Wednesday, August 27, 2008

Week 5: Goose

I seriously started major progress in my project with Dr. Souweidane from this week. I had frequent meetings with a medical student, Peter Morgenstern, to talk about the current techniques related to endoscopically guided third ventriculostomy with regard to prepontine space. I also had meetings with a visiting physician from Greece, Jonathan Roth, who helped me so much with how to use MRI stations and read the images to retrieve the specific information I want. Initially Dr. Souweidane and I had brainstormed many ways to prove his hypothesis. His experience with endoscopic third ventriculostomy hinted him that the entry site of endoscope on the skull relative to the suture shifts depending on age. The results from the study, if proven true, could provide with a more specific guideline for starting physician on what would be the generally accepted endoscopic entry site for the patients. However, this turns out to be a very difficult task as most of patients come with different symptoms such as swollen cortex and ventricles, there is no solid standards of references for measurement. We even had a brief meeting with Dr. Michael Kaplitt who provided some ideas with how to go about measuring the differences that we would see between patients of different age groups. He showed us how to reconstruct a three-dimensional brain structures from plane images and argued that the measurements should not be distances from suture but rather an angle to the target site from the entry site as patients have different skull sizes and slight shifts in the brain anatomy.

Despite all the trouble and difficulties we faced in deciding what the measurement should be, I started organizing the list of patients who underwent endoscopic third ventriculostomy. In the end we had about 70 patients with decent medical records and documentations that I could work on. The range of age at the day of surgery seemed pretty diverse, ranging from 1 day old to the 70s. The etiology of the surgery and results also varied a lot as some patients even had shunts at young age and some other patients had to revise to shunt after an unsuccessful result from the endoscopic third venstriculostomy. Would it be the nature of research in medical practice? The diverse list of patients seemed almost overwhelming for me to do a well controlled analysis.

Week 6: Goose

So finally the entire journey at New York City is over. I actually had to spend some more extra time even after the last day at the city to wrap up my project. Everything turned out nice, though the project seemed too sketchy in the beginning. Dr. Souweidane and I turned in an abstract to the American Association of Neurological Surgeons, a congress of neurological surgeons in October at Seattle, Washington. Of course I would not be able to go to the conference but I am glad that I have contributed to the work Dr. Souweidane does and made it to an abstract. Although the original ideas we had in the beginning seemed to be more attractive and with higher impact, we had to shift our ideas as to it is somewhat more doable. Original intension of the study, that is the dependence of age in hydrocephalus patients in the entry site of endoscope relative to the skull suture for endoscopic third ventriculostomy, was just way too difficult to make legitimate measurements and enough patients with cases that we can do better controlled studies. Instead, we decided to analyze the hydrocephalous patients with cases of diminished prepontine interval space, which can affect the safety and functionality of endoscopic third ventriculostomy. The result showed that functional success rate of patients with obliterated prepontine interval appeared equivalent to historical controls. The diminished success rate was functional success rate was rather apparent in young patients, which is believed that the rapidly growing bodies can soon block the fenestration on the floor of the third ventricle within a few weeks requiring them to have shunts instead.

I much enjoyed the summer immersion program and was really a blast to have a chance to work with a practicing physician. I learned so much in the privilege of meeting patients and witnessing surgeries. The lessons I learned from these experiences not only have taught me that there are endless diseases that need to be more researched, but also that what we are studying as biomedical engineers is truly worth our time and effort. The deprived quality of life that these patients are having can be immensely improved by the breakthroughs we make, and that is for sure my conclusion after the summer immersion program at the hospital.

Week3: Goose

A 4 year old boy had a retina blastoma on the back of his left eye. The left eye was surgically removed and was replaced with a prosthetic eye. To eliminate all the cancer residues, the boy went through radiotherapy. About three years later, when the boy was 7, he was again diagnosed to retina blastoma on his right eye and had to undergo the same procedures.

I met this young patient in clinics in the beginning of my third week, and now he is 14 years old. He came to clinics with several complaints for his headaches and hearing problems. I first did not notice that he was blind but after the brief physical exams Dr. Souweidane performed I realized that he could not see what was in front of him. When I heard the whole story about him, I truly felt sorry for him and his family. He was diagnosed to acoustic neuroma—it was his third cancer occurrence. Dr. Souweidane explained that he had about 50% chance of losing his hearing after the surgery if he opts to remove the tumor mass by surgical methods. As a matter of fact, the tumor mass was already quite large in size and because radiotherapy has seemed to cause more trouble than helping cancer clean up for the patient, Dr. Souweidane decided not to give him any more radiotherapy. The boy was rather calm as Dr. Souweidane explained all the possible etiology, surgical plans, its associated risks, and expected improvements as well as loss after the surgery, but I could certainly see the devastated looks of his parents through their eyes.

The privilege of seeing patients in clinics has given me mixed feelings. Sometimes my adviser Dr. Souweidane would look like a hero, giving relief to patients and even, as a result, saving their lives. Some patients would come to see him with problems which fortunately can be relatively easily treated and would not have much postoperative complication such as chiari malformation. But some other patients have to face diagnosis such as malignant brain tumors with some cases unfortunately occurring at regions of brain that require traumatic craniotomy. Not only that I feel disappointed at current medicine, but also feel responsibility to contribute whichever way I can through things I study. Also, before I tell my friends how cool my experience has been at Cornell hospital seeing patients with all kinds of diseases in clinics and witnessing topnotch surgeries, I should always keep in mind that there are always close friends and family who would weep for these patients.

Week 4: Goose

The 17 year old boy, who had a benign tumor in the middle of his left cortex and had to go through an open brain surgery, came to clinics for follow ups. The surgery the boy went through was the first craniotomy I have ever seen. I was in fact so shocked at how traumatizing the procedure was--perhaps the tears of the boy and his mother before the surgery began had also elevated my emotions. However, today when I saw him, I was quite surprised at the results. Although the boy seemed to be responding somewhat late to the questions Dr. Souweidane asked, he was perfectly normal. He walked straight without a problem with symmetric facial expression as well as full control over every limb. The scar from the surgery has already started healing, though the incision made still looked quite painfully large, and could be somehow covered by hair. However, he seemed to have some change in attitude which I thought it reflected some distrust toward Dr. Souweidane. I still think the surgery was the best solution and decisions Dr. Souweidane could provided based on MRI images to the problems he was having. I guess some patients come with trust and open mind trying their best to have the greatest results, while some other patients come with distrust and doubts towards their physicians and only are disappointed by the results.

During the week I met a patient with neurofibromatosis type 1. Her left eye was covered with a large growing tissue mass, neurofibroma. She had several brownish dime sized freckles on her skin, I could easily notice. The reason why she came to see Dr. Souweidane was her back problems. Apparently, patients with neurofibromatosis type 1 often have abnormal development of spine, termed scoliosis, which can give discomfort while sitting and standing. She did have trouble sitting straight up but was not so severe. Neurofibromatosis is known to be a genetic disorder, having mutation in proteins that control cell production. Neurofibromatosis type 1 is pretty common occurring in 1 in 3000 individual in the United States. I did not know what I would do if I had such problem and what I could say to cheer her up. Sometimes, and every since I came to Weill medical school, I keep realizing that being able to live a normal and healthy life almost seems like a miracle.