Science Is Art: Black lung disease under the microscope

Microscopic views of a coal miner’s lung. The above image shows dark coal macules (collections of coal dust in the lung cells). The image below shows dust in the lungs comprised of coal (black) and silicate (bright) particles.

Jerrold Abraham, MD, and Soma Sanyal, MDUpstate pathology professor Jerrold Abraham, MD, left, and assistant professor Soma Sanyal, MD, are examining lung tissue from coal miners with black lung disease as a part of a large study into the reasons for a recent increase in the disease, which is also known as coal worker’s pneumoconiosis.

The increase may have to do with changes in coal mining technology, as well as the enforcement of safety regulations, says Abraham.

Slice of a coal miner’s lung. Black area shows progressive massive fibrosis.

Slice of a coal miner’s lung. Black area shows progressive massive fibrosis.

This article appears in the fall 2018 issue of Upstate Health magazine

Posted in health care, lung/pulmonary, pathology, research

Consider checking newly diagnosed diabetics for pancreatic cancer

The pancreas is shown in red.

The pancreas is shown in red.

BY AMBER SMITH

One of the reasons pancreatic cancer is so deadly is because early symptoms are so vague. “The majority of cases are diagnosed at an advanced, incurable stage,” a team of Upstate doctors writes in the American Journal of Emergency Medicine. Oncologist Rahul Seth, DO, and colleagues go on to explain that controversy exists among medical professionals about a link between diabetes and pancreatic cancer.

They tell of a 59-year-old woman who was diagnosed with type 2 diabetes by her primary care doctor and prescribed insulin. Five days later, she came to the emergency room saying that she was confused and lethargic, with muscle aches and worsening abdominal pain. Those are symptoms of diabetic ketoacidosis, known in medical shorthand as DKA. It’s a life-threatening complication of diabetes that can be prompted by an infection, severe stress, inadequate insulin therapy or other reasons including, although rare, pancreatic cancer.

Rahul Seth, DO

Rahul Seth, DO

She was admitted to the intensive care unit of Upstate University Hospital for intravenous insulin therapy and hydration.

During her three-day stay, medical images of the woman’s abdomen revealed a tumor in her pancreas and some suspicious cells of her liver. Biopsies of both areas confirmed pancreatic ductal carcinoma. Like 85 percent of people diagnosed with this type of pancreatic cancer, her disease was at an advanced stage, and surgery was not a treatment option. When caught early, before it has spread, pancreatic cancer can be cured with surgery.

Seth indicates in the journal article that this woman’s pancreatic cancer probably prompted her DKA symptoms. His colleagues include physicians who are completing their residency training at Upstate: Danny Markabawi, Divya Kondapi and Vikrant Tambe.

The article references multiple medical studies. Some show that diabetes and hyperglycemia, which occurs when blood sugar levels are too high, are risk factors for the development of pancreatic cancer. Others suggest that hyperglycemia and diabetes might be caused by pancreatic cancer-associated pancreatic failure. It’s difficult to discern which happens first.

People who are newly diagnosed with diabetes have up to an eight times higher likelihood of being diagnosed with pancreatic cancer within three years, according to research that examined medical images and blood sugar values of people before they were diagnosed with cancer. Another study suggests that diabetes associated with pancreatic cancer occurs at a stage when surgery might still be an option.

That’s why Seth and colleagues propose “It might be worthwhile to consider screening patients with newly diagnosed diabetes mellitus for early-stage pancreatic cancer when other risk factors for diabetes mellitus are absent.”

They say it’s rare, but symptoms of diabetic ketoacidosis can be a clue to pancreatic cancer, especially when the most common causes of DKA are absent.

Upstate Health magazine fall 2018 issue coverThis article appears in the fall 2018 issue of Upstate Health magazine. 

Posted in cancer, diabetes/endocrine/metabolism, health care, pancreas/liver/gallbladder/bile ducts, research | Tagged , ,

Facing a crisis: Meet the Upstate experts working  to solve the opioid epidemic

opioid capsulesThe opioid epidemic is fueled both by the abuse of street drugs such as heroin and the addiction to prescription painkillers. The Centers for Disease Control and Prevention says prescription opioids contribute to 40 percent of all opioid overdose deaths in the United States.

 

BY AMBER SMITH

Solving the opioid crisis is a team effort. Many Upstate people are involved, in multiple ways.

Some are caregivers, helping those impacted by substance abuse. Some teach how to alleviate pain without using opioids. Some work to prevent addiction. Some are family members, touched in personal ways by the epidemic.

Here’s how they contribute.

The toxicologists

How did we reach the point where deaths from opioid overdoses (more than 42,249 in 2016) surpassed deaths from gun violence (38,658 in 2016)?

Willie Eggleston blames over-prescribing of opioid pain medications such as oxycodone and aggressive ad campaigns from drug manufacturers.

Willie Eggleston, PharmD

Willie Eggleston, PharmD

The use of opioids began increasing in the late 1990s when medical experts began putting more importance on pain control. Nurses started asking patients to assess their level of pain as “the fifth vital” when they recorded their four vital signs: pulse, respiratory rate, temperature and blood pressure.

Eggleston is a doctor of pharmacy who works in the Upstate New York Poison Center, specializing in opioid addiction and harm reduction. He leads the Opioid Research Center for Central New York, a group whose mission is to reduce the impact of the opioid crisis by making the best use of existing resources and expanding access to treatment.

After prescription painkiller abuse was recognized as a problem, the number of opioid prescriptions began to decline in 2010. Today, doctors in New York are limited to prescribing seven days’ worth of opioids. Eggleston says the crisis is like a sinkhole that suddenly opened.

“We covered the sinkhole, but we didn’t bother helping those who had already fallen in.”

Without their prescription opioids, many people turned to heroin or synthetic opioids such as fentanyl. Such street drugs are dangerous because buyers don’t know what they’re getting, or the concentration.

Brett Cherrington, MD, a doctor of emergency medicine with a specialization in toxicology, says, “All of our heroin is now laced with fentanyl, and a lot of times when people purchase what they think is heroin, they get fentanyl.”

Brett Cherrington, MD

Brett Cherrington, MD

Fentanyl is a drug that is used in hospitals for pain control. It’s more potent than heroin, so the overdose risk is greater. A similar drug called carfentanil is used in veterinary medicine to tranquilize elephants. It’s 100 times more potent than fentanyl — and responsible in 2017 for strings of overdose deaths including in Central New York.

Also that year, the Upstate New York Poison Center handled 59 cases of people who abused or overdosed on anti-diarrhea medication containing loperamide, an opioid. At least four of those people died.

In an effort to minimize the side effects of opioids, which include constipation and drowsiness, some people mix an opioid along with an “upper,” such as cocaine. Cherrington points out that’s also dangerous.

Too big of a dose of opioids can cause a person to stop breathing. Emergency responders are equipped with a drug called naloxone that can reverse opioid effects. Regular people have also been trained in how to administer the rescue medication, which can be purchased at pharmacies throughout New York state. Eggleston says the availability of naloxone throughout CNY is helping save lives.

Still, officials from the Drug Enforcement Administration say that more people report using controlled prescription drugs than cocaine, heroin and methamphetamine combined.

The emergency doctors

Doctors working in the emergency departments at Upstate’s downtown and community campuses combined saw more than 1,000 patients in 2017 who were overdosing or struggling with addiction, reports Jay Brenner, MD. As with smoking cessation, he points out, “Catching people when they’re at their sickest, for counseling, is sometimes when you can catch people most willing to reconsider their lifestyle choices.”

Jay Brenner, MD

Jay Brenner, MD

But the emergency department is where lives are saved and patients are stabilized. It’s not designed for more involved drug interventions. Typically, emergency doctors would send those patients home with referrals to addiction treatment programs.

Ross Sullivan, MD, said that wasn’t working. Often it took days or weeks to get an appointment, and in the interim, many patients continued using opioids to stave off withdrawal.

“There had to be a different way to help these people, to make them safer, to make them healthier,” he says. Sullivan is one of fewer than 1 percent of emergency physicians who are also certified in addiction medicine. In 2016 — the year 142 people died in Onondaga County from opioid overdoses — Sullivan established what he calls the bridge clinic.

It’s a service that bridges that gap between the patients’ trip to the emergency department and their entry into addiction recovery.

How it works today is, patients at the emergency department who want help getting off opioids receive a dose of buprenorphine, a tablet that melts beneath their tongue, and can help decrease drug cravings and suppress the symptoms of withdrawal for up to three days. They also receive a follow-up appointment a few days later at Upstate.

Ross Sullivan, MD

Ross Sullivan, MD

At that appointment, the patient meets with Sullivan, specialists in social work and case management, plus a “peer,” someone who is years into recovery. The patient may need help obtaining health insurance, food stamps, housing or other important services, things that need to be stabilized “before we can even think about them doing all the work they need to do to try to conquer their drug addiction,” Sullivan explains.

He sees about 60 patients per month, some for up to three to four visits as they prepare to enter treatment. Sullivan says 75 to 80 percent go on to enter addiction treatment, the majority in outpatient programs in the Syracuse area. “The most rewarding thing about this work really is when a patient thanks you, and they can look you in the eyes and tell you how their life has changed,” he says.

The number of opioid deaths in Onondaga County dropped to 91 in 2017 from 142 the year before. Sullivan says that doesn’t mean fewer people are using opioids. As hopeful is he is that patients will stop using, he wants them to be safe if they don’t. He provides prescriptions for naloxone, the rescue medicine that can reverse an overdose, and instructions about using clean needles.

“You don’t cure addiction,” Sullivan explains. “You learn to live with it and manage it.”

The infectious disease specialist

Overdose is not the only risk in abusing opioids. Deaths are just the tip of the iceberg, says Timothy Endy, MD, professor and chair of Upstate’s microbiology and immunology department and an expert in infectious diseases.

He’s concerned about two sets of people: those who share needles and spread infections such as hepatitis C and the AIDS virus, and those who introduce bacteria into their bloodstream when they inject a needle through skin that is not sterile.

“That’s really the problem we’re seeing related to IV drug use,” Endy says before detailing the skin abscesses, muscle and bone infections that lead to paralysis or bacterial endocarditis, an infection of the heart valves.

In 2011, five patients were treated for bacterial endocarditis at Upstate University Hospital; the number climbed to 37 in 2017, Endy says. “This is the underbelly that we don’t really talk about, and that the public should be aware of.”

Such serious infections can require lengthy hospital stays and lifelong medical care, depending on how far the infection has progressed.

If caught early, bacterial endocarditis can be treated with a six- to eight-week course of intravenous antibiotics. “The problem is, we do it through a special intravenous line called a PICC line that can stay in place for several months. With addicts and opioid users, they’re not capable of going home with PICC lines because of the potential for misuse. So they end up staying in the hospital for eight weeks,” he says.

Drug addicts also are likely to have nutritional deficiencies, and their immune system is likely to be depressed because of poor nutrition and opioid use.

Timothy Endy, MD

Timothy Endy, MD

They may also require heart valve replacements, he says, recalling a 20-year-old who recently had to have two valves replaced. “These are serious medical problems.”

Endy speaks from experience not only as a medical provider — but also as a parent.

The parent

Endy’s son, Justin, started misusing drugs in high school and had developed a serious heroin addiction by the age of 24. He overdosed twice. Both times he was saved with a dose of naloxone and wound up in the emergency department of Upstate University Hospital.

Justin Endy spent time in jail. He failed two outpatient rehabilitation programs. Three times he tried to stop using cold turkey.

“Watching him, we realized he was slowly dying,” Timothy Endy recalls of that time in 2016. “My wife and I felt like he would die in the next couple of weeks. Our son was just exhausted. We knew we had to get him into a program.”

With help from a recovery specialist, they enrolled him in a 30-day residential detoxification program called Sierra Tucson in Arizona, followed by a structured yearlong 12-step program called Bringing Real Change in Austin, Texas. “The transformation in Justin was dramatic,” Endy says. “He says he has finally found peace and serenity.”

The Endys’ health insurance plan did not cover the recovery programs, so the Endys paid for the treatment on their own. Subsequently, they helped sponsor 10 other people who were struggling with addiction and recovery through a charitable foundation they created at road2recoverycny.com

The addiction specialists

Brian Johnson, MD

Brian Johnson, MD

Some people require inpatient treatment. Others succeed through outpatient detoxification programs.

“We have not cured one person of addiction, but we have gotten people into recovery,” says psychiatrist Brian Johnson, MD, director of addiction medicine.

Upstate Addiction Medicine is a holistic medical practice that offers detoxification and treats chronic pain. Walk-in appointments (if you call ahead, at 315-464-3130) are available weekdays, and patients are asked to bring a non-addicted support person with them.

“If there’s a loved one involved, the chances that people are going to remain sober greatly increase,” explains psychiatrist Sunny Aslam, MD. That first appointment is lengthy. Some patients will make daily visits until they stabilize, and then they may come in weekly.

Sunny Aslam, MD

Sunny Aslam, MD

Johnson says he’s seen more than 17,000 patients successfully detox from opioids, alcohol and other substances. He prescribes buprenorphine, plus other medications that help with gut cramps and anxiety. “They go home with their support person,” he says. “A week later, they’re off opioids, and it was no big deal.”

One month out, he says 60 percent of those who stopped taking opioids remain sober. He says some people relapse and go through additional rounds of detox.

He explains that drugs change the brain permanently. That’s why people continue to attend Alcoholics Anonymous even if they stopped drinking years ago.

“Once you reintroduce the drug into the brain, it turns on ferocious cravings that have been dormant,” Johnson says. “If you’re addicted to tobacco, you can’t go back to cigarettes once in a while. If you’re addicted to alcohol, it’s the same. If you’re addicted to opioids, it’s the same.”

The pain specialist

Withdrawal from opioids can feel 100 times worse than the flu, with severe vomiting, diarrhea and stomach cramps. Many people who are addicted to pain killers “are not looking to get high. They just do not want to go through withdrawal,” explains nurse practitioner Theresa Baxter. “They’re just so desperate to feel normal. They did not wake up saying, ‘I want to be a heroin addict’ today.’”

Theresa Baxter

Theresa Baxter

She explains that opioids are “very effective in treating that immediate, acute pain, after a surgery or after a terrible injury. The problem is when we continue them long term. They’re a lot more addictive than we thought.”

Also, with long-term use, opioids increase a person’s sensitivity to pain, she says. It’s called opioid-induced hyperalgesia.

Opioids are not the only way to treat acute pain. Baxter advocates for the use of acetaminophen, ibuprofen and muscle relaxants. Nerve blocks can also be helpful, depending on the type of pain.

She cares for patients with chronic pain, too, many of whom get relief from massage, chiropractic care, weight loss, muscle and core strengthening, cognitive behavioral therapy and/or medical marijuana.

Not everyone can expect his or her pain to disappear. Baxter’s goal is to restore functionality, so people can go on with their lives.

The scientist

Opioids act on opioid receptors located on nerve cells throughout the brain and nervous system, producing an analgesic effect.

Until recently, scientists assumed that all opioids — those produced by the body, and those ingested as drugs – interacted in the same way with opioid receptors. Recent  research has shown differences that may help guide the design of new non-addictive pain relievers.

Stephen Thomas, MD

Stephen Thomas, MD

Not only that. Recent research has also shown the potential for impacting the effect of opioids on the brain by inducing an anti-opioid immune response.

An experimental heroin vaccine induced an immune response that prevented heroin from traveling into the brain through the bloodstreams of laboratory animals, according to a study published in the Journal of Medicinal Chemistry.

“By eliciting antibodies that bind with heroin in the blood, the vaccine aims to block the euphoria and addictive effects,” Gary Matyas, MD, told Science Daily. He is from the U.S. Military Research Program at the Walter Reed Army Institute of Research. “We hope to give people a window, so they can overcome their addiction.”

Stephen Thomas, MD, professor of medicine and microbiology and immunology at Upstate, is excited by the prospect. “A heroin vaccine could play an important role in a comprehensive approach to treating people who are suffering from substance abuse disorders,” he says.

Upstate and Walter Reed researchers have been awarded a grant to advance the development of an experimental heroin vaccine. If successful in early development, a second grant award will support testing the vaccine in human volunteers. The clinical trial would be performed by Upstate in Syracuse.

Contact information: 

Upstate Addiction Medicine, 315-464-3130; Road2RecoveryCNY.com

assorted tablets and capsulesOpioid Vocabulary

Buprenorphine — an opioid medication used to help decrease drug cravings and suppress the symptoms of withdrawal.

Methadone — an opioid medication used to help taper people off an opioid addiction.

Naloxone — a medication that rapidly reverses the effects of opioids and can save a person from overdose.

Opioids — a class of drugs that includes the prescription opiate medications codeine and morphine; plus semi-synthetics and synthetic drugs hydrocodone, oxycodone, fentanyl and others; and the illegal drug heroin.

Be aware: Emerging opioid substitute

Jeanna Marraffa, PharmD

Jeanna Marraffa, PharmD

Christine Stork, PharmD

Christine Stork, PharmD

A drug used in other countries to treat depression — and

also anxiety, asthma and irritable bowel syndrome — has the potential for abuse and addiction. Tianeptine is sold under the trade names Stablon and Coaxil in Asia and Latin America and obtained through Internet channels in the United States.

Poison centers in New York state handled nine cases of tianeptine overdose between 2000 and 2017, according to research by Upstate doctors of pharmacy Jeanna Marraffa and Christine Stork. One case involved a child who accidentally ingested the drug. Then there were five people who meant to abuse the medication, and three who had problems while taking a therapeutic dose of the medication.

Marraffa and Stork note that five patients described symptoms of opioid withdrawal, and, in two cases, patients received naloxone, a medication that can save people from opioid overdose.

Upstate Health magazine fall 2018 issue coverThis article appears in the fall 2018 issue of Upstate Health magazine

 

 

Posted in addiction, drugs/medications/pharmacy, emergency medicine/trauma, health care, infectious disease, poison center/toxicology, prevention/preventive medicine, psychology/psychiatry, public health, research | Tagged , , ,

Nurse prescribes soccer — which he plays professionally — for fitness and fun

 

Upstate nurse Isaac Kissi, playing for the Rochester Lancers in the blue jersey, has played soccer both professionally and for fun (photos by Rob Daniels)

Upstate nurse Isaac Kissi, playing for the Rochester Lancers in the blue jersey, has played soccer both professionally and for fun (photos by Rob Daniels)

BY JIM HOWE

To Isaac Kissi, soccer means many things.

Kissi works as a nurse at Upstate while studying in Rochester to become a nurse practitioner, where he lives. A native of Ghana, he first came to the United States on a college soccer scholarship and plays professional soccer in Rochester.

“It gave me a chance to change my life, get a scholarship and come to the States,” Kissi, 31, said of the sport. “It was my first livelihood, and it provides a different channel or escape to de-stress from working long hours of nursing.”

He thinks almost anyone can enjoy playing soccer at some level to stay active and have fun — he also plays in informal lunchtime matches with people of varied skill levels and ages, just to keep playing. He offers these thoughts about soccer:

Equipment:

“A good cleat is always vital; the right shoes give the right traction and ball control. Then all you need is some soccer shorts, and throw a T-shirt on if you don’t have a jersey.”

How old can someone be and still play soccer?

“I’ve seen guys still playing in their 70s. We have a lady who is close to 70, called Rosie (who plays in coed lunchtime pickup games with people of various skill and age levels). She is always smiling. It keeps the wheels turning. Playing soccer keeps you younger, but your body will get a bit sore after you play. If you keep playing, once you have it in your heart, it keeps you young and fresh. It’s all about the attitude you put into it.”

How long will you keep playing professionally?

“I think I will push till maybe 35, if the wheels are still going. I might go into coaching. I will keep playing, coaching, even being a nurse practitioner or whatever I’m doing at that time in the nursing profession, I don’t think I’m ever going to get away from the game.”

Can soccer relate to your career?

“It teaches you how to be a team player, and in nursing, you have to be a team player. In a team setting, you’ve got to be there for the guys on the field or for the nurses on the unit, when anything can change. It’s also my escape” from job stress.

Describe the non-professionals you play informal soccer with:

“Some of them are just there to get a good sweat and exercise. We always laugh and have good camaraderie. It’s a good thing, a good escape (from stress), it’s my way of life, I just love it.”

Do you pursue other activities to bolster your soccer skills?

“I go to the gym and work out. I do a lot of rehab workouts, where I’m not going too crazy but building muscles around my knees and calves, also my arms, as a forward, to look bigger (and intimidate opponents). I also ride a spin bike, which is better than running on concrete for cardio, then just getting out there to play with guys for cardio, too. Most of my exercises are rehab based. I’m still careful with my knee (more on that below), which still feels great right now.”

How do you advise dealing with injuries?

“It’s very important you listen to your body, for sure. Be smart and draw the good line on where you push through the pain threshold or draw back and heal better.”

Kissi, seen here in a yellow jersey, says soccer offers a good way to stay fit and deal with stress.

Kissi, seen here in a yellow jersey, says soccer offers a good way to stay fit and deal with stress.

Meet Isaac Kissi

Age: 31.

Born and raised: Ghana, West Africa, where his daughter, Gifty Nyarkoa Kissi, 13, her mother and the rest of his family still live.

Current hometown: Rochester.

College: Won a soccer scholarship to the University of Dayton, Ohio, in 2007.

Professional soccer career: Drafted in 2010 to Major League Soccer, but a knee injury meant he never played in MLS. He played with the Rochester Rhinos, one level below MLS, from 2010 to 2012, and has had knee surgery and worked on rehabilitating his knee since then. He currently plays with the Rochester Lancers, one level below the Rhinos.

Position: Midfielder (in college), forward (as a pro).

Health care career: Nursing degree from the University of Rochester in 2016; worked as a nurse in various locales, including Upstate, where he now works part time in physical medicine and rehabilitation while enrolled in the U of R’s nurse practitioner program.

Health care career goal: “Being a nurse practitioner specializing in family psychiatry, because I feel like a majority of what is going on medically is going to have a mental component to it. It’s about time we pay more attention to that, and it’s my way of trying to make a difference.”

Other sports he plays: Volleyball and pingpong, neither of which he claims to play well.

Upstate Health magazine fall 2018 issue coverThis article appears in the fall 2018 issue of Upstate Health magazine. 

Posted in fitness, health care, health careers, nursing, physical therapy/rehabilitation | Tagged , , , , , , , ,

Different types of aneurysms call for different types of repairs

Three ways of repairing abdominal aortic aneurysms: (from left) traditional open surgical repair, endograft for AAA repair, fenestrated endograft.

Three ways of repairing abdominal aortic aneurysms: (from left) traditional open surgical repair, endograft for AAA repair, fenestrated endograft.

BY AMBER SMITH

When a blood vessel weakens, a balloonlike dilation called an aneurysm sometimes develops. This happens most often in the abdominal section of the aorta, the largest blood vessel in the body.

If an abdominal aortic aneurysm ruptures, it can be deadly, so learning whether you have an aneurysm and seeking treatment are important.

Medicare pays for screenings for people who are at increased risk for what’s known in medical shorthand as AAA, says Michael Costanza, MD, an Upstate professor of surgery specializing in vascular and endovascular services. That includes people age 65 to 75 with a family history of aneurysms, and men who are, or were, smokers. Screening involves a painless ultrasound that provides doctors with images of the blood vessels.

Michael Costanza, MD

Michael Costanza, MD

Costanza says the size of an aneurysms helps determine its treatment. “As the aneurysm gets bigger, the stress on the wall of the artery increases. When it increases too much, it would obviously break,” he says. “We would like to repair all aneurysms before they get to that breaking point.”

Small aneurysms can be monitored without treatment, but aneurysms that are larger than 5½ centimeters in diameter are recommended for repair, Costanza says.

Repair originally meant a surgeon opened a patient’s abdomen, clamped the aorta above and below the aneurysm, and then replaced the ballooned area by sewing an artificial blood vessel in its place. That’s still an option for a minority of patients.

Endovascular repair is the predominant method of repair today. Introduced in the late 1990s, endovascular repair eliminates the abdominal incision, instead using a needle puncture into a large vessel of the leg. Surgeons use X-ray guidance to pass a wire through the vessel and deploy a fabric-covered metallic stent to the area of the aneurysm. The stent reinforces the vessel without removing the aneurysm.

Some patients have aneurysms that are located too close to their kidneys for using regular stents. In those cases, Costanza offers a custom-made fenestrated endograft, a stent made with built-in openings for the kidney arteries.

“The fenestrated endograft is a much more involved procedure, but it’s still all done through needle punctures. The patients still go home very quickly after surgery,” Costanza says.

He continues to see aneurysm patients every year, after they have recovered from their repair. This allows the doctor to monitor the integrity of the repair, and to be on the lookout for the development of any new aneurysms.

To schedule your screening, contact Upstate vascular services at 315-464-1800 or 315-492-5881.

Abdominal aortic aneurysms are:

  • more common in older men than in women, by a 3- or 4-to-1 ratio, but as women live longer, their rates of AAA are climbing.
  • responsible for the deaths of 30,000 Americans per year and are the 10th leading cause of death among older men.
  • typically located in the abdominal space between the lower breastbone and belly button.
  • likely triggered by environmental factors, such as smoking, although they are thought to have a genetic component.

Upstate Health magazine fall 2018 issue coverHealthLink on Air logoThis article appears in the fall 2018 issue of Upstate Health magazine. Click here for a radio/podcast with Michael Costanza, MD, where he discusses abdominal aortic aneurysms.

Posted in health care, surgery | Tagged , , , ,

Want to go to medical school – as a ‘patient’?

Third-year medical student Craig Pille practices his patient-exam skills with help from actress and standardized patient Annette Adams-Brown. (photo by Debbie Rexine)

Third-year medical student Craig Pille practices his patient-exam skills with help from actress and standardized patient Annette Adams-Brown. (photo by Debbie Rexine)

BY AMBER SMITH

One way future doctors and other health care providers learn is by practicing on people who pretend to be patients.

Upstate Medical University has a corps of paid “standardized patients” who are trained to portray certain medical situations for students who conduct exams for practice before caring for real patients. Afterward, students receive feedback from faculty instructors and from the patients.

“As instructors, we can give feedback from our expertise about communications, about what we saw as third parties,” says Steve Harris, director of Upstate’s clinical skills center. “What we can’t tell them is how did that patient feel when you were interacting with them. That’s what standardized patients can do that nobody else can do. They’re here to say, ‘This is how you made me feel.’ They’re going to give the student some feedback, so that hopefully when the student encounters a similar patient in the real world, they will have a better understanding of how their behaviors make patients feel.”

Annette Adams-Brown has been a standardized patient since 2003. She has pretended to have abdominal pain, diabetes and osteoporosis, among other diagnoses. She has a background in theater production and acting, but both she and Harris stress that is not a requirement.

“It’s very rewarding work, to know that you’re contributing to the educational quality of the medical industry,” she says. “Communication plays such a huge role in all walks of life.”

Standardized patients work on a temporary, as-needed basis.

They have to be at least 16 years old, with the ability to read and speak English. Harris says the program is especially in need of people in their 30s and 40s and people from a variety of ethnicities, races and sexual orientations. No acting experience or medical knowledge is needed.

“This is about education,” says Harris. “Our point here is to help our students be better communicators.”

To learn more or to apply for work as a standardized patient, visit upstate.edu/standardpatient/

 Upstate Health magazine fall 2018 issue coverHealthLink on Air logoThis article appears in the fall 2018 issue of Upstate Health magazine. To hear a podcast/radio interview about standardized patients with Annette Adams-Brown and Steve Harris, click here

Posted in health care, medical education

What’s Up at Upstate: In case you missed it …

Upstate's new Clinical Pathology Laboratory is on the fifth floor of the cancer center.

Upstate’s new Clinical Pathology Laboratory is on the fifth floor of the cancer center.

CANCER CENTER EXPANDS

When the Upstate Cancer Center opened in July 2014, only the first three floors of the five-story building were completed and occupied. The fourth and fifth floors were constructed but left empty, anticipating future Upstate needs.

The fourth floor is now devoted to exam rooms, increasing the number from 14 to 35. The second floor became all infusion rooms, upping the number from 27 to 44. The fifth floor is for Upstate’s Clinical Pathology Lab.

APPLE STORAGE

Upstate is the first health system in Syracuse to partner with Apple, so patients with iPhones can, if they choose, store all of their health records in Apple’s Health app. The app comes preloaded on the iPhone and tracks such things as heart rate, steps, calories consumed and other information. Now patients can request their Upstate records be stored there as well.

Upstate already makes medical records data available to patients through UpstateMyChart. Patients use a website or app to view test results, request appointments or medication refills, send questions to their physicians and more. The difference is, the data remains on Upstate’s servers.

Storing records in the Apple Health app means they can be mingled with records from other health providers. Chief Medical Information Officer Neal Seidberg, MD, says keeping all health information in one convenient place empowers patients. “A major consideration to partner with Apple was to provide our patients with a new and important way to monitor, manage and gain a better understanding of their overall health,” he says. “For families who are on-the-go, the ability to have access to all kinds of health information in the palm of your hand can give one peace of mind.”

GERIATRICS DEPARTMENT

Sharon Brangman, MD

Sharon Brangman, MD

Upstate has become one of a handful of academic medical centers in the United States to have a department devoted to geriatrics. For the past 20 years, the branch of medicine dealing with the health and care of older adults has been a division, or subset of a department, at Upstate. Sharon Brangman, MD, a State University of New York distinguished professor and a former president of the American Geriatrics Society, has led the division – and now leads the department. “Geriatrics is an increasing need and will be so for many decades ahead,” she says.

STUDENT PARTNERS

Newborns in the neonatal intensive care unit often need to be repositioned to aid in their growth. “If they are on their tummy, they push up; then they can develop their shoulders,” Upstate College of Nursing associate professor Karen Klingman, PhD, explained to SU News. “If they are on their back that doesn’t happen, so there is this trade-off nurses in the NICU need to think about. Should the baby be on their back or on their tummy to help with development?”

For help designing a monitor for those NICU babies, Klingman turned to bioengineering students from Syracuse University’s College of Engineering and Computer Science. As part of their capstone project, the students developed a prototype. Sensors beneath fabric connect to a custom-coded microcontroller board and measure pressure from an infant’s shoulders, bottom, head, stomach and knees.

CONCUSSION APP

Associate professor of family medicine Eugene Bailey, MD, teamed up with an athletic trainer to create an app that provides a step-by-step protocol for the diagnosis of concussion. The “Easy SCAT Sideline” app helps coaches and athletic trainers know what to do when a player is injured, so that the possibility of concussion is not overlooked.

NEW MEDICAL COMPLEX

Physicians affiliated with Upstate plan to open a new medical complex featuring more than a dozen specialty services next fall at Township 5 in Camillus.

The group expects to build a one-story, 25,528-square-foot building behind Costco and the Movie Tavern. It would provide office space for family medicine, cardiology, pulmonology, rheumatology, pain medicine, neurology, neurosurgery, orthopedics, physical medicine and rehabilitation, urology, otolaryngology, vascular surgery and psychiatry and behavioral health.

NURSING ONLINE

Starting in the spring of 2019, Upstate’s College of Nursing will offer a Bachelor of Science program fully online. The degree is 121 credits and will take students about 18 months to two years with full-time study, or up to four years with part-time study. The program requires a 135-hour practicum.

Students must complete 60 credit hours from a basic nursing program or an associate’s degree in nursing beforehand and must have a New York state registered nurse license by the start of their second semester. For more information, visit upstate.edu/con or call the admissions office at 315-464-4570.

This article appears in the fall 2018 issue of Upstate Health magazine

Posted in aging/geriatrics, brain/neurology, cancer, health care, nursing, pathology, technology, Upstate Golisano Children's Hospital/pediatrics

Questions on the body’s water needs; immunotherapy drugs; suicide prevention; back pain — answered by Upstate’s experts

Abstract illustration showing businessman thinking. Q: How can I help someone who may be suicidal?

A: “There are things you can look for. What you see leading up to suicide is, usually people will withdraw socially. They may start losing their ability to function, either at school or at work. There are going to be more strained relationships. And, the person is usually more negative; when any issue is being raised, they have a real pessimistic kind of outlook on things.

“If you know this person’s hurting and in trouble, if you don’t ask the question, you’re not going to know.

It’s easy for me to say, ‘Just ask the person: Are you having thoughts about suicide lately?’ It’s very hard to actually do, partly because of social stigma. You don’t want to insult the person. Some people are concerned it might put the idea into the person’s head.

“What we know from research is, it doesn’t put the thoughts into the person’s head. It actually is protective. You’re actually diminishing the risk of suicide by asking about it. ‘Have you ever tried to hurt yourself?’ ‘How close have you come lately?’ ‘Do you think you might actually carry out those thoughts?’

“Someone who is at imminent risk needs to be evaluated — and may even need to be hospitalized — by a professional who can determine risk. Upstate’s Psychiatry High Risk Program offers evidence-based treatment for high risk youth and young adults who are not in need of immediate hospitalization. Call 315-464-3117.

“Access to firearms is maybe the single most preventable thing that we can do as family or community. If there is someone at risk, make sure they don’t have access to firearms.”

— Psychiatrist Robert Gregory, MD, director of Upstate’s Psychiatry High-Risk Program

Upstate University HospitalQ: What’s the best way for athletes to determine how much water to drink when they train or compete?

A: “You don’t need a formula. You don’t need to do any calculations. The rule is: Drink when you are thirsty. Your body actually knows what it is doing. It will make you thirsty if you need more water.”

— Emergency physician Jeremy Joslin, MD, medical director of endurance events around the world

Q: Will a new mother get pregnant if she has sex during the time she is nursing her newborn?

A: “As long as a woman is exclusively breast-feeding — she can pump and bottle-feed breast milk, but she cannot use any supplementation, no formula or anything else, whatsoever — it is effective birth control for six months. But after that, it doesn’t work very reliably.

“It’s called the lactational amenorrhea method, or LAM.”

— Renee Mestad, MD, chief of general obstetrics and gynecology

Q: Are immunotherapy drugs a cure for cancer?

A: “The jury is still out on that. We have patients with advanced cancer who were on these drugs in early clinical trials for two years, and now they have eight years of follow-up, and they are still in remission. So, I think immunotherapy has great potential. As with many therapies, we first use these drugs in patients with advanced disease. Then, if they’re beneficial, we try them in earlier-stage disease, and that’s really where there may be greater potential for a curative effect.”

— Stephen Graziano, MD, chief of adult hematology oncology

Q: Why do women awaken to use the bathroom at night?

A: “Most times, it’s systemic diseases, not necessarily related to just the bladder. It can be things like diabetes, heart disease or heart failure, even sleep apnea. Nocturia can also be the initial sign of depression.

“People who have fluid overload, or too much fluid in them, they can also urinate at night because when they lay down, the fluid shifts, and they make more urine, and they then have to urinate.

“It’s not uncommon to have this problem. If you’re having this problem, you should mention it because a lot of physicians don’t routinely ask, especially women, about urination at night. Unless you bring it up, no one knows it’s a problem for you. And, it’s important to make sure this is not the first sign of diabetes or heart disease.”

— Urologists Timothy Byler, MD, and Mickey Daugherty, MD

Q: How do I begin to overhaul my poor eating habits?

A: “Look at what you’re doing. Are you drinking sodas? Are you eating processed foods? Are you NOT eating vegetables? Look at what you’re doing, and look at what can you change. Can you say, ‘I’m going to try to have a salad every day?’ Or, say you’re drinking two bottles of soda every day. Can you go down to one bottle, instead of saying, ‘I’m never having soda?’ You want to make a change in a way that it just gradually becomes part of your routine, and it’s not so drastic that it isn’t sustainable.”

— Maureen Franklin, registered dietitian nutritionist

Q: If I had chickenpox as a child, and I’m 50 now, why do I need a shingles vaccine?

A: “If you had chickenpox as a child, or if you don’t know if you had it, you are at risk for developing shingles later in life.

“The virus that causes chickenpox (varicella zoster) can actually remain latent in your nerve fibers, and then later in life can reactivate as the zoster virus, or shingles. We’re not exactly sure why it reactivates, but as we get older our immunity toward varicella starts to decrease. We might have other medical conditions or be on medications that suppress our immune system or our ability to fight off infection.

“The Centers for Disease Control and Prevention now recommends healthy adults ages 50 years and older to get the Shingrix vaccine. It is the new, preferred vaccine. And that’s even if you already had the Zostavax shot previously. Zostavax, the old vaccine, has about a 70-percent efficacy that wanes over time.  As you get older the efficacy of the vaccine actually decreases. In comparison, Shingrix is essentially a protein and an immune booster that are mixed together, and it has about 90- to 99-percent efficacy.”

— Pharmacist Ali Scrimenti, PharmD

Q: Does a firm mattress prevent back pain?

A: “What I advise my patients is to sleep on the mattress that’s most comfortable. Some people like a firmer mattress, but there is no evidence that makes any long-term difference in your back health.”

— Daryll Dykes, MD, orthopedic surgeon and spine specialist

Hear the experts

HealthLink on Air logoThese answers are excerpted from “HealthLink on Air,” Upstate’s weekly podcast/talk radio show in which experts  share information on a variety of subjects. Listen at 6 a.m. or 9 p.m. Sundays on WRVO Public Media, visit upstate.edu/healthlinkonair, or search for “HealthLink” in iTunes or other podcast sources.

Upstate Health magazine fall 2018 issue coverThis article appears in the fall 2018 issue of Upstate Health magazine. 

Posted in health care, HealthLink on Air | Tagged , ,

Things to think about before you buy a home genetic test kit

 illustration of a generic family tree

 

BY AMBER SMITH

If you’re intrigued by offers of direct-to-consumer medical genetic testing, Robert Roger Lebel, MD, director of medical genetics at Upstate, offers something to consider.

Let’s say you come from a family with many members who have had breast cancer, and you’re interested in knowing your risk. Many genes are associated with breast cancer. The genetic testing company you select may focus on a couple of different mutations in the most well-known of those genes.

When your results show you do not have an increased risk for the breast cancer associated with that particular mutation on the BRCA gene, “You may think that you have investigated the question and have your answer, when you really don’t,” Lebel says.

Genetic home testing cannot tell you that you will develop a particular disease but can identify factors that tell you that your risk is higher than that of the general population,” says Robert Roger Lebel, MD, director of medical genetics at Upstate. (photo by Jim Howe)

Genetic home testing can’t tell you that you will develop a particular disease, but it can identify factors that tell you your risk is higher than that of the general population,” says Robert Roger Lebel, MD, director of medical genetics at Upstate.
(photo by Jim Howe)

“If you talked with a board-certified genetic counselor about this, he or she might tell you that there are actually 50 different genes that could be of interest in regard to your family’s presentation. You were tested for two different things in one gene. You were not tested for thousands of things in dozens of genes.”

Genetic home testing can be useful, Lebel says, in the case of positive findings.

The tests cannot tell you that you will develop a particular disease. “They can identify factors that tell you that your risk is higher than that of a member of the general population.”

So, if your results show an increased risk for breast cancer, ovarian cancer and pancreatic cancer, “then you could talk to somebody with expertise about how to use this knowledge to minimize your long-term risk,” he says.

“It would allow you to talk to your physician about how to watch for early signs.”

What about genealogy?

Ancestry.com, 23andMe and others offer tests using saliva samples that explore deep ancestry.

“They won’t tell you the name of your great-grandfather, but they will tell you whether your great-, great-, great- greats came from Northern Africa or Eastern Europe or Southeast Asia,” says Lebel.

How do the tests work?

We all have genes or DNA sequences on chromosomes known as markers. “Some of those markers are very common in certain parts of the world and very uncommon in other parts,” Lebel explains, “so that they are able to state with some statistical clarity where those markers would have come from.

“If you’ve always said that you were of mixed European ancestry, German, Swedish, Czech and Hungarian, and you really want to know in detail whether you have, say, 3 percent of your genome from East Asia — which you might, because the Hungarian part might have descended from Genghis Khan — well, you can find out.”

Upstate Health magazine fall 2018 issue coverHealthLink on Air logoThis article appears in the fall 2018 issue of Upstate Health magazine. Click here to hear Robert Roger Lebel, MD, discuss home genetic testing in a podcast/radio interview with Upstate’s “HealthLink on Air.”

Posted in genetics, health care, HealthLink on Air | Tagged , , ,

In her own words: Stroke survivor JoAnn Wickman recalls the morning of Feb. 9, 2018

JoAnn Wickman (photo by Susan Kahn)

JoAnn Wickman (photo by Susan Kahn)

“I woke up at 5:20 in the morning. I woke up and thought, ‘What the heck is going on? Something’s not right,’” recalls JoAnn Wickman of Cortland. “I had this weird sensation. It felt like the tip of my tongue was somehow connected to my right cheek, with a strand like what I assume a spiderweb would feel like. It was such a weird feeling. It was pitch black outside, and I just woke up out of a sound sleep.

“Eventually I got out of bed and walked to the bathroom just fine. Then I thought, ‘Something’s not right here.’ I still had this oddball sensation.

“My heart wasn’t beating fast. I wasn’t dizzy. I come from a long line of people who have died of heart attacks and strokes, so I’ve been pretty vigilant about paying attention. I’ve never had any heart issues. But my blood pressure had been spiking, and it was under a doctor’s care.

“I thought about how I would say, ‘Ken, wake up. Call 911. I think I’m having a stroke.’ That’s not a complicated thing to say, but my tongue wouldn’t work. I could only say ‘Ken.’”

Her husband called 911. As the ambulance took her to nearby Cortland Regional Medical Center, Wickman, who was 75 at the time, remembers that she felt fine, but her blood pressure was high. “267 over something,” she recalls. A blood pressure of 120/80 is considered normal.

“They did a CT scan, and the physician came in and said, ‘There’s something weird about this CT scan.’ So they did an MRI, and the physician came in and said, ‘I want you at a stroke center. Where do you want to go?’”

Wickman chose Upstate. “By noon, exactly at noon, I was in my room at the stroke center, where I stayed for five days. By this time, I’m chatting away and walking fine.

“They did what seemed like 10,000 tests. When they looked at the MRI, it was pretty subtle, but there were two spots where they found the stroke took place that made sense with my symptoms.

“The interesting thing about all of this is, nobody knows why I had the stroke.

“What was memorable to me is that the care at the stroke center was exemplary and respectful. I never felt anyone was talking down to me. All kinds of people came in and out. Most people said, ‘You are so fortunate you knew what to do, and that you did it.’

“I tell people to remember FAST. Most of the time if a person’s having a stroke, their face will look funny. Or their arm will be weak. The S stands for slurred speech (and the T stresses that time is of the essence). I say, ‘If something doesn’t seem right, it’s better to call.’”

Wickman, herself, did not exhibit the classic symptoms of stroke. “I just felt weird,” she says. “In retrospect, why did I think it was a stroke? I don’t know, exactly, except for that sensation of my tongue being connected to my cheek. I was very fortunate.”

This article appears in the fall 2018 issue of Upstate Health magazine. 

Posted in emergency medicine/trauma, health care, medical imaging/radiology, patient story, stroke