percent will develop chronic, long-term infection. So if you're immunosuppressed with HIV or for other reasons, it might be more like 95 percent will get the chronic infection. � There are a number of hepatitis viruses. A, B, C, D and E are the most common ones, but there are actually a few others. Hepatitis C is most commonly acquired by blood exposures that can occur in a variety of ways, and it goes to the liver. So it's an infection of the liver. The word hepatitis is derived from the Greek word hepatikos, which means liver. E � Hepatitis C causes inflammation in the liver, and eventually it destroys liver cells. When the liver cells are destroyed, they're replaced by fibrosis, which is essentially scar tissue. The scar tissue is nonfunctional, so eventually people are going to develop liver failure. � You have to understand what the liver does to understand liver failure. Very simply, the liver detoxifies or metabolizes all of the medications that we take, alcohol that we drink and other recreational drugs. Also, all of the food that we eat passes through the liver. The liver builds proteins, it helps to regulate glucose, the sugar in your blood. It's essential for life. You cannot live without a fully functioning liver. � When people develop liver failure, their blood platelets go down, and they're at risk of bleeding. The protein in the blood goes down, and it's protein in the blood that holds the fluid part of blood inside of the blood vessels. So the fluid leaks out of the blood vessels and people get as cities, which is a lot of fluid in the abdomen, and they get edema, which is a lot of fluid in the lower extremities. And then, the really serious thing is, people get encephalopathy. The brain gets affected by all of the toxins that are building up. So people basically have to be admitted to the hospital for care. � There are treatments that are available that can actually cure the disease -- unlike HIV which we can control -- hepatitis C, we can cure. The two mainstays of hepatitis C treatments are interferon, which is an injection that can be given once a week, and ribavirin which are pills that are given every day. We've been using those drugs for about 10 years to treat hepatitis C, and overall the cure rate is only 50 percent. � There are three common types of hepatitis C in the United States. Type 1 is the most common, and then there's type 2 and 3. Two and 3 are only treated with interferon and ribavirin. There's about an 80 percent cure rate for them. But there was, up until recently, less than a 50 percent cure rate for type 1. Now two new drugs are on the market. One is telaprevir. The other is boceprevir. We have to give these drugs in combination with interferon and ribavirin. There are a lot of pills that need to be taken, but if we can treat the people with these medications for six months to a year, approximately 70 percent of them will have a cure. � So far, we are seeing very good results. During the first one or two months of treatment, you can tell if people are going to have a good response, and so far people are having good responses. G The Designated AIDS Center at Upstate cares for people infected with HIV in a 15-county Central New York region. For details call 315-464-5533 Knowing changes everything.SM fall 2012 U P S TAT E H E A LT H 7 HEALTH with an adventure alzheimer's Lost, frightened and helpless in China y wife and I took a bus tour of China last summer, visiting four cities in seven days, which, as our guide said, is like smelling flowers from a galloping horse. A few days in, our group was in Shanghai with plans to stop at a street market for the afternoon. I'm not a big shopper so I asked our Englishspeaking Chinese guide to write on a piece of paper the Chinese characters for the name and address of our hotel, and the restaurant where the group was going after so I could take a cab to the hotel, run on the treadmill and meet for dinner later. We agreed to meet again at 5:10, and off I went. I flagged a cab and gave the driver the paper. He nodded, and we entered into Shanghai's bumper to bumper traffic. It was a steamy 95 degrees. I tapped on the plexiglass window between me and the driver. I stuck out my tongue, waved my hand in front of my face, pointed to the air conditioner vent, and then pointed up, hoping he would turn up the air. Instead, he yelled and zipped in and out of traffic, cut people off, blew his horn. Next time we stopped I did my face-and-fan thing again, and put my finger on the vent and the control knob. He laughed, turned it up, and stopped the Indianapolis 500 imitation. Thirty minutes later, like our guide estimated, we were at the hotel. I had a good run. When it was time to head back, the doorman got a cab, looked at my paper with the restaurant address, and talked to the driver. I sat back to enjoy the sights, but soon realized we were not on the highway the other guy took to get here. Then, the cab driver pulled over to consult a map. I handed him my paper. He nodded and tapped something into his GPS that talked to him in Chinese. He u-turned, and off we went. But still, there was no highway. At the next light he rolled down the window to consult with another cabbie who gave him a shoulder shrug. I gave the driver my paper again, pointing to the guide's phone number. He dialed, but got no answer. He shrugged and took off again. Uh oh! Could this guy be taking me for a ride to jack up the fare? A cabbie license with a picture and ID number was on the window, and a phone number for what I guessed was the taxi commission, but I could not tell if my cabbie was the one in the picture. BY RICH O'NEILL M I thought briefly about getting out of the cab at a light and into another one, but who knew how that would go? Was that OK in China? I did not know if I had enough time to make it to the restaurant, or whether I should return to the hotel. I did not know if I had enough Chinese money for two cab rides. I knew it was about 6 yuan to the dollar, but were the Chinese bills I had all Yuan or some other denomination? Some cabbies took American dollars, but even if mine did, my jetlagged brain was having trouble with the math. It was 5:05 p.m. and I began worrying: Would my group wait for me? What would I do if they did not? We came to another light, and nothing at all looked familiar. I pointed again to the guide's phone number. Again, my cabbie dialed. This time there was an answer. There was talking, nodding and sounds of agreement, followed by the international thumbs up. Five minutes later, at 5:10 on the money, he pulled to the curb and pointed to a sign on a building and then to my piece of paper. Could I tell if they were the same words or characters? No. And there was no guide and no familiar faces. Should I pay him and get out? I took a leap of faith. Even up close, the sign on the building was not a match to the name on my paper. No restaurant was on the ground floor. Could it be upstairs? Where was it? No guide or fellow travelers were on this loud and crowded street, and no police were around to ask. So I stood on the corner, visible from all directions, hoping that someone who knew me would see me. It was still blazing hot. I was parched, hungry and feeling at the mercy of strangers, whom I hoped would be kind. "Richard." Did somebody say my name? I thought, looking around. "Richard?" Ah! It was my guide, smiling. He walked me two doors away and upstairs to my wife and our group. Afterward I suspected my experience was like what my 95-year-old mother, and others with Alzheimer's disease, anxiously suffer through every day: Where? When? Who? What? Why? What an amazing thing to discover in China. G Listen to psychologist Rich O'Neill on HealthLink On Air radio from 9 to 10 a.m. every Sunday on FM Newsradio 106.9 and AM 570, WSYR. Read more about his work in Upstate's Institute for Decision Excellence and Leadership at IDEAL.upstate.edu. Contact him at firstname.lastname@example.org 8 U P S TAT E H E A LT H fall 2012 w w w. u p st ate . e d u HEALTH SHOULD YOUR DOG WATCH TV? Why electronic medical records are good for patients I P aperless medical offices are becoming the norm throughout Central New York as physicians convert to electronic medical records. "This is happening partly because it's good for medicine, it's good for care," Neal Seidberg MD, Upstate University Hospital's chief medical information officer says of the digital movement. Additionally, practices receive incentives through Medicare for adopting electronic medical records now; they will be penalized for not doing so starting in 2015. Upstate began rolling out a confidential electronic medical records system called EPIC earlier this year. One feature of it is Upstate MyChart which invites patients to create free password-protected accounts that contain records of their information. "The major issue here is that seamless data about patients is available to everybody who took care of them," Seidberg says. "If you are a patient, your care now comes home with you. It doesn't just stop at the doctor's office. And it follows you from office to office." f your caregiving responsibilities extend to canines, you might be interested in a new cable television channel which provides 24-hour programming for dogs. Segments of 3- to 6-minutes provide relaxation, (with images of peaceful or slumbering canines in quiet environments) stimulation (showing dogs roughhousing, fetching balls and swimming) or habituation (with sounds and visuals to help dogs cope with doorbells, thunderstorms, toddlers and other agitators.) Will it help stay-at-home dogs beat boredom? "I think a lot of this is to make us feel better as opposed to making the pet happier," veterinarian Ann E. Hohenhaus of the Animal Medical Center in Manhattan told "The New York Times." She also says if the dog pays attention to the screen, it must like what it sees � which could help alleviate separation anxiety. Stanley Coren, a professor of psychology at the University of British Columbia, told the newspaper that placing a high-definition television at your dog's eye level will increase the chances he or she will pay attention. The channel can also be accessed online at www.DogTV.com For patients that means: 1. reduce the amount of time patients spend waiting; if they become ill or injured while traveling, their medical records 2. are available at any hour, by computer or smartphone; 3. the results of lab work are readily available; they can make appointments or seek non-urgent medical advice 4. or prescription refills by computer or smartphone; and 5. parents have access to immunization records for school children. Patients may enjoy the convenience, and electronic medical records promote consistency and communication among healthcare providers � which improves health care. G pharmacies receive digital prescriptions and, in some cases, Knowing changes everything.SM fall 2012 U P S TAT E H E A LT H 9 ADVICE For Caregivers � from Caregivers How to prevent falls T wo types of senior citizens are most susceptible to falls: those who are very active and, for instance, trip on an uneven sidewalk, and those who have lost their strength and balance reactions due to physical inactivity. Here is a daily strengthening exercise: � In a standing position, lift your body weight on your toes. This will build your calf muscles. Start with both legs, holding a chair or the wall for balance, but ideally you will work up to one leg, 25 lifts at a time. � Some falls happen when people stand up too quickly, their blood pressure drops, an they get dizzy and fall. Avoid these falls by giving them time to get their equilibrium when they stand before walking. � Household modifications such as removing throw rugs do not prevent falls as much as we might expect. However, dim lights and pets that get underfoot can present problems. � Be aware that many falls happen in the bathroom. Someone may stumble because it is dark in the middle of the night, or because they are rushing to the toilet. � Make sure you can get up off the floor by yourself if you were to fall. "There is nothing more humbling than having to call people to help you get up," Avers says. "A lot of people are afraid of falling because they can't get up off the floor." She suggests practicing pulling yourself up, even if you have to crawl to a chair for help, to build confidence and ease fear. "Basically, if you don't use it, you lose it," says Dale Avers, a doctor of physical therapy and an associate professor in Upstate's College of Health Professions. Here is her best advice for preventing falls: � Know your medications. Taking four or more increases fall risk due to potential side effects and interactions. � Older adults should be able to stand on one foot for 10 seconds. If they struggle with this, you know balance is an area that needs improvement. � You can seek physical therapy or participate in an exercise such as tai chi. Taking long steps during your walk is good, too, Avers says. "Anything is better than nothing." � Keep ankles as mobile as possible since ankles are the first line of defense when a person loses his or her balance and begins to fall. Here is a daily flexibility exercise: � Lift your leg and make circles with your ankle. Move the ankle up and down. Draw the alphabet with your foot. Tap your toes and aim for more than 35 times in 10 seconds. Attention: Caregivers, clip and save. Tips in every issue. Emergency supply kits O nondaga County's health and emergency management commissioners suggest preparing an emergency supply kit to have on hand for any emergency. It should contain three days worth of: � water, one gallon per person, per day. � non-perishable, ready-toeat canned or packaged foods and pet foods, plus a manual can opener. � battery-operated AM/FM radio and extra batteries. � flashlight and batteries. � whistle to signal for help. � personal hygiene items. � moist towelettes and garbage bags. � cell phone and chargers, including car charger. � child care supplies or other special care items. � eyeglasses and medications. � first aid kit. The American College of Emergency Physicians says these items are appropriate for a first aid kit: � acetaminophen, ibuprofen and/or aspirin tablets. � antihistamine. � decongestant tablets. � oral medicine syringe, for children. � bandages of assorted sizes. � safety pins or other bandage closures. � triangular bandages. � elastic wraps. � gauze and adhesive tapes. � sharp scissors with rounded tips. � antiseptic wipes. � antibiotic ointment. � hydrogen peroxide. � disposable, instantactivating cold packs. � tweezers. 10 U P S TAT E H E A LT H fall 2012 w w w. u p st ate . e d u ADVICE WITH FREDERICK SENGSTACKE MD Qa AND New techniques help preserve fertility U Q A pstate's Frederick Sengstacke MD was completing a fellowship in reproductive endocrinology at Georgetown University and the National Institutes of Health in 1983 when Howard Jones, Jr. MD spoke at a conference. "Dr. Jones was the first person to achieve an in vitro fertilization pregnancy in the United States. This was following the British breakthrough," Sengstacke says. "He brought the technology back to the United States and was subsequently able to have an IVF pregnancy, and then he held a big conference for doctors interested in that technology � and I was fortunate enough to attend that first conference." The first IVF pregnancy was achieved without the assistance of medications to stimulate ovulation, which are commonly used today. The eggs were retrieved through laparoscopic surgery, which has been largely replaced by transvaginal ultrasound guided needle aspiration today. What else has changed? "We have had sperm banks for many, many years. But egg freezing and embryo freezing, a lot of these technologies are still evolving. "The egg or oocyte is a unique cell. It is the largest cell in the human body. It contains a large amount of water. When you freeze a cell that contains a large amount of water, it causes the water to crystallize, and that can damage the genetic portion of the cell. That can interfere with normal cell division, and the cell can die if you crystallize it. Techniques have now evolved for freezing eggs. Pregnancies have resulted from oocyte cryopreservation, or freezing. It's a technology that is now accepted as a fairly standard technology, but it's not as routine as embryo (after the egg is fertilized) freezing. It requires much more technical savvy. "The idea is to be able to preserve fertility in patients who might otherwise not have that option. For example, take a young woman who is still in her reproductive age group who has breast cancer. She may not only require surgical therapy, but chemotherapy and radiation therapy, which can be destructive to the gametes, to the sperm and to the eggs. So as a result, once you have treated that patient, you have either completely devoided her of her egg supply, or you have significantly reduced that egg supply. What egg freezing allows you to do is to simulate the ovary in advance of her therapy, extract the eggs and freeze them, and then after she has completed her therapy she now has frozen eggs that can be used for in vitro fertilization in the future." Q A Q A Have there been advances in male infertility? "Intracytoplasmic sperm injection, ICSI, is a technique that was first used in humans in the 1990s and has allowed us to overcome male infertility in a significant way. The embryologist can take one spermatozoa, one sperm cell, and inject it directly into the egg, and you get over 80 percent chance of that egg being fertilized." Are these technologies safe? "Many people thought if you are manipulating human gametes in the laboratory you are going to create some sort of monster. That really has not borne out in reality. However, there have been some recent studies that have shown ICSI is associated with a slightly increased risk of certain genetic abnormalities. The data is still being analyzed. We're being cautious about it in terms of advising patients. Anytime you change the natural selection process, there is a potential risk. "Obviously these infertility patients have infertility problems. So if you're doing ICSI because of a male factor, if the embryo results from fertilization of that egg with a Y- bearing sperm, one that's going to produce a male offspring, then whatever problem that father had may be transmitted to his son. We know that's a potential risk. "Now, when you look at the overall risk, there's a 2 to 3 percent chance that any baby born can have a minor congenital anomaly. So the question is, if the babies that we're seeing are within that 2 to 3 percent, was it really the in vitro procedure -- or is that something that would have occurred naturally?" G Sengstacke, an assistant professor of obstetrics and gynecology, is director of Upstate's In Vitro Fertilization program. For referrals call 315-464-7249. Knowing changes everything.SM fall 2012 U P S TAT E H E A LT H 11 IN THE KNOW When (and when not) to have a medical scan hey reveal true images of the bones and soft tissues beneath our skin, without an incision. They can show lung tumors that are small enough to treat and blockages in blood vessels that can be removed before permanent damage is done. Computerized tomography is among the 10 greatest medical advances of the last century, says David Feiglin MD. chair and professor of Radiology at Upstate."It's an amazing technology. Nobel Prizes were won because of it." But all this gee-whizzery comes with concern -- that radiation exposure from repeated x-rays, CT scans and similar imaging techniques can, over time, cause cancer. The risks and concern are even greater for children, whose developing bodies are more susceptible to harm and who presumably will live many years during which cancer could develop. "Most of the effects of radiation are felt decades down the line," Dr. Marta Hernanz-Schulman told the HealthDay news service. She is the chair of the American College of Radiology Pediatric Imaging Commission, which urges the judicious use of imaging. Feiglin says manufacturers of CT scanners have developed machines that use substantially less radiation. Some of the older machines in the Central New York community do not have this capability, but he says Upstate is using some of the newer CT imaging technology that has the capability of dramatically reducing patient radiation dosages. For example, a CT scan of the chest in the past that may have given the equivalent radiation of 50 chest x-rays now is more like the equivalent of five chest x-rays with the newer model machines. In addition, Upstate University Hospital employs a pediatric radiologist, Gary Amundson MD, and tailors CT scans to children, using the least amount of radiation possible. "You have to generate enough photons to get an image. You don't want to have it so low that you have to have the scan redone," he says. Feiglin and Amundson predict that in the near future, cumulative records will be kept of an individual's lifetime exposure to radiation through medical imaging � T either by patients themselves or through a database that alerts physicians as they prepare to order scans for patients. Of course medical imaging is not the only source of radiation exposure. Radiation is all around us, including in our bodies. Our smoke detectors, household appliances and the sun all are sources of radiation. Medical physicists call this "background radiation," and a small amount is not considered dangerous. Still, a group of nine medical specialty boards is calling for reductions in the use of medical imaging at a time when usage is up. A study published in June in the Journal of the American Medical Association showed that among six large health care systems, the use of CT scans nearly tripled from 1996 to 2010. Researchers gave these reasons: physician and patient demand, improvement in the technologies that allow it to answer a broad range of questions, fear of medical malpractice lawsuits and uncertainty due to the lack of clinical guidelines on when to use imaging. The medical boards � which represent cardiologists, allergists, radiologists, family medicine doctors and others � are calling the initiative Choosing Wisely and aiming it at physicians and patients. At the same time, the Environmental Protection Agency advises that the use of X-rays and CT scans is a "gray area in which risk and benefit must be weighed by individuals and their doctors." Ultrasound and magnetic resonance imaging (MRI) do not rely on radiation to create their images, but those modalities aren't always suitable for the type of images a physician needs. DI ON I AT RA "A lot of times, our job is to make sure the right scan is being done," says Ken Galbraith Jr., an instructor in Medical Imaging Sciences in Upstate's College of Health Professions. "We spend a lot of time checking and double-checking." That's why patients who arrive for a scan often find themselves The National Council on Radiation Protection and Measurement says the average answering questions from the annual radiation dose per person in the United States is 620 millirem. Here are the sources of this average dose: technologists about why they are there. ALL ARO UN D US Radon & Thoron (background) Natural Minerals In The Ground & In Our Bodies (background) Space (background) Consumer (background) Occupational (background) Industrial (background) CT Scans (medical) Nuclear Medicine (medical) Interventional Fluoroscopy (medical) Conventional Radiography/ Fluoroscopy (medical) 12 U P S TAT E H E A LT H fall 2012 w w w. u p st ate . e d u IN THE KNOW "Computerized tomography is among the 10 greatest medical advances of the last century. It's an amazing technology. Nobel Prizes were won because of it." --DAVID FEIGLIN MD Medical physicist Kent Ogden says the number of CT scans performed at Upstate is on the decline because of a campaign to make sure any scan that is ordered has a purpose, that it is indicated for the patient. "If an exam is indicated," he says, "then the benefits far outweigh the risks. "The real risk from something like CT scans is actually pretty small, anyway," Ogden says. Time was, routine physical exams came with a chest X-ray. Not anymore. In general, physicians rely on medical imaging to assist with diagnoses. X-rays work well for bone fractures. MRIs and ultrasounds are better for injuries of the soft tissue. CT scans are used extensively in the treatment of traumatic injuries, and in oncology, and prior to surgery so that surgeons are not surprised by anything in the operating room. Given the increased use of imaging, and the potential for overuse, medical experts suggest patients ask questions of their physicians before submitting to a scan. Ask how the scan will improve care. Ask if there are alternatives that don't use radiation. Find out if the facility where the scan will be done is accredited by the American College of Radiology. And if the scan is for your child, ask if the radiation dose can be adjusted to child size. Dave Clemente, director of Medical Imaging Sciences at Upstate, says a fair question is: What do we hope to learn from this scan? "I'm not challenging the doctor when I ask him or her. I'm just curious," Clemente says. "Nowadays, doctors tend to respect that." Also keep in mind, if your doctor orders an additional scan, it does not necessarily mean he or she made a mistake. It may be that the image did not show what they were looking for, or that they are now looking for something else. If you are curious, ask. G Knowing changes everything.SM fall 2012 U P S TAT E H E A LT H 13 COMMUNITY ethicist SHOULD RESEARCH INCLUDE PEOPLE WITH DEVELOPMENTAL DISABILITIES? nstitutionalized children injected with hepatitis, adult men with syphilis studied but not treated, youngsters fed doses of radiation with their breakfast cereal � three examples of infamous biomedical experiments that lead to today's research regulations. Distrust remains. Katherine McDonald PhD was a guest lecturer at Upstate recently, speaking on the subject of research involving people with developmental disabilities. She is an associate professor in Syracuse University's Department of Public Health, Food Studies and Nutrition. Previous exploitation is part of the reason people with developmental disabilities are not part of many scientific studies. Then there are the logistics. How do researchers recruit them? Who has the authority to give consent to participate � the person or, when there is one, his or her guardian? Should the person undergo assessment before joining the study, or is it unfair to treat him or her differently than other study participants? Research is important because it can pique the public conscience and influence decision-making, and "people with disabilities need direct involvement in things that impact their lives," McDonald argues. But too often people with developmental disabilities do not have a seat at the table. They generally do not occupy public office or positions in academia or jobs reviewing grant proposals -- which raises the question of whether today's research addresses their needs. THE UPSTATE Samantha Cadet with pediatric cardiologist Frank Smith MD. George Alfieris MD did Samantha's heart surgery. I Heart surgery gives teen her adulthood S amantha Cadet was sickly and small as a child growing up in Haiti. Doctors there told her mother she had a congenital heart defect, which they could do nothing to repair. "She was basically told `your daughter will die in young adulthood,'" says Owen Robinson, who works for the international Partners in Health organization. Robinson grew up in Syracuse. His degree is in international relations and public policy. He helps coordinate medical care for poor people in countries such as Haiti at hospitals in the United States and other countries. Cadet, 15, is the oldest of three children. She lives with her two younger brothers and parents. Her father is skilled in masonry and her mother is a seamstress. Neither has a steady job. After Samantha was diagnosed at age 7, her mother took her to several doctors in Haiti and finally moved with her to a sister's home in Port-au-Prince, in hopes of finding someone to help the girl. Then came the 2010 earthquake. Partners in Health works with hospitals in Boston and Philadelphia which agree to provide a certain amount of charitable care. Because the need exceeds those resources, the organization looks for other hospitals that are able to offer specialized care. Robinson reached out to Upstate President Dave Smith MD, who was eager to help. Pediatric heart surgeon, George Alfieris MD agreed to operate, and Partners in Health set about to select an appropriate patient. This involved sending a pediatric cardiologist to Haiti to screen children with heart ailments. Frank Smith MD of Syracuse volunteered. He borrowed a portable echocardiography machine for his trip that would provide ultrasound videos of the children's hearts. It weighed about 30 pounds, and Smith carried it everywhere. "My right hand still hurts because I literally had a death grip on that machine," he quips. Smith examined 38 children, including Samantha, taking histories and determining who could be helped by surgery. He says some had damage that could not be reversed, and some had problems that could be treated without surgery. About one-fifth of the children had rheumatic heart disease, which developed in response to untreated streptococcal infections. In the cases of children who needed surgery, Smith says he told the parents to stay in contact with Partners in Health, which would receive the medical records he assembled. "It provided some hope," he says. Robinson traveled to Haiti in February to escort Samantha to Syracuse. The United States Embassy refused to issue her mother a visa to accompany her on the trip. "We sat down with her mother and said `you need to understand, there's a chance you'll never see your daughter again,'" Robinson recalls. "They understood her illness and knew that this is what she needed." The mitral valve in Samantha's heart was leaking, and she had a hole in her heart, one of the largest holes Smith has ever seen. Fluid was also collecting around her heart. After surgery, Samantha spent a few days at the Upstate Golisano Children's Hospital, and with a Syracuse family � before returning home to Haiti. On a return trip to Haiti in June, Smith examined Cadet, and an echocardiogram confirmed that she is healing well. Cadet is happy to be home and starting the tenth grade this fall. G 14 U P S TAT E H E A LT H fall 2012 w w w. u p st ate . e d u COMMUNITY Upstate physicians respond to disasters ome patients in the direst of emergencies cannot get to a trauma center. They may be pinned in the wreckage of a car, for example. That's when a specially qualified emergency medical services physician from Upstate University Hospital may be dispatched to the scene. Members of Upstate's EMS & Disaster Medicine Physician Response Team carry pagers 24 hours a day like volunteer firefighters. They take turns being on call, driving the team's white Ford Expedition whenever summoned by the Onondaga County 911 Center. It's a community service that Upstate provides without charge to individual patients. While overseeing patient care, the physicians � all of whom are professors at Upstate � provide real-time feedback to paramedics and emergency responders, explains Derek Cooney MD, the team's medical director. He says the team is activated for crises both large and small. Four physicians responded to the scene of the Megabus crash on the Onondaga Lake Parkway, which killed four and injured 23 people in September 2010. Physicians have been called to car wrecks to assess whether limb amputations were necessary. (They have not been.) Physicians have also been called to the scene of psychiatric emergencies, in which someone is refusing medical care. "It sometimes helps law enforcement and EMS (Emergency Medical Services) to get on the same page if the physician comes out," Cooney explains. S The team staffs the infirmary at the New York State Fair and provides medical oversight at Syracuse University's Carrier Dome, the Ironman 70.3 Syracuse, the Empire State Marathon and other largescale events. Mostly the physicians respond within Onondaga County, but Cooney says they could respond to adjacent counties if their services were needed. Their truck contains equipment and medications not available on ambulances. "We're providing services that nobody else can." G EXCESSIVE WORRYING MAY HAVE EVOLVED ALONG WITH INTELLIGENCE H igh intelligence and worry both correlate with brain activity measured by the depletion of the nutrient choline in brain matter, according to a recent study involving scientists at SUNY Downstate Medical Center, who say this means intelligence may have co-evolved with worry. "While excessive worry is generally seen as a negative trait and high intelligence as a positive one, worry may cause our species to avoid dangerous situations, regardless of how remote a possibility they may be," Jeremy Coplan MD said in a news release. "In essence, worry may make people `take no chances,' and such people may have higher survival rates. Thus, like intelligence, worry may confer a benefit upon the species." For the study, people with generalized anxiety disorder were compared with healthy volunteers � and the correlation between intelligence quotient and worry was significant in both groups. Previous studies have shown that excessive worry tends to exist in people with higher and lower intelligence, and less so in people of moderate intelligence. Scientists think people with lower intelligence suffer more anxiety because they achieve less success in life. Coplan and colleagues published their work in "Frontiers in Evolutionary Neuroscience." AWARD-WINNING CARE FOR HEART FAILURE Research Upstate's emergency physicians are involved in a variety of studies. Three projects underway include: 1. Examination of the time between when a patient arrives by ambulance at the emergency department and when the patient is removed from the stretcher and the paramedic gives a report to a nurse. 2. A study of how long patients are kept on backboards, since backboards are uncomfortable and can cause sores. "If we can figure out ways to reduce the time, we can do a lot of good, for our elderly patients especially," Cooney says. 3. Testing of an advanced airway device that uses a fiber optic stylet and digital images to improve the paramedic's ability to quickly and accurately insert a breathing tube down a patient's trachea, or windpipe. For the second year in a row, Upstate University Hospital received the Gold Plus award for heart failure from the American Heart and Stroke Associations. Upstate University Hospital was recognized for achieving 85 percent or higher adherence to all "Get With The Guidelines" Heart Failure Achievement indicators for two or more consecutive 12 month intervals and at least 12 consecutive months of 75% or higher compliance with 4 of 9 Get With The Guidelines� Heart Failure Quality measures to improve quality of patient care and outcomes. Upstate's EMS & Disaster Medicine Physician Response Team: Jeremy Joslin MD, Derek Cooney MD, David Landsberg MD, and Harry Wallus DO, MPH Knowing changes everything.SM fall 2012 U P S TAT E H E A LT H 15 WORK Meet Alexander Garrard, clinical toxicologist GOODJOB H HOW TO DECIDE WHAT TO DO WITH YOUR LIFE on Pilch has some unique experiences in reinventing himself. He worked as an accountant, information technology manager, financial management executive and as a massage therapist before going to medical school. Now he's a psychiatry resident at Upstate. "Everybody has his or her own way of making a big decision," he says. Some take an analytical approach; some make decisions based on intuition or gut instinct. Don found he made the best decisions when he used both methods and reached the same conclusion. For example, when he chose a place to live, he compared several apartments' features, location and cost, etc. He also sat in each apartment and imagined himself living there, taking note of how the place felt, his gut reaction. The place he chose was the one that both made sense analytically and "felt right." When it comes to choosing a career, he suggests shadowing several people in the fields in which you are interested. During each experience, consider whether you could see yourself doing the actual work you are observing. Afterwards, ask yourself: which experience felt the least like work? Which would you like doing, even if you were not being paid? Those answers can lead to more introspection. Analyze what it is about particular work that is the most satisfying to you, and that may help you decide how you want to spend your life. e's not a physician, and he's not a detective, but a large part of Alexander Garrard's job is to stay ahead of the drug dealers so he can help save their customers from bad reactions and overdoses. Garrard, 28, of Syracuse joined Upstate's Poison Center in 2011 as a clinical toxicologist. He and his colleagues lecture throughout the center's 54-county coverage area, teach and supervise residents and medical students at Upstate Medical University and consult on patients at Upstate University Hospital. what's the best way to care for those patients. "We also have administrative responsibilities. I'm in charge of continuous quality improvement. That means reviewing the cases and seeing -- Were they managed appropriately? Could something have been done differently? What did we do well? "I'm also in charge of death reports for our coverage area. Anybody who dies (from poisonings or overdose), I write up his or her death report for the American Association of Poison Control Centers. That can get kind of depressing. Last year we had 55. That's a hard part of the job." D Did you want to be a clinical toxicologist when you were little? "For the longest time, my dream job was to be a commercial airline pilot because my mom works for Lufthansa airlines. That kind of fizzled. And I ended up speaking to one of the pharmacists at a grocery store where I was a bag boy. I became intrigued. "I did a pre-pharmacy curriculum at the University of Georgia in Athens. I got my Doctor of Pharmacy degree at Mercer University in Atlanta. Most people who graduate with a Pharm D usually go into a community pharmacy. To do something like this, you have to pursue more post-graduate education. So that's where the fellowship came in. I did a two-year fellowship in clinical toxicology and emergency medicine in Jacksonville with the Florida Poison Information Center." How do you know so much about street drugs? "A unique part of our job is really trying to stay ahead of the curve, or at least as knowledgeable as possible about these substances. That means looking through the drug blogs and really kind of getting dirty and getting into that community and finding out -- What are people using? How are they using it? What are people saying? What are the effects? "There is no study out there, no release from the FDA. A lot of it is word of mouth, talking to the patients. A lot of what we know about these drugs comes from patients who have presented to the emergency room. It's a little bit like `CSI' mixed with `House,' where you have all these weird presentations: Why is this person so aggressive and agitated, with high blood pressure? What drugs out there do we know that can cause this?"G What is your day like? "Jeanna Maraffa, Christine Stork-Medicis and I are the only pharm D toxicologists here, so we rotate. Every third week, we're on hospital service. Anybody who comes into Upstate with an overdose, a poisoning, or an envenomation(venomous bite), we automatically get consulted on those patients and give recommendations on Alexander Garrard displays dangerous synthetic drugs known as "bath salts." 16 U P S TAT E H E A LT H fall 2012 w w w. u p st ate . e d u FOOD OATMEAL PEANUT BUTTER COOKIES A dd fiber and moisture without sacrificing sweet taste by using banana puree in these oatmeal peanut butter cookies from www.doctoroz.com Ingredients two ripe bananas 1/3 cup peanut butter Strawberry, Chicken and Fennel Salad BY BILL GOKEY 2 T two-percent milk 1 teaspoon vanilla 2 T agave nectar one large egg 2 1/2 cups quick-cooking or rolled oats 1/4 cup whole wheat flour S alads make for light, complete meals, and the simplicity of this salad is almost as appealing as the fresh strawberries it includes. A blender or food processor can whip up the vinaigrette, which is tossed with a sweet-and-bitter chicory called radicchio, the crunchy anise-flavored fennel and minced basil. The chicken and the walnuts provide protein, along with flavor and texture. Ingredients 10 � ounces grilled chicken breast, sliced 2 cups fresh strawberries, sliced 2 cups fresh fennel, finely diced 1 pound radicchio (red salad lettuce) � cup fresh basil, minced 1 cup walnut pieces, chopped For the vinaigrette: 1 tablespoon plus 2 teaspoons olive oil 1 tablespoon plus 2 teaspoons walnut oil 1 tablespoon plus 2 teaspoons balsamic vinegar 2 teaspoons fresh garlic clove, mashed 1/8 teaspoon salt 1/8 teaspoon ground black pepper dash of ground cinnamon Preparation Preheat oven to 350�. Make banana puree by mashing the bananas with a fork until smooth. Whisk in the peanut butter, milk, vanilla, agave, and egg. Add the remaining ingredients and stir until well combined. Drop dough onto a cookie sheet that has been sprayed or lined with parchment paper. Bake 13 to 16 minutes or until pale golden brown. Cool for 5 minutes. Makes two dozen. Preparation Use a mini food processor or blender to mix oils, vinegar, garlic, salt and pepper until emulsified to make the vinaigrette. Alternatively, use a small bowl and whisk. Combine the dry ingredients in large, chilled bowl. Toss while drizzling in vinaigrette. Serve on four chilled salad plates, or on large chilled platter for self serving. Nutritional information, per serving 465 calories 30 grams of fat (including 4 saturated) 18.5 grams carbohydrates 26 grams protein 6 grams fiber 347 milligrams sodium 744 milligrams potassium Nutritional information, per cookie 75 calories; 11 grams carbohydrate; 3 grams of fat; 3 grams of protein; 19 milligrams sodium; 45 milligrams potassium; 1 gram fiber Bill Gokey is executive sous chef for Morrison Healthcare, which provides food services for Upstate Medical University. Knowing changes everything.SM fall 2012 U P S TAT E H E A LT H 17 FOOD STOP, LOOK, STAY AND COOK t's easy to take for granted the speed and efficiency of a microwave oven. It is also easy to make a mistake that can cause a fire or damage the oven � not to mention ruin your afternoon popcorn snack. Today's generation of microwaves are smaller, have more control buttons and may use less electricity than earlier models, but you still need to pay attention when you are cooking. Some advice, from the fire prevention officers in Upstate's Office of Environmental Health and Safety, and the United States Department of Agriculture's Food Safety and Inspection Service: � Do not put butter or cottage cheese tubs or yogurt cartons in the microwave. Chemicals in these containers can migrate into the food. Foam products are also unsafe to use. � Follow directions when they call for a "resting" or "standing" time after cooking. Water, fat and sugar molecules vibrate to produce heat and continue generating heat when the oven turns off. Use a food thermometer to confirm the temperature. � To reheat foods, cover with a lid or microwave-safe plastic wrap to hold in moisture. Turn back a corner to vent steam. � Smaller-sized popcorn bags should not be cooked as long as the larger bags. � Some products come in packages that look like paper but are lined with aluminum and are not safe to use in a microwave. Chinese take-out containers are a no-no because of the metal handles. � Clean microwave ovens with baking soda, mild soap or dishwashing liquid; never use steel wool, scouring pads or oven cleaner. I 8 types areyou? I f you cut fat from your diet and are meticulous with sunscreen coverage, you may unwittingly create a vitamin D deficiency and put yourself at risk for immune problems, asthma, cancer and cardiovascular disease, in addition to osteoporosis and weakened bones. Vitamin D is present in a few foods, available as a dietary supplement or made by our bodies when certain processes are activated by sunshine. "But if you don't get exposed to the sunlight, then you're not getting sufficient vitamin D," warns Donna Bacchi MD, chair of the Public Health and Preventive Medicine program at Upstate. Those who are at particular risk of deficiency are: � people who live in cloud-covered Northern climes such as Syracuse, � babies who are exclusively breastfed, � older adults whose skin is not as efficient at synthesizing vitamin D, � vegans or vegetarians who don't eat a lot of fish or vitamin D-fortified dairy products, � dark-skinned individuals, since pigmentation prevents vitamin D from being processed, � obese people, because fat alters the release of vitamin D into circulation, of people are at risk for vitamin D deficiency. � people whose exposure to natural sunlight is limited, including those who are housebound and women who wear long robes and head coverings for religious reasons, and � people with Crohn's disease, cystic fibrosis and some forms of liver disease, who may have trouble absorbing vitamin D. The recommended daily allowance has recently increased to 600 milligrams per day for someone under age 70, and 700 milligrams for someone over age 70. The best food sources include fatty fish such as wild-caught salmon, albacore tuna, sardines, herring and mackerel; egg yolks; and fortified orange juice, milk and other dairy products. Few people get adequate amounts of vitamin D through their diets. To find out your level, ask your health care provider for a blood test. If your level is low, he or she may recommend dietary supplements. Just be careful not to take more than you need. Vitamin D is a fat soluble vitamin, which means it does not get flushed out of the body easily. If you take too much, it can accumulate and cause serious harm to your heart and kidneys. G 18 U P S TAT E H E A LT H fall 2012 w w w. u p st ate . e d u LEISURE Why I love gardening BY KRISTINA SHERMAN Sherman has a vegetable garden that is 40-feet-by-60-feet, an apple tree and some smaller vegetable, herb and flower gardens, where she spends hours each day during the growing season. Here's why she loves it: 1. I saw how happy it made my mom and grandma. And when I did some genealogy research, I found that I come from a very long family of farmers. I grew up in Aurora. In the summer my mom would have a job list for us. We'd have to weed a row before we could go down to the lake and play for the day. So it reminds me of those times. 2. My husband, Ed, didn't grow up gardening, but now he gets it. And my children � Madeline, 9, and Braden, 7 � help me plant. It's a nice family activity. 3. My extended family shares with each other whenever we may have a bumper crop. My sister and Mom share tomatoes with me, and I share things like strawberries and raspberries with them. My grandmother is 97 and still has her own gardens, and I really enjoy talking about gardening with her. 4. In the spring everybody knows that I'll put on Facebook: "I'm digging up perennial flowers. Come get some." I like trading flowers with friends. I'll plant something in my garden, and when I see it bloom, I think of the person who gave it to me. 5. I do "companion planting," which means that certain things grow better when they're near certain things, so I research all winter long. I keep a gardening journal, and I use Cornell Cooperative Extension to troubleshoot. It keeps me occupied all winter. 6. My children don't mind eating vegetables because they're so, so good when they're fresh. It's hard to buy produce at the store after you've had it fresh grown at your house. There's definitely a taste difference. 7. Nothing ever goes to waste. I'll make relish and pickles and jams forever until I use everything up. I can or freeze everything that we don't eat immediately. The only thing I haven't figured out how to preserve is asparagus. It does not freeze. I make 40 quarts of tomato sauce and that gets us through the winter. 8. I've never calculated how much, but I'm sure it saves money. If I had to buy asparagus to eat every day for two weeks, I'm sure it would get pretty pricey. A few years ago, I invested $10 for 50 strawberry plants with tiny, tiny little roots � and I picked 50 quarts of strawberries the next year. I have really good soil for strawberries. 9. People call me Farmer Kris. I take that as a compliment. G G ardening is a lot of work, but Kristina Sherman says it is rewarding on many levels. "It's hard to explain unless you actually do it. There's something very special about it," she says. "It's how I grew up. I tell people it's a genetic disorder; it's almost like I can't NOT do it." Kristina Sherman is a respiratory therapist at Upstate University Hospital's Community campus. Knowing changes everything.SM fall 2012 U P S TAT E H E A LT H 19 LEISURE Burn he exact number of calories you burn is affected by your age, body size and composition and your level of physical fitness. Use this as a guide, for a person weighing 176 pounds who does the activity for an hour: calorie T Sparring practice 660 calories Interest grows in sport that combines swimming, biking and running T Frisbee 480 calories Lawn mowing 540 calories he Athleta Iron Girl Syracuse Women's Triathlon (pictured above), on Aug. 5, 2012 sold out 1,300 slots in 25.5 hours. The first Ironman triathlon in New York City, on Aug. 11, sold out 3,000 slots in 11 minutes. Membership in USA Triathlon has ballooned above 150,000, from a mere 15,000 in 1993. Swimming, biking and running (no matter the distance, which varies depending on the race) are each challenging in their own ways. Combined, they create a sport that has become enormously popular. Drawn by camaraderie, mental and physical intensity and a fun way to stay fit, triathletes of all ages are flocking to the sport. Meet eight triathletes from Upstate: Darcy DiBiase, 33, of Fayetteville ASSISTANT DIRECTOR OF MARKETING Miriam Donohue, 28, of Syracuse POST-DOCTORAL STUDENT IN NEUROSURGERY Lying in a hammock 108 calories Bike:Women's Specialized Dolce road bike. Shoes: Brooks Adrenaline. High school activities: All things band! I never did much of anything athletic as a kid, although I always enjoyed swimming and riding my bike. Inspiration: I have an incredible network of triathletes I know through Gold's Gym in DeWitt. Some are multi-finisher IronMen, and some are training for their first tri. Having a group of friends always ready for a swim, bike, or run, while balancing life, work, and kids is extremely motivating. Post-race reward: Cheeseburger, French fries and red wine Bike: red, silver and black 2011 Giant Defy. Shoes: Asics Gel-Landreth 7. High school activity: Volleyball. Pre-race ritual: Singing in the car on the way to the race (to wake up my lungs and get psyched); stretching, smiling (a way of dispelling pre-race jitters); and thanking God for getting me to the starting line. Post-race reward: Team meeting at Panera where we get to laugh over all the things that happened in the race and decide what we're signing up for next. Sailing 210 calories fall 2012 20 U P S TAT E H E A LT H w w w. u p st ate . e d u LEISURE Karen Gibbs, 57, of Manlius NURSE PRACTITIONER, CARDIOPULMONARY SURGERY SERVICE Dan Waterman, 38, of North Syracuse CLINICAL TRAINER IN INFORMATION MANAGEMENT TECHNOLOGY Bike: gray 10-year-old Trek. Shoes: Saucony. High school activities: Running, swimming, biking. Pre-race ritual: Hydrate, hydrate, hydrate. Fuel before race: Banana or some sort of carbohydrate. Fuel during race: Just water. Post-race reward: Cookout with friends. Favorite race memory: Seeing my friends do so well. Lorrie Langdon, 55, of Liverpool NURSE, HEART FAILURE COORDINATOR Bike: teal 2-year-old Specialized. Shoes: Saucony. High school activity: Cheerleading. Inspiration: Seeing women of all ages, shapes and sizes, including a 70-yearold woman. Pre-race ritual: None. Fuel before race: Whole wheat English muffin with peanut butter and a banana. Fuel during race: Sports beans. Post-race reward: Eating anything I want. Favorite race memory: Participating with my two daughters and co-workers. Bike: black 2011 Fuji D6. Shoes: Nike Lunarfly Shield. High school activities: Swimming, baseball. Inspiration: People who have the odds stacked against them, then overcome the odds. One of the greatest inspiration stories I've ever seen is Dick and Ricky Hoyt, (a father and son from Massachusetts who compete athletically, despite Ricky having cerebral palsy.) Lance Armstrong continues to inspire me as well. He balances his competitive spirit with personal contribution to society. His first book, "It's Not About the Bike" still rates as one of my favorite books of all time. Post-race reward: Pizza. Favorite race memory: Seeing my wife holding our dog and a sign that read, "Go, Honey, Go" at the top of one of the toughest hills I've ever climbed. Catherine Wenthen, 47, of Fayetteville SENIOR WEB DESIGNER, EDUCATIONAL COMMUNICATIONS Amy Tetrault, 38, of Central Square ASSOCIATE DIRECTOR, HEART AND VASCULAR CENTER Bike: silver second-hand Cannondale 211. Shoes: Asics. High school activity: Volleyball. Strongest sport: Swimming. Inspiration: I'm inspired by so many -- including friends -- who have courageously faced cancer. I think of them while I'm racing. Fuel during race: None. Post-race reward: A nice, hot bubble bath. Bike: a borrowed Trek hybrid. Shoes: New Balance. High school activities: Soccer, cross-country running, skiing, basketball and softball. Strongest sport: Biking. Area for improvement: Definitely running. I don't enjoy running and usually dread it. Once I'm done, however, I always regret not putting more effort into it. When I was younger and doing something I didn't enjoy, my father would always tell me to `dig deep.' I'm hoping to do that this year and improve during this part. Inspiration: Other participants. Everyone's there for different reasons, but everyone seems to support each other. Fuel before race: Gatorade and energy bars. Post-race reward: A cold beer and a fresh cheeseburger. Favorite race memory: I was surprised at how many people cheer on the participants. My husband still managed to be where I could see him after every leg that I completed. Gina Lozito-Yorton, 38, of Syracuse (at right in photo) CERTIFIED CHILD LIFE SPECIALIST FOR PEDIATRIC HEMATOLOGY/ONCOLOGY Bike: black and white 2012 Kestrel Talon 105. Shoes: Saucony. High school activity: Swimming. Strongest sport: Swimming, even though I hate swimming in open water. Area for improvement: Running. Inspiration: My patients, my parents, my husband and most of all, my sister. Pre-race ritual: I think my way through the race. Fuel before race: Peanut butter on toast and a banana. Fuel during race: energy gel. Post-race reward: Beer or ice cream. Favorite race memory: High fiving my father as I came out of the water and ran toward transition last year at Iron Girl.G Knowing changes everything.SM fall 2012 U P S TAT E H E A LT H 21 LEISURE `Stone' novel appeal goes beyond medicine BY JOEL POTASH MD good read was reluctant to pick up "Cutting for Stone," because Dr. Verghese's nonfiction writing doesn't present him as a very admirable person: He exposes his own faults. But he sure writes an engrossing novel. At some 600 pages (in paperback), I found it hard to put down. Filled with medical details, it will appeal to medical professionals as well as to a general readership. I For example, Sister Mary Joseph Praise is in labor with twins who are locked together in a way that makes delivery impossible, and she is heavily bleeding. As readers we are fearful, but Verghese switches to other events while we wait anxiously to return to the labor room to find out what happens. It takes a long time for the twins' father, Stone, to reappear, near the end of the novel, and in a surprising way. Another interesting aspect of the novel deals with the reign/dictatorship and downfall of Emperor Haile Selassie of Ethiopia, a part of history of which I was unaware and which bears similarities to the struggles with current dictators/tribal leaders and their subjects who seek greater freedom and more democratic forms of government; Egypt and Afghanistan come to mind. Highly recommended. G The title comes from Hippocrates' proscription to physicians in ancient Greece not to "cut for stone," referring to the temptation of physicians to respond to patients suffering pain from kidney stones by operating on them, even though they lacked the necessary skills and could cause more harm than good. Rather, these patients should be referred to surgeons, then thought of as lesser healers. Stone is also the name of a mysterious surgeon who finds his way to Ethiopia, where he is assisted at Mission Hospital by a nun/nurse Sister Mary Joseph Praise in caring for all comers, in spite of limited facilities and supplies. Sister is a devotee of St. Teresa of Avila, known for her passionate writings about Christ. Sister gives birth to twins, Marion and Shiva, and dies during the process. Stone, father of the twin boys, is dismayed at his inability to save Sister's life and disappears. Another couple, both physicians, care for the twins. While emotionally joined as twins, Marion and Shiva are quite different. Marion decides to study medicine and eventually finds his way to a residency in the United States, the American counterpart of the Ethiopian Mission Hospital: underfunded, caring for all comers and especially a haven for the poor/uninsured. The arduous training of a surgeon will strike a familiar note for physicians and should elicit amazement and sympathy from others. Marion, in reality "cutting for stone," becomes involved in trying rare surgical procedures, including the earliest liver transplants in desperate circumstances. Shiva eventually apprentices himself to a gynecologist and becomes famous for repairing bladder/vagina fistulas caused by the birth process, a timely topic worldwide. The theme of caring for the underprivileged resonates with what happens today. Much of the training of medical residents takes place in large public hospitals where poor and uninsured patients are beneficiaries of care at the same time they provide technical practice to the future doctors. After Verghese introduces his characters, he creates tension for the reader by abruptly leaving a story or character and cutting to another event or characters. As readers, we are left hanging, almost breathlessly, waiting for the end of the original story or the return of the character. Joel Potash MD is professor emeritus of the Center for Bioethics and Humanities at Upstate and a voluntary clinical professor in the Department of Family Medicine. Abraham Verghese MD (pictured below), professor at Stanford University School of Medicine, received an honorary degree and gave the keynote address at Upstate Medical University's graduation in 2012. "Cutting for Stone" is his first novel. He is also the author of non-fiction works: "My Own Country," about caring for AIDS patients in eastern Tennessee at the beginning of the epidemic, and "The Tennis Partner," about his friendship with a medical intern. Both books are often used in teaching humanities and ethics programs at medical schools. 22 U P S TAT E H E A LT H fall 2012 w w w. u p st ate . e d u THE HUMORIST Miranda and Lily Kramer demonstrate the "inchworm." Create your own boot camp with these `Kamp Kramer' ideas L ooking for a fun, easy way to shed unwanted pounds? Here's the perfect solution: Build your own backyard boot camp using common household items such as mulch and children. The trick is to create a fitness circuit that uses your yard's existing features to pump up the pain. WARNING: Boot camp-type workouts are strenuous. Do not continue to exercise if you are no longer conscious. My decision to build a backyard boot camp was prompted by two events: one, I wanted to shake up my exercise routine, and two, I had a fast-approaching column deadline. After some deliberation I decided on eight stations, each a minute long, with an emphasis on functional movement v. gym-type routines. To lessen the risk of me hurting myself, I enlisted my two daughters, Miranda, 12, and Lily, 9, to pre-test the circuit. From them I learned that Kamp Kramer is basically safe ... OK, maybe not 100 percent, federally-approved safe, but, you know, not overtly dangerous or anything like that. The risk of an explosion is minimal. To help inspire your own ideas, check out the stations that make up Kamp Kramer: 1. Bench Steps. On our back porch we have a wooden high-back bench that won't be completely rotted through for at least another two winters. It's perfect for a step-up drill. Step onto the bench and back down, repeating rapidly for a full minute. Not miserable enough for you? Add a weighted vest, a blindfold and an MP3 player loaded with Michael Bolton. 2. Weed Crawl. The pursuit of fitness is a worthy endeavor in its own right, but why not harness its power to do an actual chore? We have a chronically weedy brick patio, but it's less weedy now thanks to this total body beatdown. Maintaining as close to a push-up position as possible, walk on all fours across any weed-infested surface, pulling up a weed each time your hand touches the ground. It's an environmentally friendly way to kill unwanted vegetation � or at least wound it � while developing the same muscles you'll need to scuttle out a side door to avoid capture by the FBI. 3. Slide Sit-Up. A seldom-used backyard slide just got repurposed into an ab workout from Hell. Lie on the slide on your back with your feet on the ground and your hands extended behind you, gripping the sides of the slide. Lift and lower your legs and repeat for a minute that feels like a month. The isolation of the muscles is so total that Lily, a fit soccer player and dancer, suffered stomach cramps, and Miranda emitted audible sounds of suffering. As a boot camp designer, these are the moments you live for. 4. Circles of Haul. A wheelbarrow with a flat tire works best. Load it with as many bags of mulch or manure as you can handle, and push it around the yard, making ever tighter circles as you go. The more uneven the load the better. This one isn't so much about feeling the burn as it is about feeling dizzy and nauseated. 5. Satan's Picnic. Grasping about 20-pounds of weight depending on your fitness level, walk sideways up and over a picnic table and then back the way you came. Repeat for 1 minute. To increase the difficulty, perform while others are sitting at the table trying to enjoy a picnic. 6. Inchworm. Put those snow tires in the garage to good use. Lay them out in a line. Pick up the first one and run it down to the far end, placing it after the last tire. Run back to the start and repeat, slowly inching the line of tires across the yard. This exercise works the legs and upper-body and has that "X" factor every boot camp needs: It feels totally pointless and stupid. 7. Sloggin' Toboggan. Load several bags of mulch or manure onto a plastic toboggan. Get a good grip with both hands on the rope handle. Pull the loaded sled across the lawn as if you're a horse pulling a plow. You'll want to wear gloves for this, too. For an extra burst of cardio -- and personal humiliation -- perform the toboggan pull while yodeling. 8. Tire Squat. Again we take advantage of the kids' play set, this time the tire swing. Hold the top of the tire with two hands and lean back at a 45-degree angle so the tire -- and your arms -- are extended in front of you. Now slowly squat and return to the leaning-back position. Repeat the movement multiple times. You should feel a searing burn in your quads. If it's a warm day you might also feel a searing burn on your palms. Youch! That tire is hot! Thanks to the pre-test, I knew to don protective gloves. Thanks for the heads-up, girls! G Veteran journalist Jeff Kramer also writes for the "What's Up at Upstate" blog the first Monday of every month at upstate.edu/whatsup. Knowing changes everything.SM fall 2012 U P S TAT E H E A LT H 23 Non Profit Org. US Postage PAID Permit No 110 Syracuse, NY 750 East Adams Street l Syracuse, NY 13210 arly heart formation in zebrafish is remarkably similar to what takes place in humans. Transparency of the embryo and rapid heart development make zebrafish especially appealing to scientists who research the causes of cardiac birth defects. Upstate's Jeffrey Amack PhD, an assistant professor of Cell and Developmental Biology, concentrates his work on cardiac morphogenesis, or how the heart takes shape. He studies genes that control positioning of the heart in zebrafish and has found that some of these genes are also critical for normal human heart development through collaborations with clinical geneticists whose patients have family histories of congenital heart defects. This image, taken by PhD student Yongchang Ji, shows a cross section of a developing heart in a zebrafish embryo only two days after fertilization. The ventricle (top chamber) and atrium (lower chamber) have formed and contraction of the heart has already established robust circulation in the embryo. The muscle layer of the heart (labeled red) covers the inner lining of the heart (labeled green). The blue areas represent individual cell nuclei. E Jeffrey Amack PhD Yongchang Ji T 1S SCIE R A NC S I E NC E IS A RT IS SCIE IS SC I T R A EN IS C 12.1650812 31.2M ELsk E IS A RT S C I E N C E