Upstate Health, Summer 2019

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Tick check

3 Renegade researchers Can you solve our crossword puzzle?

Expert advice: Thongs, sunscreen & CBD A satisfying end of life

From the experts at

Summer 2019

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What’s Up at Upstate

Upstate now provides mobile mammography services with a new 45-foot van aimed at ensuring easy access to screening for women who live in Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego and St. Lawrence counties. A grant from the New York State Department of Health paid for the van, hoping it will help increase screening rates.

The van is equipped with a 3-D digital mammogram system, private exam and dressing rooms and a waiting room. l

U.S. News & World Report ranked Upstate’s Master of Public Health program in the top 100 of best graduate schools for 2020. The program, which attracts students looking for personalized attention and mentoring, takes 24 months to complete with full-time study. Part-time students have up to five years to complete the program. l

A discharge hospitality center is open at Upstate’s downtown hospital, for patients who are ready to go home and awaiting transportation, medical equipment or medication before they leave. The room is near the cafeteria and is equipped with recliners, a television, refreshments and has a nurse on duty. l

New Staxi Medical Chairs at Upstate’s downtown and Community hospitals improve the transport experience for patients and the volunteers who move them. The chairs have smaller wheels than a traditional wheelchair, a tapered seat, stationary footrest, folding armrests and brakes that engage when the handlebar is released.

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Rome Memorial Hospital is the latest health care facility to join the telestroke network through Upstate’s Comprehensive Stroke Center. The network connects stroke specialists with medical staff at regional hospitals to assess and care for patients who may be having a stroke. l

Researchers at Upstate now have access to one of the most advanced mass spectrometers available today. Thanks to a $1.1 million grant from the National Institutes of Health, the new mass spectrometer enables further advances in the fields of structural and quantitative proteomics and metabolomics and drug discovery. l

Parents delivering at Upstate’s Family Birth Center at its community campus have been able to donate umbilical cord blood to the Upstate Cord Blood Center since 2018.

Now, parents who deliver at Crouse Health, the hospital adjacent to Upstate University Hospital in downtown Syracuse, have the option to voluntarily donate their baby’s umbilical cord blood. Umbilical cord blood, which is typically discarded as medical waste, is rich with the blood-forming cells that can give blood cancer patients and others hope for a cure. As a public blood bank, there is no cost to donate, and donated cord blood is available to anyone who needs it. u

Health C o n t e n t s UPSTATE

Upstate Health magazine is a community outreach service of Upstate Medical University in Syracuse, N.Y. Upstate is an academic medical center with four colleges (Medicine, Nursing, Health Professions and Graduate Studies); a robust research enterprise and an extensive clinical health care system that includes Upstate University Hospital’s Downtown and Community campuses, the Upstate Cancer Center and the Upstate Golisano Children’s Hospital.

Part of the State University of New York, Upstate is Onondaga County’s largest employer.

Summer 2019

in our leisure It’s a puzzle

page 18

in our Community Attracted to ticks

page 20

On a mission to help page 22

departments What’s Up at Upstate

Ask the Experts

Science Is Art Is Science

Speaking from experience page 5

page 2 page 14 back cover

patient Care on tHe Cover Tick experts from Texas relocate to Upstate.

Relief — after reconstructive surgery page 4 Helping, whether on duty or off

page 6

See story, page 20.

PHOTO BY CHUCK WAINWRIGHT

need a referral?

Contact Upstate Connect at 315-464-8668 or 800-464-8668, day or night, for appointments or referrals to the health care providers on these pages or anywhere at Upstate or for questions on any health topic.

From our experts Renegade researchers

page 8

What initials are on your nurse’s nametag? page 16 Imagining the future of medical care page 17

upstate HealtH

EXECUTIVE EDITOR Leah Caldwell Assistant Vice President, Marketing & University Communications EDITOR-IN-CHIEF WRITERS DESIGNER

Amber Smith 315-464-4822 or smithamb@upstate.edu

Jim Howe Darryl Geddes Amber Smith Susan Keeter

Visit us online at www.upstate.edu or phone us at 315-464-4836.

For corrections, suggestions and submissions, contact Amber Smith at 315-464-4822 or smithamb@upstate.edu

additional Copies: 315-464-4836 Upstate Health offices are located at 250 Harrison St., Syracuse, NY 13202

How to finish your story page 15 Attracted to ticks

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pati ent Care

Relief – aer reconstructive surgery How one man had his urethral stricture repaired

BY AMBER SMITH

Urologist Dmitriy Nikolavsky, MD, and Hemant Tandi at an appointment.

PHOTO BY ROBERT MESCAVAGE

emant Tandi knows other men suffer, as he did.

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He wants them to know how he was helped, because maybe they can be, too.

For 30 years, Tandi, 58, of Endicott experienced slow, burning urination.

It wasn’t until he found Dmitriy Nikolavsky, MD, that Tandi got relief.

He grew up in India. He had no idea that slow, burning urination was a symptom of a condition called urethral stricture. When his stream became a trickle, Tandi sought care from a doctor in India who was not familiar with reconstruction. He underwent a painful procedure in which a rod was inserted to widen his urinary tract.

That helped for a brief time, but his situation eventually worsened.

By then, Tandi was living in the United States. He ended up at a hospital in Binghamton when he became unable to urinate. Doctors there referred him to Nikolavsky, who is known worldwide for his expertise in reconstructive urology.

“He was so patient, and so willing to hear me,” Tandi recalls.

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His stricture was close to his bladder and would need to be removed surgically, Nikolavsky told Tandi. In the operation, the surgeon would cut away the damaged tissue and replace it with a buccal mucosa graft that he would take from the inside U P STAT E H E A LT H l summer 2019 l upstate.edu

of Tandi’s cheek. The cheek tissue would heal similar to the way a burn from a hot bite of pizza would heal.

And the graft inside Tandi’s urethra would settle into its new location over several days.

Tandi had “100 percent faith” in Nikolavsky. He was observed in the hospital overnight after the operation, and his catheter was removed almost three weeks later. His urinary system has worked fine ever since.

“I’m very thankful for him,” Tandi says of his surgeon. He hopes other men with urethral strictures will realize they may have options. u

learn about reconstructive urology at upstate by calling 315-464-6106.

pati ent Care

Breathing easier Respiratory therapist speaks from experience

BY JIM HOWE

Respiratory therapist Amy Bradt talks with Muyan Pen, 14, who breathes with a ventilator because of complications from a brain tumor.

PHOTO BY RICHARD WHELSKY

hen Amy Bradt reassures an anxious child

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not to be afraid of a breathing tube she is

giving them, she speaks from experience.

“I understand. I know what you’re going through,” she tells her patients.

“I’ve been through this myself.”

Bradt, a respiratory therapist who works mainly in the pediatric intensive care unit at the Upstate Golisano Children’s Hospital, spent a lot of time in hospitals as a child. She was diagnosed at age 6 with a cancer called Ewing sarcoma.

The disease led to multiple surgeries, and several times she was intubated — with a tube inserted into the windpipe, so a ventilator can help with breathing.

She also had three tracheotomies, where a hole is cut directly into the windpipe to help with breathing.

Dealing with an intubation or a tracheotomy can frighten children, and it can be uncomfortable.

“We get a lot of kids who are scared to be intubated, so I can tell them it’ll be OK. I understand how they’re feeling when we do certain things,” Bradt says.

“My experience helps a lot with the parents, too, to reassure them these are the best decisions, that their child will be uncomfortable but not in too much pain.”

She likes that she can watch her interventions make breathing easier for her patients most of the time. “It’s nice to have that instant effect in kids. My favorite part is when kids who are scared realize this is helping. They smile.”

Bradt was drawn to science, partly because she was in and out of hospitals so often in childhood.

After she got her bachelor’s degree in respiratory therapy, she went into the pediatric side of the specialty so that “I could help kids the way people helped me,” she explains.

“I feel like I can connect with them, and through personal experience let them know they’ll be OK.” u

interested in respiratory therapy?

Upstate Medical University offers a bachelor of science degree in respiratory therapy and was one of the first schools to offer a baccalaureate degree in the profession. Faculty have national, state and local recognitions and more than 100 years of combined experience. Students enter as college juniors. The 21-month program includes more than 1,000 hours of clinical experience in a variety of settings.

Learn more at upstate.edu/education upstate.edu l summer 2019 l U P STAT E H E A LT H

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pati ent Care

Emergency action When someone is in distress, they respond octors, nurses and others in caring professions

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spend their careers taking care of people.

Sometimes their lifesaving efforts occur outside

of their work hours.

Though not legally obligated to help, many professional caregivers are programmed to respond in an emergency.

Gridiron collapse During a football game at Christian Brothers Academy at the end of last summer, sophomore running back Melvin Beard was leaving the field after a touchdown when he collapsed. He became unconscious. His heart stopped.

Several medical providers helped revive him using the school’s automated external defibrillator.

Among those who helped were anesthesiologist Joe Reagan, MD, an Upstate graduate and family practitioner Mike Picciano, MD, who are on the CBA staff of assistant coaches, along with physician assistant Ben Connor and spine surgeon Rich Tallarico, MD, Upstate people who were attending the game.

A month later, Beard explained that he had an undetected birth defect in his heart. “If it didn’t happen on that field, I probably wouldn’t be here right now. So, I’m just thankful for that,” he told Syracuse.com. He underwent heart surgery and returned to the CBA field for the homecoming game at the end of September.

Teammates awarded him the game ball.

Heimlich help Upstate nurse anesthetist David Vargo was eating at New Ling Ling Chinese Buffet in North Syracuse in mid-May when he noticed a commotion at a nearby table.

“Grandma is turning blue,” a young girl cried.

Vargo determined the older woman was choking. He tried to unblock her windpipe while she remained seated in her chair. When that didn’t work, he pulled the woman to the floor, straddled her thighs and did eight abdominal thrusts, which dislodged the food that was choking her.

“In anesthesia, the primary concern is always the airway, the breathing. So I just went into auto mode and knew what to do,” says Vargo. The incident brought back memories of the first time he performed the Heimlich maneuver in a restaurant – 30 years ago when he was 18 and working as an emergency medical technician.

Runner revived Four nurses sprang into action when they heard that a runner fell and was bleeding from his head as they were finishing a class at CrossFit Syracuse. One of them grabbed the gym’s automated external defibrillator as they dashed out the door.

Greg O’Polka had tied on his sneakers and started a warm-up run on Thompson Road, near CrossFit, when he fell forward. Fellow runners immediately began cardiopulmonary resuscitation. Upstate nurse Katie Freeborn, Continued on page 7

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pati ent Care

Emergency action

continued from page 6

Shannon Kaupp stopped to render aid to the young man, who stopped breathing. “My mind was racing,” she admitted to Spectrum News. “If you could’ve heard my mind during those moments, I was like ‘OK, Shannon, think. You got this. You’ve got to help him out.”

colleagues Katheryn Dunn and Lindsay Watkins and another nurse took over CPR when they arrived.

Freeborn says the nurses easily fell into their professional caregiving roles.

“After the fact, I was like ‘Wow. That just happened.’ ” Later, a doctor told them they had likely saved the man’s life.

O’Polka recovered from heart bypass surgery and attended the American Red Cross Real Heroes Breakfast in December, where the nurses received the “Good Neighbor Award.” He returned to working out at the CrossFit gym on Memorial Day weekend.

Crash reaction A third-year medical student from Upstate sprang into action in April in Brighton, N.Y., when she witnessed a car crash that left one driver critically injured.

The Brighton Police Department gave Kaupp the Citizen Citation Award, saying “had you not assisted, it is likely the driver would have died.”

Kaupp says the young man is recovering in a rehabilitation center. u

‘Pets’ for patients Battery-operated companion dog and cat PHOTO BY RICHARD WHELSKY

pstate has a dozen animatronic pet puppies

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heartbeat that patients can feel. With a lifelike coat, authentic sounds and the ability to respond to the patient’s voice, the dog and cat are meant to provide comfort. They operate on alkaline batteries.

Donations from the Upstate Foundation’s “Friend in

The manufacturer — at joyforall.com — sells the yellow Lab puppy for $120 and cats for $100, with your choice of an orange tabby, tuxedo or silver with white mitts. u

and kittens available to help older patients who are hospitalized with dementia, loneliness

or depression related to a prolonged hospitalization.

Deed” fund made this program possible.

The Joy for All Companion Pets are gifts for selected patients to use in the hospital and take home with them, explains Assistant Director of Nursing Kelly Dolan. They are not shared among patients because of infection control concerns.

The pets have built-in sensors that respond to motion and touch, and a

to donate to the Friend in deed fund, contact the upstate Foundation at 315-464-4416 or upstatefoundation.org upstate.edu l summer 2019 l U P STAT E H E A LT H

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From our experts

Renegade researchers

These Upstate scientists provide new ways of looking at long-standing medical problems

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From our experts

Rethinking Kaposi sarcoma Viral immunologist sees patient improve aer treatment for inflammatory response

BY AMBER SMITH

hristine King, PhD, studied both virology

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and immunology for her doctorate. Years of laboratory research have developed her deep

understanding of endothelial cells, mast cells and a disease called Kaposi sarcoma. She is known as a voracious reader of scientific journals.

So, when a 46-year-old man with Kaposi sarcoma developed seemingly random symptoms that were making him miserable soon after he had his appendix removed, infectious disease doctors at Upstate University Hospital asked King if she had any ideas.

Boy, did she.

She proposed a novel treatment that worked.

But first, some background.

a special research lab King’s lab is focused on the origin and development of viral diseases, particularly those affecting endothelial cells, which line the blood vessels throughout the body.

These cells have an innate resistance to cancer, something researchers are trying to better understand. King studies two diseases that are characterized by faulty endothelial cells: dengue fever and Kaposi sarcoma, which is caused by a herpes virus. In severe cases of dengue, endothelial cells become leaky. In advanced Kaposi, the cells proliferate uncontrollably and don’t function properly.

Many doctors who treat patients with Kaposi blame the herpes virus for getting into the endothelial cells and causing inflammation. That’s not how King sees it.

“No virus wants to make you sick. It just wants to survive,” she explains.

“When you feel sick from a cold or a flu, it’s the immune response that’s making you feel sick. It’s not the virus.” It’s the same with Kaposi, she says. It’s the body’s immune reaction to the virus that causes the inflammation, which leads to skin lesions and other symptoms.

Continued on page 10

Christine King, PhD PHOTO BY WILLIAM MUELLER

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asK tHe experts

Rethinking Kaposi sarcoma

continued from page 9

A team of scientists from various medical schools collaborates with King.

They believe Kaposi is dependent not just on the herpes virus but also the body’s immune reaction, and they say the disease will go away if the inflammation goes away.

They also believe it’s not the endothelial cells that initiate the inflammation but their companion cells, mast cells, that do. Mast cells are the cells that release histamine during inflammatory and allergic reactions. They are located in connective and mucosal tissue throughout the body and work closely with endothelial cells.

King noticed that the Kaposi lesions appear in areas where mast cells are prevalent. She began thinking mast cells may play a role in the disease. Blood analyzed from people with Kaposi suggest she is on the right track. “We took random samples, and the levels of mast cell specific mediators were incredibly high, suggesting we have this constant activation going on,” she says.

this is what helped the patient A 46-year-old man with Kaposi sarcoma suffered multiple symptoms that went away soon after he started taking: • 20 milligrams cetirizine, daily (commonly used for allergy relief, it is a type 1 histamine receptor antagonist also known as Zyrtec, available over the counter) • 300 milligrams ranitidine, twice a day (commonly used to relieve stomach acid and digestive problems, it is a type 2 histamine receptor antagonist also known as Zantac, available over the counter) • 10 milligrams montelukast, daily (commonly used to treat asthma, it is a leukotriene receptor antagonist also known as Singulair, which requires a prescription) • 1 gram vitamin C, daily (a mast cell stabilizer) SOURCE: A JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER RESEARCH CALLED CLINICAL CANCER RESEARCH, JULY 2018.

anti-inflammatory called montelukast, or Singulair, and vitamin C, known as a mast cell stabilizer.

“He did fabulous. His regression was dramatic, and it happened right away,” King recalls. At the man’s follow-up appointment two weeks later, many of his symptoms had gone away. “Over the next three months, they continued to resolve. His lesions shrank. He felt better. He told me he felt the best he’d felt in years and years and years.”

Success in a single patient doesn’t prove anything. But, this case gives King and her team more to explore.

They’re gathering data for a future clinical trial that could find an affordable and effective way to treat Kaposi.

Meanwhile, the researchers are getting the word out by presenting their findings at international scientific conferences and in medical journals.

The medications they’re working with are relatively inexpensive, have been in use long term and are readily available, so doctors with Kaposi patients may want to try the combination. Says King: “I suspect it’s going to work in most patients.” u

about Kaposi sarcoma testing a theory Soon she got the chance to test her theory, when infectious disease specialists at Upstate asked for her input on a patient.

The man had been diagnosed with HIV 14 years before, and he had the hallmark lesions of Kaposi sarcoma on his legs and feet. After an emergency appendectomy, those skin lesions began getting darker and bigger. He developed intermittent vertigo, headaches, ringing in his ears, eye pain and a worsening of longstanding symptoms such as gastroesophageal reflux, nausea and diarrhea, achy muscles and joints, night sweats and fatigue. It was like a horrible episode of allergies.

King met with the man and quickly recognized his symptoms as those of mast cell activation. She told him about her laboratory work and what she thought might help him. He was eager to try.

“We hypothesized that his worsening constitutional symptoms and progression of his previously stable Kaposi sarcoma both resulted from extensive mast cell activation triggered by his recent inflammatory appendicitis and abdominal surgery,” King and her colleagues wrote in a journal of the American Association for Cancer Research.

The man took high doses of antihistamines — cetirizine and ranitidine, or Zyrtec and Zantac — which are available over the counter, along with a prescription 10

U P STAT E H E A LT H l summer 2019 l upstate.edu

This cancer develops from the cells that line lymph or blood vessels and usually appears as lesions on the skin (which may be purple, red or brown) or mucous membranes inside the mouth, lungs, stomach or intestines.

In America, most cases of Kaposi are seen in people with human immunodeficiency virus, or HIV, but the disease can also affect people with reduced immunity, such as those who have undergone an organ transplant. In other parts of the world, Kaposi is prevalent among the general population, including people who do not have HIV. Kaposi can be treated with chemotherapy, radiation or surgery to remove the lesions, but the disease often returns.

SOURCE: AMERICAN CANCER SOCIETY

asK tHe experts

Rethinking hydrocephalus Neurosurgeon asks: Would a medication work better than surgery?

BY AMBER SMITH

rain surgery to install a shunt is currently the

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only solution for hydrocephalus, a buildup

of fluid in the brain. Most research on this

condition is related to devising a better shunt.

Satish Krishnamurthy, MD, goes a step further.

The Upstate neurosurgeon seeks a better solution — one that could more certainly help a greater number of people, one without so many risks, one that doesn’t even involve surgery.

He thinks in a new way about the enduring problem of hydrocephalus. It’s a condition that can affect anyone.

Bleeding in the brain is the most common cause, but 180 disorders can lead to hydrocephalus — in older kids, adults, senior citizens. Sometimes babies are born with it. Any condition that results in the accumulation of cerebrospinal fluid through brain cavities known as ventricles can result in hydrocephalus.

“We really don’t understand how, exactly, this process of extra fluid damages the brain, but we do know that if you don’t treat hydrocephalus it causes both cognitive and physical handicap,” Krishnamurthy says.

Surgical treatments were developed based on the idea that excess fluid accumulates in the ventricles because of a blockage in the pathways that help absorb the fluid. This discrepancy between the amount of fluid produced and then absorbed in the ventricles results in hydrocephalus.

“There are two different kinds of surgeries that we do,” Krishnamurthy explains. “One is to put a tube into the ventricles and put the other end of the tube elsewhere — the most popular place is the belly — so the extra fluid is diverted through this tube into the belly.

This is called a shunt.

Continued on page 12

Satish Krishnamurthy, MD

PHOTO BY SUSAN KAHN

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From our experts

is it hydrocephalus?

Symptoms of fluid on the brain, or hydrocephalus, vary depending on a person’s age.

Infants may develop an enlarged head, and their eyes could deviate downward.

Older children or adults may experience headaches, nausea, vomiting or blurred vision.

Senior citizens may appear to have dementia, difficulty walking and incontinence.

Rethinking hydrocephalus “Another way to treat the hydrocephalus is to make a hole in the bottom of the brain, called endoscopic third ventriculostomy,” he says. “But it doesn’t work in everybody. Especially in infants, it doesn’t work very well at all. In adults, it works in two-thirds of people.”

Either operation may require adjustments, and serious and lifethreatening complications are possible.

Care includes close monitoring, which includes repeated medical imaging to make sure the shunt or ventriculostomy is working properly, and additional surgery for adjustments.

“For the patients and their families, this means that a diagnosis of hydrocephalus condemns them for multiple surgeries,” Krishnamurthy explains.

“Since there is little warning before the shunt gets blocked, resulting in deadly hydrocephalus, the patient has to live with the constant fear of shunt blockage or infection.

“All of these issues compel us to seek better solutions that are predictable and more effective.”

Surgery undoubtedly helps most people with this condition. Before shunts were developed in the 1950s, everyone with hydrocephalus died.

redefining the disorder Solutions are developed based on what you think the problem is.

If you believe hydrocephalus happens because too much fluid is produced, and the brain is unable to drain the excess, you would envision a plastic bag full of water needing to be drained.

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U P STAT E H E A LT H l summer 2019 l upstate.edu

continued from page 11

But the brain is actually permeable to water, Krishnamurthy says. Water can pass through the tissue, as it does in other organs. Proteins and other large molecules cannot move out of the brain cavities easily; they draw in water through a process known as osmosis.

The surgeon says the brain is not like a plastic bag. Instead, it’s like a saturated tea bag.

Rather than a problem of fluid circulation, he says, “we have to redefine hydrocephalus as a disorder of protein transportation.” This calls for a very different solution.

To understand what Krishnamurthy proposes, you first have to understand a force called osmotic gradients. He has published several scientific papers on his research at Upstate explaining how the osmotic gradient causes hydrocephalus. Basically, it draws water into the ventricles when more proteins are inside the ventricles and pushes water out when there are fewer proteins.

“As osmotic gradients play an important role in the water transport into the ventricles, the transport of osmotically active macromolecules plays a critical role in the genesis of hydrocephalus,” he writes in the medical journal Translational Pediatrics. That means getting rid of the proteins in the ventricles will make the water go away from the ventricles, relieving hydrocephalus.

The surgeon envisions a medication that could coax the proteins and other molecules out of the ventricles and into the venous system, where the body would handle them like other wastes.

He is currently working on testing several different medications, along

with a new diagnostic test to understand how the proteins are transported in a given patient. u Much of Dr. Satish Krishnamurthy’s research has been paid for by the Syracuse nonprofit Reach Organization, at www.reachorg.org Reach stands for Research, Educate and Cure Hydrocephalus.

the downsides of shunts Hydrocephalus is often treated surgically with the installation of a shunt, a tube that diverts excess fluid from the ventricles in the brain to the belly or elsewhere in the body. Neurosurgeon Satish Krishnamurthy points out problems with shunts: • Few medical devices have a higher rate of failure. Shunts often malfunction — 40 percent fail in their first year — and have to be reimplanted. Many new shunts are programmable, but the complication rates have not decreased.

• Once in place, they provide no data and no easy method of determining if they are functioning properly.

• When a patient with suspected shunt problems is treated in the emergency department, he or she faces radiation exposure from X-rays or other imaging scans.

• Repeated shunt operations are common and are disruptive to patients’ lives, as they are usually emergency surgeries.

• Patients face a lifetime of monitoring, including diagnostic tests and surgeries.

From our experts

Rethinking schizophrenia Researchers believe the digestive tract links to the brain disease

BY DARRYL GEDDES

breakthrough study published in the journal

a

Licinio says the way the microbiome from people with schizophrenia affected the mice behavior suggests that a promise of new treatment of the mental disorder could be on the horizon.

Julio Licinio,

Julio Licinio, MD, PhD, a professor of psychiatry, medicine and pharmacology at Upstate, together with a team of international researchers, have been searching for the past five years to show the effect of the gut microbiome on behavior and the brain. Peng Zheng, MD, is the study’s first author. An associate professor at Chongging Medical University in China, Zheng is currently a visiting scholar at Upstate.

“This would give us MD, PhD a completely new pathway toward treating schizophrenia,” he says. “No treatments that we give today are based on a change of the microbes in the gut.

So if you could show that would change behavior in a positive way, we would have a whole new way to approach schizophrenia.”

Science Advances provides evidence of a link

between schizophrenia and the gut.

Researchers from Upstate, along with colleagues at universities in China, say their findings could transform treatment for schizophrenia, a severe, chronic mental illness that impacts how a person behaves.

The gut microbiome refers to microbes that live in the intestines. While people share some of the same microbiomes, most of the organisms differ from person to person.

As part of the study, Licinio and his team, through genetic sequencing of the gut microbiomes of healthy individuals and people with schizophrenia, found a vast difference in the makeup of the microbiomes. There were far fewer different gut microbiomes in people with schizophrenia.

The next step of the study was to transplant the microbiomes taken from people with schizophrenia into germ-free mice.

“The mice then behaved in a way that is reminiscent of the behavior of people with schizophrenia,” Licinio recalls. “The brains of the animals given microbes from patients with schizophrenia also showed changes in glutamate, a neurotransmitter that is thought to be dysregulated in schizophrenia.”

Mice that received microbiomes from healthy individuals showed no unexpected behavior.

Ma-Li Wong, MD, PhD, was a co-investigator in the research with Licinio. She’s a professor of psychiatry and behavioral science and neuroscience and physiology at Upstate.

“We understand schizophrenia solely as a brain disease,” she says. “But maybe we need to re-examine this line of thinking and consider that maybe the gut has an important role.” u

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From our experts

Advice from the experts at Upstate Q A

What’s this i hear about sunscreen chemicals getting into my body?

A recent study found that if you apply sunscreen under maximal conditions — frequently enough, using a high enough sun protection factor and covering adequate body surface area — some of the chemicals in the sunscreen are absorbed into the bloodstream and measured at a higher concentration than was previously thought.

The federal Food and Drug Administration has called for further studies on the effects of those chemicals. “The main concern is that these chemicals may affect endocrine and reproductive systems,” explains Ramsay Farah, MD, chief of dermatology at Upstate.

He emphasizes that “the study did not suggest that people should not wear sunscreen. On the contrary. The study still recommended that people wear sunscreen.

“Look for sunscreens with zinc oxide and titanium dioxide. These are physical blockers. Yes, they are absorbed into the bloodstream, but they are absorbed less than the chemical blockers. And even though they are absorbed, they are considered inert, so they don’t have the same potentially disruptive effects on the endocrine and reproductive systems.”

How high of an SPF does he recommend?

“Thirty or above. There’s nothing wrong with using 50 or 60, but the general principle is using SPF 30 properly — meaning every two hours — is better than using 50 and just applying it once. So 30 is the minimum number. Reapplication is the key.”

Q How does CBd work?

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Hemp and marijuana are like cousins from the same plant family. The Farm Bill that became law in December legalized hemp cultivation. CBD, short for cannabidiol, is extracted from hemp. THC, short for tetrahydrocannabinol, the compound that creates a high, is found in higher concentrations in the marijuana plant.

Marijuana contains some CBD, and hemp may contain small amounts of THC – no more than 0.3 percent, according to the Farm Bill. “By itself, CBD does not cause a high,” says Caitlin Sgarlat Deluca, DO, who specializes in rheumatology and integrative medicine at Upstate.

She explains that CBD and THC both work on the body’s endocannabinoid system, which regulates certain inflammatory processes, functions such as sleep and immune system and pain responses. CBD is thought to inhibit inflammatory and neuropathic pain processes.

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“Some preliminary research shows that CBD may help curb addictions to heroin and other dangerous opioids. There’s also some preliminary evidence of efficacy in certain pain syndromes and rheumatoid arthritis,” Deluca says. “I think there’s great potential with CBD.” U P STAT E H E A LT H l summer 2019 l upstate.edu

But, she says, scientific studies are needed to answer what dose is safe and effective, and how CBD interacts with medications.

wrong Q What’s with thong underwear?

Especially when worn while working out, thongs can set a woman up for infection. Thongs tend to slide from back to front, moving fecal bacteria, Renee Mestad, MD, told a fitness newsletter called Greatist.com. Mestad is division chief of general obstetrics and gynecology at Upstate.

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Sweating during your workout is liable to make things worse. “As the area gets damp, you’re going to experience a lot more friction,” Mestad says.

“You might find yourself with small abrasions or other irritations that can then cause issues, which makes it easier for skin bacteria to penetrate the area.”

Mestad recommends breathable underwear made with performanceready fabrics, especially if you can’t shower immediately after working out.

“If you’re running, doing hot yoga or any other activities that result in a significant amount of sweating, it would benefit you to change out of your clothes, all the way down to the underwear, and into something fresh afterward.” u

From our experts

How does your story end?

6 considerations toward the end of life

BY AMBER SMITH

regory Eastwood, MD, is a physician

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and ethicist who served for many years as

president of Upstate Medical University.

In his new book, “Finishing Our Story: Preparing for the End of Life,” he discusses the dying process, how the quality of life may influence a person’s death, physicianassisted death, palliative care and the importance of making one’s wishes known.

“Each of us will confront our own mortality someday, if we haven’t already,” he says.

Aside from practical advice, such as the selection of a health care proxy, Eastwood’s book also offers guidance in making the end of life more fulfilling.

1. reflect on what quality of life means to you and how much importance it has compared to biological life. In other words, would you want everything to be done to keep you alive if your quality of life would be greatly diminished?

Do you want your life extended at all costs — financial, social and emotional?

2. think about what could happen to you in different health and social circumstances, and talk about that with loved ones. If you have a chronic disorder, such as diabetes or heart trouble, anticipate the types of decisions you may face in the future. Would you want to be resuscitated if your heart stops? Are you OK with having a breathing tube in your trachea? What about intravenous fluids and a feeding tube? Would you want to remain in the hospital or go home?

3. “Bear in mind that some of the characters who populated the earlier chapters of your story are likely to reappear in the last chapter,” Eastwood writes. “What are the implications of that to you?”

4. do you have any emotional debts to pay, someone to whom you need to apologize or explain an earlier behavior?

5. if you are nostalgic, you may want to reinforce memories by revisiting places that have meaning to you, reconnecting with friends or reliving certain experiences.

6. you may find yourself thinking more about the legacy you will leave. While you cannot change facts or experiences, you may find opportunities to renew context or derive different meanings so that you conclude your story in a way that satisfies you.

The book may be purchased at local bookstores or online at Barnes and Noble, Amazon or the Oxford University Press website. u

Hear him: an interview with gregory eastwood, md, about end-of-life issues is available at healthlinkonair.org by searching for “eastwood.”

upstate.edu l summer 2019 l U P STAT E H E A LT H

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From our experts

Nurses are raising the bar

Jolene Kittle is one of Upstate’s most-certified nurses. She is the trauma program manager, and she holds six certifications: as a flight registered nurse, adult gerontology clinical nurse specialist, trauma registered nurse, adult critical care nurse, emergency nurse and nurse executive.

PHOTO BY ROBERT MESCAVAGE

ore than 570 of the nurses working

m

at Upstate University Hospital hold

specialty certifications, awarded for

acquiring additional skills, knowledge and expertise in a special area. Many hold multiple certifications.

Experts say certified nurses raise the standard of practice in the profession and ultimately improve patient safety and care. “Nursing is a very dynamic profession with new information and techniques being disseminated every day. Certification is a way to validate specialty knowledge and remain current while constantly enhancing skills and knowledge base,� says Upstate chief nursing officer Nancy Page, who holds the advanced nurse executive specialty certification.

To earn a certification, nurses must meet various eligibility requirements that include experience in the specialty, a specific number of continuing education hours in the specialty and participation in a rigorous program of study before taking an exam required for each specialty. u

of 95 nursing specialties, these 10 certifications are held by the highest number of upstate nurses: 90- CMSRN, certified medicalsurgical register nurse 89- CCRN, acute or critical care registered nurse, including adult and pediatric 53- CPN, certified pediatric nurse 40- SCRN, stroke certified registered nurse 34- OCN, oncology certified nurse 26- NP-C, certified family nurse practitioner (by American Academy of Nurse Practitioners) 21- FNP-BC, board certified family nurse practitioner (by American Nurses Credentialing Center) 20- CNOR, certified nurse, operating room

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U P STAT E H E A LT H l summer 2019 l upstate.edu

18- CEN, certified emergency nurse 15- ONC, orthopedic nurse certified

From our experts

e future is now Innovation comes from reimagining health care

BY JIM HOWE

cartoon that premiered in 1962 offered a

a

whimsical glimpse of a future where science and technology made everyday tasks a breeze.

Who could have predicted six decades ago that several of the advances imagined in the Jetsons’ world of 2062 would come true much sooner?

Consider the “future” world of the Jetsons: george Jetson uses a flat-screen tv to consult with his doctor.

Telemedicine looks a lot like that today.

the Jetson family gets a robotic dog named lectronimo.

Robotic cats and dogs in use today provide companionship or stimulation to lonely or demented people who are unable to deal with real pets. (See page 7 for a look at how Upstate is using animatronics.)

young elroy Jetson travels to school by drone.

Small, unmanned aircraft are being used for small package deliveries that may include medical transports someday.

Health care is constantly being reimagined, New York State Health Commissioner Howard Zucker, MD, JD, said during a recent presentation at Upstate.

He said it doesn’t hurt to dream a little about how to improve public health.

At one time, he noted, horse manure created a terrible health problem in cities; someone had to come up with the idea of a future with automobiles.

Our future may hold some of the technology depicted on “The Jetsons,” along with a revival of older practices, such as the house call, Zucker said.

In the early 1900s, doctors provided care in peoples’ homes. By the 1940s, doctors tended to dispense care from offices, and medical testing became more

prevalent. “Today, we’re moving more toward home care, allowing patients to do things we couldn’t do before, such as using a smart watch to look at an electrocardiogram and tell you things about your health,” he said.

Many more innovations are in the works.

Zucker mentioned a “spider sense” body suit equipped with pressure or motion sensors to detect what’s going on in the environment; a gene-altering technology known as CRISPR that might be able to fight cancer; and the ability of fitness trackers, clothing and home appliances to record and transmit personal information in a way that may be useful for health monitoring.

Working together, government officials, medical professionals and the public will decide what is needed to improve the well-being of society.

Zucker says, “Collective will, rather than money, will drive these changes.”

Will doctors someday wield tricorders the way Dr. Leonard “Bones” McCoy did in “Star Trek”? Despite many attempts, the medical version of that fictional multifunctional handheld device has not been duplicated in real life. Yet. u upstate.edu l summer 2019 l U P STAT E H E A LT H

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in our lei sure

A 9-letter word starting with C Aer ‘Jeopardy!’ appearance, here’s a clue to her new hobby

BY AMBER SMITH

Rachel Fabi working on a crossword puzzle in the courtyard in front of Upstate’s PHOTO BY RICHARD WHELSKY Weiskotten Hall.

achel Fabi, PhD, starts her day with a cup

of coffee and The New York Times crossword

far this year has had four published in newspapers and crossword publications.

puzzle.

So, which is more challenging— making or solving a puzzle?

“It gets my brain working,” she says.

In the evenings, she likes to attend trivia games, watch “Jeopardy!” or create crossword puzzles (like the one she created specially for Upstate Health magazine, page 19.)

Fabi is an assistant professor of bioethics at Upstate.

She fulfilled her lifelong dream of appearing on “Jeopardy!” this year — a few weeks before host Alex Trebek disclosed his diagnosis of pancreatic cancer, and before James Holzhauer began his winning streak.

Since she was 13, Fabi has made a daily habit of completing The New York Times crossword puzzle as a way to train for “Jeopardy!”

Can you answer the ‘Jeopardy’ questions Fabi faced?

“Born in 1866, he has been called ‘The Shakespeare of Science Fiction.’”

Fabi became a “Jeopardy!” champion her first night when she edged out her opponents by $1 by wagering nothing on a Final Jeopardy answer, which they all got wrong. She played the next night, too, but fell to a teacher from California.

“The title of this musical that opened in 1956 came from the last line of a nursery rhyme about a structure that spanned the Thames.”

After her “Jeopardy!” appearance, Fabi followed a new pursuit: to create crossword puzzles. She purchased software, found mentors willing to guide her, and so

answer: What’s “My Fair Lady.”?

18

“Definitely making them.” u

answer: “Who is H.G. Wells?”

r

U P STAT E H E A LT H l summer 2019 l upstate.edu

in our lei sure

Academic Challenge 1

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Sarcastic applause Comment (on) Everest's home Oscar nomination, e.g.

Trailblazing doctor Blackwell Ibsen play “___ Gabler” Michael of “Arrested Development” Unusual occurrences Financing abbr.

Punctual Popstar Carly ___ Jepsen Blocks, as an artery Golisano or 44-Across, for example Single Complete collection Up to ___ New York region Part of the A.M.A. Green agency, for short

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Weather-related gloom (abbr.)

Too Neighborhood; also an Upstate campus nickname Spotless Before, poetically Interest on a bank offering Measure of fuel efficiency 19th century reformer Dix Inflammatory suffix Pal in Paraguay Some child star managers Do over It may be developed with repeated exposure Cries for help at sea Home of 35-Across + 37-Across

down 1

2

“Isn’t ___ Lovely?”

(Stevie Wonder hit) Adjective for Wayne or Kim

3 4 5 6 7 8 9 10 11

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Greek Os App for maps Mild cigars Biblical father-in-law Yes vote Paul Revere, e.g.

“Didn’t see you there!”

Audre Lorde or Lord Byron New Delhi airport namesake Gandhi Business offer rejection Deletes Decorative pillow cases Advocated for, slangily Org. concerned with freedom of speech Onomatopoetic water noise Old-fashioned pronoun “____ while they're hot!”

Washington airport code Clinical ____ Stop the flow of

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“The Problem with ___” (“Simpsons” documentary) Vietnam Veterans Memorial architect Lin Secondary school with a 51-Down mascot Stat Actress Nia Winged ally of He-Man Fragrant trees Cry from a balcony Decision factors Latin clarification words Latin list word Siberian or Bengal Monster Plays (with) Apple on a desk Six-time Olympic medalist Raisman Hosts Witness

Answers on page 23 upstate.edu l summer 2019 l U P STAT E H E A LT H

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in o ur Co mmunity

Attracted to ticks Scientists come to Upstate for in-depth opportunity to study ticks

BY AMBER SMITH

Saravanan Thangamani, PhD, shows test tubes of ticks harvested from other parts of the world, so his research team can compare them to ticks found in Central New York.

PHOTOS BY CHUCK WAINWRIGHT

aravanan Thangamani, PhD, moved from Galve-

s

ston, Texas, to Central New York for the ticks.

So did five members of his lab, which is devoted

to research on tick-borne and mosquito-borne diseases.

Recently they collected 115 ticks to study from Green Lakes State Park, near Fayetteville.

“Our lab tries to understand what really happens at the feeding site of the tick,” Thangamani describes. “That is the only time the tick is delivering the germ to a human. If we can decipher what really happens at the time of the virus delivery — at the time of the Lyme disease agent delivery — we can develop novel countermeasures to stop the transmission.”

Thangamani is a SUNY Empire Innovation Professor in the department of microbiology and immunology at Upstate, and he leads the Center for Environmental Health and Medicine.

He shared some of what he knows about ticks:

ticks are numerous. Hundreds of species of ticks exist. However, not all ticks carry or transmit diseasecausing germs to humans or pets.

About 20 to 50 species have medical importance, meaning they carry pathogens that could cause significant human disease or veterinary disease.

ticks are germy. Multiple pathogens can be transmitted by a single tick, including the bacterium Borrelia,

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U P STAT E H E A LT H l summer 2019 l upstate.edu

Continued on page 21

in our C ommunity

Attracted to ticks

continued from page 20

Thangamani and his team collect ticks by dragging white fabric through fields and woods in Green Lake State Park.

which causes Lyme disease and the Powassan virus that can lead to encephalitis, both of which are carried by the deer tick.

ticks are patient. Just as people have favorite cuisines, ticks prefer certain mammals on which to feed.

If they don’t find a preferred host immediately, they wait. “That’s why the tick life cycle in nature takes about two to three years to complete, from eggs to larvae to nymphs to adults,” Thangamani says.

ticks are tiny. During their larval stage, some ticks including deer ticks are smaller than poppyseeds. As nymphs (adolescents) ticks grow to maybe twice that size. Adult ticks are bigger and easier to spot. “That’s one reason we don’t often get bitten by adult ticks,” Thangamani says.

“It’s easy to find them on the human body, and we can pick them out.”

Some species of ticks are three or four times bigger than the deer tick.

ticks are transmitters. Mother ticks almost never transmit bacteria to the eggs they lay. But if the mother tick carries a virus, almost 90 percent of the time she will transmit that to her babies. “It depends on what germ we are talking about,” Thangamani

says. Ticks that are born free of the bacterium Borrelia may contract it by feeding on white-footed mice. Ticks that carry pathogens can pass them to the humans and pets.

ticks are slow. Ticks spend from 10 minutes to an hour looking for a place to attach. “It crawls on your skin and tries to find a perfect hiding spot. Then, it actually injects its mouthpart,” Thangamani says.

“Deer ticks particularly have longer mouthparts, and they have to stay attached to the human body at least three to five days, so they try to latch on and anchor themselves nicely.”

ticks are (potentially) dangerous. “The deer tick has to stay attached to a human for at least 24 hours for the bacterium Borrelia to be transmitted. The Powassan virus will be transmitted to the human within the first hour after the bite,” Thangamani describes.

“That means when you have a coinfected tick, the virus gets in first, and it primes the feeding site. Then when the Borrelia comes 24 hours later, it makes it easier for the Borrelia to infect and make the clinical outcome worse.” u

submit your tick The Center for Environmental Health and Medicine offers free tick testing, to learn the species of the tick and whether it carries any of 10 pathogens. The test is not a diagnostic tool but rather is used for academic research purposes. Learn more at www.thangamani-lab.com 1. Put the tick, dead or alive, in a plastic bag with a piece of moist tissue or grass.

2. Place the bag in an envelope with this information: A. date, B. ZIP code where the tick was found, C. whether the tick came from a human or a pet, and D. an email address for the results.

3.Ship the envelope to: Thangamani Lab, 4209 Institute for Human Performance, 505 Irving Ave., Syracuse, NY 13210 upstate.edu l summer 2019 l U P STAT E H E A LT H

21

in our C ommunity

On a mission to help Doctor’s intensive care skills help poor children with heart trouble in Peru

BY JIM HOWE

To care for a Peruvian child with a heart condition, I. Federico Fernández Nievas, MD, created this elaborate life-support apparatus which included a ventilator, monitors, pumps, a maze of tubes and electrical cords and an inflated rubber glove as a support.

PHOTOS COURTESY I. FEDERICO FERNÁNDEZ NIEVAS, MD,

career spent caring for very sick children, plus

“It was like a jail, with police, security and so much poverty,” he says.

some mechanical ingenuity, helped I. Federico

“Children have very little access to heart surgery there, especially the farther they live from Lima,” he says.

“I was told that people with money will go to Mexico or Chile for pediatric cardiac surgery.”

a

Fernández Nievas, MD, when he accompanied

a medical charity team to Peru.

He joined about two dozen other medical professionals from around the United States to treat poor children with congenital heart problems. The nonprofit humanitarian Hearts with Hope Foundation, which sponsored the trip, needed a specialist in pediatric intensive care.

Fernández, who works in the pediatric intensive care unit at Upstate Golisano Children’s Hospital, heard about the trip through a former colleague and volunteered to go.

The mission took place in a city hospital in a poor, dangerous area of the capital, Lima. Vans carrying the volunteers had to pass through various security checkpoints and fences to get into or out of the hospital.

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U P STAT E H E A LT H l summer 2019 l upstate.edu

Cardiac specialists in Lima preselected patients, then, together with the American team, chose the 10 children to be operated on. Some of the work done was corrective, some palliative. “We tried to choose surgeries that are meaningful for the patients, what is possible and sustainable to improve the quality “of life, at least, if not correct it,” Fernández explains.

Continued on page 23

in our C omm uni ty

On a mission

continued from page 22

What’s a pediatric intensivist?

Pediatric intensivists are doctors who specialize in the care of infants and children and who usually work in a pediatric intensive care unit, or PICU. They see children who have long-term illnesses as well as those temporarily in need after surgery, serious injury, septic shock, seizures or various heart and lung problems. Monitoring children’s breathing and setting up machines to help them breathe is a major concern.

I. Federico Fernández Nievas, MD, the son of a pediatrician, has a lifelong interest in using technology to help the sickest patients, which led him to decades of work in pediatric intensive care, life support and pulmonary medicine. He came to Upstate in 2015, where he is medical director of respiratory therapy and of the ECMO program, which uses a life-support machine to keep the heart and lungs going.

He has worked in major hospitals around the United States and Canada, and before that in his native Argentina — from the capital, Buenos Aires, to remote Tierra del Fuego, at the tip of South America, where he set up a training program for pediatric intensivists.

The team completed 10 complex heart surgeries in five days.

In addition, several other children underwent cardiac catheterization, where a thin tube is threaded through a blood vessel to diagnose a heart problem or plug a small hole in the heart without surgery. The doctors also held a clinic to examine additional children.

“We did about 10 complex cardiac surgeries in five days,” Fernández says. The team arrived at 5 a.m. on a Saturday, was in the hospital discussing cases through that evening and got the equipment ready on Sunday. On Monday they started performing two surgeries a day. By Friday night, they removed the breathing tube that the last child had needed. They left the next day.

Fernández-Nievas

answers to crossword puzzle on pg. 19

The patients, ranging in age from infants to midteens, all came through well and have received follow-up care from the local doctors in Lima.

Because certain supplies were not always available, the team had to improvise.

Fernández cobbled together an elaborate life-support apparatus for one child that included a ventilator, monitors, pumps, a maze of tubes and electrical cords and an inflated rubber glove to support some of it. He also rigged up breathing devices for some patients.

This was his first such trip. It was humbling. It reminded him why he chose medicine for a career.

“It was very intense, the emotions, and the people were so grateful. There was a sense of special connection,” he says.

“When I was young and idealistic, people asked, ‘Why do you want to be a doctor?’ This is the answer.” u

upstate.edu l summer 2019 l U P STAT E H E A LT H

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Non Profit Org. US Postage

PAID 750 East Adams Street l Syracuse, NY 13210

Permit No 110 Syracuse, NY

SCIENCE IS ART IS SCIENCE IS ART IS SCIENCE IS

A research team at Upstate identified an unusual form of neurodevelopmental delay that is caused by deficiency in a protein called paxillin. They have discovered that brain cells that are deficient in paxillin move more slowly than healthy brain cells, and there is a corresponding delay in the development of the cerebral cortex. This tissue sample shows multiple layers of the cerebral cortex, which have been labeled red and green with specific histological markers.

19.055 0819 44.0553mQMCsk

Researchers: Mamunur Rashid, Judson Belmont, David Carpenter, Christopher Turner, PhD, and Eric Olson, PhD.

19.017 0319 43.8M ELsk