Health UPSTATE
U P S TA T E M E D I C A L U N I V E R S I T Y
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THE LESSONS PATIENTS TEACH DOCTORS page 11
DOME DRAMA: HOW A COLLEGE STUDENT WAS BROUGHT BACK TO LIFE page 5 HOW MUCH EXERCISE DO KIDS NEED? page 17 COOKING WITH A GASTROENTEROLOGIST page 20
Spring 2017
WELCOME
WHY YOU MUST COME TO UPSTATE FOR TRAUMA CARE PHOTO BY SUSAN KAHN
PHOTO BY WILLIAM MUELLER
IF YOU’RE SERIOUSLY HURT in a car wreck, a lawn mower mishap or knife fight, your chances of survival are higher if you quickly get to a Level 1 trauma center.
Trauma patients receive prompt attention when they arrive at Upstate University Hospital.
Upstate University Hospital is the only Level 1 trauma center within the 14 counties of Central New York. Paramedics know this, so if your injury is severe and renders you unconscious, the ambulance likely will bring you to Upstate. If you are not near Upstate, you may first be stabilized at an outlying hospital and then transferred to Upstate.
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Trauma centers didn’t exist until physicians began studying the survival of trauma patients in the late 1960s. ey discovered people who would have lived if they had not bled to death and others who would have lived if they had been able to breathe. at led to the concept of the “golden hour,” the time within which trauma patients need definitive care for the best odds of survival. Officials from the American College of Surgeons visit Upstate every three years for an extensive evaluation that ensures that staff are capable of providing the highest level of medical care for adults and children 24 hours a day, seven days a week.
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Imaging scans that are needed are obtained immediately, most in a suite in the emergency department. A surgeon with expertise in trauma and critical care can be at the bedside of the most severely injured patients within 15 minutes. Since most traumatic injuries are unique, having a doctor with a wide range of experience caring for trauma patients is valuable. An operating room is always available for immediate surgery if necessary. Specialty doctors, such as orthopedic surgeons or plastic surgeons, are available within a half hour.
Upstate also maintains an intensive care unit staffed by trauma surgeons trained in critical care and a burn unit staffed by physicians with expertise in burn care, plus a rehabilitation unit if the injuries require extensive recovery. Staff at a Level 1 trauma center care for people with severe injuries, but they apply that same expertise to those with minor traumatic injuries — making the trauma center the best place to go for treatment of any trauma. ●
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WELCOME
Contents 6
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PATIENT CARE
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FROM OUR EXPERTS
Why you must choose Upstate for trauma care
page 2
Brought back to life amid a crowd of 27,553
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IN OUR LEISURE Cooking with a pediatric gastrointestinal specialist page 20
page 5
3 doctors share what they’ve learned from patients
page 11
Recipe: Asian Salmon
page 21
The value of a cord blood bank
page 15
She brings color to her life
page 22
page 7
Why drugs work differently in seniors
Creative coping
page 9
Caring for your bones
page 16
page 10
How to stifle a sneeze
page 16
What’s Up at Upstate
page 10
How much exercise do kids need?
page 17
Lessons from Upstate page 15 Protecting seniors from medication interactions
Follow the leader
page 18
Mosquito control
page 19
Science Is Art Is Science Anatomage
Practicing stroke care Refugees arrive with unique health needs
PHOTO BY SUSAN KAHN
Health UPSTATE
U P S TAT
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IN OUR COMMUNITY
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Spring 2017
THE LESS ONS PATIENT S TEACH DOCTOR S
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back cover
page 11
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On the cover: William Paolo, MD, in the emergency department. See story, page 11.
DEPARTMENTS
DOME HOW A DRAMA: COLLEGE WAS BROU STUD GHT BACK ENT HOW MUC TO LIFE page H EXER 5 CISE DO COOKING KIDS NEED WITH A ? page 17 GASTROEN TEROLOGI ST page 20
Health UPSTATE
Spring 2017
EXECUTIVE EDITOR Leah Caldwell Assistant Vice President, Marketing & University Communications EDITOR-IN-CHIEF
Amber Smith
WRITERS
Jim Howe Amber Smith
DESIGNER
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
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.
ADDITIONAL COPIES: 315-464-4836 Upstate Health offices are located at 250 Harrison St., Syracuse, NY 13202
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.
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News you may have missed
WHAT’S UP AT UPSTATE
e national ALS Association and its Upstate New York chapter certified Upstate’s ALS Research and Treatment Center as a Treatment Center of Excellence. is signifies that the center exhibits the highest levels of established national standards of care in the management of amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease. In addition, the national association and local chapter both awarded separate grants of $25,000 each to benefit patient care. Upstate treats nearly 185 patients with ALS from throughout Central New York. l
Kelli Maher, left, donated her kidney in September to help someone in need, but she did not know whose life she saved until two days before Christmas. That’s when she met Cecilia Brown, 8, a girl from Ilion who suffered from double renal failure. Their transplant was one of the 109 performed by surgeons at Upstate in 2016, more than triple the number of transplants that took place in 2010. PHOTO BY WILLIAM MUELLER
An Upstate researcher is testing drugs to treat shingles, a painful skin rash caused by the varicella zoster virus. Jennifer Moffat, PhD, is working with a Connecticut company called NanoViricides to find an antiviral drug that’s safe and effective for clinical trials. “Using nanoparticles to target viruses is an innovative approach, and we’re eager to collaborate on this project,” said Moffat, an associate professor of microbiology and immunology. l
Robert Sherman, MD, performed the region’s first total knee replacement using the Mako robotic-assisted surgery system, in February. His patient was discharged to home rehabilitation two days aer surgery. e surgeoncontrolled robotic-arm system allows for more precise alignment and positioning of implants to achieve greater accuracy than through conventional surgery. “More precise alignment of the implant means less wear and tear, less initial pain and greater lifespan of the implant,” Sherman said. Upstate has used the Mako system for partial knee and hip replacements since late 2014, but the Food and Drug Administration only recently approved the system for total knee replacements.
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e state Department of Health awarded Upstate a five-year, $1 million grant to support Upstate’s newly created program to keep vulnerable populations free of HIV, the virus that causes AIDS.
Upstate was named a National Pancreas Foundation Center for Care and Treatment of Pancreas Disease, one of only 37 medical institutions nationwide and the only one in New York outside of New York City. l
Chris Arnold, Ellen Yeomans and members of the Paige’s Butterfly Run Committee presented a check early this year for $232,000, money raised from the 2016 run named in honor of their daughter, Paige Yeomans Arnold. Paige’s Butterfly Run has raised more than $2.5 million in 20 years to support pediatric cancer research and patient and family services at the Waters Center for Children’s Cancer and Blood Disorders at the Upstate Cancer Center and Upstate Golisano Children’s Hospital. e money goes into a permanent endowment established with the Upstate Foundation. is year’s run is June 3 in downtown Syracuse. Learn more at www.pbrun.org ●
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PATIENT CARE
Comeback kid Syracuse University student Alex McMillan with Christopher Tanski, MD, at the Syracuse/Georgia Tech basketball game at the Carrier Dome on March 4, a month after McMillian’s heart stopped and he was revived during the Syracuse/Virginia game.
PHOTO BY MICHAEL J. OKONIEWSKI/SYRACUSE ATHLETICS
He died at the Dome – and lived to tell about it BY AMBER SMITH
FEB. 4 was “pretty much a typical morning” for Alex McMillan, 20, an economics major at Syracuse University. An alto sax player, McMillan would be at the noon basketball game against Virginia as part of the Sour Sitrus Society, a student pep band. He remembers eating a pulled pork sandwich and drinking a bottle of water at the Carrier Dome. Next he knew, he awoke in a hospital bed. IV lines were poking from each arm. Electrodes were taped to his chest. Medical machines surrounded him. He was in the cardiac intensive care unit at Upstate University Hospital. e Orange were celebrating a 66-62 come-from-behind victory. But it was McMillan who made the more dramatic comeback at the Dome that day.
Not even four minutes aer tipoff, without warning, McMillan’s heart just stopped. His body slumped onto a band mate. He and the person on McMillan’s other side laid him on a riser. ey called for help. Emergency physicians from Upstate University Hospital staff the first-aid station at the Dome. Depending on the size of the crowd, a dozen or more paramedics and emergency medical technicians are on duty for SU basketball games and other mass-gathering events at the Dome. A pair of EMTs were about 20 feet from where McMillan collapsed. “ey started CPR right away,” explains Christopher Tanski, MD, the emergency doctor on duty that day. eir compressions kept blood circulating through McMillan’s body, keeping his vital organs nourished. continued on page 6
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PATIENT CARE
Comeback kid
continued from page 5
doctors marvel at the young man’s good fortune. “If you put me in his shoes and I got to pick where I had this event, if it couldn’t be inside a hospital, I’d want it to be in the Dome,” Joslin said. “e Dome is known for having good survival rates,” said Tanski, adding that the outcome surely would have been different if McMillan had been driving, or alone in his dorm room, when his heart stopped. Syracuse University’s mascot, Otto, poses with Upstate emergency physician Christopher Tanski, MD, and SU student Alex McMillan. PHOTO BY MICHAEL J. OKONIEWSKI
Meanwhile, Tanski made his way down the stairs from the first-aid station. He directed other EMTs to bring an empty stretcher down an elevator. One look at McMillan, and the emergency doctor knew the situation was serious. Young people rarely suffer sudden cardiac arrest. A handful of things can cause a heart in a healthy young person to suddenly stop beating — but Tanski was too busy to ponder them. “Once the heart is stopped, it doesn’t really matter why,” he explained. “You just need to get it started again.” Briefly, Tanski considered moving McMillan to a more private location, but he knew he could not afford the seconds that could take. Instead, he and the EMTs cared for McMillan behind the Syracuse baseline. e game continued, punctuated by roars from the 27,553 in attendance. McMillan’s heart was in a dangerous quivering rhythm known as ventricular fibrillation. An electrical shock, delivered by an automated external defibrillator, prompted it to begin beating somewhat normally again. His pulse returned. He began moving around. One of the paramedics started an IV, and McMillan was moved to the stretcher and wheeled to the ambulance. He was half asleep, half awake and really confused by the time the ambulance got him to the adult emergency department at Upstate, where its director, Jeremy Joslin, MD, happened to be working that aernoon. Joslin quickly connected McMillan to a monitor to watch his heart’s electrical activity, and he kept close watch on his blood pressure, which required some supportive medication. Hearts in healthy young people typically don’t stop beating except in cases of trauma, or if the heart grows abnormally large, or if an electrical malfunction occurs. Joslin summoned cardiologists and set about determining what caused McMillan’s heart problem. A groggy McMillan kept asking the same question, not remembering the answer: Did SU win? Did they beat Virginia? Tanski stopped at the emergency department aer the game to check McMillan’s condition. Both emergency
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McMillan is from Ashland, in suburban Boston. His parents were away on Feb. 4, visiting a college with his younger brother. Somehow, the social worker in the emergency department — whom Joslin says regularly works miracles — tracked them down quickly. While he remained hospitalized, McMillan underwent a series of tests to determine what caused his heart to stop beating. Structurally, his heart was normal. e problem appeared to be electrical. He recalled that he was still hooked to a heart monitor on Feb. 7 when SU traveled to South Carolina to play Clemson. As the clock ticked down to the 82-81 “buzzer beater” win, McMillan watched the lines of his heart rate spike. In a cardiac catheterization procedure the next day, cardiac electrophysiologist Tamas Szombathy, MD, determined that McMillan needed an implantable cardiac defibrillator, a small battery-powered device designed to shock him back to life if his heart ever stops beating again. “I can definitely feel it in my chest,” McMillan said of the defibrillator. A month aer its insertion, he says the bruising and swelling had subsided, but he was forbidden to li his arm above his head, to prevent the defibrillator system from being displaced. What caused his heart to stop beating? “ey think it’s a genetic thing,” McMillan said. He had blood drawn and met with a genetic counselor at Upstate. If other members of his family are found to have the same genetic mutation, and receive pre-emptive care, more than just McMillan’s life will have been saved that Feb. 4 day in the Dome. McMillan missed several days of classes while he was in the hospital, but by the end of the month he was caught up with his studies. He was not allowed to play his saxophone again yet, but he did feel up to attending another Dome game on Feb. 22. at was the Duke game. e Orange won with an epic 3point basket sunk in the final second of the game. People started once again referring to the team as the “Cardiac Cuse.” McMillan felt his heart racing. He was thrilled to be part of the court-storming, aer-game celebration. In more reflective moments, he’s grateful he was at the Dome game 18 days prior, where, aer his heart stopped, he could be brought back to life. ●
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Jackson’s birthday gift
PATIENT CARE
A donation of blood from a newborn’s umbilical cord may save or improve someone’s life, or aid in medical research BY AMBER SMITH
MARK AND NICOLE MOORE’S FIRST ACT as new parents, as a family, was to give back. Aer Dad cut Jackson Hunter’s umbilical cord and while Mom cuddled the newborn in her arms, one of the labor and delivery caregivers turned attention to the remaining length of umbilical cord. Using a needle, blood was extracted from the cord and placed into a sterile bag about the size of a credit card. at 3 to 5 ounces of stem cell-rich cord blood has the potential to save the life of someone with leukemia or lymphoma. Or it may be used in the treatment of a wide range of other cancers, blood disorders and genetic diseases. Or, it could be used to research new treatments for a variety of diseases. e umbilical cord connects a developing baby to the placenta, the organ that grows within the uterus during pregnancy. Aer birth, the cord is severed and clamped, its tip becoming the baby’s belly button. e remaining length of umbilical cord has been discarded as medical waste, but new parents are now being asked to donate their baby’s cord blood to the Upstate Cord Blood Bank, which opened in February. Such blood is rich with young stem cells, which are valuable because they can develop into many different types of cells or be used to repair many types of tissue. When a stem cell divides, each new cell can either remain a stem cell or become another type of cell with a specialized function, such as a muscle cell, a red blood cell or a brain cell. Under certain physiologic or experimental conditions, stem cells may be induced to become tissue- or organ-specific cells with special functions. Stem cells offer new potential for treating diabetes, heart disease and other diseases because of their unique regenerative ability. “We understood it has the potential to help,” Mark Moore said as he cradled Jackson during the bank’s ribbon-cutting event. at’s why he and his wife were eager to make the donation, the bank’s first. “Even if it’s not used for a patient,” Nicole said, “they can still use it for research.” Each donation is tested, processed and stored at the bank, a 20,000-square-foot building on Upstate University
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Jackson Moore photo by SuSan Kahn
The Upstate Cord Blood Bank is one of 32 such banks in the United States and one of two in New York state. There is no charge to make a donation of cord blood. Families will pay a collection and storage fee if they want their baby’s cord blood stored for their own future use.
Hospital’s Community campus. ey are kept in liquid nitrogen tanks at minus 196 degrees Fahrenheit. Each donation becomes part of a database and could be used for transplant locally, nationally or internationally. ere is no cost to donate. Families soon will have the option of storing their babies’ cord blood at the bank for a fee. e blood would then be available for transplants or stem cell therapy for family members or others, as determined by the family. is may appeal to families who are prone to certain conditions. Contact the bank at 315-464-6746.
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Brothers battle cystic fibrosis together
PATIENT CARE
BY AMBER SMITH
THE DAY AFTER TREVOR DELANEY TURNED 6, his mother took him for an appointment with his pulmonologist, Zafer Soultan, MD. e division chief of pediatric pulmonary medicine at Upstate was eager for Trevor to start taking a new medication for cystic fibrosis, which he could not prescribe until the boy turned 6. A month aer Trevor began taking Orkambi, one of the first medications to target the underlying cause of cystic fibrosis, Tina Delaney of Fulton says her son looks better and is not getting as sick as oen. She’s encouraged. Still,
she has been at the Upstate Golisano Children’s Hospital with Trevor and his almost-5-year-old brother, Michael, for nearly three weeks. Both boys have cystic fibrosis, an inherited disorder that affects the lungs and digestive system. From time to time, their condition warrants a hospital stay. “When they were younger, we were in every other week for months,” Delaney recalls. She and her husband, George, learned about cystic fibrosis when Trevor was born. en when she was pregnant with Michael, an analysis of amniotic fluid revealed that their youngest son would also be born with cystic fibrosis. eir daughters, Tara, 12, and Elizabeth, 7, do not have the disease — but they are affected by it. Delaney strives to keep things normal for them, relying on help from her husband, mother, father, the doctors and nurses and child life specialists at Upstate. She is optimistic about Trevor’s new medication. Orkambi is a combination of two drugs that work together to help a protein reach the surface of cells where it is needed to help regulate the flow of salt and fluids in and out of the cells of the lungs and other organs. Lumacaor helps move the protein to the cell surface, while ivacaor increases the protein’s activity once it is there. Supporting the flow of salt and fluids is important because that helps thin the mucus that builds up in the lungs of people with cystic fibrosis.
Upstate Golisano Children's Hospital certified child life specialist Maggie Zick leads the Delaney brothers, Trevor and Michael, and their sister Elizabeth, in medical play at their bedside. Medical play is a tool that child life specialists use to explain procedures to patients and that offers a way to include siblings, who may feel left out. This photo was selected for the 2017-2018 Children’s Hospital Association’s traveling photo exhibition, which promotes the value of children’s hospitals nationwide. PHOTO BY KATHLEEN PAICE FROIO
While Orkambi is promising for Trevor, Delaney says, it hasn’t changed his routine. Just like his younger brother, he still must take medicine every day, ingest enzymes before he eats and undergo nebulizer treatments and airway clearance techniques multiple times a day. “My boys, they’re fighters,” Delaney says, describing how her sons both resist the nebulizer and other treatments. “ey’re just so tired of it. I can’t blame them,” she says. “But, we’ve got to do what we’ve got to do.”●
The Robert C. Schwartz Cystic Fibrosis Center is affiliated with Upstate Medical University and has been caring for the medical and emotional needs of people with cystic fibrosis since it was founded in 1970. New patients can contact the program by calling 866-543-5437.
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PATIENT CARE
Creative coping Pediatric art therapist brings art to the bedside
Zenabo Jadama, 17, enjoys an art therapy session during her recovery from spinal surgery to treat scoliosis. PHOTOS BY KATHLEEN PAICE FROIO
THE THERAPY MARIA FAZZINI PROVIDES may involve paints, crayons or other art supplies. She’s the art therapist at the Upstate Golisano Children’s Hospital. “I really enjoy the little smile that starts to form on a patient’s face, and on the faces of their family members, when I introduce them to art,” she says. “e excitement is clearly visible when a child is able to make their own art, oen right in their hospital bed.” Art therapy is used to distract younger patients, or as a coping mechanism for teenage patients. It can become a form of communication for those who are not able to verbalize their thoughts. Fazzini logged more than 1,000 patient sessions in her first year at Upstate. “Art therapy provides so many benefits to our patients and families. It can provide a sense of normalization, an avenue allowing them to share their thoughts and emotions in a safe and nonverbal way. And, it can foster new relationships among family members as they observe and listen to each other in ways they may not have tried before,” Fazzini says. ● Maria Fazzini spring 2017 l upstate.edu
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Sharing expertise
PATIENT CARE
Doctors learn stroke care from experts at Upstate Identifying and treating stroke “takes coordination and rapid analysis. It’s a sophisticated interpretation,” Masoud says. He adds that through the simulations — in which one resident plays the role of the patient while another provides the care — residents learn how to make crucial decisions quickly.
LIKE NEUROLOGY RESIDENTS throughout the United States, the doctors training in neurology at Upstate learn the National Institutes of Health “stroke scale.” is is a tool that helps health care providers measure a patient’s impairment from a stroke. In addition, the neurology residents participate in a simulation program with details from patient care that took place at Upstate University Hospital. Chief neurology residents Gurmeen Kaur, MBBS, and “is is different from watching Vishal Shah, MBBS, facilitate a stroke simulation with resident videos on the Internet,” says Claribel Wee, MD, and a “patient” (Puneet Kapur, MD). Hesham Masoud, MD. “ere’s a lot of utility and advantage in practicing stroke skills in front of an audience.”
Masoud, a member of Upstate University Hospital’s stroke team, is a clinical assistant professor of neurology, neurosurgery and radiology. at means when he is not taking care of patients, he is involved in stroke research and the education of doctors who will care for stroke patients.
“It’s essentially a confidencebuilding exercise,” agrees Vishal Shah, MD, one of the chief residents. He says nurses and pharmacists are part of the simulation, so that the resident in the spotlight goes through the motions as he or she would in the emergency department.
Aer the simulation, the residents ask and answer questions, hear about pertinent research that has been published and discuss the reasoning behind certain aspects of treatment. ey also take tests before and aer the simulations to show their level of knowledge of vascular neurology. ●
Welcome to New York
Refugees arrive with unique health needs NEW YORK STATE, AND CENTRAL NEW YORK in particular, are big refugee resettlement areas, and those refugees can face a wide range of health problems, notes Ranit Mishori, MD, a Georgetown University professor who lectured recently on the topic at Upstate. New York state welcomed nearly 4,000 refugees in 2014, with 95 percent resettling outside of New York City and Long Island. Nearly half are from Burma (Myanmar) or Bhutan, about a quarter from Africa, fewer than 20 percent from the Middle East and about 2 percent from Cuba. Every refugee’s case is different, says Mishori, who grew up in Israel and witnessed torture while in the Israeli military and whose grandparents were German Jews who fled the Holocaust.
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She tells health care providers that: l
refugees are not necessarily poor. ey might be intellectuals or members of an elite group and may have Westernized diseases, such as diabetes.
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refugees may have experienced malnutrition, exhaustion, rape, torture and other violence, as well as a lack of vaccinations, dental care and sanitation.
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practices such as female genital mutilation present a range of cultural as well as health problems.
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post-traumatic stress disorder, depression, anxiety and panic attacks are common among refugees.
Mishori cites a survey that showed doctors neglected to ask refugees whether they had been tortured, and that refugees rarely volunteered that information. As a remedy, she says a new model for refugee health care may include taking a trauma history. ●
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FROM OUR EXPERTS
Healthy humility In caring for patients, doctors better themselves
Some of the most profound pieces of medical education have little to do with medicine. They are lessons that come from the experience of caring for patients. A neurologist, an emergency physician and a pediatrician from Upstate share their stories on the following pages.
Continued on page 12
photoS by SuSan Kahn
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FROM OUR EXPERTS
Healthy humility
continued from page 11
Everyone deserves quality care Emergency physician William Paolo, MD, trained for four years at NYC Health + Hospitals/Bellevue, the oldest hospital in America. Now a world-renowned academic medical center comprising 11 acute and community hospitals, Bellevue opened as a sixbed infirmary in 1736, when George Washington was 4 years old. Nurses and doctors who work at Bellevue are used to caring for a diverse population that oen includes wealthy, powerful dignitaries and celebrities. Paolo’s mentor during his residency training was Lewis Goldfrank, MD, one of the founding fathers of modern emergency medicine. One day, Goldfrank pulled Paolo aside. He told the young protégé to prepare himself for a special patient. Escorting him toward the patient’s bed, Goldfrank explained that the patient had a sensitive problem and would require Paolo’s complete attention and best care. Goldfrank pulled back the curtain. Paolo’s VIP sat on the bed in soiled and smelly clothing. He reeked of alcohol. His head was infested with lice. Paolo recalls Goldfrank’s lesson that emergency medicine was an egalitarian specialty — and every patient was a VIP, deserving of the same quality of care. “We can’t make it as a society unless everyone makes it,” Goldfrank is known for saying. If doctors were to discriminate, to overlook the disenfranchised, or offer substandard care, Goldfrank warned, “we fall apart as a humanistic group.” It’s a foundational belief that Paolo carries with him in his role as an associate professor and residency program director in emergency medicine at Upstate University Hospital. Continued on page 13
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FROM OUR EXPERTS
Listen. Patients will tell you the problem Medicine is so much about storytelling, about the story the patient tells the doctor when the doctor asks some variation of “What seems to be the problem?” Patients have taught pediatrician Beth Nelsen, MD, the importance of listening. “If you are not listening, you are going to miss what you need to know,” she says, explaining that it’s a lot more difficult than it sounds. “It’s almost a meditative experience. You have to quiet your mind.” She recalls a new mom and dad who brought in their 3-month-old son because he was not gaining weight, a potentially serious complication for an infant. In the exam room, he was whiny and clearly miserable. Nelsen had the couple start from the beginning with their story. e whole family had suffered from a terrible stomach bug. Only, everyone else had gotten better, and the baby continued to be cranky. He continued to vomit, didn’t sleep well and had recently begun refusing his bottle. It was unusual in such a little kid, but Nelsen suspected the baby was suffering from a severe case of reflux. “is kid had already figured out that when he ate, it hurt.” She prescribed a baby-sized dose of Zantac and told the parents how to safely raise the head of his crib. Two weeks later, the couple returned with what appeared to be a new baby. He was happy. He’d been sleeping better. And he was putting on weight. In some babies, the lower esophageal sphincter muscle is not fully developed at birth and can cause reflux where stomach acid or bile irritates the lining of the esophagus. e condition can be treated with medication until the sphincter strengthens, usually by the time the baby reaches 6 to 9 months of age — but only if the condition is diagnosed, which only happens if the doctor listens to the patient story. “at probably took 20 minutes, but it’s so important to do that,” Nelsen says of the time she spent during the first visit. “If I hadn’t heard the story from the beginning, I would have missed it.” Continued on page 14
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FROM OUR EXPERTS
Healthy humility
continued from page 14
Miracles happen With four years of medical school and three years of a neurology residency under his belt, Gene LaTorre, MD, believed he had a pretty good idea of how the brain behaves. en he did fellowships in neurocritical care, vascular neurology and clinical neurophysiology. During those years, he encountered hundreds of patients who taught him even more about the brain and the practice of medicine. Today, as medical director of Upstate’s stroke service, LaTorre easily admits: “e more patients I see, the more I have this healthy doubt that we don’t exactly know how our bodies are going to work. We have an idea, but we can never be sure. “A number of patients have given me this humility.” One, for example, was a man in his 30s who suffered a horrible motorcycle crash. e man broke multiple bones. A severe head injury caused a stroke. His kidneys shut down. And he developed severe pneumonia. He was liable to be paralyzed, unable to speak and dependent on others for the rest of his life, if he recovered at all, LaTorre thought. e man’s condition eventually improved enough that he was discharged to a nursing home. A year later, LaTorre saw a patient who looked vaguely familiar in the hospital’s stroke clinic, where patients receive follow-up care. It was the man from the motorcycle crash. He sat next to his mother in the exam room. He had a request of the neurologist: “I would like you to tell my mom to let me go back to my own apartment.” LaTorre was shocked. He considers the man’s recovery a miracle, as well as a lesson. “Now I have a healthier respect,” he says. “ere’s definitely something more than medicine that’s working here, making this outcome possible.” ●
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upstate.edu l spring 2017
When good drugs have bad effects
FROM OUR EXPERTS
LESSONS FROM UPSTATE
Seniors susceptible to medication interactions BY AMBER SMITH
AN 83-YEAR-OLD WOMAN arrived at the hospital emergency department with a loss of energy, low blood pressure and slowed heart rate. While myriad medical problems could cause such symptoms, ultimately hers came from an adverse drug event, a problem that is not uncommon among senior citizens. Adverse drug events can happen when someone receives the wrong drug, or the right drug in the wrong dosage, or when a drug is administered incorrectly. Even the correct drug in the correct dose could cause potentially deadly problems if a person has a change in his or her ability to clear the drug. e risk for adverse drug events rises with a person’s age, the number of health problems they have and the number of medications they take. e risk is greater in those with low body mass or impaired kidney function and in those with visual problems or cognitive impairment that makes it difficult to take medicines correctly. e woman’s doctor had recently doubled the dose of her blood pressure medicine, metoprolol, and switched her heart medicines from amlodipine to diltiazem. She was also taking digoxin, another heart medicine. She had diabetes, kidney insufficiency and a history of an irregular heart
rhythm called atrial fibrillation. e diltiazem clashed with the digoxin, and her body reacted to the increased dosage of metoprolol, the Upstate New York Poison Center staff wrote in the Toxicology letter, produced quarterly by the New York State Poison Centers. e woman got worse — lapsing into unconsciousness and requiring a breathing tube — before she got better. e whole episode may have been avoided, wrote toxicologist Christine Stork, PharmD, Michael Holland, MD, and Benjamin Craxton, a fourth-year medical student at Upstate. ey describe a vicious cycle. When the woman’s blood pressure dropped, so did the blood flow to her organs. at exacerbated her kidney problems and impacted the absorption and clearance of the drugs she took. As they accumulated in her system, so did their effects, eventually landing her in the hospital. Craxton, Holland and Stork suggested that a more gradual increase in her blood pressure medicine, with an attempt to reduce the number of her prescription heart medications, could help avoid future adverse drug events.●
5 reasons drugs work differently in seniors lA
person’s percentage of body fat increases with age, and more body fat can mean an increase in the duration of action for fat-soluble drugs, such as the antidepressant amitriptyline and the antianxiety drug diazepam.
l We
lose muscle mass as we age. at leaves our bodies with less space to distribute certain medications that circulate to lean tissue, including caffeine, the pain reliever acetaminophen and the blood pressure medicine digoxin. erefore, the drugs may end up in a higher concentration than intended.
l Our
blood changes, with levels of the protein albumin declining. is could lead to decreased drug-protein binding and result in higher-than-desired active drug levels in the blood.
l Some
of the liver’s ability to process drugs decreases with age. So, depending on how they are metabolized, some medications – including the blood thinner warfarin and the anti-seizure medicine phenytoin – are likely to have a longer therapeutic duration in older people than in young.
l Most
people have kidneys whose filtering ability declines with age, although up to a third of elderly patients have kidneys that function just the same as in their younger days. Toxicologists recommend assuming that elderly patients have reduced kidney function and using extra care when prescribing drugs that are processed in the kidneys, including the heart medicine digoxin, the antacid cimetidine and opioid painkillers. ●
Source: Article by toxicologist Christine Stork, PharmD, Michael Holland, MD, and Benjamin Craxton, a fourth-year medical student at Upstate, in the Toxicology letter, October 2016.
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FROM OUR EXPERTS
How best to protect your bones 10 protective steps that promote bone health in adulthood:
1.
Know your risk of fractures. e American College of Rheumatology offers an online assessment at www.rheumatology.org Measure your height annually. A loss of more than 1½ inches could indicate vertebral fractures, which are oen silent.
OUR BODIES are always breaking down old bone and rebuilding new. Changes in this process can cause problems in later adulthood, but an Upstate expert says there are ways to help keep bones healthy. “Bone is constantly remodeling. We get new bone laid down, and some goes away, and unfortunately, as the years go on, more goes away than is being laid down,” says Karen Kemmis, a doctor of physical therapy at Upstate. “You need calcium and vitamin D to get bone laid down, and what happens over the years is that the thickness of the bone tends to decrease at a microscopic level, and so the whole structure of the bone gets weaker,” she says. People can develop a condition called osteopenia as their bones thin, or the more serious osteoporosis, in which bones become fragile and can fracture easily. Both conditions can lead to decreased height, stooped posture and pain. Gender, age, diet, body size, race and family history are all risk factors for osteoporosis. About 80 percent of the people with osteoporosis are women, mostly those past menopause. Both genders are at fairly high risk by the time they reach their 80s.
2. your calcium intake, and increase 3. Estimate food/fluid sources and supplements as needed. your vitamin D levels, which can be 4. Know learned from a blood test. Take in more if needed. Discuss medications with your health care 5. provider. Improve bone density by performing appropriate weight-bearing and muscle6. strengthening exercises. Check your posture and do exercises to decrease strain on the spine; also, use proper body mechanics through the day.
7. Prevent falls: Most osteoporotic fractures are 8. the direct result of a fall. Assess and improve your balance. 9. Move safely: Avoid positions that increase the risk of spine fractures, especially flexing 10. (rounding) the spine. Activities such as yoga, Pilates and golf have benefits but may need to be modified. ●
e foundation of good bones is usually built before adolescence, Kemmis says, noting that “osteoporosis is a pediatric problem with geriatric consequences.”
How to stifle a sneeze
THIS IS MOST EFFECTIVE when you first feel that tickle of a sneeze starting to form.
Find the center space below your nose and just above where the pigment of your upper lip stops. Take your index finger and press that spot. You can strike a contemplative pose. “Press for a moment, and that will short-circuit the sneeze,” says Upstate neurologist Anuradha Duleep, MD. You’ll be blocking a branch of the trigeminal nerve, which will literally reroute the neurologic signal that is sent when your body is preparing to sneeze. ●
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FROM OUR EXPERTS
How much exercise do kids need? Upstate’s weekly radio show/podcast, “HealthLink on Air” spoke recently with pediatrician Travis Hobart, MD, about exercise for children. He says government guidelines prescribe an hour a day of moderate to vigorous activity for most kids from age 6 into the teens. e types to include:
Aerobic Examples: walking, running, bike riding As they reach school age, youngsters may become involved in activities (gymnastics, soccer, karate) that raise their heart rate and are structured for kids at various developmental stages.
Muscle strengthening Examples: climbing, playing on playground equipment Weightliing is OK starting around age 12 or 13 for those who want to build muscle with low weight and high repetition.
Bone strengthening Examples: hopscotch, running, jumping, basketball Exercises that involve impact with the ground help strengthen bones. By our teens or early 20s, our bones reach peak bone density. Parents, keep in mind, school-age kids in New York get some physical education during school — 120 minutes per week for elementary schoolchildren, and 90 minutes per week for grades seven to 12. Depending on the school, kids may or may not get any unstructured play since some schools have done away with recess. Hobart says, “For young kids, part of their developmental process is learning how to play with other kids, learning what rules mean and making their own rules, not necessarily rules imposed on them by adults.” In other words, kids also need time to be kids — and that can count toward their daily exercise. ●
Listen to HealthLink On Air at 6 a.m. or 9 p.m. Sundays on WRVO Public Media, or anytime at healthlinkonair.org spring 2017 l upstate.edu
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Follow the leader
IN OUR COMMUNITY
Be flexible, adaptable, imaginative, focused, decisive and emotionally intelligent ROBERT CORONA, DO, MBA, was recently asked about the qualities of good leadership by the Syracuse Media Group in CNY Conversations. “Flexibility and adaptability are key,” he told the news organization. “So is humility. “When good things happen, take less of the credit. When bad things happen, take a disproportionate amount of the credit. Really take the responsibility. Don’t just say “I’m responsible” and not change anything. “Have imagination. I’m a huge Disney fan. I love the idea of not accepting that there’s only one solution.
“Sometimes, when you have to be really focused on a problem, military-style leadership works. You focus. You have to make decisions that may irritate people, but you have to get that problem solved. “When the tension isn’t so bad, you have to be soer and use emotional intelligence and get people to buy in and build them a bridge, so they have a pathway to the side that you’re hoping to get them to.” Corona, the John B. Henry Chair of Pathology and Laboratory Medicine and vice president for innovation at Upstate, leads the Central New York Biotech Accelerator center. ●
Unlocking a lifelong mystery brings hope and health FROM CHILDHOOD, Georgia Diefendorf struggled with recurring, debilitating bouts of dizziness, nausea and severe flushing, unstable blood pressure and muscular pain. en, nearly 40 years ago, her teenage son became ill with similar symptoms. ey were referred to a renowned endocrinologist at Upstate Medical University — David Streeten, MD. It was a referral that would unlock a lifelong mystery for Georgia, as well as bring hope and health to both mother and son.
Streeten’s research at Upstate led him to suspect that Georgia and her son suffered from a rare genetic disease called mastocytosis, a systemic disorder that had only been discovered 30 years previously. He recommended that Georgia and her son travel to Vanderbilt University Hospital, where advanced research in mastocytosis was then being conducted. Streeten’s diagnosis proved life changing for Georgia, her son and later her daughter as well. “I know that knowledge changes everything and is both a power and a blessing for my children and me,” Georgia said. Streeten’s diagnosis was only the first step toward better health. Mastocytosis occurs when an excessive number of “mast cells,” a type of white blood cell, infiltrates tissues and organs. When they release their chemicals, it affects the skin, lymph nodes and vital internal organs such as the liver, spleen, lungs, stomach and intestines, similar to 18
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that of an allergic reaction causing flushing, pain and even shock. e sudden release of the mast cell chemicals, known as mediators, produced the low-level shock responses that Georgia and her children had been experiencing.
Once the family was diagnosed, they began a lifelong regimen of medications targeting the mast cells and blocking the effects of the debilitating chemical release. eir treatment and disease management were carefully conducted by Upstate endocrinologist and Professor Emeritus Arnold Moses, MD. Because of the side effects from the medications needed to manage this disease, Georgia is considered prediabetic, and is now also a regular patient of Ruth Weinstock, MD, PhD, at the Joslin Diabetes Center. “It was that wonderful team of Drs. Streeten, Moses and Weinstock who saved me and my children,” Georgia said. “I shall be forever grateful to Upstate Medical University and its Joslin Diabetes Center for finding the cause of my illness and helping me and my family manage its effects over the past 37 years. “We are living good and fairly healthy lives, thanks to an Upstate Medical University team whose legacy of outstanding clinical research continues and whose care we can count on the rest of our lives. So it is only proper that Upstate count on the support of our family as truly grateful patients.” ● ARE YOU GRATEFUL? A gift of gratitude is a meaningful way to both express your appreciation to special caregivers and to help patients during their time of great need. To donate and/or share your story, contact the Upstate Foundation at 315-464-4416, visit upstatefoundation.org or email kistnerb@upstate.edu upstate.edu l spring 2017
Mosquito control
IN OUR COMMUNITY
Upstate scientists learn form succes of malaria control effort UPSTATE SCIENTISTS CREDIT international collaboration with keeping a region along the border of Ecuador and Peru free of malaria since 2012. e coastal area of El Oro Province in Ecuador and the city of Tumbes, Peru, were once endemic with the mosquitoborne viral infection. From the 1980s into the early 2000s, this region experienced an upsurge of malaria. Climatic fluctuations and livelihoods that involve water contact, such as rice farming, are some of the factors that increase this region’s risk for malaria. Working together over 20 years, leaders from both nations strengthened surveillance and treatment strategies, Upstate researchers point out in the Nov. 28 issue of the Malaria Journal. A grant from the Department of Defense helped pay for the research, done through Upstate’s Center for Global Health and Translational Science. e study highlights key principles of a successful malaria elimination program, which can inform the next
generation of public health practitioners, says Mark Polhemus, MD, director of the center. He and co-authors Rosemary Rochford, PhD, and Anna Stewart Ibarra, PhD, found these elements important: l
National policies and standards were translated into local realities.
l
An active case-finding surveillance system was paired with a strict treatment plan.
l
A small team of dedicated public health practitioners was nimble and effective because they were empowered by regional and national networks.
e scientific trio suggest that the systems and technologies that were necessary for a successful malaria elimination program should be maintained, in order to prevent a relapse. ey also hope this collaborative approach can be a model to reduce mosquito-borne diseases in other areas of the world. ●
Closer to home, EEE remains a threat Denise Broton of Cicero was flown to Upstate University Hospital from the hospital in Lake Placid three summers ago aer she was diagnosed with the eastern equine encephalitis virus. Hospitalized for four weeks, Broton slowly has recovered. She shared her experience with reporters, hoping her story can convince others to guard against mosquito-borne illnesses. e EEE virus can be deadly; those who survive may be le with disabling and progressive mental and physical difficulties. Broton says she struggles with balance and coordination and light sensitivity. Mosquito prevention techniques include the use of insect repellent when outdoors; wearing pants and long-sleeved shirts; keeping door and window screens in good repair; and eliminating standing water around your home to reduce mosquito breeding sites. Some county health departments offer aerial spraying to help combat mosquitoes. ●
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IN OUR LEISURE
Setting an example
Pediatric gastroenterologist/ amateur cook eats lots of vegetables, grains BY AMBER SMITH
AS A CHILD growing up in Kashmir, India, Prateek Wali ate mostly locally grown vegetables and farm-raised animals. In the snowy winters, his family dined on kidney beans, turnips, hearty grains and other foods that stored well. e spring, summer and fall months meant eating whatever vegetables were in season. It was very farm-to-table. “We shopped for dinner each morning in the local outdoor market,” he describes. Wali, chief of pediatric gastroenterology at Upstate Golisano Children’s Hospital, brought that part of his culture with him as an 8-year-old boy when his family moved to America. He and his sister routinely helped their mother in the kitchen, developing a love of cooking. He characterizes Kashmiri cooking as rustic and flavorful. Vegetables and meats are made decadent with a range of spices to produce unique curries. Today, he continues to expand that palate with his wife, Mikki Kollisch, through travels to experience new cultures and new food. While they enjoy making Indian food, they also try their hand at other cuisines, including Italian, French, ai and Korean. As a physician specializing in the organs of digestion, Wali is particularly mindful of how food and drink can impact human health. He nudges his patients toward incorporating nutritious choices into their diets. ose with irritable bowel syndrome can benefit from diets low in sugar, fat and dairy, for instance, and patients with gastroesophageal reflux may benefit from low-acid, low-fat foods. Prateek Wali, MD, in his kitchen preparing a marinade for salmon. Recipe on page 21.
continued on page 21
photo by SuSan Kahn
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Setting an example
IN OUR LEISURE
continued from page 20
He says it is unusual for a particular food to be the cause of a disease, except for gluten in celiac disease. Instead, “Patients who have difficulty with intestinal symptoms, or those who have a diagnosed gastrointestinal disease oen can improve their health if they consult with a dietitian.” at’s an option for children at the Karjoo Family Center for Pediatric Gastroenterology at Upstate. (Visit upstate.edu/pedsgi) Wali and his colleagues care for children with celiac disease, inflammatory bowel disease, intestinal failure, allergic gastrointestinal disease, feeding and swallowing disorders, liver disease, pancreatitis and other diseases. Wali describes himself as an enthusiastic amateur cook. He shares healthy, tasty and practical recipes such as Udon Noodles With Bok Choy and Poached Egg, Butternut Squash With Farro, and Vegetarian Stuffed Peppers on a blog that he writes mostly for family. HaakandChai.com, as it is called, refers to Kashmir dietary staples, collard greens and tea. Wali writes, “Both are examples of how food defines our culture and interactions among our family.” ●
OUR GRADS HAVE GREAT CAREERS… BUT FIRST THEY GET GREAT EDUCATIONS.
Asian Salmon Preparation
Whisk soy sauce, Dijon mustard, olive oil, honey and brown sugar together to create marinade. Rub over the meaty surface (skin side down) of the salmon, and allow this to sit for 10 minutes. Heat an iron skillet on medium-high heat with a thin layer of olive oil. Place the salmon, skin side down, into the pan. Cook for 4 minutes, then turn using a fish spatula. Cook for an additional 3 to 4 minutes until salmon is firm to the touch or registers 135 degrees Fahrenheit on a meat thermometer. Transfer salmon to a flat plate, skin side down, and allow to rest for 10 minutes. Serve with rice and soy sauce. is pairs well with a riesling or pinot grigio wine.
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Ingredients 2 fillets fresh salmon For the marinade: 1 tablespoon Dijon mustard 2 tablespoons soy sauce 4 tablespoons olive oil 1 tablespoon honey 2 tablespoons of light brown sugar
Nutritional information For each of two servings, assuming half of the marinade is absorbed 395 calories 35 grams protein 25 grams total fat 78 milligrams cholesterol 575 milligrams sodium 715 grams potassium 9 grams sugars
upstate students benefit from nationally recognized professors, excellent job placement and Suny tuition. open houses are held each fall and spring. DEGREE PROGRAMS Biomedical Sciences (MS, PhD) Cardiovascular Perfusion (BS) Medical Biotechnology (BS) Medical Imaging (BS, BPS) Medical Technology (BS, MS) Medicine (MD, MD/PhD, MD/MPH) Nursing (BS, MS, DNP, post-master’s certificate) Public Health (MPH) Physician Assistant (MS) Physical Therapy (DPT) Radiation Therapy (BS, BPS) Respiratory Therapy (BS)
Education • Healthcare • Research
www.upstate.edu/students
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A more colorful life
IN OUR LEISURE
Pathology specialist enjoys painting, drawing BY JIM HOWE
AFTER A DAY working with an electron microscope in Upstate’s pathology department, Joyce Yue Qi might pick up an artist’s paintbrush or a pastel crayon and create a picture. Qi has won awards for her work each of the three times she entered CNY Arts’ “On My Own Time” exhibition, which exhibits works by employees of local businesses and organizations at the Everson Museum of Art. In 2015, her oil painting “Chinese Tea Set” (reproduced here) was used for the exhibit’s reception brochure. Qi’s interest in art as a hobby began about five years ago, when a co-worker, now retired, encouraged her to attend some sessions with her art group. Qi, 58, found that she liked painting, drawing and sketching as well as being able to learn from experienced artists. “I like oil the best because as a beginner, I need to make lots of corrections on each piece, so if you did it wrong, you can put another layer on top of it,” she says with a smile. For the same reason, she likes sketching, where she can erase anything she doesn’t like.
She creates many of her works from photographs she took, such as one of herself canoeing near Old Forge with her younger son, Alan, 21, a student at Clarkson University. Another work shows her older son, Kun, 28, a biological researcher in Massachusetts, holding a chunk of ice in Alaska. “I think I surprised myself,” she says of her pastime, because she never thought she would be able to paint, and she finds the creative aspect satisfying. She estimates she spends three to five hours a week painting or drawing at home or in painting classes. “You will never find other things you may enjoy in your life unless you spend some time and energy to give them a try,” she says. “Some hobbies will make your life more colorful and enjoyable.” ●
Qi, who grew up in Beijing, uses Joyce as a first name because it’s easy for Americans to pronounce and because her Chinese name means “joy.” She was an ophthalmologist before coming to the United States in 1992 to do eye research in the laboratory of the late Barbara Streeten, MD. Her current job as a technical support specialist finds her doing mostly pathology related to kidney diagnoses. Her husband, Hengsheng Fang, is a researcher in Upstate’s medicine department.
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DAKOTA AND HER PEDIATRIC ONCOLOGIST, GLORIA KENNEDY, MD
If your child faces a diagnosis of cancer, turn to the experts at Upstate for personalized care and treatment options. We offer access to clinical research studies, exceptional technology and support services at the Upstate Golisano Children's Hospital and outpatient treatment at the Upstate Cancer Center. Our multidisciplinary teams of oncology-certified nurses and board-certified physicians are here for you.
MORE INFORMATION: CALL 855.964.HOPE OR VISIT UPSTATE.EDU/CANCER
Expertise. Expe rtise. Compasison. C ompas si on.Hope. Hope.
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750 East Adams Street l Syracuse, NY 13210
SCIENCE IS ART IS SCIENCE IS ART 1S SCIENCE Upstate’s Molecular Pathology Next Generation Sequencing Lab has an Anatomage Table, an advanced anatomy visualization system that can display patient scans to accommodate virtual autopsies, educational opportunities, pre-surgical planning and research. Pictured: Sam Carello, director of laboratory informatics, and nurse practitioner Bridget McCarthy. photo by robert MeScavage
The Anatomage Table was purchased with support from the Upstate Foundation. 17.102 0317 41.8M MIDsk