STUDENT JOURNAL OF NEW YORK MEDICAL COLLEGE
ABOUT THE COVER: Cover artwork by Oded Tal. Cover design by Quill & Scope Art Staff.
Quill & Scope, Volume VI is dedicated to those who donated their bodies to the New York Medical College Gross Anatomy Program. Your generous gifts have inspired many, and will endure as the ultimate lesson on “where the heart lies.” For more on the artwork, please see Convocation of Thanks — June 2013 by Oded Tal (p. 44).
NOTE TO OUR READERS: Quill & Scope is transitioning to a Fall publication schedule. We apologize for any confusion in the chronology of Quill & Scope, Volume V (Winter 2013) and Quill & Scope, Volume VI (Fall 2013).
PUBLISHED ANNUALLY BY THE STUDENTS OF NEW YORK MEDICAL COLLEGE
FALL 2013 EDITORS IN CHIEF Molly Deacutis David Gedeon Ryan Lippell Victoria Mock MANAGING EDITORS Julia Cooperman Bailey Fitzgerald Eric Routen
ART DIRECTOR Joanne Liu
EXECUTIVE FACULTY ADVISOR Gladys Ayala, MD, MPH
Gladys Ayala, MD, MPH Francis Belloni, PhD Christopher Cimino, MD Montgomery Douglas, MD Jan Geliebter, PhD Kenneth Lerea, PhD Stephen Moshman, MD
EDITORIAL BOARD Padmini Murthy, MD Elliot Perla, MD Susan Rachlin, MD Sansar Sharma, PhD Sean Kivlehan, MD, MPH Linda DeMello Navid Shams
Amin Esfahani Michael Rahimi Molly Deacutis David Gedeon Ryan Lippell Victoria Mock
STAFF EDITORS Syed Ali Xiomara Antonetti
Matthew Garofalo Erica Jacovetty
ART EDITORS Zan Naseer Oded Tal Grace Yau
Meghan Kiley David Shottland
Parvati Singh Jane Song
WEBMASTER David Shottland
Quill & Scope is an annual NYMC student publication dedicated to promoting awareness of the personal, social, economic, and ethical issues confronting the modern physician. It was founded in 2008 by medical students Christine Capone and Sean Kivlehan. The articles selected for publication have been chosen for their literary or artistic merit. They do not necessarily represent the opinions or views of the editors, faculty, or New York Medical College. All rights reserved. No part of this publication may be reproduced, stored in electronic format, or transmitted in any form without the express permission of New York Medical College.
Quill & Scope 2013, Vol. 6
Quill & Scope 2013, Vol. 6
Quill & Scope 2013, Vol. 6
A Letter From The Editors... On the cover of this Sixth volume of Quill & Scope, we see one medical student’s creative reflection on “Where the Heart Lies.” Medical school can at times bewilder and overwhelm students, just as a New York City subway map can perplex and intimidate tourists. But even if you go uptown instead of downtown, reach the platform as a train departs or find yourself seatless in a stuffed rush-hour subway car, there is an intangible excitement in taking the slightly longer, more challenging route, knowing that perseverance will ultimately steer you to your destination. As medical students pursuing our dreams of becoming physicians, a part of all our hearts lies in medicine. However, we all still maintain individual lives outside of medical school, leaning on these personal interests and endeavors for balance in the inevitable moments of uncertainty. Inside this issue of Quill & Scope, students explore and share these balancing forces with the same fervor with which they approach the study of medicine: commitments to family and loved ones; creative outlets in art, photography and poetry; patient and healthcare advocacy; basic sciences and clinical research. Just as many people and places seem to need our hearts’ careful attention, we need outlets like Quill & Scope to self-reflect and achieve sustenance. Through artwork, poetry and prose, this volume of NYMC’s student journal reminds us to wear on our sleeves that which we value outside of medicine. And in so doing, perhaps we will be better suited to hold close to our hearts the unbridled enthusiasm that first called on us to dream and aspire to become physicians. We hope this collection of pieces paints an insightful picture revealing the human side of medicine. It would not have been possible without the dedicated efforts of so many contributors, student editors, and faculty editors and advisors. To our faculty advisor, Dr. Gladys Ayala, MD, MPH, we thank you for your continuous support throughout the creative process; for six years and counting students’ voices have been heard and published and this is a testament to your efforts. To Dr. Edward Halperin, MD, MA, we welcome you to the NYMC community and thank you for offering students the opportunity to get to know you through our journal. To Drs. Patrick Lento, MD and Julia de la Garza, MD, we thank you for sharing your path with us (pun intended) and continuing to educate and inspire students. And to our readers, may this issue find its way into your hands and your hearts.
From the bottom of our hearts, Molly Deacutis, David Gedeon, Ryan Lippell, and Victoria Mock Editors-in-Chief, Quill & Scope, Vol. VI
Quill & Scope 2013, Vol. 6
Table of Contents CONVERSATIONS Behind the Man in the Suit: Interview with the Chancellor
Quill & Scope Managing Editors and Art Director Interview with Drs. de la Garza and Lento
Quill & Scope Editors in Chief
PERSPECTIVES Cancer Immunotherapy Comes of Age
Michael Karsy & Bryant England Modern cancer immunotherapy is the reemergence of an old field striving to use the bodyâ€™s immune system to target cancer. Though cancer subverts the innate and adaptive immune systems, various non-cellular and cellular based therapies have been developed to overcome these mechanisms. The variety of these techniques and their potential in the treatment of cancer has been a truly exciting development in medicine. A Case for Patient Empowerment Through Education
Gabrielle Hatton Non-communicable diseases are now the leading causes of morbidity and mortality in the United States. These non-communicable diseases are primarily influenced by sustainable health behaviors such as eating, exercise, and substance use. In order for patients to be held accountable for their health behavior, they must be properly educated on the relationship between behavior and disease prevention. The investment in primary and secondary health education should be a top strategy in decreasing the incidence of chronic diseases and health care spending in the United States. For Pappou: Loss During the Clinical Years
Christopher Meltsakos Our medical education is comprehensive in that it is a compilation of book learning, clinical skills, and life experiences that come together to help shape us into the best possible physicians. We sacrifice many things, whether it is our sleep, holidays, or weekends, and part of our ordeal is learning to balance our family lives with our work lives. This piece is a personal account of the authorâ€™s experience with the loss of his grandfather at the start of the third year clinical rotations.
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Table of Contents REFLECTIONS Convocation of Thanks The text of speeches delivered at the annual Convocation of Thanks ceremony, in remembrance of those who donated their bodies to the NYMC gross anatomy program.
POETRY Memoirs of a Machine
Joshua Liu Against Hasty Rotations
Allison Maidman Quitting
Julia Meisler Child
Kanthi Dhaduvai Surgery (Itâ€™s All About)
Jordan Teitelbaum Selected Poems
ORIGINAL FINDINGS A 10mm Posterior Inferior Cerebellar Artery (PICA) Aneurysm Missed on DSA: Case Report
Christopher Meltsakos An unusual case in which the gold standard technique of Digital Subtraction Angiography failed to reveal a left PICA aneurysm after previous detection on 64-slice Computed Tomography Angiography.
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Table of Contents NYMC MEDICAL STUDENT RESEARCH FORUM ABSTRACTS ORAL PRESENTATION WINNERS Omega-3 Polyunsaturated Fatty Acid Status in Major Depression With Comorbid Anxiety Disorders
Joanne Liu, 1st Place A Murine Lung Cancer co-Clinical Trial Identifies Genetic Modifiers of Therapeutic Response
Katherine Cheng, 2nd Place Repair of Nonunion Defects in Rat Femurs Using Multipotent Adult Stem Cells
John Swietlik, 3rd Place
BASIC SCIENCE POSTER PRESENTATION WINNERS Artificial Lamellar Cornea Based on PEG/PAA
Luo Luo Zheng, 1st Place A 34-Amino Acid Peptide as a Neurotropic Vector for Mediating Treatment of Neuronopathic Lysosomal Storage Diseases
Ryan Lippell, 2nd Place
CLINICAL SCIENCE POSTER PRESENTATION WINNERS Impact of Hormone Therapy in Women’s Health Initiative on Glioma Incidence
Bryant England, 1st Place & Dean’s Research Award Winner Surveillance Strategies for Severe Traumatic Brain Injuries Undergoing Arctic Sun Protocol
Mohamed Saleh, 2nd Place
ART AND PHOTOGRAPHY Creation — Joanne Liu
Cellist (2010) — Oded Tal
Cellist (2010) — Oded Tal
Balance — Michelle Wu
Studious — Nina Beizer
Wake Up — Shirley Hu
Untitled — Nina Beizer
Spotted — Joanne Liu
The Climb — Joanne Liu
Alice — Grace Yau
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Quill & Scope 2013, Vol. 6
Behind the Man in the Suit: Interview with the Chancellor Quill & Scope Managing Editors & Art Director
uill & Scope (QS): To start off, for someone who has never met you, how would you describe yourself?
Dr. Edward Halperin (EH): As a pediatric radiation oncologist, as an administrator. People who spend their lives deciding whether or not to irradiate children with cancer, how to aim beams, and what are the best beam arrangements are usually very thoughtful, meticulous, and contemplative people.
patients are very sick, and you’d be good at that.” After that, I took a two-week elective in radiation oncology because a psychiatrist from Waterbury, Connecticut thought I might be a good radiation oncologist, and I hadn’t found anything else that I wanted to be. That’s how I ended up as a radiation oncologist. I ended up as a pediatric radiation oncologist because I was always concerned with what I thought was the most consequential, high-risk thing a person could do; I decided that for radiation oncology it was taking care of kids with cancer.
QS: What set you on the path to be a pediatric radiation oncologist, or a physician in general?
EH: The system at Yale Medical School was that you were assigned a faculty advisor. The faculty advisors were often volunteers, not full-time members of the faculty. I was assigned to a private practice psychiatrist in Waterbury, Connecticut named Irwin Greenberg. Dr. Greenberg established a custom of meeting at the Connecticut Mental Health Center, where we would get two cups of tea from the vending machine, and he would talk to me. That was my advising system. When I was a first semester, first-year medical student, he asked me how school was. I told him that Embryology was very hard, and asked if he had any advice. He told me to study, and that Embryology was very important. When I was a second semester, firstyear student, he asked me how things were going and I told him that Gross Anatomy was very hard. He told me to study, and that Gross Anatomy was very important. For three years, once per semester, Irwin Greenberg told me that I needed to study. That was his general proposal to my problems. At the end of the third year of medical school, he asked me what I was going to go in to, and I said that I didn’t know—that I hadn’t found anything that particularly caught my attention. He said to me, “You should be a radiation oncologist. It’s very hard, and has a lot of physics. The
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QS: That really speaks to the importance of mentors in your life. Has anyone else been a mentor to you?
EH: The literature on mentorship is actually quite mixed. What you just said is standard in medicine: that mentors are very important. If you look critically at that literature in medical education, it’s debatable whether they are or not. But if I had to pick people, I would say my chief-ofservice when I was a resident. Dr. Herman Suit is known as the inventor of the Fletcher-Suit Apparatus for treatment of carcinoma of the cervix, for the identification of hypoxia as an important issue in tumor radio-resistance, and for the limb sparing surgery for sarcomas. He is a very polite, very thoughtful man with extremely high standards. He never raised his voice, never belittled anyone who worked for him, and is quite genteel. I think the proudest moment I ever had in my career in academic medicine was to say that I was a House Officer of the Massachusetts General Hospital, and that I was Herman Suit’s Chief Resident. Where I went to medical school, you had to write a thesis for your MD, the same way that you have to write a thesis for a PhD. My thesis advisors were Samuel Thier and Leon Rosenberg. Thier later became President of Brandeis, President of the Institute of
Interview with Dr. Halperin Medicine, and Physician-in-Chief of Massachusetts General Hospital. Rosenberg was later the Dean of Yale Medical School. I admired them. I suppose the last person I could tell you about was my uncle [Dr. Halperin shows us a picture he keeps on his bookshelf]. Justice Nathan Jacobs of the New Jersey Supreme Court was the judge who desegregated the schools of New Jersey, issued the rulings on administrative law—what the difference is between laws made by government commissions versus the elected officials of the legislature—and he also wrote a well-known decision on freedom of speech. When I was a little boy, I wanted either to grow up to be my uncle Nat and be a judge on the Supreme Court or to grow up to be Nicholas Katzenbach, the Associate Attorney General [who took an active role in the Justice
Department’s fight for civil rights].
QS: So you didn’t always want to be a doctor? EH: No. I wanted to be a lawyer and a judge. When I was your age, there was a famous picture of a balding man, perspiring profusely, mopping his brow with a handkerchief, standing in the door of the University of Alabama followed by federal marshals, telling George Wallace to get out of the way because the University of Alabama was going to be desegregated. Then, the same man stood at the University of Mississippi. His name was Nicholas Katzenbach. He died about a year ago. He was the Associate Attorney General under Bobby Kennedy, and I thought that the most glorious thing must be the person whose job it was to create equal opportunities in education. I wanted to be a lawyer. Because my uncle had gone to The Wharton School and Harvard Law School, that seemed like the right thing to do. I was an undergraduate at The Wharton School and I decided partway through Wharton that lawyers spend a lot of time getting people out of trouble that they got themselves into, whereas doctors spend more time grappling with the fundamental forces of evil in the world. I had dinner with my parents and told them that I didn’t want to go to law school anymore; I was going to medical school. But I never dropped out of Wharton. I graduated from Wharton and then went to medical
school. I have no stories for you about always wanting to be a doctor as a little boy. I got the idea when I was about eighteen or nineteen.
QS: You mentioned that when you were meeting with your advisor while at The Yale School of Medicine, medical school was hard for you. That is certainly something medical students today would agree with. What are some other similarities and differences that you see between your experiences as a medical student and being a medical student today?
EH: If you were to give me a psychological test, you would find that I score high on the introversion scale. I am not an outgoing person. I was not at ease talking to strangers. When I was assigned to walk into the hospital and find any patient at all to do a history and physical, I was too embarrassed to do it. I couldn't do it. I wasn’t going to walk up to some stranger. I wrote a case history about myself in order to complete the assignment because I was too embarrassed to interview anyone else. Medical school was hard because I was an Economics major. When I went to Yale, some of my classmates had already published in the peer-reviewed scientific literature, while I had never taken biochemistry. For the first couple of weeks, I didn't think medical school was that hard because I thought, “You don’t have to know that much detail. You just have to know the broad concepts.” Then I did terribly on my first exams and thought, “This is serious. This is very hard. I had better get out little index cards and write everything down.” I don’t know about similarities with current students. I never had a car until I was an intern, so I couldn’t go anywhere for rotations that I couldn’t either walk to or take the bus to. I lived in the dormitory for all four years in New Haven, and walked everywhere that I had to. The faculty thought I was unusually serious for a medical student. Even when I was a resident, the other residents used to call me “The Professor.” I was 24 or 25, and I didn’t seem to act as young as they thought typical. Even though I was much younger than they were, I always took things very seriously.
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Quill & Scope Staff I was single until well into my residency, so my life was school and work. That’s what I did. That, indeed, was almost everything I did. I used to say that a lot of the patients are not going to do well, but if I make a mistake they definitely won’t do well, so I had better not make any mistakes. I was very attentive to the patients.
started sending emails to people asking for advice, “Is this the best thing to do for my patient?” I was compulsive about my reading. I read about every patient I take care of and also read general medical journals so I know what’s going in medicine.
I started medical school in 1975. Statistically, that was one of the hardest years to get into medical school out of the last 40 or 50 years. The ratio of available medical school seats to applicants was least favorable to applicants in those years. There was still a war in Vietnam. Some people were going into medicine, divinity, and public health not because they were interested in it, but because they just wanted to stay out of the war. The probability of not getting into medical school at all was very high in my years, but I never had any idea of doing anything else. Whether I was foolish or not, I never had a Plan B.
I decided, when I was your age, that I wasn’t going to get sick being a doctor. I wasn’t going to get into the habit of eating take-out and junk. People who don’t eat and don’t sleep eventually get sick and aren’t very good doctors. Before I became an intern I had my mother give me a lesson in how to shop for food and how to cook so I knew how to make a small number of things, enough so that I knew how to feed myself. I would go to the supermarket and I would buy real food. I swore that I wasn’t going to end up with bags of greasy take-out. I was going to sleep when I had time to sleep so that I wouldn’t get sick. That doesn’t sound like the most profound advice, but it’s the advice I followed when I was young.
QS: I think many of the students here will relate to a
QS: Does it sound similar to the advice you might give
lot of the experiences that you have just described. If you could go back to the young Dr. Halperin in training and give him any words of advice or warnings, what would you say to him?
your students now going forward? To take care of yourself?
[contemplative pause] Patients are perishable; you always remember that. Everything that a patient tells you is a potential clue to what’s wrong. People have diseases, organs don’t. Therefore, I took detailed histories and made long lists. I decided when I was your age that you didn’t have to be William Osler and have enormous insights to be a good doctor. What you have to be is extremely compulsive. If that meant that Mr. Jones had a chest x-ray, and you put it on your list of things to do, then you didn’t go home until you checked the results of Mr. Jones’ x-ray. Therefore, I always walked around with my pocket full of index cards and my lists, and I didn't go home until everything was checked off of my lists or I was sure that somebody was going to follow-up on something on my list. I was the same way as a resident. I learned, I think, as a young doctor, to always ask for help from people who knew more than I did. I got into the habit, very early, of spending a lot of time on the phone calling people who didn’t know who I was for advice about patients. When email came along, I 4
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EH: Medicine is the most important secular work a human can engage in. If there is holy work in our secular lives, it’s medicine. It’s a calling; therefore, you devote yourself to it. But you’re of no use to your patients if you’re not taking care of yourself. In the years since I went to medical school, there’s been lots more interest in self-actualization and self-awareness and being in a good mental place yourself. I am clearly not of that generation. I doubt that my professors ever spent any time worrying whether Edward Halperin was feeling good about himself or comfortable in his space, and all the sorts of mental health things that people talk about now. I’m sure they’re important, but when I was your age you took care of your patients and tried to “take care of yourself.”
QS: What are some of your crazy stories from your time in medical school?
EH: I don’t have any stories to tell you about my wild younger years because there are not any stories to tell. I never had a taste for beer. I couldn’t understand the point of it. I have no moral objection to peo-
Interview with Dr. Halperin ple who drink liquor but it didn’t taste good to me. If I was thirsty I wanted to drink something so I wasn’t thirsty anymore. I have no stories of drunken binges in college or medical school. I drank some beer and thought, “This tastes like burnt bread to me. I don’t know what the point of this stuff is.” And that was the end of that. I have no stories for you about experimenting with drugs. I wasn’t interested. I never was involved in it. I never was on any soap boxes preaching against it; I was just indifferent.
Haven. He had the windows open. The wind was blowing off of Long Island Sound. It was freezing. I was wearing my little interview Harris Tweed sport coat, and his office was covered with plaques of silly little slogans like, “When the going gets tough, the tough get going.” He had longhorns bolted on his wall because he’d gone to the University of Texas. I sat down and said, “Interesting office, Sir.” And he told me his life story for the next 59 and ½ minutes. He didn’t ask me a single question. I listened politely and after I left, since I didn’t drive, my sister picked me up and asked, “How’d it go?” I said, “I don’t know. The man didn’t ask me a single question!”
My first interview for admission to medical school was at Hahnemann [Drexel University]. I walked 25 I was admitted to Yale. blocks to my interview in downtown Philadelphia. The I was working as a janitor interviewer’s first question to that summer at the end of me at my first admissions incollege, cleaning a typewriter terview was, “Tell me, young factory and a bank, and a “Patients are perishable. man. What do you think of all woman called me one afterYou always remember this illicit, immoral, outranoon and said, “This is Lilian geous, disgusting, premarital Dalton, the Registrar of the that.” sex that is rampant in your Yale School of Medicine. I am generation?” I said to him, instructed to offer you a posi“You know Sir, I’ve been tion in the incoming raised in a somewhat religious class. Do you accept?” I said, household. I am told there is a “Well, thank you very sexual revolution going on in this country but I am a much. I’ll have to think about that.” (I was planning noncombatant. Perhaps we could talk about someto go to Einstein at that time.) She said, “I beg your thing else this afternoon?” He looked back at me and pardon?” I said, “I’m on my way to work now, Ma’am, said, “Oh. Ok.” That concluded that part of the conand I’ll have to think about this. I’ll get back to you in versation. I’m sure if anyone asked such a question a few days.” There was a pause, and Mrs. Dalton said, now they’d be up on charges. “Young man. People usually know if they want to go to Yale.” I said something like, “Well, this one needs to I don’t have any fabulous stories about my wild and think about it, Ma’am.” Eventually I decided not to go dissolute youth. I missed all that. to Einstein and to go to Yale. I had to tell the foreman for the janitorial service that I was leaving. He said, QS: You told us in the History of Medicine class about “Where are you going?” I said, “I’m going to Yale.” He said, “You’re leaving me for a lock company?” how medical school admissions started, and that is a very interesting start to your medical school admissions journey. Do you have any more stories that stick out in your mind about that time in your life, when you were trying to get into medical school?
I remember my interview for admission to Yale. The man who interviewed me was in a tiny office, an oversized closet, and it was January in New
QS: Can you tell us a little bit about your path to academic medicine?
EH: I never went through a stage of either going into private practice or thinking much about going into private practice. When I finished my residency, I interviewed for a couple of jobs in private practice. I Quill & Scope 2013, Vol. 6
Quill & Scope Staff tried to calculate what my income would be and how I would run a practice. By that point, Sharon and I had just gotten married and we tried to think it through. I went back to talk to my chief at Massachusetts General where I was Chief Resident. I told him about the jobs that I was looking at. When I mentioned that I had interviewed for some private practice jobs, he took his left hand, and went [waving it across his body in a dismissive fashion], “Oh no, no, no, no, no, no, no.” That ended my thoughts about ever going into private practice.
ent accents, but you can plop an academic physician down in another academic medical center and, in my experience, you’re ready to go to work in about an hour or so, once you figure out what floor the diagnostic radiologists are on, where the pathology department is, where the linear accelerators are, and how to do the medical records. All the discussions about getting oriented have to do with life outside of medicine in my experience: Where is the supermarket? How do I pay taxes? How do I get a driver’s license?
The job I wanted was the position of pediatric radiotherapist at the Hospital for Sick Children in London. I interviewed by phone in an era before cell phones. It was a big deal to have a long distance call. I got the job. I asked what the salary was going to be. The man said, “Why... £10,000.” And I said, “Per?” He said, “Year.” I thought, “I’ve just been offered $18,000 a year to live in London and I’m married and have a baby. I can’t afford it.” I watched my career in London disappear. Therefore, I interviewed for a few other academic jobs at Hopkins, Yale, and Duke. The only place that I had a really good offer that didn’t already have somebody doing pediatric radiotherapy was Duke. They had fired the entire department of Radiation Oncology and were rebuilding from scratch. The new chairman needed people. I was 29, an Assistant Professor, and I was in charge of Pediatric Radiation Oncology at Duke. I stayed at Duke for 23 years.
The transition from Louisville to here is mostly about the transition from being dean of the medical school to being Chancellor of the college and being Provost for Touro. When you’re dean of the school of medicine, you are concerned with the MD students, the residents, and hospital relations. In this job, I have to be responsible for that, plus the Ph.D. students, the Masters students, the D.P.T. and M.P.H. students, the audiology students, things in the Touro system, buildings and grounds on this property, fundraising, the budget of the college, etc.
I do not have any stories for you about any time in private practice. It never substantively occurred to me.
QS: You came to New York Medical College from the University of Louisville School of Medicine. What’s been the biggest adjustment for you?
I was the chairman of radiation oncology at Duke, then I was vice dean of Duke University School of Medicine, then I was the dean of the School of Medicine of the University of Louisville, and then I came here. What are the biggest adjustments? In academic medicine, there are actually relatively easy transitions. There’s a hierarchy. There are professors, associate professors, and assistant professors. There are attendings, residents, and medical students. There are departments and divisions. The patients have differ6
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I could answer your question by doing stand-up comedy about New Yorkers compared to Kentuckians and North Carolinians, but people are people; they have somewhat different accents, and the weather is different, but I don’t think there are any substantive differences.
QS: How do you balance all of your various roles? EH: This is the longest I’ve gone in my life without practicing medicine and I’m not happy about that. I still don’t have my credentials to practice. I’m going to resume practicing medicine as soon as that paperwork is done. That’s very important to me. Once I’m back practicing medicine, the most important thing is taking care of patients. And I have to be responsible for teaching. When you are an administrator, all sorts of people come rushing around saying, “This is a crisis.” A crisis is a 9 year old with a brain tumor. Whether someone has their laboratory equipment delivered on the wrong day or preparing press releases... these are not crises. When you continue to practice medicine, then you will understand how to keep things in perspective. Whenever I would have a difficult time at work as dean, Mrs. Halperin would say, “Don’t wor-
Interview with Dr. Halperin ry. It’ll be Wednesday soon, and you can relax. You’ll see people with cancer.” What she meant by that was, “Once you’re practicing clinical medicine again you’ll be okay and things will be in perspective.”
QS: Are there any other humanities that you’d like to
How do you maintain balance? It’s a marathon, it’s not a sprint. You figure out what needs to be done and you put things in order. In academic administration it’s more important that you get things right than that you get them fast.
tersection of Religion and Medicine” and it will be offered to second year medical students. It will be a medical ethics course, but rather than beginning with lectures about beneficence, nonmaleficence, and justice, we’ll talk about practical issues where medicine and religion butt up against each other. How do you handle a patient who says, “I won’t eat that. My religion says I can’t eat that, doctor,” but you think they ought to eat that? How do you handle someone who says, “I won’t take a blood transfusion because my religion says I can’t take a blood transfusion”? How do you handle a case where a family says, “I won’t accept an autopsy for religious reasons”? You may think it’s indicated, but they say their religion won’t tolerate that. What do you do if someone says, “I hear voices in my head of Satan arguing with Jesus and they’re telling me to hurt myself and others”? You reply, “I think we should get a psychiatric consult.” The patient says, “That’s fine, but I’ll only see a Christian psychiatrist.” Right now the only psychiatrists on duty are Dr. Vischwanan and Dr. Weinberg. You haven’t asked either of them their religion, but you don’t think that either of them are going to meet the criterion of ‘Christian psychiatrist.’
You already told us a little bit about the importance of teaching. You’ve already managed to add a History of Medicine class to the first year curriculum—can you tell us a little bit about where that interest came from?
EH: When I was an assistant professor I started to wonder how the hospitals had been desegregated in North Carolina. Who had decided how to desegregate a hospital? What did it mean to desegregate a hospital? What does it mean to racially integrate a medical staff? I started driving around North Carolina with my Dictaphone and interviewed black and white physicians, dentists, and hospital administrators who had lived through the desegregation of the hospitals in the 1960s. That is when I did my first article on the history of medicine, which I ended up publishing in the New England Journal of Medicine. I probably should have retired then. I remained interested in the history of racial, religious, and gender discrimination in medicine. Subsequently I did projects on anti-Semitic quotas for admission to medical school, on bias against women in standardized tests, and on the role of white physicians in the care of enslaved African Americans. How did I get interested? I’m nosy. I think there are interesting stories in the world. Medicine is fundamentally a story-telling field. That’s why clinical medicine includes a medical history. When I was vice dean at Duke, I went to graduate school and got an MA degree (going to school during my lunch hour and at night) to get some formal training.
involve in the medical school curriculum going forward, or any other changes that you’d like to see?
EH: The next course I’ll offer will be called, “The In-
All of the stories that I just told you are from my practice; I didn’t make any of them up. I think an interesting way to start grappling with medical ethics is to have a course about that. So we will.
QS: Is that for the 2013-2014 school year? EH: Yes.
QS: Let’s talk about some of the other changes that are happening on campus. We got an email about plans for a newly purchased building. Can you tell us a little bit about that?
EH: We bought the IBM building at 19 Skyline Drive. It’s a quarter of a million square feet. Munger is ninety-thousand square feet. We are going to move everyone out of Munger, “mothball” Munger, and put eveQuill & Scope 2013, Vol. 6
Quill & Scope Staff ryone in Skyline. I think Munger is an embarrassment construction. We’ll end up with an enormous clinical and has been an embarrassment since 1971. We ought simulation facility on Dana Road for you folks. to have a decent building for academic purposes, where the professors meet with the students. Skyline was used by IBM as an education building and for QS: Do you have a timeline for these things? computer science research. It is in very good condi- EH: The Dana Road facility is supposed to be done in tion, and it’s very large. It has a 130-seat lecture hall, a April. We move into Skyline between Labor Day and full cafeteria, lots of conference rooms, lots of seminar Christmas. The exercise facility in Skyline depends rooms, and lots of offices. It will also allow us to have upon if we raise the money. Bloomingdale’s—if we additional space for the medical ethics program. If we pull it off—probably a year from now. open a nursing school, a P.A. school, and a dental program, I can put them there also, because it’s a quarter of a million square feet compared to the ninety thou- QS: Is the Dana Road facility the biotech incubator? sand in Munger. I’m going to ask the county to take Can you tell us a little about that? Sunshine Cottage Road and allow us to extend it EH: Yes. Dana Road was built straight to the back of Skyas a mutagenesis research faline Drive. I’m going to try to cility in the 1960s for the Naraise money for a campus tional Cancer Institute. It congate and money for a garden tains a vivarium and several in the middle of campus pods for research. We’ll put “My legacy will be if we with some seats. the clinical simulation facility graduate good physical Bloomingdale’s [Furniture in Dana Road, and we’re going Outlet] building is owned by to take one of the Pods and therapists and doctors New York Medical College. make it into the biotech incuand public health profesBloomingdale’s is moving bator, leaving two pods for fuout and I have three prosionals.” ture expansion. A biotech incuposals to lease Bloomingbator is a facility which leases dale’s. Two of them are from space to startup pharmaceutiexercise companies. If they cal companies and medical get a lease, then I am going equipment manufacturers who to insist that it’s a lease that think they’ve got a product includes discounted rates for New York Medical Col- that will make a big hit, but they want to have a place lege students. There may be a donor who wants to to get their company launched. It might be a company give a wellness facility for New York Medical College that makes a new drug, makes a new hearing aid, students, but if I get the tenant to agree to discounted makes a new anti-head trauma device, makes a new rates then what we’ll probably do is to build an exer- pin for orthopedic surgery, or makes medical softcise room with Stairmasters, treadmills, and other ex- ware for your iPad. All those kinds of companies ercise equipment for the students in Skyline. If you would be prospective tenants. want a swimming pool, an indoor soccer court, indoor tennis, or racquetball, that will be in the exercise building. So we’ll end up with a rather impressive—if QS: Will this have the NYMC name attached to it? this all works—set of exercise facilities for the stuEH: It will be the NYMC Hudson Valley Biotech Incudents on campus, some of which will be free just by bator. using your card (Skyline), and some of which will be for an extra fee. We’ll probably put in more housing on campus. The other big project is Dana Road. Dana Road is under 8
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QS: Those are big changes. What do you see as your legacy here? Is it this kind of thing, with new build-
Interview with Dr. Halperin ings and expanding? What’s your vision?
long answer to your question, but that’s what I think.
EH: My legacy will be if I cure or ameliorate any of the symptoms of children with cancer when I resume practice. My legacy will be if we graduate good physical therapists and doctors and public health professionals. My legacy will not be buildings and grounds, although that’s usually what people attach to legacies. It will not be how I perceive my legacy. Simeon the Righteous said, “A person is known by three things: by acts of charity, by knowledge, and by their good name.” Your most important legacy is your good name.
QS: Where do you see yourself in 5 years, 10 years, or 20 years?
EH: I think my last job will be taking care of patients and teaching history and ethics. Whether my last job will be here or someplace else, I don’t know. I would envision after I’m done being an administrator I will continue as a clinician and teacher. What is unusual about what you just asked me is that very few people with jobs like mine still take care of patients and still teach. They administrate and go to meetings. There are several reasons why I do not agree with that. I think that people who administrate should remember what business the school is really in. The business that the school is really in is not administrating, it’s doing science, providing education, and taking care of patients. I should be doing it like everybody else. There is an old expression in academics: “What is the definition of a spayed administrator? The definition of a spayed administrator is one who is unwilling to be fired or quit over a matter of principle.” People who are spayed administrators are people who don’t know how to do anything else except administrate. I decided when I was your age that I would never be in a position where I was afraid to be fired or to quit if I thought something was wrong, because I was afraid I wouldn’t be able to make a living except as an administrator. I have never been in such a position in my life. I’m always in a position where, if I think that there is a matter of principle, I could resign and go back to practicing medicine or teaching. That’s the
QS: Do you think that there are some hospital administrators who might not have that sort of insight or vision? If so, does that cause a clash between the physicians who are willing to quit or move on for their vision? Conflict between physicians and administrators seems to be an essential clash.
EH: You may encounter people who you think are doing the wrong thing but they have decided that they have a mortgage to pay or a family to support and they back down because playing in the back of their mind is the thought, “I need this job.” Therefore they will make compromises. If you want to read about this concept, I published an article called “The battle of Louisville: money, power, politics, and publicity at an academic medical center.” It was published a year or two ago. In that article, I describe how the entire Department of Neurosurgery threatened to resign from the University of Louisville and close a Level 1 Trauma Center, and what I did in response to that. I felt it was a test of my will. We were going to see what I was made of. I was not going to lose. I thought that it was racist to threaten a Level 1 Trauma Center. I thought that the doctors were worried about their own personal incomes rather than the care of the poor, black, and marginalized of Louisville. I thought they were going to destroy the school. I said, “I will fight this to the end. I will not lose. I am prepared to be fired or resign over this.” I think other people might back down in situations of crisis, because they say, “I need this job.”
QS: You know what the real crises are, as you told us. If we could segue to a not-as-serious part of the interview: a lot of the students know you as “the man in the suit” when they see you in the cafeteria during lunchtime. In the History of Medicine Course, firstyear medical students got a little bit of a taste of the things you do outside of the office. You told us about your stamp collection and we’ve seen pictures of you traveling around the world. What are some of your hobbies? What else do you do for fun?
EH: I decided, when my children were born, that I
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Quill & Scope Staff was never going to miss a ballet recital or a dance performance, or the school songfests; so I never did. I would always work my schedule around what the children needed. I suppose, if you ask what are my hobbies: they’re my children. My children are all grown now. They’re all your age. I went to every school trip, every school recital, and every school performance. I fixed little ballet shoes and Barbie dolls and playhouses and dollhouses. Whatever the girls wanted. I rode my bicycle to work for 6 years when I worked in Louisville. When I took this job, I asked about a place to live where I could ride my bike to work. The real estate agent told me I’d die if I tried to do that. I ride my bike around where I live in Greenwich. What the students thought about me in Louisville was that I was the funny man in the suit on the bicycle who pedals by and says, “Good morning!” I collect stamps. I play the piano badly.
that you read?
EH: I’m reading The Emperor of All Maladies. I just finished Mark My Words, the autobiography of the chairman of the board of Touro. I’m reading The Lander Legacy, about the founder of Touro. I have a couple of books on slavery and medicine that I have to get to.
QS: Do you have any favorite films? EH: Z. It’s a French movie about the military coup in Greece. It traces the behavior of an investigating judge in Greece. He identifies and prosecutes a group of Greek generals for the murder of a politician. It has a lot of flashbacks—it’s a movie from the 1960s. You’re way too young, but it was considered quite the cutting-edge film. I know a lot of the Marx Brothers movies by heart. If
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QS: What about music? What’s on your iPod or mp3 player right now?
EH: Showtunes: Guys and Dolls. Pete Seeger, Joan Baez. I was probably the only student at The Wharton School who, if I ended up working in labor relations, I wanted to work for the union, not labor. I know all kinds of union-organizing songs and I have a lot of those on my iPad. When I think about who won the minimum wage, the 40-hour workweek, the end of the sweatshops— those were the unions. On my iPad are a lot of folk songs and union songs. Aren’t you impressed that I even have one of those little i-somethings? My children gave it to me. I figpie. I think ured out how to use it.
“I really like they should give the Nobel Prize to whoever thought of pie.”
QS: What was the last book
you said something from Horsefeathers, Monkey Business, or Duck Soup, I could keep reciting it. For example, the scene about President Wagstaff of Huxley College at the beginning of Horsefeathers. I can do the whole bit.
QS: You already said you didn’t have a Plan B when you decided to go into medicine. But if you had to have a Plan B—if you couldn’t be a doctor—what would you do?
EH: When I was your age, I wanted to be an attorney. I went through periods of time when I thought I wanted to be a Professor of Theology at a liberal arts school. I went through a stage when I thought I might be a sufficiently good percussionist in the school orchestra to pursue that. I am not good enough at playing the piano, but I was the percussionist in the university orchestra: tympani, xylophone, snare drum, bass drum, and all those things that get whack-banged and crashed in the back of the orchestra. I know how to play all those sorts of things. I played all those in classical music, so I may have gone through a stage where I thought I may be able to do that.
QS: If you could have a dinner party with any three people, dead or alive, who would you pick?
Interview with Dr. Halperin EH: Maimonides. David Dubinsky. Henry Sigerist.
QS: Favorite kind? EH: I like Boston cream pie, coconut custard pie, pe-
QS: And why would you pick these three? EH: I would want Maimonides to talk about the balance of faith or religion and science. David Dubinsky was one of the great labor leaders of American history. I wrote a paper about him when I was in college. I think it would be interesting to talk to him. Henry Sigerist was the great historian of medicine. He would be interesting dinner company.
can pie, and blueberry pie. I really dislike peach pie. I think there is no reason on Earth for there to be asparagus. I actively dislike asparagus. Whoever came up with asparagus—that was a mistake of evolution.
QS: To wrap up, what’s the best advice that you’ve ever received?
EH: My father and mother were married for over 60 QS: And what foods would you serve your dinner guests? Do you have any favorites in particular?
EH: I like a toasted bagel with cream cheese and chocolate milk. That’s my favorite. Another favorite is cottage cheese and sour cream with fruit. I like a hot dog. I like delicatessen food. I could have a potato knish with a corned beef sandwich and a Dr. Brown’s Black Cherry Soda five days a week, and I would be happy too. I like pie. I really like pie. I think they should give the Nobel Prize to whoever thought of pie.
years. I asked them for their advice regarding success in marriage. They both replied, “Be quiet. Remember to listen. People talk too much. Spend more time listening.” The fact that I have talked to you about myself for an hour is agony for me. So that would be a good way to end.
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Cellist (2010) Bethesda Terrace, Central Park, NY. 35mm Black and White.
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Interview with Drs. de la Garza and Lento Quill & Scope Editors in Chief
uill & Scope (QS): Dr. Lento, we understand that
you completed a residency in Internal Medicine and then decided to pursue an additional residency in Clinical & Anatomic Pathology. That’s rather unique, no?
Dr. Patrick Lento (PL): Yes. The bruises around my neck from my wife’s hands are just now fading! Actually, I’ve talked about this a lot with medical students. I entered medical school hoping to be an internist— either generalized or sub-specialized—in perhaps oncology, which is something I’ve always enjoyed. This thinking continued through medical school. But during residency I realized that I was really interested in teaching. The day-to-day workings of internal medicine were not so overwhelmingly gripping for me. On some days patient care was exciting for me; on other days it wasn’t. For some people, patient care and patient contact are what drive them and they want to see patients every day. But I found that I didn’t need to see a patient every day. Instead, I found that the science and the puzzle [of disease processes] were most exciting. Coupled with my love for teaching, I decided to do another residency. It’s interesting that it ended up being Pathology because that is sort of a 180-degree turn from what I had been doing. In retrospect, it was the best decision I could have made for myself. It was an exciting time; it still is! I like to talk about this with students because it highlights the circuitous path that very commonly weaves between medical school, residency and practice. What is right today is not necessarily right tomorrow. You can change your mind. You can always develop new interests that may differ from what you originally thought you wanted to do.
over time. For me, my mom was a nurse so I was somewhat exposed to the medical field. But my mom certainly never pushed me. I also enjoyed being with people so I thought medicine would suit me. As it turns out, I guess I sort of transformed being with patients to being with students. While it has seemingly been a 180-degree turn on the surface [Internal Medicine to Pathology], I don’t really see them as that different.
Dr. Julia de la Garza (DLG) : I never wanted to be anything but a doctor. When I was a 4 years old, FAO Schwartz did not make a doctor’s costumes for girls, so I had to dress up as a nurse and pretend to be a doctor.
PL: That looks like a ballerina to me!
QS: Is there any particular reason? DLG: I was just born this way, it was in my genes. PL: Well, I wanted to be a baseball player when I was younger. DLG: Honestly, I don’t ever recall wanting to be anything but a physician. It is probably part of the Nurture-Nature balance in life. I always wanted to be a physician, my father was a surgeon, and my mother was a PhD, linguist. My father would take me on rounds with him to two or three hospitals every weekend. It’s what I grew up exposed to; it was normal and natural to me.
PL: I can’t recall ever thinking about doing something
Then at the age of seven, I wanted to learn how to knit. My mother was an expert knitter, as were both of my grandmothers and since I always said I wanted to be a surgeon, my father stated that I should learn how to knit to keep my fingers nimble for surgery. And it had to be accomplished perfectly or it was ripped out. Except for the very first item I made. It was a blue wool scarf which was cockeyed and uneven, but my father wore it.
else. You think you know or want something, but it’s not always for the right reasons. These things evolve
When I was ready to go to college, I applied to the Union College seven-year med program and I was accept-
QS: Did you always want to be a doctor?
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Quill & Scope Editors in Chief ed. My father said, “Absolutely not! You have to be a well-rounded individual in art, music and the humanities as well as the sciences as a physician. You need to be able to communicate with patients and understand their perspective. If you are unable to construct analogies and discuss a disease in human terms with a patient, then you’re not going to be a good physician.” So I agreed. What did I know at 17 years old, he had much more experience and wisdom than I did, so I went to Columbia University instead, and had a much longer and circuitous route in my goal of becoming a physician.
places wanted to know as a woman how many words a minute I could type. I actually walked out of those interviews. Then at Kidder Peabody, I was asked “Are you a quant?” I replied, “Yes! I count a million cells, you count a million dollars, and we both get to a million.” The interviewer said, “You’re hired, if you can give me an answer like that.”
I was accepted into the Institutional Sales and Trading program at Kidder Peabody. Relatively early on, I realized that I lacked a financial background and enrolled in a basic economics course at Columbia. Kidder Peabody has a program, that if you received an A As I neared graduation from Columbia, I applied to or B they would reimburse you 100%. That was motimedical schools but didn’t get in. I had a good GPA, vation enough for me to do well at school. I returned but we were in a recession, and the competition was to Columbia at night and began preparing for busihigh and I was applying to ness school. When I menonly New York schools tioned the plan to a runand a native New Yorker. ning buddy who was a Not my best strategy. physician he said, “You never talk about anything That Summer, 1991, I be“I count a million cells, you but medicine. Apply to gan a year of graduate this medical school [St. count a million dollars, and work in cell and molecuGeorge’s].” I said, “I’m an lar biology at Columbia. we both get to a million.” Ivy League snob, I’m not During my final exam going off shore.” But he week, my father returned — Dr. de la Garza persisted, “Come on! You from the hospital after a never talk about anything long day of surgery, ashen else.” I obliged him and grey, and had a MI in gave my word. sleep and died. I was home with my mother, While interviewing at and I called 911 after she could not. I then proceeded Harvard, Columbia and University of Pennsylvania to give my father CPR until EMS arrived. When EMS for business schools, I received an interview from St. told me to leave the room I refused. I had always George’s University, School of Medicine. I was subsepromised my father, in some crazy little pact we had, quently accepted to Harvard Business School and St. that I would be there and take care of him in the end. George’s Medical School. It was a no brainer for me, It was very ironic I always envisioned that he would medical school here I come. At work they inquired, be 85 years old in my home and with a grandchild on “You’re going to business school in Granada, Spain??” his knee. I never thought he would be 62, and I only No, medical school in Grenada, the West Indies.” My 24. I took my final exams that week and dedicated mother was very angry and did not speak with me for them to him, and earned my highest grades ever. a while and stated that “You’re going to pay for this on your own.” I did. That Fall I applied to 20 medical schools again, but did not get in. Since my father had passed, I thought, “I’ve One of the unexpected advantages of going to St. got to get a job and work! Dad’s gone, there’s no in- George’s School of Medicine is that it is 3000 miles come.” So I poured over the New York Times with a from New York City. I was excused from every family yellow highlighter, made phone calls and interviewed obligation for four years without guilt. It was the best for entry level financial job on Wall Street. Many thing for me, to be sequestered on an island, not much
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Interview with Drs. de la Garza and Lento larger than the island of Manhattan, with nothing else to do but study medicine. I had to focus, no excuses. We called it “the rock,” completely surrounded by water and only one flight a day back to the U.S. My parents had a quote, “Everything happens for a reason. We may not know at the time why, but it will become apparent later on.” I have never regretted my decision to go offshore to medical school. As a matter of fact it was probably one of the best decisions I ever made. I love what I do and I do not have “grass-isgreener syndrome.” I enjoyed what I did on Wall Street, it was a great experience, but I was not fulfilled by it. Medicine is what I was meant to do.
QS: Dr. Lento, you describe how you liked the sciences and teaching. Something a lot of us have wondered about is how does something like performing autopsies enter onto your radar?
PL: I know a lot of people view it as a sort of morbid
thing that is gruesome. But the autopsy is the ultimate puzzle for trying to figure out what’s wrong with someone and it’s a tremendous educational tool. For me it was also a marriage of two worlds: my background in medicine and teaching. I see autopsy as perspective. Whether it’s asking for autopsies or gathering information, it helps guide your perspective. It really helps close the chapter of that individual’s life and disease in a way that modern technologies cannot. For example, medical errors are a major concern in healthcare today. Autopsy is a great way to evaluate medical errors. When we as pathologists do an autopsy we do it with the understanding that someone may view the body afterwards. We retain a level of respect that you would show any patient. The individual being autopsied is the patient for the pathologist. Even with an open casket funeral, you would not know an autopsy was performed. After I finished my training, I was asked to stay on as the Autopsy Director.
DLG: Autopsy, is a Greek word meaning, “to see for
oneself.” To see and evaluate for oneself the human body in a very systematic manner. You read the investigator’s report or chart and formulate an impression or a set of differential diagnoses. Then you begin from head to toe, external to internal. You get a sense for socioeconomic status, epidemiology and medical history all the while documenting everything in three ways: the body and organ diagrams, photography, and the written report.
You are able to assess every aspect of a person — the obvious and subtle differences. In the end, a final report is written, a summation of the scene, evidence and the autopsy with all of its toxicology reports, labs, medical records, and legal documents. The report writing was the most difficult part for me. I wrote my first autopsy report in residency in 2000, Dr. Lento as my attending. I never had a paper returned to me with so much red ink on it before in my life. I was devastated, but did not give up. And now, not only do I write them all the time, but I guide residents on how to write them. The autopsy also offers incredible perspective into not only the pathogenesis of a disease but the epidemiology of death. Deaths in the each of the five boroughs of New York City are very different and these are very different from those in Suffolk County, Newark, New Jersey, and Miami, Florida. Death is very cultural and dependent upon your socioeconomic status. People generally die the way they want to die. We create our own destiny.
QS: What might be an anecdote for someone “dying the way he/she wants to die”?
DLG: My mother was diagnosed with pancreatic can-
cer in February 2010. She had a Whipple, followed by chemotherapy and then we found out that she had metastatic disease to the liver. At this point she opted for home hospice. I had accumulated extensive vacation time, and I took a leave of absence to care for her at her home in Sag Harbor. She wanted to die this way. She had witnessed her mother pass away in a nursing home, spending only an hour a day with her, then only to return home to her own family. She did not want to be alone like her mother had been, and she did not want any heroic measures after receiving what we felt was the best medical care . It’s great that in this day and age we still have a right to die the way we want. She would not have been influenced to select home hospice had she not seen her mother’s experience. My sister, who is not in medicine, just told me two weeks ago that she thinks, “It’s the most horrible thing the way our mother died.” But my mother thought that even if she was not able to get out of bed, the people she loved were all around her and therefore she was never alone. She could hear them walking upstairs, chuckling, laughing, fighting (I’m one of five kids—there are always arguments and differences of opinions). But, she could hear life and familiar voices.
QS: Was there a particularly memorable autopsy that you performed, either as a resident or as a Medical
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Quill & Scope Editors in Chief Examiner in NYC?
DLG: It’s not one specific case, but the big picture of the variation of a disease progression and the epidemiology of diseases and death in every jurisdiction. It’s simply amazing.
QS: Dr. de la Garza, you’ve mentioned how you entered medical school hell-bent on doing neurosurgery… how did you land in pathology?
DLG: After my father passed, I was mentored by a col-
play with my sister and she’ll make one rule, “no medical terms!” I would probably win at Pictionary, hands down.
Let’s talk a little bit about the M2 Pathology course. What parts of the course do you most enjoy?
PL: For me it’s small groups. In the future I would like
to have more small group sessions. A big challenge is to try to create an environment among the faculty where there’s a little more uniformity. It will never be perfect, but I want the students to feel excited and enthusiastic about what we’re doing, and part of that has to come from the faculty. In other words, we have to exude enthusiasm, and show why it’s exciting. I think this will help students better learn and understand the matehad a quote, rial.
league of his who stated “You can’t do surgery without understanding what happens to your specimens, therefore you need to do a pathology rotation.” Given this advice I did a one month pathology rotation at Mount Sinai in New York. I loved it and was fortunate “My parents enough to be offered a spot outside the match. ‘Everything happens for a reaAlso, I’m less interested A foreign grad … Mount in whether you get it son. We may not know at the Sinai … was I dreaming? right or wrong. I mean, I But seriously, I had to time why, but it will become want students to get the think about it for a few answer right, but I think months before I arrived apparent later on.’” that unless they try to do at my final decision as it it, it’s so passive that it’s a was such a dramatic very lackluster experi— Dr. de la Garza change from surgery, let ence overall. And it can alone neurosurgery. be fun! Learning should But once the decision to be fun! It shouldn’t all be enter pathology was “ugh, not again” or “not made, I knew that I this long” or “not this perwould be pursuing a cason again.” reer in forensics and teaching. I needed to be able to get into the body and see what going on and I always DLG: For me it’s the fall and the Fundamentals of Pahad a passion for teaching and passing on the “art of thology. Have you seen The Sound of Music? When medicine” as my father had. Julie Andrews sings, “When you know the notes to sing: do re mi fa sol la ti do”? These are the fundamenHaving said this, if anyone had ever told me I was gotals that we teach in the fall. If we don’t teach the funing to be a pathologist, I would’ve said you’re crazy! damentals well, then you never learn how to properly But you know, I’ve had a series of mentors who’ve use your voice in music or critically create a differenguided me and exposed me to things I never thought I tial diagnosis in medicine. This is how I look at the would’ve been and it has been tremendous. course. I am fully aware that you’re going to pass on your notes, the books, and your recommendations. I just have one request: pass on to the first years to QS: Who wins a game of Scrabble between you two? trust us. If we ask you minutiae, it’s not to torture you, it’s to give you the fundamentals of “do re mi fa sol la PL: [laughter] ti do” so you can, in an educated and critical manner DLG: I always cheat in scrabble. [Dr. Lento laughs in Systemic Pathology, use the fundamentals to undereven more.] My husband was so good at Scrabble that stand a disease process, make a differential diagnosis, I literally have to go to the bathroom and open the and care for a patient in the future. I do not want dictionary. He had the Scrabble dictionary memoyou to order a test because that is what you see others rized. Who wins Scrabble between us? I don’t know. do. I want you to order a test because you are expectWe’d probably have really good terms though. When I ing the results to be aberrant. 16
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Interview with Drs. de la Garza and Lento
QS: Is there anything you wish you knew before you took on the job as directors of the course?
PL: I wish I knew that a job like this was available. I
never thought I would leave where I was. I had been there for so long, was very successful, and sort of felt like I was one of the baseball players, for lack of a better analogy, from the 50s and 60s, that played for the same team forever. Mickey Mantle was a Yankee, and I always thought I was going to be a Mt. Sinai person. But this opportunity became available and I took it as an exciting challenge. I actually wish I had done it beforehand because I really have enjoyed the experience. It’s given me a different perspective on education and encouraged me to step outside the box especially to teach something that in the past I would not have done.
DLG: When I completed my fellowship and landed my
dream job as a medical examiner in New York City, I honestly never thought I would leave. But then my mother passed, and my life focus changed. I believe in the expression that “everything happens for a reason.” You may not know at the time, why, but it’ll come to you. And so I made it up here to NYMC, and it has been very challenging and very rewarding. In the past almost two years, New York Medical College has pushed my comfort zone on so many different levels: personally, professionally and commutingwise. It has been a tremendous experience for me, to come and teach. Collectively, the students and faculty have pushed the envelope on so many levels and pushed me so far out of my comfort zone, it has been great. In the past two years I’ve done things I never thought I would have.
QS: We’re wondering if you could tell us about one of the most rewarding days in your career so far.
PL: I think that in medicine there’s no single rewarding day. Actually the most rewarding day is getting into medical school. After that it just continues to build on itself, so you recognize that today was great, but the next day, or the next week, there’s going to be something else. You’re always learning regardless of what level you are.
my first lecture and make needed improvements to content and my lecture style. The second time around was far superior, and a tremendous hurdle to get beyond.
QS: Well, there are never 200, unfortunately. DLG: No, I know there are fewer in my lectures than when Dr. Lento lectures and he gets applause…
PL: That’s because I start it. And people just don’t know what to do!
DLG: A rewarding day for me occurred when I least
expected it. I was a 3 rd year medical student in England and it was Christmas Eve. This little old lady came to the ER after suffering a stroke. I did the history and spent time with her, trying to do what I could possibly do as a 3rd year medical student. I went home that night and I literally said to myself, “I have no life and I need to get one. It’s Christmas Eve, my family is home in the U.S.A. having dinner and I’m in the ER.” Two weeks later a letter arrived for me in the ER from that woman. It was the nicest, most beautiful letter thanking me, it was completely unsolicited, I never expected anything, I wept when I read it. All I had done was spend time with her, being professional, courteous and as helpful as a 3rd year medical student could be. This was a great day.
PL: For me it’s a little different. Two examples come
to mind. One thing that I find personally rewarding and that sort of drives me are the students who come to my office who obviously are, you know, top of the class students, because they seem to get it. They just read the text or literature and they understand it the minute they read it. I’m amazed by that. The rewarding part is that I can have a conversation and I even learn from them. It’s amazing. I mean, I learn from all my students, different things, right? That’s one end of the spectrum. The other end is the student who is having some trouble and comes to me saying, “I don’t understand something.” I spend time with the student and when I see the student either understands the concept by the end of the conversation or I see the student develops a different sense of excitement, or he/she does well on another exam. To me, that’s very rewarding.
DLG: Getting through the GI perspectives, the second time around was very rewarding. The most uncomfortable part of the job for me is the large lecture hall format. Two hundred students staring at me, transcribing my every word and capturing it on Camtasia is daunting and overwhelming for me. I much prefer the modules or problem solving. The second time around was an opportunity for me to critically review
QS: What were you guys like when you were our age and in medical school?
DLG: I was just as energetic, intense and passionate about medicine. I was always this inquisitive.
I had more hair… But a lot of things haven’t
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Quill & Scope Editors in Chief changed. When I was interviewing for medical school, I remember asking a similar question. He was an oldtimer, and he said something that I never forgot. He said medicine “is a lot like taking the train. You get on the train at this station, and you reach the next station, and some people get on, and others get off. And that’s what happens to our knowledge base. Certain things become obsolete, and you forget about them, and then you have to assimilate the new information.” For me that was an important way of capturing what we mean when we talk about lifelong learning. And I never forgot it and I always hoped that, when I reached the station, I can let more people on and get rid of the old information.
QS: What were some of the things you did to keep yourself grounded, outside of medicine, as a student?
DLG: As a student, I went for a run, swam, roller bladed. I needed to blow off steam and release endorphins. Then on the complete opposite spectrum, there is knitting which is my yoga.
PL: You have to have something. Hopefully you have
more than one thing, but you have to have at least something. And it doesn’t matter what it is. When I was a resident I played ice hockey, actually with one of my attendings. Once a week we would play, and it’s good to have something intense, that takes your mind off of everything, even if it’s just for an hour. Now it’s my wife and kids. Doing things with them is probably the one thing that I look forward to the most.
DLG: For me I guess it was athletics and knitting. I was a big swimmer, I danced classical ballet for 14 years, so music, running, swimming, biking. I used to cycle a lot. I love rollerblading. I used to pretend I was Eric Heiden [Olympic speed skater] and race down Fifth Avenue.
Knitting is my yoga. If I sit in a lecture, I can’t sit still with my boundless energy. Knitting allows me to keep my hands busy so I can listen and process what’s going on. More recently, it’s my nieces. My oldest niece says, “Aunt Julia, I’ve got a lot of love to give.” And I say, “OK, Alex.” [In her niece’s voice] “When are you coming ohva?” She’s got such a heavy New York/Long Island accent. And then the other one goes, “I love you too, Aunt Julia! Don’t forget me!”
QS: You’re both New Yorkers. What’s your favorite food or pizza in New York?
DLG: Koronet, by Columbia University on Broadway.
QS: If you had to offer us advice now, in 5 years and in 10 years, what would it be?
PL: The only advice I would say is that you should
choose to do something that you enjoy. I think that if you do that, it will never be a job. It will always be something you enjoy doing. You should try to be the best that you can be in whatever that thing happens to be. It may not necessarily be as a physician. There are students who go to medical school who go into the pharmaceutical industry or do things that are not classically associated with having an MD. And that’s okay. As long as you use the education you’ve gotten, you enjoy what you’re doing, and you strive to be the best that you can be. That doesn’t mean that you’re going to be the best. I look at my own experience in medicine, and then in pathology—well I should say I look back on it—as an important lesson for myself. I hope that students will try to do the same, because I know there are a lot of pressures out there: money and loans and you name it. And sometimes that puts you on the wrong path.
DLG: With respect to a career in medicine: Do as
many different rotations in as many possible specialties as you can. See the full spectrum of hospitals: large academic centers, small, rural community centers and the VA hospitals. See as much as you can expose yourself as much as much as possible, in order to make an educated decision about what will work for you in residency. It is called the match for a reason. Don’t have “what-ifs” and grass-is-greener syndrome. The world is your oyster right now. Take that little pearl: spit on it, polish it and throw sand in it. Make it brighter and bigger. You never know—you may just get a Mikimoto. In general, I would say maintain an open mind. You can be opinionated and voice your opinion, but use it to provoke a debate and a discussion. Don’t be afraid to discuss or debate an issue. One needs to discuss patients in order to provide the best treatment. Realize that maybe you don’t know everything out there. It is courageous when you guys catch us saying something incorrectly and stop us. And we respond “Okay, good. Now let’s discuss it.” It is important for physicians to be open about to critically evaluate themselves and colleagues. It is through these experiences and opportunities that we become better physicians and people. Through these discussions we better appreciate the differences in medicine and the world, it knocks down prejudices allowing us to become less judgmental in our daily practice of medicine and our personal life.
PL: I like to go to a place called Piper’s Kilt for hamburgers.
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QS: Since you first entered the medicine what is a
Interview with Drs. de la Garza and Lento change of which you’re not particularly fond?
DLG : I think the ease and access to which everybody can get on the Internet is a challenge and concerning as a physician. Medicine is the “last apprenticeship”, and much of it learning and understanding the subtleties and the differences in each of us, the grey scale. This can be very difficult to explain to an ill patient. “But my friend is taking this pill!” Or “had the test performed!” We, as the American culture, are so demanding that if the patient doesn’t get this pill or that test, is he/she going to sue me? This aspect of medicine concerns me.
PL: I agree that the time crunch is a huge change for
PL: I have to [watch Nickelodeon] because I have kids. The problem with things like pathology is not that different from some other fields, where the exposure is very low. People don’t choose to be pathologists because they’re limited by the biases we talked about before with the movies and TV and all that stuff. There’s the exposure issue. Nobody knows what a pathologist does. Most people say, “Oh, I had a teacher, and he was good (or terrible).” And it’s very limited. That’s a shame. When I see that, and I see more people being interested potentially I think it’s great. However, we don’t necessarily need that as much anymore because the amazing things that are medicine today are a lot of pathology things: genetic, molecular biology, you name it. All that stuff really has a home in pathology. There are more and more students today interested in pathology. It’s very difficult, in fact, to get a position in many programs because of the is a lot like interest.
physicians. As a patient I know what’s it’s like to have a problem, go to the doctor’s office, and the physician spends five minutes with you. You’re out the door and feel like the doctor didn’t listen to you. On the flip side, I know what it’s like to have been that physician under a significant time crunch, “Medicine or even money crunch, and there’s not enough support taking the train...” staff. It’s unfortunate when you DLG: In the history of medilook at all the money that’s becine, the pathologist has been — Dr. Lento ing perhaps spent on things that the doctor’s doctor. I’m not askmay not necessarily require ing you to be a pathologist, but that much money and yet medidon’t forget that there is that cine today may be getting shortdepartment there. If you’re changed. It’s a major topic for stuck and have a question, debate. your pathologists will more than gladly help you out and try to figure it out.
QS: You guys have spent a lot of time around the bod-
ies doing autopsies. What do you think about the cultural obsession with zombies and vampires? Where do you stand on that?
PL: I never watched any of those television shows, so I
have no idea. The only thing I will say is this: it’s an interesting enticement, perhaps, for things like pathology, because I think that—not for medical students necessarily—but for kids in high school, maybe college, there has been an increased interest in pathology. Since CSI came out, in who knows how many cities now, it serves as a potential attractant for pathology.
DLG: When I leave the medical examiner’s office and
I go home, I pet my cat. My house is very Zen and tranquil, believe it or not. I go from 5 th gear at work to reverse. I pet the cat, knit, read Harry Potter or watch Nickelodeon. Aside from the person who committed the act of what I’ve seen, nobody else needs to see it or know it. There are things that you just don’t have to talk about.
PL: [Pathologists are] the invisible team player. DLG: [Pathologists are a] huge reference, as if you went to the library. Just use your pathologist.
QS: Where might we find you on any random weekend this summer?
DLG: I will be in Sag Harbor, gardening or swimming.
You will probably hear me laughing with my nieces in the water, as they try to climb on top of me as I try to swim across the cove.
For me, it’s either hanging out with my kids watching TV, or walking the Rockefeller Preserve with them. Also, I’ll be enjoying the sunshine—when and if it ever comes back.
DLG: Perhaps roller blading PL: Oh my goodness! Well now that there aren’t so many rocks on that road since they finished that construction…
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Quill & Scope Editors in Chief QS: If you could pick one person, living, not living, to
DLG: When I’m writing exam questions or preparing
have lunch with right now:
a lecture on Sundays, I cook. I begin early in the morning and slow-cook all day. On Sunday evening I watch 60 Minutes, which is something I love to do. Since I’m alone, colleagues reap the benefits. When I bring in food, we actually pause for a moment and enjoy a meal together with old school manners. It’s quite nice to get everybody to stop and sit for 30 minutes. It’s like your dinner table: we don’t start until everyone is seated and don’t leave until everyone is finished. And if someone is on the phone we tell them to hang up.
DLG: My mother, my father, my maternal grandmother (for whom I’m named after her) and Dr. Zachrau.
QS: No historical figures? DLG: Dr. Zachrau is historical! PL: He’s not going to like that! DLG: They advised me when I needed advice. They
scolded me when I needed scolding. They encouraged me when I didn’t want to do things that they knew were good for me. I miss my mother more than anything in the world. She was my best friend and my mother, and she was my role model and confidant— someone I could always go to; I would do anything to have a conversation with her again. My mother was the first person to say, “I don’t need to wait for you to do it, I’ll show you how to do it. Let’s rotate the world.” It was long standing joke in my house that I would rotate the house 17 degrees, North by Northeast on any given day and that was usually just by lunch.” My mother was always this energetic, creative, and brilliant. She was a phenomenal mother, friend, mentor, and role model. I miss her camaraderie. I enjoy having lunch with Dr. Zachrau. It would probably go on for hours between my list of questions for him and his in depth and well thought out responses. His depth and breadth of knowledge and life is immense. He has been an incredible mentor guiding me through this very new experience at NYMC.
PL: I’d just like to have a decent lunch once in a while!
DLG: I cook! I’ve brought lunch! PL: Yes, she does.
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There used to be doctors’ dining rooms in hospitals where doctors could come together at lunch and discuss cases in private. It fell out of favor. Honestly, I really enjoy when we have lunch together on Friday afternoons. Drs. Argani, Fallon, and Zachrau are there and we chat about things, believe it or not, I usually listen and learn about medicine from people who have accomplished more than me. A meal and food brings people together. It’s nice in its simplicity.
QS: Is there anything you’d like to add? PL: I know that medical school is difficult and can
sometimes be painful. My hope is—and I’ve heard from some students that second year is the worst— this will change over time and students won’t look at it as so much of a chore. My vision is to help transform second year so that students see it as a challenge and approach it with enthusiasm and even a little fun. Our ultimate goal is for you to learn as much as you possibly can. I think that there are different ways to do that. I happen to feel that learning doesn’t have to be boring. It can be fun. Perhaps with a little bit of fun, we’ll be able to open up someone’s eyes to different and exciting possibilities!
Cellist (2010) Bethesda Terrace, Central Park, NY. 35mm Black and White.
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Cancer Immunotherapy Comes of Age Michael Karsy & Bryant England
magine training the body to attack cancer. As defined by the National Cancer Institute, cancer is a process by which abnormal cells divide without control and are able to invade other tissues.1 This complex process is governed by genetic mutation, which results in cancer cells losing their resemblance to the normal cells they are ultimately derived from, overcoming built-in cellular mechanisms to prevent runaway growth, inducing neoangiogenesis or the formation of new blood vessels, as well as eventual metastasizing to foreign tissue sites.1 Importantly, cancers develop an ability to evade the body’s immune system through a variety of mechanisms, such as changing surface proteins that immune cells normally use to home in on foreign cells, accumulation of regulatory T-cells (Treg) that suppress the immune response, as well as secretion of specific immune signaling cytokines (e.g., interleukin 6 [IL-6] and 10 [IL10]) to inhibit lymphocytes that normally kill tumor cells.2,3 So if cancer has developed an ability to subvert the immune system, how is it possible to overcome this mechanism of tumor self-preservation? The burgeoning field of immunotherapy may hold some answers in creating novel treatments for cancer as well as new ways of thinking about this old disease.
The immune system is a complexity overcome by the cleverness of cancer cells. This system has been classically divided into the innate and adaptive immune systems.2-4 The innate immune system is the first-line defense system involving anatomical barriers to infection, cytokine-mediated recruitment of immune cells, as well as complement proteins, (molecules used to identify and destroy foreign cells while recruiting immune cells). Other players in the innate immune system include macrophages that ingest and destroy foreign cells, neutrophils that secrete destructive enzymes, basophils and eosinophils that aid in eliminating parasites, as well natural killer T-cells that target foreign cells, including tumor cells. One of the ultimate results of the innate immune system is the activation of the adaptive immune system via antigen
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presenting cells. The adaptive immune system consists predominantly of CD8+ cytotoxic T-cells that monitor and destroy infected cells, CD4+ helper T-cells that identify foreign antigens to signal antibody production, and B-cells that are involved in sensing antigens and forming antibodies. This system also includes gamma/delta T-cells that share characteristics of CD8+ and CD4+ T-cells. Despite each of these intricate, wellregulated components, cancer cells have developed methods to overcome nearly every mechanism of the immune system.
Cancer immunotherapy is broadly defined as the ability to induce the innate and adaptive immune system to neutralize neoplastic cells. Multiple methods have developed over the past 50 years with the most interesting clinical applications unveiled only recently. These include non-cellular methods such as antibodies and drugs to regulate the immune system (Figure 1) as well as cellular based techniques to manipulate the immune system such as adoptive cell transfer (ACT) and tumor vaccines (Figure 2). These methods have shown mixed effects in different cancers again reaffirming the immense heterogeneity of cancer and difficulty in treating this disease.
A straightforward strategy to treat cancer includes inducing the immune system. Administration of the body’s own signaling molecules (cytokines such as IL2 or interferon-α) has been shown to stimulate the immune system to fight cancer (Figure 1A).5 In fact, pegylated interferon-α2b was approved by the Federal Drug Administration (FDA) in 2011 for the treatment of melanoma.6 These initial approaches have been expanded by recent knowledge regarding immune-modulating antibodies and cell signaling. Tumor-specific monoclonal antibody, generation is an approach that uses purified antibodies generated in the lab towards a specific tumor cell surface target.7 Rituximab (Biogen Idec/Genentech, San Francisco, CA) is a monoclonal antibody used to target CD20 cell re-
Cancer Immunotherapy Comes of Age
Figure 1: Non-cellular methods of immunotherapy. Various methods of immunotherapy using non-cellular means are shown. A) Treatment with interleukin-2 (IL-2) or interferon-α can stimulate the immune system to fight cancer. Examples include the use of pegylated interferon-α2b in the treatment of melanoma. B) Designed tumor-specific monoclonal antibodies can target tumor cells via induction of an immune response (Antibody-mediated cell-dependent cytotoxicity) or via activation of the immune system’s complement cascade (Complement activation). Examples include Rituximab for the treatment of non-Hodgkin cell lymphoma and chronic lymphocytic leukemia as well as Trastuzumab in the treatment of breast cancer. C) Immune-modulating antibodies are used to target co-regulatory proteins that allow T-cells to interact with tumor cells or antigen presenting cells. Examples include Ipilimumab and Tremlimumab for the treatment of metastatic melanoma. D) Antibody-drug conjugates and antibody-toxin conjugates are being developed to target tumor cells. Antibody-radioisotope conjugates may allow for earlier tumor diagnosis. Bispecific monoclonal antibodies are useful for localizing the body’s immune cells to tumor cells.
ceptors which has been approved by the FDA in the treatment of non-Hodgkin cell lymphoma and chronic lymphocytic leukemia, as well as several nononcological diseases.8 Recent studies have surprisingly shown that this antibody helps induce the immune system to kill targeted tumor cells in a process known as antibody-dependent cell-mediated cytotoxicity (ADCC) (Figure 1B).9 The drug Trastuzumab (Genentech, San Francisco, CA), also known as Herceptin and used to target the Her2/Neu growth factor receptor in the treatment of breast cancer, has also been shown to mediate ADCC in addition to its well known effects on altering growth factor signaling of targeted cancer cells.10
Other novel uses of monoclonal antibodies include
immune-modulating antibodies. Two new compounds, Ipilimumab (Bristol-Myers Squibb, Princeton, NJ) and Tremlimumab (Pfizer, New York, NY), have been shown to target CTLA-4 (Figure 1C)11. Normally CTLA-4 is a co-regulatory receptor on T-cells that binds to molecules B7-1 and B7-2 found on dendritic or tumor cells and inhibits the immune system, which can allow cancer cells to escape targeting. Ipilimumab and Tremlimumab disrupt this inhibition and have shown response rates of 10-15% with metastatic melanoma and renal cell carcinoma. 12 Ipilimumab has been FDA-approved as a first-line therapy for metastatic melanoma based on promising phase III trials.13 Even newer therapies are looking at additional co-regulatory immune-checkpoint targets such as programmed cell death 1 (PD1) which are present in many cancers and may result in a more universal on-
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Michael Karsy & Bryant England
Figure 2: Cell-based methods of immunotherapy towards cancers. Various methods of immunotherapy using cellular means are shown. A) Adoptive cell transfer (ADT) is demonstrated. Tumor infiltrating lymphocytes are extracted from patients, expanded ex vivo in laboratory cultures, and reinfused back to patients. Engineered T-cells can also be generated in cultures before reinfusion. B) Cancer vaccines are shown. Tumor cells are extracted from patients and specific tumor proteins are extracted before either being reinjected into patients or used to sensitize patient-derived dendritic cells to target tumors. Examples include Spuleucel-T used in the treatment of hormone-resistant prostate cancer.
cological therapy.6,14 The ability of bifunctional antibody-like molecules to bind cancer cells and retarget T-cells towards cancer cells (Figure 1D)15 or use antibody-drug/antibody-toxin conjugates to directly target individual cancer cells (Figure 1D)16 is also an area of open investigation. Antibody-radioisotope conjugates have also been investigated as methods to diagnose tumors earlier as well as identify disease progression sooner than current modalities. These methods suggest that non-cellular based techniques to regulate the immune system can be potent ways of treating cancer.
One form of immunotherapy that has gained momentum in recent years includes adoptive cell transfer (ACT). This technique utilizes anti-tumor T-cells that are manipulated ex vivo and then infused into a patient, in a similar method to bone marrow transplantation. In one study, tumor infiltrating lymphocytes obtained from patients, expanded ex vivo in a lab, 24
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and then re-infused in patients with metastatic melanoma showed that in addition to standard therapy, a clinical response of 34-72% was seen (Figure 2A).17 Therapies using such multicellular treatments have shown greater efficacy than therapy with purified single cells, again highlighting the heterogeneity of cancers and their surface markers in striving to achieve personalized therapy.18 However, the limitation of ACT involves the cumbersome cell-extraction process. Newer approaches utilize engineered T-cell receptors inserted into lab cultured CD4+ and CD8+ peripheral lymphocytes that can be transfused into patients.19 ACT can achieve tumor-inhibiting activity so long as a patientâ€™s tumor possesses the required target. Combinations of ACT treatments along with standard treatments are being investigated in various early phase clinical trials for some cancers.20
One of the most exciting avenues in immunotherapy is the development of cancer vaccines. Initially set-
Cancer Immunotherapy Comes of Age back by a variety of early clinical trial failures in the 1960s, this approach has generated renewed interest along with a recent FDA-approved treatment. Cancer vaccines involve the administration of tumor proteins to generate an immune response or immune cells (i.e. dendritic cells) sensitized to tumor proteins (Figure 2B). Spuleucel-T/Provenge (Dendreon, Seattle WA), FDA-approved in 2010 for the treatment of advanced hormone-resistant prostate cancer, involves inoculating patient-derived peripheral blood mononuclear cells with prostatic acid phosphatase linked to granulocyte macrophage colony-stimulating factor – essentially training a patient’s own cells to target prostate cancer specifically.21 In phase III trials, Spuleucel-T resulted in a 4-month overall survival benefit; The cost of this treatment, however, has been estimated to be approximately $100,000, which may limit its eventual application.22 Vaccines towards melanoma23, high-grade glial24,25, breast26, pancreatic27, lung28 cancers are currently in development. New knowledge of immune regulation in cancer has improved the efficacy of these approaches by using improved target antigens, high quantities of antigens to sensitize immunity, and proper co-stimulatory signals to activate immune cells.
The field of immunotherapy is emerging significantly as a viable option in the treatment of cancer. Much work has yet to be done before this dream can become a reality for many patients. In addition, new developments have dramatically altered the concept that cancers have unilaterally circumvented the immune system. Instead, various methods of inducing the immune system to fight cancer have been developed, methods which will hopefully act as precursors for the development of similar methods in the near future.
REFERENCES 1] What Is Cancer? National Cancer Institute Available at: http://www.cancer.gov/cancertopics/ cancerlibrary/what-is-cancer. Accessed January 27, 2013. 2] Topalian SL, Weiner GJ, Pardoll DM. Cancer immunotherapy comes of age. J. Clin. Oncol. 2011;29 (36):4828–4836.
3] Mellman I, Coukos G, Dranoff G. Cancer immunotherapy comes of age. Nature. 2011;480(7378):480 –489. 4] Liu Y, Zeng G. Cancer and innate immune system interactions: translational potentials for cancer immunotherapy. J. Immunother. 2012;35(4):299– 308. 5] Tarhini AA, Gogas H, Kirkwood JM. IFN-α in the treatment of melanoma. J. Immunol. 2012;189 (8):3789–3793. 6] Kirkwood JM, Butterfield LH, Tarhini AA, Zarour H, Kalinski P, Ferrone S. Immunotherapy of cancer in 2012. CA Cancer J Clin. 2012;62(5):309–335. 7] Reichert JM, Dhimolea E. The future of antibodies as cancer drugs. Drug Discov. Today. 2012;17(1718):954–963. 8] Bauer K, Rancea M, Roloff V, et al. Rituximab, ofatumumab and other monoclonal anti-CD20 antibodies for chronic lymphocytic leukaemia. Cochrane Database Syst Rev. 2012;11:CD008079. 9] Dall'Ozzo S, Tartas S, Paintaud G, et al. Rituximabdependent cytotoxicity by natural killer cells: influence of FCGR3A polymorphism on the concentration-effect relationship. Cancer Research. 2004;64(13):4664–4669. 10] Vu T, Claret FX. Trastuzumab: updated mechanisms of action and resistance in breast cancer. Front Oncol. 2012;2:62. 11] Sharpe AH, Freeman GJ. The B7-CD28 superfamily. Nat. Rev. Immunol. 2002;2(2):116–126. 12] Ribas A. Clinical development of the anti-CTLA-4 antibody tremelimumab. Seminars in Oncology. 2010;37(5):450–454. 13] Robert C, Thomas L, Bondarenko I, et al. Ipilimumab plus dacarbazine for previously untreated metastatic melanoma. N. Engl. J. Med. 2011;364(26):2517–2526. 14] Dong H, Strome SE, Salomao DR, et al. Tumorassociated B7-H1 promotes T-cell apoptosis: a potential mechanism of immune evasion. Nat. Med. 2002;8(8):793–800. 15] Topp MS, Kufer P, Gökbuget N, et al. Targeted therapy with the T-cell-engaging antibody blinatumomab of chemotherapy-refractory minimal residual disease in B-lineage acute lymphoblastic leukemia patients results in high response rate and prolonged leukemia-free survival. J. Clin. Oncol. 2011;29(18):2493–2498. 16] Younes A, Bartlett NL, Leonard JP, et al. Brentuximab vedotin (SGN-35) for relapsed CD30-positive lymphomas. N. Engl. J. Med. 2010;363(19):1812– 1821. 17] Besser MJ, Shapira-Frommer R, Treves AJ, et al. Quill & Scope 2013, Vol. 6
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Clinical responses in a phase II study using adoptive transfer of short-term cultured tumor infiltration lymphocytes in metastatic melanoma patients. Clin. Cancer Res. 2010;16(9):2646–2655. Hunder NN, Wallen H, Cao J, et al. Treatment of metastatic melanoma with autologous CD4+ T cells against NY-ESO-1. N. Engl. J. Med. 2008;358 (25):2698–2703. Johnson LA, Morgan RA, Dudley ME, et al. Gene therapy with human and mouse T-cell receptors mediates cancer regression and targets normal tissues expressing cognate antigen. Blood. 2009;114(3):535–546. Clinicaltrials.gov. Kantoff PW, Higano CS, Shore ND, et al. Sipuleucel-T immunotherapy for castration-resistant prostate cancer. N. Engl. J. Med. 2010;363(5):411– 422.
22] UPDATE 4-Dendreon plunges as Provenge prospects wither. Reuters; 2011. Available at: http:// www.reuters.com/article/2011/08/04/dendreon-
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idUSL3E7J43V720110804. Accessed January 27, 2013. Zeiser R, Schnitzler M, Andrlova H, Hellige T, Meiss F. Immunotherapy for malignant melanoma. Curr Stem Cell Res Ther. 2012;7(3):217–228. Johnson LA, Sampson JH. Immunotherapy approaches for malignant glioma from 2007 to 2009. Curr Neurol Neurosci Rep. 2010;10(4):259–266. Thomas AA, Ernstoff MS, Fadul CE. Immunotherapy for the treatment of glioblastoma. Cancer J. 2012;18(1):59–68. Wright SE. Immunotherapy of breast cancer. Expert Opin Biol Ther. 2012;12(4):479–490. Plate JMD. Advances in therapeutic vaccines for pancreatic cancer. Discov Med. 2012;14(75):89– 94. Thomas A, Hassan R. Immunotherapies for nonsmall-cell lung cancer and mesothelioma. The Lancet Oncology. 2012;13(7):e301–10.
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A Case for Patient Empowerment Through Education Gabrielle Hatton
he United States spends more money on healthcare than any other country in the world. It was reported that almost 18% of Americaâ€™s Gross Domestic Product was spent on healthcare in 2011, while the next highest country, Switzerland, spent only 11.5%.1 This sizeable spending difference has resulted in neither increased longevity nor a higher quality of life.2 I am sure this is not the first time you have heard these facts. While politicians, pharmaceutical companies, healthcare providers, lawyers, and insurance companies continue to place blame, pointing fingers at each other, I would like to suggest an alternative approach to this glaring problem. Patient empowerment through education should be one of the top strategies for effecting change in the health of our nation. The United States has recently undergone an epidemiological shift. The decreasing incidence of acute problems such as chicken pox and tuberculosis over the past century can be attributed to effective public health initiatives, such as the development and administration of effective vaccines and improved sanitation and food safety standards. Currently, noncommunicable diseases such as chronic respiratory disease, diabetes, cancer, and cardiovascular disease are much more significant in our society.3 In 2005, the Center for Disease Control and Prevention attributed 70% of deaths to non-communicable diseases and estimated that almost 50% of adults were living with at least one chronic disease.4 In 2010, the World Health Organization predicted a 15% worldwide increase in deaths due to non-communicable diseases by 2020.5 Most non-communicable diseases are causally linked with behaviors such as tobacco use, exercise activity, nutrition, and harmful alcohol use. These findings strongly suggest that our approach to healthcare should shift from treatment to prevention. Detection and treatment of non-communicable diseases are costly and often unsuccessful. If risk factors are addressed before a disease develops, there is no reason 28
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to believe that overall quality of life, longevity, and health care affordability would not improve. Individuals must be educated to make the necessary lifestyle changes that will considerably reduce their chances of succumbing to a non-communicable disease. Since 98% of children aged 16 and younger attend organized schools, the classroom provides an effective venue to reach the population. Furthermore, this age group is in the developmental phase in which they are most likely to develop critical health behaviors.6,7 Specific public health programs have been successful when using schools to reach their target audience. For example, students are now required to receive vaccinations, such as the Measles/Mumps/Rubella vaccine, prior to their first year of attending a traditional school. This has resulted in a noticeable reduction in targeted disease transmission. Health education focusing on tobacco use has also been introduced as a new requirement for students. This, in addition to other factors such as hazard labeling and tax adjustments, has resulted in a large decrease in tobacco use over the last fifty years.8 It is difficult to provide direct evidence for the effectiveness of these types of health programs individually, but they strongly correlate with important health improvements. Nevertheless, there have been few studies that have examined the cost-benefit ratio of health education programs in schools. The studies that have been released focus on the costbenefit ratio of specific educational programs for patients with a specific disease, initiated by medical professionals. A 1995 compilation of these education initiatives revealed that not a single study found their program to cost more money than it saved. Some studies even found the cost-benefit ratio to be as high as 1:12.9 If these results are not evidence enough for an education-based focus for reducing healthcare costs, they at least warrant further investigation.
A Case for Patient Empowerment Through Education An important concept that must be noted when conschool districts did not have sufficiently trained teachsidering the effectiveness of the programs mentioned ers in their health education departments. 11 It could previously is that the patients’ educators were highly be argued that these discrepancies are due to overall trained. Likewise, in any potential health education improper educational standards in the United States, program, the instructor should be qualified and the but that is a topic that will not be discussed further. program should be delivered to the highest standards Regardless of the cause, if students are not getting the possible to ensure maximal effectiveness. When you health education they are supposed to, they cannot think back to your own health education, what comes truly be held accountable for their health behavior. to mind? A gym teacher in a sweat suit? Sleeping in Additionally, part of the health education problem the back of a classroom instead of watching outdated may be attributed to the complex relationship befilms? These were my personal experiences. The curtween educators, students, and parents. This relationrent standards for primary and ship should be examined and secondary school health educaworked into health education protion seem to be inadequate – and grams to maximize chances for many students do not take the success. curriculum as seriously as they “… our approach to would with other educational The most cost-effective way of subjects. The CDC provides broad fixing any problem is to prevent healthcare should guidelines for states to adopt the problem from occurring in shift from treatment their own health curricula. In the first place. Our society needs New York, the New York State to shift away from merely treatto prevention.” Education Department decides ing diseases and move towards the specific topics their teachers promoting the prevention of are required to cover. The New chronic illnesses that are now York State Education Department topping the morbidity and mordoes not work with the CDC or tality charts. Only when Amerithe Department of Health and cans are properly educated on the Human Services to assemble an adequate curriculum. behavioral risks associated with the diseases plaguing Schools then implement the recommended curricusociety, will they be required to take responsibility for lum with a wide degree of freedom. Subjects such as illness prevention and their overall well-being. Primareading, math, and science, are tested through ry and secondary school programs appear to be the statewide assessments. However, there are no standmost cost-effective and improvable environments to ardized assessments that gauge a students’ health provide the education that is associated with prevenknowledge and the CDC even recommends against tion. I urge all Americans and especially politicians, using traditional exams for this subject matter. 10 educators, and health professionals to put health education at the top of their list of priorities when adThe goal of health education in schools is to provide dressing the effectiveness and cost of healthcare now students with the basic knowledge required to lead a and into the future. healthy and safe lifestyle and to access health professionals when necessary. There is a direct correlation REFERENCES between school health education programs and health 1] Centers for Medicaid and Medicare Services, Ofliteracy later in life.7 However it is unacceptably comfice of the Actuary, National Health Statistics mon that schools do not comply with their health eduGroup. National Health Expenditure Projections 2011-2021. http://www.cms.gov/Researchcation requirements. In a startling 2003 report, Scott Statistics-Data-and-Systems/Statistics-Trends-andStringer revealed that 75% of New York City school Reports/NationalHealthExpendData/Downloads/ districts were in violation of at least one of the govProj2011PDF.pdf. Accessed January 14, 2013. ernment mandates for health education and 63% of 2] The World Bank. Health expenditure, total (% of Quill & Scope 2013, Vol. 6
GDP). http://data.worldbank.org/indicator/ SH.XPD.TOTL.ZS. Accessed January 14, 2013. Stringhini S, Sinon F, Didon J, Gedeon J, Paccaud F, Bovet P. Declining Stroke and Myocardial Infarction Mortality Between 1989 and 2010 in a Country of the African Region. Stroke. 2012;43, 2283-2288. doi:10.1161/STROKEAHA.112.658468. US Department of Health and Human Services and Centers for Disease Control and Prevention. National Vital Statistics Reports. http:// www.cdc.gov/nchs/data/nvsr/nvsr56/ nvsr56_10.pdf. Accessed January 14, 2013. World Health Organization. Non-communicable disease report. http://www.who.int/nmh/ publications/ncd_report_chapter1.pdf. Accessed January 14, 2013. Population Education. School Days. http:// www.populationeducation.org/ docs/300millionlessons/school.pdf. Accessed January 14, 2013. The American Cancer Society, The American Diabetes Association, and The American Heart Association. Health Education in Schools – The Importance of Establishing Healthy Behaviors in our
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Nation’s Youth. http://www.cancer.org/ d o w n l o a d s / P E D / Healthy_Ed_Learning_for_Life_Fact_Sheet.pdf. Accessed January 14, 2013. Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future national survey results on adolescent drug use, 1975-2010. http:// www. moni t ori ngt h e fu tu re . org//pu bs / monographs/mtf-vol2_2011.pdf. Accessed January 14, 2013. Bartlett, EE. Cost-benefit analysis of patient education. Patient Education and Counseling. 1995;26,87-91. https://www.theparentreview.com/ e x t r a / C o s t benefit_analysis_of_patient_education.pdf. Accessed January 14, 2013. Centers for Disease Control and Prevention. Understanding Health Education Assessment. http:// www.c dc . gov/hea lth yy outh /h eca t/pdf/ HECAT_Append_6.pdf. Accessed January 14, 2013. Stringer, S. Failing Grade: Health Education in NYC Schools. http://assembly.state.ny.us/ member_files/067/20030622/. Accessed January 14, 2013.
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For Pappou: Loss During the Clinical Years Christopher Meltsakos
hen I saw that one of this year’s themes for the Quill & Scope journal was “loss”, I was immediately brought back to a very emotional experience that I had endured at the very beginning of third year. ———— It was a week into our third year rotations and my class was eagerly awaiting our Step 1 scores, while juggling the struggles to find time to study and read while adjusting to the new responsibilities of checking vitals, examining and presenting patients, and writing SOAP notes. When the day came that our scores were to be released, I received a phone call from my aunt who told me that my Pappou (grandfather), who was in Greece on his yearly summer trip, had collapsed on his veranda and was en route to a local hospital. Almost instinctively I began to think, “Stroke? Myocardial infarct? Orthostatic hypotension? Ruptured aneurysm? Hip fracture?” As scores of different diagnoses popped into my head, I began to feel quite uneasy and overwhelmed. Suddenly, the “stress” of awaiting Step 1 scores meant nothing. Later that evening, my aunt called back to update me about the situation. Physicians at the local hospital believed that my Pappou had suffered a subarachnoid hemorrhage, but, because they didn't have a CT machine at the hospital, they were going to send him to another local hospital to confirm the diagnosis. In the meanwhile, my father and uncle were booking tickets to try to get to Greece as soon as possible. When the phone rang at 8:30 PM, I was so uptight, I jumped. For the past several hours I had heard every tic toc of the clock, every drop of water from the leaky faucet, every car that passed by outside. I dreaded looking at the caller ID. It was my aunt. She informed me that they had rushed my Pappou to Thessaloniki, the nearest large city, because the smaller hospitals were not equipped to handle a subarachnoid bleed. She then broke the news to me that he had passed 32
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away shortly after his arrival. She told me that my uncle had received a phone call from the hospital while he and my father were sitting on the Tarmac awaiting take off. There was a long pause and I could feel my eyes welling up as I gritted my teeth and clenched my fists as tightly as I could. I no longer was aware of the clock, the dripping water, or any passersby. My heart seemed to rush with anger, sadness, uncertainty, and anguish. My Pappou and I were very close and this was a surreal and wrenching moment. As we both cried for a few minutes I got off the phone to answer a call from my mother who had called to bear the same bad news. Even the second time around it did not seem real. I then took a deep breath and continued on with my responsibility to forward the news to my younger sister. It was a day that I'll never forget. After experiencing alternating anger and sadness for about an hour, I quickly realized that this was just the beginning of what would be a long and difficult ordeal. I knew that it was going to be hard to get the body back to the United States, but that it would be even harder to afford the time off from my first clerkship to travel to Massachusetts in order to adequately mourn and be there with my family for the wake, funeral, and visitors. I was correct in my thinking. It took us nearly 10 days to get my Pappou home and I knew I couldn’t feasibly take more than a day or two off from the clerkship, so we scheduled the wake for a Friday and the funeral the next day. Being the first-born grandchild and the closest to my grandparents, I wrote a eulogy in honor of my Pappou that I shared during the traditional Greek fish dinner that followed the funeral. Although my story is not a story of patient interaction, or of an experience on the wards, this whole experience exemplifies the intricate connection between our work and our lives. Those of us in the healthcare profession have entered into a field that requires us to
For Pappou: Loss During the Clinical Years make many sacrifices, whether it be late nights, weekends, or holidays. Experiencing the loss of my Pappou, while learning to balance this magnitude of work, was a difficult task. Medical students simply do not take off time when there’s only a month or two to experience an entire specialty. The feeling that one is constantly being evaluated, judged, and tested evokes even the slightest anxiety when one wants to even take a short break from clinical responsibilities to answer bodily functions or to even eat an uninterrupted meal. How was I supposed to be able to take several days off to leave the state and mourn? Was I going to be considered a slacker? Was I going to miss something critical? Was I attempting to avoid my feelings and emotions in order to continue on? I was numb, confused, and overwhelmed. This is the responsibility we take on as young physicians. Not only is our workload extensive, but the work is not merely limited to the hospital. Medicine is a life choice. It is not spent sitting at a desk and punching out at the end of the day, but rather, it’s a 24-hour per day immersion of social interactions and mental acuity. We are required to make these sacrifices in order to help improve and save the lives of others. I can certainly say that I’ve seen myself grow as an individual and as a young physician over these past few months. Thus far my clinical experiences have shown me what it is to take care of another human being, while remaining a devoted family member and good friend to others. I wanted to share this story as a story of loss in medicine because familial losses are just as trying as the losses we experience in the clinic and our struggles with dealing with such matters overlaps with our clinical duties. ———— The following is my eulogy to my Pappou. Although difficult to read again, I wanted to share it with the readers of the Quill & Scope in honor of the lessons he taught me and the undying pride and support of my medical career that he constantly emitted.
From July 23, 2012 - For Pappou (Panagiotis Meltsakos) Before I share with all of you some of my thoughts, I’d like to share the words of a Ralph Waldo Emerson poem that I remembered reading in high school entitled “To laugh often and much.”
To laugh often and much; to win the respect of the intelligent people and the affection of children; to earn the appreciation of honest critics and endure the betrayal of false friends; to appreciate beauty; to find the best in others; to leave the world a bit better whether by a healthy child, a garden patch, or a redeemed social condition; to know that one life has breathed easier because you lived here. This is to have succeeded. Why did I want to start with this poem? Well, written and spoken language remain inadequate to express the whirlpool of emotions that the human mind and soul may experience, but this poem at least serves as a starting point to discuss the magnitude of Pappou’s contributions to our lives. From the time I was very little Pappou has always shown me how to succeed. Whether it was putting a smile on my face while playing with my sister and me during childhood or, more recently, the way he would sit me down over lunch to talk with me about my goals in life and the “paths that lay before me,” Pappou always wanted to instill within me the power to succeed. Though his words, carefully chosen and perpetually succinct, offered great insight into his philosophies, it was Pappou’s presence that seemed to have the most profound effect on me. Pappou was the kind of person you could quietly sit next to on a veranda for hours and not speak a word with, but remain in a state of mutual understanding and appreciation for the world and the details that surround us that words cannot capture. I can recall many of these moments over my lifetime, but the most powerful moments come from the summer of 2005 that I spent with Yia Yia and Pap-
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Christopher Meltsakos pou in Greece. I often think back to those moments spent sitting out on the balcony in the afternoon, either before or after some mezedes, just looking down at the garden below and the river just beyond. I remember simply taking in the details, sights, sounds, and smells and appreciating the comforting presence of Pappou next to me, while simultaneously chuckling in my head at Yia Yia yelling at us to get into the shade. I am grateful for the evenings spent with Pappou sipping Greek coffee or frappe at the “Pappoudes” Kaffenio (grandfather’s coffeehouse). Through his silent observation of the world around us during these moments, he taught me that we should not be alive, yet blind to the life we are living, but rather that we should celebrate life and appreciate the moments we can capture. To me, this short time period marked the most personal growth that I’ve experienced in my life to this date. It was a period of time marking my growth from adolescence to young adulthood. I strengthened a relationship with my Yia Yia and Pappou that brought me closer to each of them than I could have possibly imagined. It was after this experience that I truly came to appreciate the etiology of the word “grandparents.” Our forefathers were wise in their careful selection of language because grandparents are nothing but a second set of parents. They are there to help you, love you, nurture you, and to assist you in your development to the best of their ability. It’s unfortunate that, far too often in modern society, we forget this. Too many times we don’t appreciate the depth of love, knowledge, and experience that our elders offer. I am so grateful for having realized this in my youth and for making the most of my relationships. Pappou’s careful observation of the world around him oftentimes went unnoticed. At Christmas or Pasxa (Easter), I would routinely glance over at Pappou, either sitting at the head of the table or by the arni (lamb), intently and proudly watching and listening. He would briefly offer his input in conversations and then return to that state of profound pride and observation. From the time I was about 14 years old, each year at Pasxa, it was almost an unsaid rule that I would help Pappou to cut the lamb and clean the souvles (kebab skewers) after. I loved these moments because, as we worked in unison, oftentimes after the 34
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others had brought the food inside, I was able to spend one on one time with Pappou, watching, learning, and listening in the same fashion he demonstrated by his careful enjoyment and observation of the world around him. Pappou fostered and taught me much over the course of my life, and I’m so grateful for everything he has done for me. His passing marks one of the most difficult days of my life, because there was so much more that I was hoping to give back to him. I was looking forward to making him proud upon my medical school graduation, or sharing smiles with him on a wedding day, and even one day introducing a great grandchild to him because I know these would be the most profound and valuable gifts I could offer for all of the knowledge, love, care and pride he’d shown to me throughout my life. But we cannot dwell on what could be or the plans we intended on, for life is as much a mystery as death is. We must take solace in knowing that Pappou lived a long life full of love, care, pride, and happiness. I am forever grateful for making sure that I was never too “busy” for a phone call or lunch date. I am forever grateful for the kind of man I have become, in part due to the lessons of my Pappou. Though Pappou may not be here with us in the physical realm, he is far from absent. He lives on in each and every one of us: in memory, in thought, in lessons and laughs. The greatest gift we can offer to Pappou is to celebrate his life and to try to embody his hard work, dedication, passion, love, kindness, and perpetual appreciation for the world around him each and everyday. So as we weep and mourn the loss of a great man, I figured I’d part with a final quote by Washington Irving that is more than fitting at this point:
“There is sacredness in tears. They are not the mark of weakness, but of power. They speak more eloquently than ten thousand tongues. They are messengers of overwhelming grief...and unspeakable love.”
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Convocation of Thanks —June, 2013 Nina Beizer
etting into medical school is something to be proud of, sure, as is, I suppose finishing my first year in medical school. But one of my absolute proudest moments in medical school so far is a little less traditional: not fainting in anatomy lab. For quite some time, I have had some non-medical problems maintaining consciousness. When I was 18, I worked in an emergency room. On my very first day of work, a nurse called me over to let me watch her draw blood. I saw the needle go into the patient’s arm. Then I woke up in a hospital bed. I was the laughing stock of the emergency room for the entire summer. I wish I could say I was squeamish – then I would just avoid blood. But unfortunately, my fainting isn’t limited just to bodily functions. A few years ago, I visited Yad Vashem, the Holocaust museum in Israel. Somewhere among the rooms and rooms of absolutely devastating pictures and artifacts, I fainted yet again. When others suffer, I suffer, too. Generally speaking, empathy is a good quality to have. A good physician feels empathy. Empathy makes us human. But empathy unrestrained clearly presents a problem for a person who wants to help people in need, rather than repeatedly becoming a person in need herself. Still, while I understood my problem, nothing helped me control my sense of empathy so that I could maintain control of myself and actually be a useful human being. One of my biggest fears upon entering medical school was anatomy lab. I just knew that the second I walked into the classroom, I would feel overwhelmed with sadness, the sadness one feels at the loss of a loved one. Your sadness. And I would faint. And besides the embarrassment of being that kid who faints in anatomy, I would also never pass anatomy, and I would never become a doctor. On the first day of anatomy, I walked into the lab, absolutely terrified, counting down until the moment I lost control. 36
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But then something happened. All of a sudden, I grew deeply aware of the fact that I was in a classroom. My role had shifted. I could no longer be a casual observer, whose presence could easily be missed. My anatomy group counted on me, and someday in the not so distant future, my patients would count on me, and on the lessons I had learned in this classroom. I was able not to distance myself, per se, but I learned to take the empathy I felt, recognize it, and move it aside. While I would never forget it, I could serve a higher purpose: to learn and to help. I was there to learn information that someday would help another human being. A physician’s sense of empathy feeds the common, human connection between physician and patient, but empathy unrestrained to the point where the physician is more incapacitated by emotion than the patient hinders the physician’s true role: to support, to be a source of strength, and ultimately to heal. That first medical school class was almost a year ago. I passed anatomy! I want not only to express my deep gratitude to you, but also to tell you that I am here to support you in any way that I can. I promise that I won’t faint.
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Convocation of Thanks —June, 2013 Julia Cooperman
ife is filled with uncertainty. Big and small decisions to make, unexpected outcomes, accidents happen, you’re in the right place at the right time or the wrong place at the wrong time. There is a limit on the extent of what we can be sure of in life. Uncertainty can feel like an uncomfortable space, a coat that doesn’t fit quite right. Certainty seems easier; there’s no wondering, no excitement, no need to adapt at a moment’s notice. But let’s be honest: all of the important decisions, the really monumental decisions we make, we can never be 100% sure of them. We can never predict the outcomes of life’s complicated challenges with complete assurance.
and want to do everything in our power to fight the injustice. We spend much of our adult lives trying to slow the process of aging and idealizing a youthful appearance, refusing to process the meaning of our mortality.
Many of us find it more comfortable to actively fight death as an unnatural event to be avoided at all costs than to accept it as an inevitable part of life. When we are young children, we are unable to fully grasp the significance of death. During adolescence, we realize that death is irreversible and that we are sure to die someday. This truth can cause intense despair and bewilderment. We feel that we are being robbed
Doctors have a unique role in that they are often present and active in helping others during pivotal life events, the times during which people face uncertainty the most. In order to help our patients confront their own uncertainty and to understand our limitations (alas, we are mere mortals), it is crucial that we doctors-in-training confront our feelings about death and learn to operate within the confines of the uncer-
Given how we deal with death and dying in our society, it can be a shock to arrive at medical school and literally stare death in the face, perhaps not for the very first time, but certainly in a new context and with a new purpose. Why is this the defining entrance ritual into our chosen profession? What are the lessons we doctors-in-training need to learn from this experience? We need to learn gross anatomy, of course. “… it can be a shock One aspect of life that is not unWe need to identify each struccertain, however, is that there ture within the body, know its to arrive at medical will come a day when each one of connections to other structures, school and literally us will take our last breath of air and formulate a roadmap so that in and exhale for the last time. when we study its normal and stare death in the Death is the final act of life. For pathological states, we can visualface....” some, the last breath is not wholize what’s going on. For me, this ly unexpected. Some people have aspect of anatomy was like slowtime to put their affairs in order, ly piecing together an elaborate say goodbye, and make peace puzzle. The puzzles pieces fit inwith what they are facing. For to place most of the time, except others, a tragic accident or a sudden heart attack hapwhen they didn’t (which is to say that structures were pens, seemingly at random. It’s not a question of if, in their predicted locations except when they were but of how and when. This can be a terrifying proelsewhere or absent altogether). Though I highly valspect, knowing that we ultimately don’t have all the ued the technical aspects of the anatomy course and information we might like to plot our course in life; the images I gathered are seared into my memory, that we can never really anticipate the last exhale no behind the scenes there were equally important lesmatter how we may try. sons being learned.
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Convocation of Thanks tain world that exists around us. Just as confronting our own mortality can initially lead to distress and discomfort, coming to terms with othersâ€™ mortality and the unique responsibilities of the profession in matters of life and death is unavoidable when someoneâ€™s husband, mother, or grandparent is on the table in front of you. Just as I learned about the extraordinary variability in the make-up of each personâ€™s body from our months-long exploration, so did I learn about my feelings and reactions to the task at hand and the role I am being prepared for.
Though this is just the beginning of the journey to becoming a doctor, these first steps would not have been possible without the generosity of the people who donated their bodies to this program. They made a decision to help people after their last act in life, so they really have achieved a new life after death, both in your hearts and in our minds. To them, and to you, their loved ones, I will always be grateful. This is an absolute certainty.
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Convocation of Thanks —June, 2011 Ali-Reza Force
his past Monday was Memorial Day and I didn’t know what to think about it. It was a day off; I knew that much. I was grateful for the extra time to catch up on the studying I had set aside. I had the apartment to myself and I sat alone studying for hours as the sun rose and set and the day, for the most part, passed like any other. That evening I turned my television on and came across a program on PBS dedicated to the veterans. The program was entirely based on the letters written by soldiers, volunteers, their families, and loved ones from the Revolutionary War, the Civil War, World Wars I & II, Korea, Vietnam, and the Gulf War. Different actors and actresses reread words and re-expressed emotions corresponded many years ago. I sat there and listened for over an hour to voices, thoughts, and experiences of men and women, many of whom died only days after their letter’s had been posted. All the sacrifices, all the horrors, and all the events that had occurred in this world that I had never known became real again for a moment. I heard their words as I saw their bodies, those that fell to the ground, that were destroyed, maimed, and given up long ago. Soldiers and innocent people lying in ruins passed by in front of me, yet somehow through me as well. Death to me remains a surreal thing and seeing it there on the screen reminded me how strange and foreign it still was. The first dead body I ever saw was in the anatomy lab beneath the sky lights. I was late actually, and I walked into the lab for the first time with all the bodies in sight, students talking around them, and listening to second years point out different structures. I hardly could focus and my eyes watered up from the smell of formaldehyde. I moved strangely past rows of bodies toward my group’s table. I remember just standing there, looking down, not listening to anything. For some reason all I wanted to do was touch the body before me, to touch death for the first time, as if death could be touched, as if some other world could be felt. I asked permission from the second year, and half laughing he said ‘yes, of course.’
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With a pair of blue gloves on I reached down to feel the cold wet skin. I’m not sure why, but I thought for a moment it would change me, would transform something inside of me. I felt nothing, though, and later left the lab disenchanted. Death had never felt so real before. I wanted it to be more, to speak to me more, to feel more. I came to learn, however, that it would take more from me and why a day like Memorial Day, is so important. It is up to us now — post-mortem, post-life — to find meaning now in the lives that once were, just as letters written in the past require a reader to give them voice. Though the meaning may be different for each of us, it is up to us to reread the lives, to find and create meaning by remembering what they have given us. Thus, it is only through us that the dead can be heard, listened to, and learned from again. The body I worked with was a woman, one of the smallest bodies in the lab and one of the youngest as well. She was thin and had long fingers. Her heart was a good size and my lab partners and I were amazed at how clear structures would appear in her body, like an answer to a question. We spent hours together with her on the top floor beneath the windows. I would look up sometimes and see sunlight, a sky, or the moon above us. I thought of her again the other day when I heard a song on the radio by PJ Harvey. The song is about a woman in New York City running around at night and climbing to the top of roofs in Brooklyn and Manhattan with a friend to see the city. And up there, she sings, that “you said something / that I’ve never forgotten, you said something / that was really important.” The singer never tells the listener what was said, but only of the sights and sounds that she remembers. What was said, rather, was kept in silence. What she remembers was what they saw and felt up there looking out onto the city and how they could feel each other inside it. I looked down across a city with a woman once, a city made of blood vessels and nerves, a city made of tissue, organs, and a heart. We spoke in silence and I watched and listened in wonder.
Convocation of Thanks —June, 2013 Matthew Garofalo
t first glance, medical dissection is an academic exercise used to learn the human body. We study our patients to gain a grasp of normal and abnormal human anatomy. However, anatomy lab was also an exercise in interpersonal skills and compassion. We had to intimately work with three other people and designate responsibilities according to skill, affinity, and fairness. We conducted rounds at other tables and worked with our colleagues’ patients. We learned never to be too proud to ask questions. Most importantly, we learned how to treat patients with dignity, respect, and care. We grew attached to our patients, becoming protective of their care and privacy. As spring rolls around, images of rebirth abound: flowers bloom, animals are born, and the
world turns green. On this day, we thank our first patients and their families for the incredible gift they have given to medicine, and remember that they have been reborn in our hearts and minds. As we honor our patient’s lives and their sufferings and sacrifices, I would like to conclude with a quote by Martin Luther King, Jr.,
“As my suffering mounted I soon realized that there were two ways in which I could respond to my situation – either to react with bitterness or to transform the suffering into a creative force. I decided to choose the latter.” Thank you for choosing the latter.
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Convocation of Thanks —June, 2013 Andrew Silapaswan
would like to start with an excerpt from Heaven’s Coast: A memoir by Mark Doty, an American poet and memoirist who tragically lost his partner, Wally Roberts, to AIDS in 1994:
the author’s emotions. There are also shared experiences that resonate with many in the audience here today: Loss of a loved one, mourning, legacy, and remembrance.
“The past feels diminished when the future seems to
You know, it is interesting—before today I didn’t know anyone who travelled here—your names, faces, or stories. Even though we might have not directly known each other prior to today, we actually shared a common bond through your loved ones. As a result of their noble gift to science and medical education, we are brought here together, to finally meet in person, and I would now like to take this opportunity to hopefully share with you some of my experiences this past year and what I have learned. service of
shrink. When I am overcome – as I am, about once a week – by the prospect of losing my lover, I can’t see any kind of ongoingness; my vision becomes onepointed, like looking through the wrong end of a telescope, and the world seems smaller, further away, sad a difficult place which no one would much want to inhabit.
Almost eighteen months after Wally died, I know a little differently. I see a little more broadly “… the than the man who wrote these your loved one is pages, adrift in the sea-swirl of On the first day of our anatomy now braided with shock and loss. But something’s course, we were brought to the gained by allowing the voice of laboratory, and like any other mine.” those hours, the long days of new medical student, I had many mourning, to have its say. In a mixed emotions. I was eager to way I know less now too. The learn, but at the same time enLakota Sioux say that when natirely anxious and not knowing ture gives one a burden, one’s what to expect. also given a gift. Loss brought with it a species of vision, an inwardness which was We were met, however, by our second-year colleagues the gift of a terrible time – nearly unbearable, but who actually gave us our first educational lesson in bracingly real. the lab. This is one of those days that will stay with me Death requires a new negotiation with memory. Because the story of Wally’s life came to a conclusion, at least those parts of the story in which he would take an active role, the experiences of our past needed to be re-seen, re-viewed. Not exactly for his story to be finished, but in service of the way his life would continue in me, braided with the story of mine.” 1
throughout my future medical career. What struck me was their poise, their skill, and their knowledge attained from the previous year of study, which they were now passing down to us. I did not realize this at the time, but after a year of intense study and learning, I am soon to be in the position to help the next incoming medical class transition into the study of Anatomy.
I chose this piece not only for the beauty of its language, but also for the honest and faithful portrayal of
This would not have been at all possible, if not for the gift of your loved ones. It has been said that teaching
Mark Doty, Heaven’s Coast: A memoir (New York: Vintage Publishing, 1997).
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Convocation of Thanks is the profession that makes all other professions possible, and in this case, your loved ones were our teachers. They were just as much our teachers as our other Anatomy professors, some of whom you have met today. For that I am in eternally grateful to you, your support by coming here today, your remembrance for your loved ones, and for the lasting impact that they will have in the continuation of medical science. Although we will leave here today and continue down
our own life journeys, the education I have received from your loved ones will serve as the foundation for the rest of my future career. Information that not only will help me to deliver medical care in the future, but to one day pass on to the next generation of aspiring physicians. Therefore, I want to emphasize that today is a celebrationâ€”I look out and I see the legacy of our loved ones on your faces, in your memories, and now as a part of me and the rest of my colleagues. As Mark Doty mentioned, the service of your loved one is now braided with mine.
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Convocation of Thanks —June, 2013 Oded Tal
grew up in Queens, New York, taking the train since I was 13 years old to high school in Manhattan. Needless to say, I got lost on my first day. Over the years I have learned the system and have grown fond of the city I’m from. I had the idea to create a piece with a heart using the train paths as veins and arteries. So this piece sort of represents “where my heart lies.” Now, I’ve seen many pieces of art with this map as a canvas, and I’ve looked at that map countless times, but only recently have I noticed that several of the boroughs are conveniently shaped like an actual heart. But the more I thought about this piece, I found a much deeper symbolism expressed in this. My journey of learning the city became much like that of learning the anatomy of the heart, and of the human body as a whole. I found a strong connection between the two. Learning the intricacies of the system, the way things work and can work. The 7 train being my coronary bypass when the E or F trains decide to give out. A storm hits and floods the vessels but surgeons in the form of transit workers are right on it. Flow coming into the right atrium we know of as Grand Central Station, but the 6 train during rush hour will give anyone hypertension.
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The subway map of New York City has granted me the opportunity to explore the place I call home. Even having found my way for 10 years, to this day I feel I have so much to see. However, I will always go back to this map when I seek guidance. I came into the anatomy lab like a 13-year-old boy— nervous, but excited on his first day of high school. It was time to go from reading maps to riding the train. As I grew comfortable, the journey continued with each dissection: something new to learn and explore. Just as I will never forget my first travels on the subway system—the emotions, the paths, the mistakes—I will forever keep the memory of this opportunity and the knowledge that it has bestowed upon me. This donation was our first map in this journey of medicine. Although medical school is definitely not the express train, this opportunity will eventually guide us in our career path. I hope to know the human body as well as I do the subway system, and the generous donation given to us was the first stop in doing so. We hope we have made you proud of the gifts given by your family and friends to the medical community, and with our success, hope to inspire future generations to do the same.
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Memoirs of a Machine Joshua Liu I cut where I am told, my arms moving with a mechanical precision that follows imaginary lines strewn throughout the body, I follow instructions with an obedient ease, every sentence analyzed for meaning and then analyzed once more. The book identifies each anatomical component and I agree automatically, storing each valuable tidbit into some corner of my mind; I am a machine, one that has endured two years of apprenticeship, I know not of complaint, nor of exhaustion - I simply exist. Two years past I constructed myself from well-oiled parts, thinking I would be ready for the torrential storm to come, Fueled by motivation, guided by some unseen hand, I assembled myself to become a healer. Today, my parts are rusty; The bright sheen of my exterior has become muddled with cracks, wear, and dirt. I often wonder what is my purpose? Have I misunderstood my calling? Deluged under the weight of books that carry unknown, fervent meaning, I memorize and regurgitate those words without pause, without hesitation - that is what I am conditioned to do. Every month I endure grueling performance check-ups - I am grilled for recall, turned over for examination and finally assigned a number based on my overall skill. This number determines my total potential, I fail when it is low, succeed when it is high - I see the world through numbers. Looking around me I notice others, machines to the one, Each appears different, but we all serve the same purpose, Led by authorities in long, white coats, we strive to be just like them, Mimicking our robotic movements to their human fluidity. Ultimately we fail at this petty imitation because some component is missing, They say it comes from the inside and cannot be constructed, Compassion and empathy. Foreign concepts to our analytical minds, but familiar scenes to our once-human eyes, I begin to remember why I was created - to help the sick, to give expertise, to heal the injured, I realize I have strayed from my path - the machine is not suitable for this purpose, I must become more - I must relearn how to be human. Joy, sorrow, gratitude, guilt, pleasure, anger - the emotions ripple in like a whirlwind, But I embrace them, for it's been too long, We reconnect like long-lost lovers. I see a change coming to the others, the spark has been lit, We are becoming human again. I try to see the end of the tunnel where we fulfill our purpose, Not as perfect machines, but as imperfect humans, As physicians who aren't afraid to fail, who will not stray from their natural calling; The metamorphosis has begun.
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Against Hasty Rotations Allison Maidman Our hearts beat, Voices change, But would we know the passage of time without a line in the sand? We live within a world that can't contain us. A fleeting time and place, A fleeting life. As the seconds drip between our fingertips, We try to prevent the particles of what we once were from disappearing into the sand. Reason replaces intent, And logic sits heavy on our chests. Our efforts have preceded us, Quantifying failure And rattling off lost time. Yesterday is now a distant past, And today, a replacement.
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Quitting Julia Meisler I miss cigarettes the most when mom spends ten minutes deciding what to wear. I begin to shake as she asks for my opinion. “Do you depend on everything I say?” I say, no time to spare: right now I miss cigarettes the most. When she asks me again I can’t breathe, clawing for air I begin to bite my fingernails, a habit I had when I was ten years old, before I was aware of missing cigarettes. Mostly when my mother orders from the waiter, that’s when I want to cry. She acts as though he can’t hear and I begin to sweat. I can’t pretend that she is my friend when she can’t bear to see that I miss cigarettes the most when I begin to breathe without them.
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Child Kanthi Dhaduvai Child, Where are you now? Where have you been? Gathering hangers, Zipping up jackets, Giggling through tangled hair. Do you know You are a god. Do you know The past and the future Make love in you, Dance on your perfect crown, And touch your eyes with gold dust. As I watch, stumble across The wisdom of your life, Faintly familiar, enchanting Like a smell, Your petals are poised skyward. Free, unbroken, unafraid Of gravityâ€™s greatest pleasure And the blind beatings Designed to quiet you.
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Sũrgery (It'’s All Aboũt) Jordan Teitelbaum It’s all about tension versus counter-tension Ativan for pre-op apprehension Bupivicaine in liposomal suspension Jackson-Pratt’s to prevent distention Tightened sphincters at first mention Of a leak Free air - somewhere - and the stapler’s weak Time to freak But methodically, set the next steps in motion Out with the trocars, we’re converting to open. Pre-plan, post-plan, and peri-act, unlike Picasso this art form’s exact. It’s all about what’s viable and in tact Respecting the tissue while still addressing the issue It’s all about each step, and only then the composite: One can’t make withdrawals without first deposits. About assistance and focus, Multiple hands become one machine, hand-made and hand-done The most human form of pristine Hands on hands, and the stages are set, the lap pads are dry and the saline is wet. The aim is to help, to detract, to correct. It’s all about that active drive to direct a symphony of instruments, technologies, and efforts; a repertoire of practiced and proven endeavors To read, to learn, to train, to execute To figure out how in the hell to be resolute In a career of statistics, risk factors, and uncertainties Yet also a sport, an art, a way of doing everything purposefully It’s all about urgency and diagnosis, It’s all about doing your job best, Knowing over opining, conquering the beat in your chest. Creativity meets productivity, Action smacks into reactivity. It’s all about accuracy, spelling that word right, letter for letter It’s all about the patientall about making things better. 50
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Selected Poems Jason Fishel Neoplasm
They say that if they let it grow unchecked,
My eyeballs have left me in the dark,
this cancer would soon develop into a mass
packed their emergency duffel bags
the size of the Earth, and but of course, science
and rolled aboard the first subway
being so positivist these days, how could
train they could find, they left a note,
they possibly even know that, you know docs
I think, but I couldn’t read it, I’m guessing
don’t have to ask for your permission for
it was something about long work hours
anything these days, I really bet they just went
or taxation without representation,
ahead and did it, shot that little piece of tumor
it hardly matters now because they’re
they whacked out of me into space and watched
gone, off to see the world, their long
it grow unchecked into a mass the size of the Earth,
misuse now ancient history between we
you know, they say that every cell in the human
three, I miss them quite a bit, you know,
body comes from one single great great great
there’s always a chance in these sorts of
great great great great granddaddy, I guess
abusive relationships, a chance they might
I too could have just as easily grown up into
come back, I know that wouldn’t be any
a cancer planet instead of me, but I bet that I’d
good for either of them but that doesn’t
make the same choice if they let me try again,
stop me from dreaming about it, picturing
the giraffe still gets a kick out of his graceful legs,
them in my mind’s eye only, circling on back
even as the lion takes him down to earth for dinner.
into my empty sockets, coming to rest focused in on a single point like we used to do in the old days, and then back to it, to long nights, small text, bleariness, pulsing blood percussion even when they try to sleep, oh, they’ll get sick of it again, they’ll leave again, maybe next time they won’t come back, finally enticed by the lasting freedom of sunsets over the Pacific, of places they never got to go when they were still with me.
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Jason Fishel Manse
medical school lesson 4
This old house is senile,
patients experiencing anaphylaxis often describe
demented, out of its gourd,
a feeling of impending doom, in one of those rare
the comings and goings
but firmly documented instances that the practice
have blurred into a fleshy
of medicine shares its linguistic origins with
the tendons are tenuous,
holding the doors, stairs,
that’s right, christian death metal bands from riverside,
and windows in a creaky limbo, I hear the phthisis, crawling through old, wasted basement lungs, this old house has meant a great deal to each of us over the years of storms, holding its tenants tightly against a warm breast, muffling the screaming wind, now who will save this old house, I wonder, even as it sways in an odd, dusty dignity, giving even in the last moment, rotted
california, which, come to think of it, is perhaps as paradoxical a concept as predicting one’s own, like, metaphysical fist clenching around one’s anyone? anyone? that’s right, trachea, we would also have accepted throathole, but the point is simply that hohohoholy shit, it might even be happening to me right now, even as i stand here lecturing you, i’m seeing this, like, really anatomically accurate skeletal visage looming over about three or four of you in the back row, yes looming, hovering, impending
but still standing, begging
and the air is thick with meaning and could somebody call a
us inside for one more meal,
one more song, one more
smiling family portrait in front of the fireplace before we pull the plug.
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Selected Poems Popular Culture Tenet number one, the media matters, one must not simply throw in whatever chicken broth one finds at the downtown rescue mission and expect the organisms to grow out of a sense of poignant duty, a certain amount of bloodshed is often essential for success, sing to the creatures, let them grow toward a voice, do not coddle, sprinkle generous pinches of rat poisons and chemicals to make their walls brittle and tragic, unable to accommodate the screaming struggle to grow, this will breed that millennial resistance right into their little plastic bodies, they must be strong yet detached, contamination falls from the sky as it will, and the life can only be good for so many in these United States of gelatin, natural selection, forget or be forgotten.
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ORIGINAL Â FINDINGS
A 10mm Posterior Inferior Cerebellar Artery (PICA) Aneurysm Missed on DSA: Case Report Christopher Meltsakos Objective: We present an unusual case in which the gold standard technique of Digital Subtraction Angiography (DSA) failed to reveal a left Posterior Inferior Cerebellar Artery (PICA) aneurysm after previous detection on 64-slice Computed Tomography Angiography. Clinical Presentation: A 74-year old female presented with symptoms of a subarachnoid hemorrhage. An initial CT was performed which confirmed the diagnosis by depicting extravasation of contrast into the subarachnoid space. Follow-up computed tomography angiography (CTA) was performed to screen for possible presence of aneurysms. A 10mm fusiform-shaped aneurysm was observed in the middle portion of the left PICA. Subsequent DSA failed to reveal the same aneurysm with the standard procedural protocol. We were then only able to locate the aneurysm with selective advancement of the catheter closer to the site of the aneurysm. Intervention: With the combined information from both studies, endovascular treatment with surgical glue (Onyx HD 500) was performed to embolize the aneurysmal sac. The procedure was completed without any complications and follow-up angiography revealed no contrast enhancement within the previously described aneurysm, suggestive of successful embolization. Clinical Opinion: Pathophysiological factors such as rapid flow, presence of a thrombus, vessel dissection, or pseudoaneurysm may lead to omission of obvious aneurysms on DSA. In such cases CTA plays a crucial role in detecting these aneurysms due to the increased time of contrast distribution within the arterial system.
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neurysms can typically arise from a multitude of physiological and anatomical pathologies such as hypertension, trauma, atherosclerosis, hereditary predispositions, and turbulent blood flow at arterial junctions. Despite increasing innovations in diagnostic techniques, non-traumatic subarachnoid hemorrhages, although rare with an incidence of 6-8 per 100,000 individuals, have remained among the most serious causes of death with a mortality rate of 50% and a significant morbidity among the survivors.1,2 Approximately 2.8% of intracranial aneurysms occur in the Posterior Inferior Cerebellar Artery.3 Currently, computed tomography angiography (CTA) is used as a screening technique due to its relatively noninvasive nature and wide availability in the acute setting. Furthermore, it can be performed immediately after the initial CT scan to provide rapid diagnosis and assist in treatment planning.4 However, the current gold standard among institutions for the detection of intracranial aneurysms is digital subtraction angiography (DSA) because of its significantly higher sensitivity and specificity for diagnostic detection of vascular malformations in comparison to other imaging modalities. The mean size of missed aneurysms by DSA in a study involving 350 patients was 1.94mm (median, 2; range, 0.5-4mm).5 In the presented case, the patientâ€™s aneurysm was nearly five times the magnitude of the average missed aneurysm by DSA. The focus of this paper is to examine the possible causes and/or reasons behind the failure of DSA to detect a 10mm fusiform aneurysm. Existing literature does not document missed aneurysms of such size on DSA, though microaneurysms can be missed and are commonly documented. Our purpose is to propose several possible mechanisms for why an aneurysm of such magnitude might be missed.
Figure 1. Non-contrast CT Showing Subarachnoid Hemorrhage
A 74-year-old right-handed female was transferred from an outside hospital after awakening and complaining of a severe headache before vomiting once and rapidly becoming unconscious. Her past medical history was significant for atrial fibrillation and hypertension. Her social history revealed that she was an ex-smoker. On physical exam her blood pressure was 95/60, pulse 86, and respiratory rate 22. A neurological exam was performed, which revealed absent eye opening with sluggish, 2mm pupils bilaterally. The patient displayed withdrawal to pain of all four extremities. The patientâ€™s clinical presentation suggested a pathological localization on the left side.
DSA is commonly a reliable means to detect intracranial aneurysms, and it is virtually undocumented to miss aneurysms of the magnitude observed in this case. With such a unique case, there are many questions that remain unanswered. Although there are cases of missed aneurysms reported in a number of studies, these studies did not attempt to analyze the data in a way that acknowledges the discrepancies. 5 The importance of understanding the etiology of missed aneurysms could provide additional information in selecting appropriate diagnostic techniques for particular situations, thus improving patient outcomes.
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Figure 2. CTA Displaying 10mm Fusiform Aneurysm of the Left Posterior Inferior Cerebellar Artery.
There is much debate regarding the potential for CTA to supersede DSA in the near future as the primary diagnostic tool for intracranial aneurysm assessment.6 From our experience, we believe that CTA and DSA are complementary imaging modalities as they provide different aspects of the same vascular anatomy. While the sole use of DSA will hold greater clinical value in determining flow dynamics, CTA is superior at providing valuable anatomic detail due to its ability to display parent and vessel relationships that occur at the neck of an aneurysm.7 Furthermore, CTA is superior at defining the morphology of aneurysms, which is very valuable for surgeons in preparing to embolize the pathologic vessels. Regardless of which study is superior, it is notable that an aneurysm of such magnitude was missed on DSA. Though no current literature on the subject exists, we hypothesize several mechanisms that may account for the failure of DSA in detecting intracranial aneurysms.
Dissection: Though notably rare, a dissecting aneurysm could have led to the negative findings on DSA in this particular case. Hypertension is the most common risk factor that predisposes an individual to developing a dissecting aneurysm.8 Hypertensive patients show degenerative changes and loss of smooth muscle cells in the lamina media that is suggestive of mechanical injury to the vesselâ€™s integrity.9 Given the patientâ€™s age and history of hypertension, it would not be uncommon to observe vessel damage and moderate to significant atherosclerosis. If a dissection were to be present in the PICA, this lesion may weaken the integrity of the vessel wall and cause a fusiform aneurysm. Such a lesion may be missed upon DSA if contrast did not have enough time to fill the volume of the dissection. Furthermore, CTA was able to clearly identify this aneurysm due to the slower rate of the study which allowed for more filling time. Pseudoaneurysm: Another rare occurrence in vessels is the pseudoaneurysm, or false aneurysm. These malformations involve the development of a tiny hole in
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Figure 3. DSA with contrast in the left vertebral depicts no obvious aneurysm in the Posterior Inferior Cerebellar Artery. the vessel wall, which leads to extravasation of blood outside of the 3-layers of the vessel.10 The fibrotic reaction, which takes place over time when the blood contacts the extravascular space, maintains communication with the artery and allows for blood to circulate. In a similar fashion to dissections, contrast might not have had enough time to fill the pseudoaneurysm and thus could be a reason for its omission on DSA. Rapid Flow: In this scenario, a true aneurysm involving all three vessel layers could be missed on DSA due to rapid flow through the arterial system, which would lead to inadequate filling of the aneurysmal sac and therefore negative findings upon DSA.11 Although the size of our patient’s aneurysm makes this scenario unlikely, this nonetheless remains a possible cause for missed aneurysms on DSA. Thrombosis: Partial intra-aneurysmal thrombosis in the fusiform dilation could potentially be visualized as a patent lumen in DSA.12 This new “pseudo-lumen” would show on CTA because it is better at visualizing
anatomical details of the vessel as opposed to flow. Other Possibilities: In addition to the previously mentioned hypotheses, there are a few other possible causes that are less frequently observed, yet require consideration when compiling a comprehensive list of possible contributing mechanisms for the failure of DSA to detect an intracranial aneurysm. These other considerations include superimposed normal vasculature overlying the aneurysm, which may lead to a false negative by showing normal vasculature on DSA due to the overlap.13 CTA, on the other hand, allows for visualization of the vasculature at more obscure angles, which may aid in detecting aneurysms that may have surrounding vasculature, or overlying vessels.13 Another mechanism would include focal arterial spasms that could obliterate the aneurysmal neck, leading to impeded contrast flow into the aneurysm. With decreased contrast flow into the aneurysm, visualization of the aneurysm would be insufficient.
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Figure 4. Selective enhancement of the left PICA with catheter enhancement directly into the Posterior Inferior Cerebellar Artery.
Clinical Opinion: Despite the fact that it is rare to miss an aneurysm of the size mentioned here with the use of DSA, an examination of the possible mechanisms behind the failure of DSA in this particular case can help compile a comprehensive set of factors that may contribute to an understanding of this phenomenon. An extensive literature search revealed a lack of data and discussion surrounding the possible mechanistic causes in the rare cases in which DSA failed to properly identify aneurysms that were detected upon adjunctive imaging modalities. By providing a detailed discussion that highlights a number of limitations associated with the use of DSA, we hope to provide a concise reference source that proposes a number of mechanisms that may explain these findings. We propose that pathophysiological factors such as rapid flow, presence of a thrombus, vessel dissection, focal arterial spasm, superimposed normal vessels, or pseudoaneurysm may lead to omission of obvious aneurysms on DSA. In such cases CTA plays a crucial role in detecting these aneurysms due to the increased time of contrast dis-
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tribution within the arterial system. Although the adjunctive use of CTA and DSA is a commonly accepted practice, this case report not only provides an important application of the two imaging modalities, but also offers a concise compilation of the possible physiological factors that may affect aneurysm detection on our current gold standard, DSA. REFERNCES 1] Hacein-Bey L, Provenzale JM. Current imaging assessment and treatment of intracranial aneurysms. AJR Am J Roentgenol. 2011; 196:32â€“44. 2] Xing W, Chen W, Sheng J, Peng Y, Lu J, Wu X, Tian J. Sixty-four-row multislice computed tomographic angiography in the diagnosis and characterization of intracranial aneurysms: comparison with 3D rotational angiography. World Neurosurg. 2011 Jul-Aug; 76(1-2):105-13. 3] Peluso JP, van Rooij WJ, Sluzewski M, Beute GN, Majoie CB: Posterior inferior cerebellar artery aneurysms: Incidence, clinical presentation, and outcome of endovascular treatment. American Journal of Neuroradiology. 2008; 29: 86-90.
Figure 5. Post Operative intervention with surgical glue, showing successful embolization of the aneurysm.
4] Mohan S, Lee W, Tan JT, Wee LK, Hui FK, Sitoh YY. Multi-detector computer tomography angiography in the initial assessment of patients acutely suspected of having intracranial aneurysm rupture. Ann Acad Med Singapore. 2009; 38(9):769-73. 5] Van Rooij WJ, ME Sprengers, de Gast AN, Peluso JPP, and Sluzewski M. 3D Rotational Angiography: The New Gold Standard in the Detection of Additional Intracranial Aneurysms. Am. J. Neuroradiol. 2008; 29: 976-979. 6] Katada, K., M. Hayakawa, M. Nakane, K. Sano, Y. Kato, Y. Ogura, and T. Kanno. "Can 3D-CTA Surpass DSA in Diagnosis of Cerebral Aneurysm?" Acta Neurochirurgica. 2001; 143(3): 245-50. 7] Farsad K, Mamourian AC, Eskey CJ, Friedman JA. Computed tomographic angiography as an adjunct to digital subtraction angiography for the pre-operative assessment of cerebral aneurysms . Open Neurol J. 2009; 28(3):1-7. 8] King JT Jr. Epidemiology of aneurysmal subarachnoid hemorrhage. Neuroimaging Clin N Am. 1997; 7(4):659-68. Review. 9] Kim C, Kikuchi H, Hashimoto N, Kojima M, Kang Y,
Hazama F. Involvement of internal elastic lamina in development of induced cerebral aneurysms in rats. Stroke. 1988;19(4):507-11. 10] Murias QE, Gil GA, Vega VP, Meil谩n MA, Botana FM, Gutierrez MJC, L贸pez GA. Our experience in the diagnosis and treatment of cerebral pseudoaneurysms. Radiologia. 2012; 54(1):65-72. 11] Schuierer, G., W. J. Huk, and G. Laub. Magnetic resonance angiography of intracranial aneurysms: Comparison with intra-arterial digital subtraction angiography. Neuroradiology.1992; (35): 50-54. 12] Fontanella M, Innocenzo R, Pier PP, Bawarjan S, Chiara B, Diego G, Christian C, Walter V, Federico G, Gianni BB, and Alessandro D. Subarachnoid Hemorrhage and Negative Angiography: Clinical Course and Long-term Follow-up. Neurosurgical Review. 2011; 34(4): 477-84. 13] Villablanca JP, Jahan R, Hooshi P, et al. Detection and characterization of very small cerebral aneurysms by using 2D and 3D helical CT angiography. American Journal of Neuroradiology. 2002; 23 (7):1187-1198.
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NYMC MEDICAL STUDENT RESEARCH FORUM Oral Presentation 1st Place
Omega-3 Polyunsaturated Fatty Acid Status in Major Depression with Comorbid Anxiety Disorders Joanne Liu1,2, M.S., Hanga C. Galfalvy1,3, Ph.D., Thomas B. Cooper 1,4, M.A., Maria A. Oquendo1,3, M.D., Michael F. Grunebaum1,3, M.D., J. John Mann1,3,5, M.D., M. Elizabeth Sublette1,3, M.D., Ph.D. 1
Department of Molecular Imaging & Neuropathology, New York State Psychiatric Institute, NY, NY Institute of Human Nutrition, Columbia University, NY, NY 3 Department of Psychiatry, Columbia University, NY, NY 4 Nathan S. Kline Institute for Psychiatric Research, Orangeburg, NY 5 Department of Radiology, Columbia University, NY, NY 2
BACKGROUND: Essential polyunsaturated fatty acids (PUFAs) may influence brain function and neuropsychiatric health. Specifically, lower levels of omega-3 PUFAs have been found in depression. Despite the high comorbidity of anxiety disorders with depression, the potential relationship between PUFA status and depression comorbid with anxiety disorders has not been explored. METHODS: Medication-free participants with DSM-IVdefined major depressive disorder (MDD) with (n=18) and without (n=41) comorbid anxiety disorders, and healthy volunteers (n=62) were recruited from October 2006 to May 2010 at the New York State Psychiatric Institute. Depression and anxiety severity were assessed using depression and anxiety subscales from the 17-item Hamilton Depression Rating Scale. Plasma PUFAs eicosapentaenoic acid (20:5n-3, EPA), docosahexaenoic acid (22:6n-3, DHA), and the ratio of arachidonic acid (22:4n- 6, AA) to EPA (AA:EPA) were quantified. This secondary analysis employed ANOVA with a priori planned contrasts to test for diagnostic group differences in log-transformed PUFA levels (logDHA, logEPA, and logAA:EPA).
RESULTS: Plasma levels of logDHA (F=4.92, df=2,118, p=0.009), logEPA (F=6.44, df=2,118, p=0.002), and logAA:EPA (F=3.81, df=2,118, p=0.025) differed across groups. MDD participants had lower logDHA ( t=2.324, df=118, p=0.022) and logEPA (t=3.175, df=118, p=0.002) and higher logAA:EPA (t=-2.099, df=118, p=0.038) compared with healthy volunteers. Lower logDHA (t=2.692, df=118, p=0.008), logEPA (t=2.524, df=118, p=0.013), and higher logAA:EPA ( t=-2.322, df=118, p=0.038) distinguished anxious from non-anxious MDD. Depression severity was not associated with PUFA status; however, anxiety severity across the entire sample correlated negatively with logDHA ( rp=0.22, p=0.015) and logEPA (rp=-0.25, p=0.005) and positively with the logAA:EPA ( rp=0.18, p=0.043). CONCLUSIONS: The presence and severity of comorbid anxiety disorders were associated with the lowest EPA and DHA levels. Further studies are needed to elucidate whether omega-3 PUFA supplementation may preferentially alleviate MDD with more severe anxiety.
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NYMC MEDICAL STUDENT RESEARCH FORUM Oral Presentation 2nd Place
A Murine Lung Cancer co-Clinical Trial Identifies Genetic Modifiers of Therapeutic Response Chen, Zhao, Katherine Cheng, Walton Z, Wang Y, Ebi H, Shimamura T, Liu Y, Tupper T, Ouyang J, Li J, Gao P, Woo MS, Xu C, Yanagita M, Altabef A, Wang S, Lee C, Nakada Y, Peña CG, Sun Y, Franchetti Y, Yao C, Saur A, Cameron MD, Nishino M, Hayes DN, Wilkerson MD, Roberts PJ, Lee CB, Bardeesy N, Butaney M, Chirieac LR, Costa DB, Jackman D, Sharpless NE, Castrillon DH, Demetri GD, Jänne PA, Pandolfi PP, Cantley LC, Kung AL, Engelman JA, Wong KK. Dana Farber Cancer Institute, Boston, MA 02115, USA PURPOSE: Non-small cell lung cancer patients may differ in their responses to the same treatment plan even if they share the same oncogene. The inactivation of tumor suppressors can contribute to these differences in response. To test this hypothesis, three cohorts of mice were generated with the genotypes Kras, Kras Lkb1, and Kras p53. A corresponding human clinical trial in patients stratified by KRAS activating mutations also took place simultaneously when the mouse trial was performed. The goal of this “coclinical” trial in mice was to predict the efficacy of combining selumetinib, a MEK inhibitor, with docetaxel, a standard chemotherapeutic, and provide additional insights for future clinical trial design. METHODS: Genetically engineered mice harboring inducible Kras G12D activating mutation and conditional p53 or Lkb1 knockout alleles were induced by nasal inhalation of adeno-cre when the mice were seven weeks old. Expression of Cre recombinase in infected cells activates expression of mutant Kras and inactivates endogenous p53 or Lkb1 genes. Using a previously defined viral titer (5x106), these mice are expected to develop lung cancer within 6-14 weeks. Established disease is defined by tachypnea and bulk tumor mass on magnetic resonance imaging (MRI). Mice with suitable tumor burden, as determined by quantification of MRI results using 3D slicer software, were randomly assigned to two treatment arms: docetaxel or docetaxel plus selumetinib. For PET-CT studies, Siemens Inveon PET/CT system was used along with 14 MBq of 18F-FDG injection.
RESULTS: 30% of Kras only mice treated with single agent docetaxel showed partial response, in sharp contrast to only 5% of Kras p53 mice. None of the Kras Lkb1 mice responded to docetaxel treatment.
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Combining docetaxel with MEK inhibitor selumetinib did not show significant improvement for Kras Lkb1 mice; however, the combination dramatically improved the rate of response for the other two genotypes: 92% for Kras and 61% for Kras p53 mice. We found that Kras p53 mice had the highest MEK/ERK activity among all 3 mouse cohorts, and this activity was markedly reduced after treatment with docetaxel and selumetinib. Interestingly, Kras Lkb1 tumors seem to be rewired from MEK/ERK pathway to other pathways such as PI3K/Akt and SRC. MEK/ERK activity is much less prominent in Kras Lkb1 tumors. In addition, MEK inhibition in combination with docetaxel was not able suppress Kras Lkb1 tumor metabolism as reflected by PET-CT studies. Consistent with higher 18FDG uptake in Kras Lkb1 tumors as compared to Kras only tumors in both mouse models and patients, Kras Lkb1 mice have a higher expression of GLUT1. More importantly, the combination treatment in both Kras and Kras p53 mice showed better progression free survival than those treated with single agent docetaxel, and this result was confirmed later by the parallel phase II clinical trial. CONCLUSIONS: Our study demonstrated that "coclinical" trials in mouse models of lung cancer can faithfully recapitulate patient clinical trial results. The elevated ERK activity in both Kras and Kras p53 mice perhaps best explains the effectiveness of the addition of the MEK inhibitor selumetinib to docetaxel. Given that the status of LKB1 and p53 in patients were not known in the human clinical trial, it can be inferred that screening patients for tumor suppressor mutations in future clinical trials can be both beneficial and pivotal for treatment plans. Our data also identified 18FDG-PET as a useful tool to determine the efficacy of treatment methods and to predict patient response by examining changes in tumor metabolism before and after treatment .
NYMC MEDICAL STUDENT RESEARCH FORUM Oral Presentation 3rd Place
Repair of Nonunion Defects in Rat Femurs Using Multipotent Adult Stem Cells John Swietlik, B.A., Timothy Achor, M.D., Kevin Khalsa, M.D., Vincent Vigorita, M.D., David E. Asprinio, M.D., and Paul A. Lucas, Ph.D. New York Medical College, Valhalla, NY, USA
PURPOSE: Nonunions represent a continuing clinical problem. Adult stem cells are one possible treatment. Multipotent adult stem cells (MASCs) are easily isolated and have an unlimited proliferation potential. MASCs in a polyglycolic acid felt (PGA) have been shown to regenerate bone in a critical-size rat calvarial defect. In this study we ask whether a unique adult stem cell, MASCs, will regenerate bone in a standard adult rat femur nonunion defect? Do MASCs differentiate into bone forming cells in vivo without added transducers or pre-differentiation? METHODS: MASCs isolated from an adult rat transduced with green fluorescent protein (GFP) were seeded into PGA and cultured for 7 days in vitro. in an undifferentiated state. Seventeen adult male rats had a 8 -10 mm defect created in the right femur of Einhorn et al.  and divided into 3 groups: empty defect, defect treated with PGA alone, and defect treated with PGA + MASCs. Animals were euthanized at 8 weeks and union assessed by histological evaluation.
RESULTS: The empty defects PGA alone treated groups showed no histological union. In contrast, all 7 of the defects treated with PGA + MASCs had histological union with bone. Mean scores for the empty, PGA alone, and PGA + MASC treated defects were 0.6, 2.0, and 5.7 respectively.
CONCLUSIONS: Undifferentiated MASCs embedded into a PGA mesh were able to achieve bone regeneration and union 8 weeks post operation in this nonunion defect. MASCs were found to have differentiated into bone forming cells in vivo. MASCs are easily obtained and can be expanded in culture to virtually unlimited numbers and thus may represent an effective prevention or treatment of nonunion fractures.
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NYMC MEDICAL STUDENT RESEARCH FORUM Basic Science Poster Presentation 1st Place
Artificial Lamellar Cornea Based on PEG/PAA Luo Luo Zheng, BS1, 2, Yichieh Shiuey, MD3, Dale J. Waters, BS4, Phil Huie, MS1, Richard Manivanh, BS1, Jennifer R. Cochran, PhD2, Curtis W. Frank, PhD4, Christopher N. Ta, MD1 1
Department of Ophthalmology, Stanford School of Medicine, Stanford, CA. Department of Bioengineering, Stanford University, Stanford, CA. 3 KeraMed Inc, Sunnyvale, CA. 4 Department of Chemical Engineering, Stanford University, Stanford, CA. 2
PURPOSE: Corneal damage and diseases cause bilateral blindness worldwide in 5 million people, 40% of whom require corneal transplantation. The global shortage of human corneal donor tissue demands the search for an artificial cornea. We fabricated a novel hydrogel composed of an interpenetrating network of polyethylene glycol (PEG) and polyacrylic acid (PAA). PEG/PAA bears a rare combination of high mechanical strength to mimic natural cornea and high water content to permit oxygen and nutrient diffusion. Our design is a lamellar cornea that has the potential to support re-epithelialization through surface functionalization and to be implanted without staged procedures or a donor corneal carrier. METHODS: A PEG/PAA was cast with a diameter of 7mm and raised central button of 3-mm in diameter. After sterilization through autoclaving, the hydrogel was treated with chemical crosslinkers EDC and NHS to covalently bind bovine collagen Type I and bovine fibronectin to the hydrogel surface. Immortalized human corneal epithelial cells were seeded on top of the artificial cornea at a density of 2.5 x 10^4 cells/mL and cultured for two weeks. The molded hydrogel was implanted into a stromal pocket in enucleated rabbit eyes created with the Keramed RoboTome Cornea Pocket Maker.
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RESULTS: The surface-modified hydrogel supported a confluent growth of human corneal epithelial cells in culture. Cells stained positively for cytokeratin 3, indicating their corneal epithelial phenotype. The artificial cornea could be manipulated to fit into an 8.0-mm uniform circular stromal pocket created at a depth of 300 Âľm, such that the raised central button fit within the trephined anterior cornea. CONCLUSIONS: An artificial lamellar cornea has been fabricated with a PEG/PAA hydrogel that possesses high mechanical strength and nutrient permeability. The surface-functionalized hydrogel has the potential to support re-epithelialization in vivo. Delivery of the device into a corneal pocket is a simple procedure, aided by dehydration or insertion with a graft injector.
NYMC MEDICAL STUDENT RESEARCH FORUM Basic Science Poster Presentation 2nd Place
A 34–Amino Acid Peptide as a Neurotropic Vector for Mediating Treatment of Neuronopathic Lysosomal Storage Diseases Ryan Lippell, Ben Papapietro, Daniel Murphy, Kostantin Dobrenis PhD Department of Neuroscience, Albert Einstein College of Medicine, Bronx, NY 10461, USA
PURPOSE: Lysosomal storage diseases (LSDs) are a group of ~60 often fatal, inborn errors of metabolism that result from defects in lysosomal system proteins and have limited treatment options. Over 2/3 of LSDs include neuropathologic involvement with cognitive decline, motor and sensory deficits, and seizures. Due to the protective blood brain barrier (BBB), poor constitutive endocytosis of neurons and need for widespread delivery in the CNS, the effectiveness of therapeutic strategies like enzyme replacement (ERT), hematopoietic stem cell replacement (HSCRT) and gene therapies (GT) is greatly hindered. We recently developed and characterized a 34amino acid peptide (HcPEP), derived from the 50kDa atoxic Hc fragment of tetanus toxin, that confers neuronal binding, uptake, lysosomal delivery and retrograde axonal transport to a fluorescent partner protein when coupled to HcPEP (protein-Hcpep). The purpose of this project was to evaluate the degree to which an HcPEP-mediated strategy can overcome obstacles to treating the CNS in neuronopathic LSDs. Utilizing a murine model of the GM2 gangliosidosis, Sandhoff disease (SD), a neuronopathic LSD in which the β subunit (hexβ) of β-N-acetylhexosaminidase is deficient resulting in absence of both HexA and HexB isozymes, we evaluated fusion genes and lentiviral particles encoding hexβ-HcPEP chimeric protein. Importantly, Hex is the only multimeric lysosomal enzyme in which subunits are encoded by multiple genes. METHODS: To produce recombinant Hex-HcPEP enzyme, cDNA encoding hexβ-IRES-hrGFP and hexβHcPEP-IRES-hrGFP were used to prepare 3rd generation lentiviral particles and transduced into immortalized hexβ -/- microglia. Enzyme assays on medium collected from transduced SD microglia were performed fluorometrically using 4-methylumbelliferyl-6 -sulfo-2-acetamido-2-deoxy-β-D-glucopyranoside (4MUGS) to measure HexA, and 4-methylumbelliferyl2-acetamido-2-deoxy-β-D-glucopyranoside (4MUG) to measure total Hex. To evaluate neuronal uptake, binding and GM2-levels, neuron-enriched (~90% neurons) WT and SD cultures were prepared from fetal day-15
mouse neocortex from hexβ +/- matings and used in the following experiments: (1) transduction of neuronal cultures; (2) indirect co-cultures with transduced hexβ or hexβ-Hcpep SD microglia on a semipermeable membrane; (3) direct enzyme dosing. Cultures were subsequently fixed and assayed for XHEX (Hex artificial substrate) and/or labeled for MAP2 (neuronal marker), hrGFP and GM2 for subsequent confocal microscopy. RESULTS: Hex activity was verified in both hexβ and hexβ-HcPEP transduced SD microglia and recorded enzyme levels in dish medium were consistent with effective microglial secretion. Assays using 4MUGS, a substrate specific for HexA, additionally verified activity. Preliminary results showed that transduction with Hexβ-HcPEP leads to a statistically significant decrease in the percentage of GM2-positive cells in SD microglial populations (p<0.0001, chisquare). CONCLUSIONS: As HSCRT and GT invariably rely on the the degree to which Hex-corrected CNS cells can cross-correct deficient host cell populations, confirmation of microglial secretion is an important prerequisite for successful cell-mediated therapy. Verification that HexA-HcPEP retains HexA activity indicates that fusion hexβ-HcPEP subunit is successfully combining with native hexα subunit to create a recombinant HexA-HcPEP, eliminating concern that HcPEP would compromise post-translational processing and assembly. Importantly, the finding that all GFP-positive cells in Hexβ-HcPEP-IRES-hrGFP transduced microglia were GM2-negative supports the fact that HexAHcPEP is active against its natural substrate, GM2 ganglioside. Ongoing studies are aimed at more fully characterizing recombinant Hex-HcPEP, comparing it to native Hex and purifying both to begin in vivo ERT trials.
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NYMC MEDICAL STUDENT RESEARCH FORUM Clinical Science Poster Presentation 1st Place & Dean'’s Research Award Winner
Impact of Hormone Therapy in the Women'’s Health Initiative on Glioma Incidence Bryant England1, Erol Arslan2,3, Fred Moy4, Alicia Young5, Michael Karsy1,4 1
Department of Neurosurgery, New York Medical College, Valhalla, NY, 10595, USA. Institute for Fertility Preservation, New York Medical College, Valhalla, NY, 10595, USA. 3 Department of Obstetrics and Gynecology, Derik State Hospital, Mardin, Turkey. 4 Department of Pathology, New York Medical College, Valhalla, NY, 10595, USA. 5 WHI Clinical Coordinating Center, Fred Hutchinson Cancer Research Center, Seattle, WA, 98101, USA. 2
PURPOSE: Gliomas are the most common type of primary brain tumor in adults and while low-grade gliomas show a good prognosis, high-grade glioblastoma (GBM) confer approximately a 12-month survival. Although specific genetic mutations in p53, epidermal growth factor receptor, phosphatase and tensin homolog and NF1 amongst others are common drivers of gliomagenesis, there remain significant gaps in understanding the etiology of GBM. Recent epidemiological and in vitro studies have suggested that hormonal factors, including estrogen treatment, may impact the risk of glioma incidence. However, these clinical findings have been limited to case-control trials and retrospective cohort studies. The purpose of this study was a secondary analysis of the impact of hormone therapy (HT) on glioma incidence from the Women’s Health Initiative (WHI) prospective randomized clinical trial database. METHODS: Results from the WHI included 161,808 women with data regarding HT and medical followup. The initial trial was terminated in 2002 with extension studies currently in progress. The clinical trials included a HT clinical trial (n=27,347), and two non -HT clinical trials, including a dietary modification trial (n=48,835) and calcium/vitamin D trial (n=36,282). Eligible subjects could enroll in one, two or all three trials and subjects not eligible for the clinical trials were invited to enter the observational study. The relationship between HT (estrogen-alone [E -alone] or estrogen plus progestin [E+P]) on glioma incidence was evaluated using Kaplan-Meier survival analysis and Cox proportional hazards models.
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RESULTS: During a 12.7-year median follow-up, 167 cases of glioma (130 cases of GBM) were ascertained. Within the HT clinical trial, no significant difference between groups was observed in glioma incidence between the E-alone or E+P groups and respective controls. However in evaluating all WHI patients with HT, Kaplan-Meier survival analysis and logrank testing demonstrated a significant reduction in incidence for the E+P group (p=0.0035). Cox proportional hazards modeling showed there was no change in glioma incidence for the E-alone group (HR=0.76, 95% CI=0.43,1.36) but there was an inverse associated risk for E+P (HR= 0.48, 95% CI= 0.26, 0.88, p=0.02) after accounting for patient demographics and reproductive factors.
CONCLUSIONS: The results of this study did not show that E-alone or E+P impacted glioma incidence within the HT dataset however aggregated data for all women in the WHI study with E+P exposure showed a 43% reduction alone being compared to glioma risk and a marked 52% reduction in glioma risk after controlling for all other variables including patient demographics and reproductive factors. Further studies are warranted to elucidate the role of HT in the potential treatment of glioblastoma.
NYMC MEDICAL STUDENT RESEARCH FORUM Clinical Science Poster Presentation 2nd Place
Surveillance Strategies for Severe Traumatic Brain Injuries Undergoing Arctic Sun Protocol Mohamed Saleh, BS, Erwin P. Rusli, MD, Heidi Hansen, MD, Brian Kinkead, Mary George Kutty, Corrado P. Marini, MD, and Juan A. Asensio, MD, Francis B. Baccay, MD Department of Surgery, New York Medical College, Valhalla, NY 10595
BACKGROUND: There have been many innovative treatment strategies for traumatic brain injuries (TBI). The Artic Sun protocol combines pharmacological intervention, intra-cerebral oxygen tension manipulation, intra-cranial pressure monitoring, and hypothermia for management of severe traumatic brain injuries. Although the results are promising on its effects on TBI, as with all new treatment options, there may be side-effects that may counteract all the gains of its intention. Even though an "isolated" brain injury may be the cause for admission to the hospital, the injured brain cannot be thought of in isolation from the remainder of the body. TBI is a complex disease process that requires constant attention as one manages the associated body systems. With fever suppression, Artic Sun may be delaying in the diagnosis and treatment of sepsis. Fever plays a key role in increasing the clearance of microorganisms, the immune response and the heat shock response. After the initial resuscitation, medical maneuvers are directed at limiting secondary damage to the brain. Signs of sepsis risk and temporal duration on the Artic Sun protocol were examined to arrive at early detection and appropriate initiation of sepsis treatment. It is with the conjunction of early sepsis intervention with the Artic Sun protocol that may maximize therapeutic outcomes.
METHODS: This is a retrospective study of data collected from a single institution Level I/Tertiary Referral Center. ISS and GCS were evaluated. Two groups were compared, the group on the Artic Sun and those patients admitted with similar ISS and GCS in the 2 years prior to the Artic Sun. All patients that were classified as severe traumatic brain injury (GCS<8) were placed on the Artic Sun protocol for the complete 5 days of treatment. The Artic Sun machine bath
water temperature, patient’s foley temperature, cultures were scrutinized in order to recognize signs of sepsis risks and assess for any correlation to any specific time frame during the protocol when sepsis most likely to begin. Through extrapolation of data, there may be an identifiable trend during the Artic Sun time sequence that can be used to elucidate the need for early treatment of sepsis even without clinical signs of sepsis.
RESULTS: PRE-ARTIC SUN (01/01/2010 to 06/19/2012
236 patients identified (60 Deaths)
ISS (Average) 25.8
Intubated/No tracheostomy 88/236 (37.2%)
Intubated/Tracheostomy 67/236 (28.3%)
No Intubation 19/236 ( 8%)
Terminal Extubation 2/236 (.8%)
72/236 (30.5%) Tracheal Aspirate/Sputum/ Bronchial Alveolar Lavage Positive for combinations of Gram +/Gram- bacteria
32.3 average ventilator days/all intubated patients
21.5 average ventilator days/patient with tracheostomy
4.9 average ventilator days/patient without tracheostomy
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NYMC MEDICAL STUDENT RESEARCH FORUM Clinical Science Poster Presentation 2nd Place
Surveillance Strategies for Severe Traumatic Brain Injuries Undergoing Arctic Sun Mohamed Saleh, BS, Erwin P. Rusli, MD, Heidi Hansen, MD, Brian Kinkead, Mary George Kutty, Corrado P. Marini, MD, and Juan A. Asensio, MD, Francis B. Baccay, MD Department of Surgery, New York Medical College, Valhalla, NY 10595
RESULTS (continued): ARTIC SUN
26 patients identified
ISS (Average) 27.3
24/26 (92.3%) with tracheostomy
28.5 average ventilator days/patient
26/26 (100%) Tracheal Aspirate/Sputum/Bronchial Alveolar Lavage Positive for combinations of Gram +/Gram- bacteria
Temp max percentage: Foley 1st day 6/26 (23%), 2nd day 2/26 (7.7%), 3rd day 8/26 (30.1%), 4th day 7/26 (27%), 5th day 3/26 (11.5%)
Temp max percentage: Bath water 1st day 4/26 (15.3%), 2nd day 3/26 (11.5%), 3rd day 7/26 (27%), 4th day 8/26 (30.1%), 5th day 4/26 (15.3%)
The hypothesis is that there may a delay in diagnosis of sepsis in patients undergoing the arctic sun protocol secondary to fever suppression. Early treatment of septic patients results in an improved outcome in terms of morbidity, mortality, length of ICU stay. Although antibiotic use is a mainstay for sepsis treatment, there has to be judicious application of antibiotics in order to prevent many unwanted sequelae of
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indiscriminate usage. By comparing the group of patients before the Artic Sun with those on the Artic Sun protocol, the incidence of sepsis can be determined.
CONCLUSIONS: Timely detection and initiation of antibiotics is crucial for treatment of sepsis. The fever suppression of the Artic Sun poses new challenges in the detection and treatment of sepsis. Early detection and treatment of a septic process may ameliorate any systemic response while the Artic Sun can facilitate neurological recovery. Whether or not surveillance needs to be initiated empirically before signs of infection are apparent is a question that will need to be addressed. As our understanding of pathophysiology develops, strategies for recognition and intervention of sepsis are likely to improve. Ultimately, due diligence in detecting signs of sepsis risk in the critically ill TBI patient will lead to improved overall mortality and functional outcomes under the Artic Sun protocol. All body systems need to be addressed as one moves from the initial to the long-term management of the TBI in order to obtain optimal recovery.
Grace Yau Quill & Scope 2013, Vol. 6
Contributors Nina Beizer (New York Medical College, Class of 2016).
pp. 31, 36, 37
Katherine Cheng (New York Medical College, Class of 2016). p. 62 Julia Cooperman (New York Medical College, Class of 2016): Julia grew up in Ohio and completed her BA in History at the University of Michigan. She spent three years as an English as a Second Language teacher in New York City as part of the New York City Teaching Fellows, completing her MS in Education at CUNY, Lehman College. She then completed a Postbaccalaureate premed program at New York University and conducted public health research at Mount Sinai School of Medicine before matriculating at New York Medical College. In her free time, she enjoys exploring NYC, traveling the country, and spending time with family and friends. She is a co-Managing Editor of Quill & Scope. p. 38 Kanthi Dhaduvai (New York Medical College, Class of 2015). p. 49 Bryant England (New York Medical College, Class of 2015): Bryant England is a 3rd year MD candidate who studied genetics at Ball State University. He is interested in neurosurgery. pp. 22, 66 Jason Fishel (UNC School of Medicine, Class of 2015).
Ali-Reza Force (New York Medical College, Class of 2016). p. 40 Matthew Garofalo (New York Medical College, Class of 2016): Matthew studied anthropology at Washington University in St. Louis, graduating in 2009. He went on to complete post-baccalaureate studies at The University of Vermont and do musculoskeletal research at Hospital for Special Surgery before attending New York Medical College. He is from Norwalk, Connecticut. p. 41 Gabrielle Hatton (New York Medical College, Class of 2016): Gabrielle graduated from the University of Michigan in 2012 with a degree in Biology and Spanish. She previously researched infectious diseases where she was constantly exposed to harmful bacteria. She’s still alive, so her sterile technique must have been decent. She continues to live and breathe the Wolverine lifestyle and attends Michigan sporting events as often as her first-year medical courses will allow. Her future will hopefully include passing board scores, a puppy, and hiking Kilimanjaro for a second time. p. 28 70
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Shirley Hu (New York Medical College, Class of 2016).
Michael Karsy (New York Medical College, Class of 2013): Michael Karsy studied neuroscience at UCLA and recently obtained his MD/PhD from NYMC. He completed his PhD in the departments of Pathology and Neurosurgery at NYMC. He is currently a neurosurgery resident at the University of Utah School of Medicine. p. 22 Ryan Lippell (New York Medical College, Class of 2015): Ryan is a co-Editor in Chief of Quill & Scope and graduated from Tufts University in 2007 where he studied History and Music, played competitive table tennis and DJ’d a weekly radio show on WMFO, Tufts’ Freeform Radio Station. To put these pursuits to good use, he did a 180 after college and spent several years researching novel therapies for lysosomal storage disorders. Outside of science and medicine, Ryan has written for AllAboutJazz.com, enjoys New York pizza and watches too much professional tennis. p. 65 Joanne Liu (New York Medical College, Class of 2016): Joanne Liu is the Art Director of Quill & Scope. She received her B.S. from MIT in 2011, and completed her M.S. in 2012 at Columbia University. While studying at Columbia, she conducted clinical research at the New York State Psychiatric Institute on the potential role of omega-3 polyunsaturated fatty acid status in neuropsychiatric disease. In her spare time, Joanne makes messes and sometimes she makes movies.
pp. 1, 45, 60, 61
Joshua Liu (New York Medical College, Class of 2015): A native from sunny California, Josh entered medical school with an optimism found only in a naïve college graduate. After endless days of monotonous studying, that optimism is still there. When he's not undertaking fascinating sojourns with Robbins, Josh spends his time being ridiculously good looking. Needless to say, he hopes his humor brightens the day of those around him. p. 46 Allison Maidman (New York Medical College, Class of 2016): Allison grew up in a small town in Maine but moved to New York to study history in the big city. She now studies medicine at New York Medical College. p. 47 Julia Meisler (New York Medical College Class of 2016): Julia studied English and Psychology at Grinnell College, and graduated in 2009. p. 48 Christopher Meltsakos (New York Medical College, Class of 2014): Chris grew up in Massachusetts and attended Boston University as an undergrad to study
Human Physiology. In addition to his interests in the biological sciences and writing, Chris is an avid sports fan and enjoys participating in exercise and fitness in his spare time. As a future physician, Chris hopes to continue his involvement in writing or editing, while continually pursuing his interests in sports and science by including a Sports Medicine background in his practice. Chris contributed to the 2012 edition of the Quill and Scope with his piece on Delayed Onset Muscular Soreness and writes an online sports medicine column for the Boston local of Examiner.com.
Oded Tal (New York Medical College, Class of 2016).
Mohamed Saleh (New York Medical College, Class of 2014). p. 67
Grace Yau (New York Medical College, Class of 2016).
pp. 32, 54
Andrew Silapaswan (New York Medical College, Class of 2016). p. 42
p. 12, 21, 44
Jordan Teitelbaum (TouroCOM-NYC, Class of 2014): Jordan studied English, writing, and theatre at the University of Michigan before coming to New York for medical school. He enjoys writing about what he learns, and he makes sure to never stray too far from the things he loves. He plans on doing his residency in ENT/facial plastics. p. 50 Michelle Wu (New York Medical College, Class of 2016). p. 27
Luo Luo Zheng (New York Medical College, Class of 2016). p. 64
John Swietlik (New York Medical College, Class of 2015). p. 63
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Quill & Scope Staff Syed Ali (New York Medical College, Class of 2016). Xiomara Antonetti (New York Medical College, Class of 2015): Xiomara studied Biology and Spanish at Muhlenberg College in Allentown, Pennsylvania. After graduating she worked for HealthCorps, a non-profit organization devoted to preventable disease education, and pursued a Master of Science degree at New York Medical College before beginning her undergraduate medical education. Xiomara was born and raised in New York City which is where she plans to continue working with health education and advocacy in her nascent medical career. Julia Cooperman (New York Medical College, Class of 2016): Julia grew up in Ohio and completed her BA in History at the University of Michigan. She spent three years as an English as a Second Language teacher in New York City as part of the New York City Teaching Fellows, completing her MS in Education at CUNY, Lehman College. She then completed a Postbaccalaureate premed program at New York University and conducted public health research at Mount Sinai School of Medicine before matriculating at New York Medical College. In her free time she enjoys exploring NYC, traveling the country, and spending time with family and friends. She is a co-Managing Editor of Quill & Scope. Molly Deacutis (New York Medical College, Class of 2015): Molly graduated from Emory University in 2010 with a B.S. in Neuroscience and Behavioral Biology. Following her undergraduate studies, she received an MPhil in Neuroscience from University of St Andrew in2011, a research degree consisting of a thesis regarding the ethics of diagnosis and treatment in pediatric psychiatry. She is a co-Editor in Chief of the Quill & Scope. In her spare time, she enjoys travelling, playing piano, and having a good laugh. Linda DeMello (New York Medical College, class of 2013): Linda is a senior editorial board member of Quill & Scope and a member of the Alpha Omega Alpha Medical Honor Society. She graduated magna cum laude from the University of Massachusetts Dartmouth in 2007 with a B.S. in Biology and a minor in Biochemistry. She worked in clinical laboratories for six years in several hospitals across southern New 72
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England before her acceptance into NYMC. She recently had poetry accepted into the Journal of the American Medical Association, which is slated for publication in March. When she isn't studying or taking care of patients, she writes fiction and spends as much time with her husband as possible. She loves to run, drinks coffee by the gallon, and she hopes to be a successful radiologist when she grows up. Amin Esfahani (New York Medical College, Class of 2014): Amin was born in Tehran, Iran and moved to Toronto, Canada at the age of thirteen. He obtained his Bachelorette and Master of Science degree from the University of Toronto. He was a former co-Editor in Chief of Quill & Scope and President of the Student Senate. Aminâ€™s interests include research in the area of Nutritional Science, with emphasis on dietary prevention and management of chronic diseases such as heart disease and diabetes. Amin has contributed to over forty published works in the form of book chapters, peer reviewed journal articles and research abstracts. Even though he is uncertain of the medical specialty he is to pursue, his ultimate goal is to integrate his passion for clinical research with the practice of medicine. Bailey Fitzgerald (New York Medical College, Class of 2016): Bailey is a co-Managing Editor of Quill & Scope. She graduated in 2012 from Syracuse University, where she received degrees in both Biochemistry and English & Textual Studies. At NYMC, she is also a coPresident of the American Medical Student Association, with particular interests in health policy. Matthew Garofalo (New York Medical College, Class of 2016): Matthew studied anthropology at Washington University in St. Louis, graduating in 2009. He went on to complete post-baccalaureate studies at The University of Vermont and do musculoskeletal research at Hospital for Special Surgery before attending New York Medical College. He is from Norwalk, Connecticut. David Gedeon (New York Medical College, Class of 2015): David graduated from Cal Poly (San Luis Obispo) with a B.S. in Biochemistry. Before joining NYMC, he earned a M.S. in Physiology and Biophysics from Georgetown and worked for the Princeton Re-
Quill & Scope Staff
view teaching Organic Chemistry for the MCAT. Now he is a co-Editor in Chief of the Quill & Scope. He enjoys golfing, backpacking and spending time with friends. Erica Jacovetty (New York Medical College, Class of 2016). Meghan Kiley (New York Medical College, Class of 2015). Sean Kivlehan (New York Medical College, Class of 2011): Sean is an Emergency Medicine Resident at the University of California San Francisco and a member of the Editorial Advisory Board for EMS Magazine. He graduated from NYMC with an MD and an MPH in International Health with honors in 2011 and cofounded the Quill & Scope journal in 2008. He also holds a summa cum laude bachelor’s degree from Hunter College in Biology and History. Prior to residency he worked as a NYC paramedic for ten years. Ryan Lippell (New York Medical College, Class of 2015): Ryan is a co-Editor in Chief of Quill & Scope and graduated from Tufts University in 2007 where he studied History and Music, played competitive table tennis and DJ’d a weekly radio show on WMFO, Tufts’ Freeform Radio Station. To put these pursuits to good use, he did a 180 after college and spent several years researching novel therapies for lysosomal storage disorders. Outside of science and medicine, Ryan has written for AllAboutJazz.com, enjoys New York pizza and watches too much professional tennis. Joanne Liu (New York Medical College, Class of 2016): Joanne Liu is the Art Director of Quill & Scope. She received her B.S. from MIT in 2011, and completed her M.S. in 2012 at Columbia University. While studying at Columbia, she conducted clinical research at the New York State Psychiatric Institute on the potential role of omega-3 polyunsaturated fatty acid status in neuropsychiatric disease. In her spare time, Joanne makes messes and sometimes she makes movies. Victoria Mock (New York Medical College, Class of 2015): Victoria is a co-Editor in Chief of Quill & Scope. Zan Naseer (New York Medical College, Class of 2016). Mike Rahimi (New York Medical College, Class of
2014): Mike was a former co-Editor in Chief of Quill & Scope. He graduated magna cum laude from The George Washington University with a BS in Biological Sciences and minors in Psychology and Art History, and was a campus radio DJ and talk show host for four years. Prior to coming to NYMC, he taught molecular biology lab techniques as part of an Army educational outreach program, worked as a clinical research coordinator of Neuroradiology at the Hospital of the University of Pennsylvania, and played electric guitar in several bands. He was Vice President of the NYMC Radiology club. Eric Routen (New York Medical College, Class of 2016): Eric is a co-Managing Editor, Quill &Scope. He is a 2011 graduate of the University of Notre Dame, equipped with a degree in Psychology and a passion for social justice. Always one to marry passion and service, he has worked with people suffering from mental illness and homelessness in Sacramento and individuals living with HIV/AIDS in Baltimore. He is currently doing research in Music Therapy with cancer patients undergoing radiation therapy in Manhattan. His interests include the sound of the cello, nonfiction books, and fast-food sustainability. He looks forward to entering a residency program that allows him to combine music, homelessness issues, and a 9-5 workday. Navid Shams (New York Medical College, Class of 2013): Navid graduated from Carnegie Mellon University in 2007 with an undergraduate degree in Creative Writing and Biological Sciences. Prior to medical school, he attended Boston University where he earned a Masters in Public Health, with concentrations in International Health and Epidemiology. Next year he will be further exploring his interest in research as the Fulbright-Fogarty Fellow in Public Health for Lima, Peru. David Shottland (New York Medical College, Class of 2016). Parvati D. Singh (New York Medical College, Class of 2015): Parvati received her BA from Colgate University in 2009. At Colgate, she majored in Molecular Biology and minored in Political Science. In 2010, she completed her Master’s in Nutrition at Columbia UniversiQuill & Scope 2013, Vol. 6
Quill & Scope Staff ty. Parvati has done research on esophageal cancer, heart failure, and Toxoplasma gondii. Parvati is interested in health policy and the role genetics and nutrition plays in medicine. Jane Song (New York Medical College, Class of 2015): Jane was born in Seoul, Korea but has lived all over the states during her childhood, including LA, Albuquerque, Austin, and Boston. Jane studied biology and English at Emory University in Atlanta, GA and took two years off to work in pediatric neuroscience research at the NIH before starting med school. In her free time, she enjoys traveling, running, photography, brunching, and exploring new cities through food. Oded Tal (New York Medical College, Class of 2016).
Quill & Scope 2013, Vol. 6
John Wainwright (New York Medical College, Class of 2014): John is a graduate of The George Washington University where he studied Chemistry and Art History. Prior to coming to NYMC he traveled to Australia and China and attended Georgetown University for a Masters in Physiology and Biophysics. He is currently one of his classâ€™ representatives on the First and Second Year Curriculum Subcommittee and is President of the Neurosurgery Club as well as a member of the AMA-MSS and AMSA. John is also engaged to a fantastic fourth year medical student who will be matching into Pediatrics. Grace Yau (New York Medical College, Class of 2016).
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BACK COVER: Back cover design and illustration: “ Lost” by Quill & Scope Art Staff
QUILL & SCOPE
Published on May 2, 2014
a platform for medical students of all years at NYMC to express their views on the contemporary issues in medicine. Diversity and breadth o...