news&viewsSEPTEMBER/OCTOBER 2012 A PUBLICATION FOR THE NYU LANGONE MEDICAL CENTER COMMUNITY

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Karsten Moran

Of the event that changed her life, Stephanie Quito remembers nothing. In March 2010, she was on spring break in the Dominican Republic. With Quito in the passenger seat of an all-terrain vehicle, the driver—one of her friends—swerved to avoid a bump in the road. As the vehicle started to tip over, her friend hit the brakes, throwing both of them onto the ground. Quito was knocked unconscious, her head badly injured and bleeding profusely.

At a local hospital, she underwent surgery to remove a blood clot pressing against her brain. Once back home with her parents in Ozone Park, New York, Quito was admitted to NYU Langone Medical Center, where her mother, Zoila, is a patient care technician. She became an inpatient in the brain injury unit of the Rusk Institute of Rehabilitation Medicine, located at the Hospital for Joint Diseases. “My memories start with my last week at Rusk,” Quito recalls. “One of my assignments was to make cupcakes. I went to the grocery store with my therapist, bought the ingredients, and baked

Despite the pain and discomfort of having had knee replacement surgery, the 65-year-old patient flashes a smile when the nurse enters her room at NYU Langone Medical Center’s Hospital for Joint Diseases (HJD). In the banter that follows, the reason becomes clear. The nurse, Francesca Tedesco, RN, was the woman’s caregiver one year earlier, when she had the same procedure per-formed on her other knee, and for her return visit, she insisted on the same proven performer.

“Working at a smaller hospital gives me more time to be with my patients and get to know

them,” says Tedesco, who shelved a college degree in business to become a registered nurse. “I love this work. I can’t imagine doing anything else.”

Tedesco is one of some 280 staff nurses at HJD, all of whom, says Ann Vanderberg, RN, vice president for nursing and patient services at HJD, are prized by physicians and patients alike for their skill, dedication, and compassion. Now, that admiration is official. In August, HJD received Magnet® recognition for its nursing excellence and quality patient care. The new status, conferred by the American Nurses Credentialing Center (a

subsidiary of the American Nurses Association), puts HJD in the select company of only 6% of hos-pitals and medical centers nationwide, including NYU Langone’s Tisch Hospital and Rusk Institute of Rehabilitation Medicine, which earned Magnet recognition in 2005 and were redesignated in 2009. “We began applying for Magnet 10 years ago as part of our plan to become a world-class institution,” notes Vanderberg. “The designation is recognition by our peers of the culture of excel-lence we’ve built here, and which we now have to work harder than ever to maintain.”

Believing in Your Own Brain

One Small Triumph at a Time, Survivors of Traumatic Brain Injuries Rebuild Their Lives

HJD Earns Magnet Recognition for Nursing Excellence

Stephanie Quito puts the finishing touches on her self-portrait, which she started working on after her traumatic brain injury to enhance her various forms of therapy.

Francesca Tedesco, RN, shelved a degree in business because she wanted something “more fulfilling.” One year after graduating from NYU College of Nursing in 2007, she joined HJD, where she is one of 280 staff nurses and is certified in orthopaedic nursing.

All Three of NYU Langone’s Hospitals Now Boast a Coveted Status

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Medicine is one of the few professions

Benjamin Franklin did not choose to enter

and excel at, but when he noted that “an

ounce of prevention is worth a pound of

cure,” he encapsulated in one of the wisest

of proverbs what all physicians know to be

true. As bedside caregivers who are ever

vigilant, nurses know it, too. So we can be

especially proud of the nursing staff at our

Hospital for Joint Diseases, which in August,

based on its nursing professionalism,

teamwork, and superiority in patient care,

joined Tisch Hospital and the Rusk Institute

of Rehabilitation Medicine in having earned

Magnet recognition by the American

Nurses Credentialing Center. The power of

prevention is a theme that runs throughout

this issue, in fact. At our new Center for

Women’s Imaging, it’s never been easier for

a woman to get a mammogram that can

save her life. On several units of Tisch

Hospital, pharmacotherapists now

round with physicians to help ensure that

drug selection, dosage, and titration are all

on target. In Tisch’s outpatient pharmacy, a

vaccine for shingles, a potentially devastat-

ing disease, is now available by prescription,

thanks—I’m proud to say—to the crusading

efforts of my wife, Dr. Elisabeth Cohen,

professor of ophthalmology.

Robert I. Grossman, MD

From the Dean & CEO

page 2 | news & views

A Meal Fit for a MomLess than 24 hours ago, the young woman had given birth to a beautiful, healthy

baby boy. As she held him in her arms, sitting up in bed in the mother-baby unit

on the 13th floor of NYU Langone Medical Center’s Tisch Hospital, it was time

to celebrate in style. Calling room service, she ordered spinach salad mimosa,

red wine–braised beef short ribs on a bed of smoked gouda polenta, sautéed

asparagus spears, and Tahitian vanilla crème brûlée. The restaurant-style

menu was developed by Ronald Brandl, director of culinary operations, who is a

talented, internationally trained chef with years of experience in the resort busi-

ness. Dinner, delivered by a cheerful, vested concierge, was served with a linen

napkin, elegant flatware, fine china, and a fresh flower in a tapered vase.

The gourmet-style meal program for obstetrics patients was introduced

in January 2012 to “acknowledge the specialness of having a baby,” explains

Karen Goodman, RN, nurse manager of the unit. Because babies arrive on

their own schedule, it makes sense to give new moms the opportunity to order

at a time that’s convenient for them, rather than make them adhere to the

hospital’s meal-time schedule. While patients in other parts of the hospital

often have dietary restrictions, new mothers are typically healthy and able to

eat whatever they want.

Betty Perez, senior director of Food and Nutrition Services, says that many

patients are “amazed” when they see the top-notch selections. Mothers who have

sampled the breakfasts, lunches, and dinners from the room service menu offer high

praise: “Fantastic to be able to order at a time that suited me.” “I felt like I was ordering

from a five-star restaurant.” “Excellent menu, presentation, quality, and service.”

The room service staff includes chefs, concierges, and dining associates with

degrees in nutrition. When mothers phone in their orders, the meals are prepared indi-

vidually and delivered to their rooms within 45 minutes. Special diets are no problem,

and the kitchen caters to any palate. “Our goal was to create a world-class dining experi-

ence,” says Perez. “The fact that our OB patients actually look forward to a hospital meal

testifies to the success we’ve achieved.”

Run to Your Heart’s ContentIt’s a marathon runner’s worst fear: after months of training, hopes are dashed in the

instant it takes to pull a muscle or twist an ankle during a rigorous workout. That’s why

“Marathon Training: Your Guide to a Smart Start and Safe Finish”—the first wellness

seminar from NYU Langone Medical Center’s new Center for Musculoskeletal Care

(CMC) on East 38th Street—was something of a runner’s high for many of those 40 or

so people who attended the August event, some of them in training for the upcoming

New York City Marathon.

Physical therapist Colleen Brough, PT, offered valuable advice on how to avoid

the seven most common running injuries, including pulled hamstring, Achilles tendini-

tis, plantar fasciitis, and stress fracture. “There’s a consistency between weakness and

imbalance in the glutes, back, and core muscles and runners who are injured,” Brough

told the audience, which ranged from novice to seasoned marathoners. “If you can

predict it, you can prevent it.” Her prescription was a three-phase corrective exercise

program, demonstrated with the help of volunteers, for strengthening those muscles.

Alison Peters, an exercise physiologist with CMC’s Sports Performance Center,

explored the mechanics of running, including the proper foot strike. Hitting the pave-

ment with your heel slows you down and leads to injuries, she cautioned, whereas

striking with the mid to forefoot provides the ideal weight distribution and minimizes the

injury risk. The proper running shoe, she pointed out, is critical.

An admitted “heel-striker,” four-time marathoner Jennifer Ishii (shown below)

found the seminar “extremely helpful” and vowed to retool her workouts around

the training tips. She had the opportunity to put the new mechanics to work as she

helped demonstrate the Sports Performance Center’s Alter-G™ antigravity treadmill,

used for both athlete training and injury recovery. Air rushing into a pressure-con-

trolled chamber from the waist down gently lifted Ishii up so that she hit the treadmill

with only a fraction of her body weight. “It was an effortless run,” she said afterward,

“and for the first time, I didn’t strike with my heels.”

NYU Langone Is First in the US to

Offer New Ultralow-Dose CT ScansNYU Langone Medical Center is the first medical center in the US to offer patients

an ultralow-dose CT scanner. The Siemens Edge CT, a single-source, 128-slice-per-

second scanner, combines rapid scanning speeds with even less radiation than our

current low-dose scanners to provide the highest-quality 3-D images. Advanced

electronics in its detector system allow radiologists to capture images

of structures as small as 0.3 mm.

Without sacrificing image quality, the Edge CT makes possible precise

diagnoses using doses that are 70 to 80% lower than levels already considered safe

by accrediting organizations, explains Alec Megibow, MD, professor of radiology

and director of outpatient imaging services. Some patients may need only a dose

comparable to natural background radiation in the outdoors. This is a significant

improvement over the current scanning doses of NYU Langone’s other CTs, which

are 50 to 60% lower than national standards.

Decreasing the amount of radiation normally results in images that are

less clear because there is insufficient X-ray to create the image. But the Edge

CT decreases the force of the X-rays and uses a more sensitive and efficient

detector and advanced image-processing techniques, yielding images that are

indistinguishable from those obtained at higher dose levels. While the patient is

scanned with a lower dose, the technology provides 3-D capabilities that contribute

to a proper diagnosis. The first Edge CT system is now available at NYU Langone’s

Faculty Practice Radiology. A second is planned for Tisch Hospital.

On Tisch Hospital’s mother-baby unit, Maria Rivera delivers a gourmet lunch to Marne Friedman, a new mom.

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When NYU Langone’s hospitalist program was launched in 2004, Dr. Katherine Hochman (center) was the first and only physician of her kind at the Medical Center. Now there are 28.

In the Critical Care Center of NYU Langone Medical Center, on the 15th floor of Tisch Hospital, John Papadopoulos is a familiar and reassuring presence. As a 12-member medical team rounds among pa-tients, they listen to him intently. On this particular morning, he’s explaining how to break the seizure of a patient with epilepsy by using propofol, and then how to wean him safely to a longer-acting drug. Shortly afterward, the attending physician, fellows, residents, and nurse practitioners are, once again, all ears as he warns of the potential renal damage from a long-term course of aminoglycosides (a group of antibiotics). That Papadopoulos is a trusted and valued member of the clinical team that reviews each case daily is quite clear. Less obvious, though, is the fact that he’s not a physician.

Papadopoulos, clinical assistant professor of medicine, is a board-certified pharmacotherapist. As director of the Division of Pharmacotherapy, he heads up a 15-member team of clinical pharmacists that’s changing the notion—and expanding the role—of the pharmacist beyond that of the behind-the-counter dispenser of drugs. “We round with the medical teams, see patients at bedside, and are proactively involved in their ongoing care,” says Papadopoulos. Indeed, pharmacotherapists are ex-perts in the therapeutic use of medicines, particularly antibiotics used to battle infectious diseases. Thanks to years of education and postgraduate training, they can provide evidence-based information and reliable advice to physicians, as well as patients, about safe, appropriate, and cost-effective drug management.

With outcomes gaining ever more currency in healthcare, pharmacotherapists have proven their ability to significantly reduce adverse drug events, medical errors, and the length of patient stays, according to a number of national studies. “They give us good advice about medication dosing and help us to identify drug-drug interactions,” notes Eduardo Iturrate, MD, instructor in medicine and co-director of the hospitalist program at NYU Langone’s Hospital for Joint Diseases. “They’re an extra set of eyes and ears that allows us to manage a very busy medical service.”

One of the pharmacotherapy team’s greatest assets is its laserlike focus on potential complications and side effects. “By rounding with the medical team

on a daily basis, we help determine whether a prob-lem could be medication induced or a consequence of medication interactions,” explains Xian Jie (Cindy) Chen, a pharmacotherapist specializing in internal medicine. “For those rare side effects, I often do a literature search to confirm whether the same reaction has been reported in other patients on the same drug.”

The probing minds of pharmacotherapists are particularly valuable—and welcome—in the medi-cal and surgical intensive care units, as well as the Emergency Department (ED). It’s not unusual for a critically ill patient to be on more than a dozen drugs at the same time, some of them potent antibiotics, creating a flashpoint for possible adverse events. “It gets complicated,” notes Papadopoulos, “so it makes sense to have a pharmacotherapist at the bedside to help with drug selection, dosing, and titration.”

For different reasons, a pharmacotherapist is stationed in the ED. Studies have shown that EDs have the highest rate of preventable adverse events of any clinical environment, yet Tisch Hospital is

among the less than 5% of hospitals in the country that assign a clinical pharmacist to their ED.

The Division of Pharmacotherapy was created in 2008 under the stewardship of Papadopoulos to, as he puts it, “give us a clinical pharmacy capability as strong as our medical and nursing services.” The program has grown modestly in size every year since and now includes specialists in the fields of critical care, internal medicine, infectious disease, pediatrics, hematology/oncology, and emergency medicine. At the same time, it has broadened its clinical reach, developing protocols and guidelines to optimize the use of medications across the hospital, as well as a medication counseling service that works directly with patients.

“Medicines have become so incredibly nu-merous and complex that it’s a challenge even for pharmacists to stay current,” acknowledges Papadopoulos. “That’s why it’s so important for us to be at the bedside, where key decisions about patient care are made.”

A Prescription for Enhancing Patient CareAs Hospital Pharmacists Join Physicians at the Bedside, the Result Is Better-Informed Clinical Decisions

Pharmacotherapists like Cindy Chen (center) are particularly valuable—and welcome—in the medical and surgical intensive care units, where it’s not unusual for a critically ill patient to be on more than a dozen drugs at the same time.

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Believing in Your Own Brain (continued from page 1)

them. But when she asked me the names for ‘knife’ and ‘fork,’ I couldn’t answer.”

More than 1.7 million Americans suffer trau-matic brain injuries (TBIs) each year from causes that include motor vehicle accidents, sports injuries, and assaults. But that number is rising because our aging population is more prone to falls—the leading cause of TBI.

Serious brain injuries like Quito’s affect virtu-ally every aspect of life, from attention and mood to reasoning and communication. As one of the coun-try’s leading brain injury treatment centers, Rusk marshals an array of specialists to address each patient’s various deficits, based on comprehensive evaluation of brain function.

“We treat all the problems associated with brain injury,” explains Steven Flanagan, MD, the Howard A. Rusk Professor of Rehabilitation Medicine and chair of the Department of Rehabilitation Medicine, “including difficulty walk-ing and performing daily activities, depression, irritability and sleep disorders, and problems with memory and concentration.” Dr. Flanagan, a leading expert in the field, plans to expand Rusk’s rehabili-tation services for TBI patients in the years to come.

Like the stark realities that become apparent only after the fog of war has lifted, the true damage from any brain injury becomes discernible during the early stages of treatment. In the weeks follow-ing the initial trauma, as bruising and swelling subside, some damaged brain cells heal, while other damage may require months of therapy. Deficits that don’t respond to treatment may be permanent. Rehabilitation aims to maximize healing, helping patients to retrain their brains and develop coping and compensatory strategies.

When Stephanie Quito entered Rusk, her gait and balance were impaired, and she was having difficulty using and processing words, a condition known as aphasia. Stephanie was prescribed a regi-men of physical, speech-language, cognitive, and occupational therapy, plus psychological counseling. Drills included tracing letters with her hand, conjur-ing words for different categories, and relearning how to follow instructions.

By the end of her three-week stay, Quito’s physical and behavioral issues were resolving themselves, and her vocabulary had improved markedly—progress that boded well for her ulti-mate recovery and also reflected her will to succeed.

“We talk about the science of recovery,” says Karen Gendal, Quito’s speech-language therapist, “but there’s a lot to be said about people’s own belief that they’ll get better. Stephanie really believes in herself.”

In May, Quito graduated from the State University of New York at Stony Brook with a dual degree in healthcare management and art. Her outpatient therapy with Gendal focuses on spell-ing, word finding, reading comprehension, and note taking. Meanwhile, she is sharpening her cognitive skills, such as attention, organization, and plan-ning, with the help of neuropsychologist Donna Langenbahn, PhD, clinical associate professor of rehabilitation medicine. “She has to work harder than before to accomplish similar tasks,” says Dr. Langenbahn, “but she’s willing to put in that effort.”

Although her cognitive abilities still aren’t what they used to be, Quito, now 24, has seen steady improvement. “My memory and concentra-tion get better all the time,” she says. “It’s incredible to me how far I’ve come. I want to inspire people who’ve had accidents like mine. I want them to understand that if you’re motivated and involved in your recovery, it will happen.”

Noticing a small bump near her hairline, Elisabeth Cohen, MD, professor of ophthalmology, figured it was a mosquito bite. But a few hours later, a cluster of blisters had arisen. It was then that she knew the di-agnosis: herpes zoster, or shingles. Dr. Cohen began taking Valtrex, an antiviral medication, hoping that it would ward off the worst ravages of the disease. Still, she knew that shingles is wildly unpredictable—and potentially devastating.

Although more common with increasing age, shingles can strike anyone who’s had chicken pox. Like a sleeping tiger, the varicella zoster virus lies dormant until roused by a lapse in the immune sys-tem. It travels down nerve fibers to the skin, erupting in a rash of liquid-filled vesicles, typically on one side of the body or face, along with severe neuralgia and itchiness. The agony usually lasts about a month, but it can persist for far longer, even years. If the infec-tion strikes the trigeminal nerve, it can spread to cranial arteries, triggering a stroke. It can also invade the eye, causing severe damage. Antivirals may shorten the duration of the rash, but they reduce the incidence of eye complications by only 50%.

Dr. Cohen had treated ocular zoster patients with pain so unbearable that they begged her to remove the affected eye (not an option with this disease). Yet she felt confident when her own battle with shingles began in 2008. At the time, she was 58 years old, healthy, and fit—and director of the cor-neal department of the renowned Wills Eye Institute in Philadelphia, the nation’s first eye hospital. “My reaction was, ‘I’ve got the very best care. I’m going to be fine,’ ” says Dr. Cohen.

Her optimism, unfortunately, didn’t alter the course of the disease. For six weeks, she recalls, her forehead felt as if it were being zapped by light-ning. Anticonvulsant drugs dulled the neuralgia but made her so groggy that she tried to avoid them. Dr. Cohen’s husband, Robert I. Grossman, MD, dean and CEO of NYU Langone Medical Center, told her one night, “I can’t stand to see you this way. Take what-ever you need to stop the suffering.” Meanwhile, the infection attacked her right eye, scarring the cornea and threatening her with glaucoma. Steroid eyedrops tamped down the inflammation, but the medication caused cataracts. One year later, her career as a cor-neal surgeon came to an end. Though she continued to teach, eventually she had to give up her medical practice, a wrenching blow. Dr. Cohen’s eye remains badly impaired; its visual acuity is 20/100, and she still uses drops to keep it from deteriorating further.

The experience has turned her into an advocate. “My goal,” she says, “is to help protect people from this disease.” That means prevention. According to the Centers for Disease Control and Prevention (CDC), one in three Americans will develop herpes zoster at some point—a number that could be greatly reduced if more people were vaccinated. Since 2006,

the CDC and the Food and Drug Administration (FDA) have recommended the vaccine for everyone age 60 and over with a healthy immune system, yet only 14% of those eligible receive it. (Last November, the FDA extended its endorsement to those 50 and over, but the CDC has not yet followed suit.) “We need doctors to recommend the vaccine to their 60-plus patients the way they do the flu vaccine,” says Dr. Cohen. “I’d be happy if they’d encourage people in their 50s to get it, too.”

The shot doesn’t guarantee immunity, but it reduces the incidence of shingles by 55%. For patients under 60, whose insurance won’t cover the vaccine, the cost (up to $250) can be prohibitive. But in vaccinated patients who still contract the disease, symptoms are greatly lessened. For Dr. Cohen, that’s reason enough to roll up your sleeve.

At NYU Langone, she’s striving to increase both availability and awareness of the vaccine. The logistics, however, are complex and challenging. Because the vaccine is made with a live virus, it must be stored in a special freezer and administered within 30 minutes of removal. Most doctors don’t have those freezers, and though pharmacies do, New York State pharmacists won’t be authorized to administer the shingles vaccine until October 2012.

Last year, Dr. Cohen began working with Tisch Hospital’s outpatient pharmacy to stock the vaccine and have it administered by nurses. Thanks to that effort, about 160 patients per month now come in—with a doctor’s prescription—for the shot. One recent recipient was clothing-industry executive Jack Gross, 62, who suffered through shingles 19 years ago and wanted to reduce the chance of a recurrence. “It was the most uncomfortable experience I’ve ever had,” he recalls, “and it took me a good six months to get back to normal.” Gross, whose rash was on his torso, remembers vividly how the disease robbed him of sleep, sapped his energy, and made it excruciating to wear a shirt and jacket to work. “I would never want to go through that again,” he says.

Dr. Cohen educates her colleagues about shingles through lectures, and she has collaborated with the Medical Center’s IT Department to alert physicians electronically when their patients become eligible for the vaccine. She’s also helping to conduct studies (supported by Merck, the vaccine’s manufac-turer) on physicians’ knowledge, attitudes, and prac-tices regarding the vaccine, and on ways to increase usage among underserved urban dwellers.

“Shingles can really destroy a person’s quality of life,” she says. “If we can save some people from this terrible illness and make it milder for the rest, that would be beautiful.”

page 4 | news & views

A Sleeping TigerHer Life Forever Changed by Shingles, Dr. Elisabeth Cohen Has Turned from Patient to Advocate

One in three Americans will develop herpes zoster at some

point, but that number could be greatly reduced if

more people were vaccinated.

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As Dr. Elisabeth Cohen (far left) looks on, Jack Gross, who suffered through shingles 19 years ago, receives a vaccine to help prevent a recurrence at Tisch Hospital’s Outpatient Pharmacy.

HJD Earns Magnet Recognition for Nursing Excellence (continued from page 1)

Even before Magnet, HJD was special. One of only five hospitals in the US dedicated solely to orthopaedics, it performs more than 20,000 ortho-paedic and musculoskeletal procedures annually. It is ranked among the nation’s top 10 institutions for both orthopaedics and rheumatology by U.S. News & World Report’s annual survey of the best hospitals in America.

For nurses, working at a specialty hospital poses both opportunities and challenges. “People think being a nurse here is simple because our focus is so specialized, but it’s not,” notes Vanderberg, who joined HJD 13 years ago. “Our patients often have co-morbidities, such as diabetes and heart failure, and we ask our staff to do a lot. But we also give them considerable support and encouragement in areas like professional development and lifelong learning.”

HJD’s culture of achievement and expertise was not lost on the Magnet appraisers, who found

the high number of certifications per nurse and the nursing staff’s overall level of engagement “exemplary.” On average, 27% of nurses at Magnet organizations have specialty certifications, but at HJD the number is nearly 40%, with many nurses holding multiple certifications in, say, orthopaedics, medicine-surgery, rehabilitation, and critical care. What’s more, 86% of HJD’s nursing staff hold a bachelor of science

in nursing (BSN) degree, twice the nation-wide average. The emphasis on ongoing education translates into enhanced patient care.

“I like the way we’re empowered because it allows us to be advocates for

our patients,” says Virginia Brosnan, RN, a nurse in the postanesthesia care unit and

a 10-year HJD veteran. “If we have issues, we’re encouraged to sit down and talk about

them. At most other hospitals, we’d have no voice. We feel valuable here, and that makes a difference for us.”

Magnet status is the culmination of a rigorous evaluation process. Appraisers—all senior nurses

from Magnet institutions—spent three days shadow-ing HJD’s nurses on every patient floor of the 190-bed hospital, including the night shift. Reams of quality- and performance-based data were assembled and handed over, a project coordinated by Patricia Lavin, RN, director of quality and outcomes.

HJD’s nursing administrators acknowl-edge, however, that the coveted Magnet status is no excuse to rest on their laurels. “Because we’re a specialty hospital and 90% of our surgeries are elective, patients come here expecting a lot,” says Vanderberg. “Magnet will change the meaning of excellence for us. It will require us to constantly evaluate and improve our performance to keep meeting those expectations.”

The Magnet Recognition Program®, developed in 1994, actually has its roots at NYU Langone. The research team that conducted the study that evolved into the program was led by Margaret McClure, EdD, RN, a former chief operating officer and chief nursing executive at NYU Langone and former president of the American Academy of Nursing.

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Why do we dream?Dr. Llinás: Dreaming is essential for our well-being. If you were to be woken up every time you start to dream, after a while you will begin to hallucinate during your wake state. Indeed, just as one has to clean one’s desk to avoid clutter, one has to dream to avoid “mind clutter.” Dreaming is a cleansing act.

Dr. Llinás, you’ve written that dreaming is not all that different from wakefulness. How so?Dr. Llinás: Dreaming is what the brain is all about— it’s a dreaming machine. Wakefulness, or conscious-ness, is simply a dream state modulated by input from the senses. Consciousness is actually the description our brain makes of the external world. The brain has evolved to make the best possible description of the external world, and to formulate precise movements and know the consequences of each movement. Prediction is the brain’s ultimate function.

Dr. Rosenthal, as a psychoanalyst, how do you see dreaming?Dr. Rosenthal: When psychiatrists talk about dreaming, we talk about what happens in our minds at night when we’re sleeping. It’s a movie of sorts that’s choreographed by the sleeper and has a storyline, which we call the manifest content, which is often a disguise for more complex thoughts and feelings. In psychoanalysis, dreams become a window onto thoughts and feelings that the dreamer is not fully conscious of.

Do you use dreams to help patients address their problems?Dr. Rosenthal: One of my teachers called dreams “mean-ing makers.” It’s really a question of what meaning people make of their dreams. Everyone dreams, although not everyone remembers their dreams. I can teach people how to remember dreams so that they can learn more about what their dreams are saying, and ostensibly learn more about themselves.

Dr. Llinás: I once had a dream that one of my children had died in an accident. I woke up very upset. Then I remembered that there was something wrong with the brakes in my car, and I had to take care of it. I wasn’t paying attention to a problem, but it was my unconscious that made me aware of it.

Why do some dreams recur again and again?Dr. Rosenthal: One theory is that a dream keeps reappearing because it represents an unresolved emotional conflict.

Are some dreams so common that they’re almost universal?Dr. Rosenthal: Many people dream about flying, which often represents mastery, strength, and ability—being able to take control. It’s also common to dream about going somewhere and realizing that you’re not dressed, which reveals a fear of being exposed—vulnerability.

Can patients control or change their dreams?Dr. Rosenthal: Some therapists who work with lucid dreaming teach patients to “rewrite” their dreams. This is most often done with patients who have suffered enormous trauma, and their nightmares are reiterations of the trauma. Outside of dreams linked with post-traumatic stress phenomena, I think it’s more productive to understand disturbing dreams rather than get rid of them.

Do any examples come to mind?Dr. Rosenthal: I followed a patient on the neurosurgery service who became very anxious after having spinal surgery. He told me he had a dream about a construc-tion site, with all this scaffolding, that was like the World Trade Center after 9/11. It was very disturbing to him, and he didn’t know what to make of it. I suggested that maybe it had to do with the “scaffold-ing” surgeons applied to his spine. “Of course,” he said. “I’m terrified that my scaffolding won’t hold, and I’ll collapse like the Twin Towers.” Comforted by this insight, his anxiety began to improve.

Are dreams a source of creativity?Dr. Rosenthal: Dreams are a place where unconscious thoughts can be expressed, thoughts that you don’t have access to during waking hours. Great inven-tions are said to have emerged from dreams. The German chemist Friedrich August Kekulé von Stradonitz supposedly discovered the shape of the molecule benzene in a dream. Paul McCartney has said that he awoke from a dream with the song “Yesterday” fully written.

Can everyone access their dreams, or their imagina-tion, in this manner?Dr. Rosenthal: Only some people can achieve this the way creative artists or scientists can, but I think

practically everybody has the capacity to be highly creative. The question is whether or not you allow yourself to be. People can certainly learn to access their dreams, their creativity. Many artists and writers engage in psychoanalysis when they have trouble accessing their imagination. A psychoana-lyst can help you become more aware of all the goings-on in your mind, and to tap the uncon-scious, which can get trapped in common-day problems and conflicts.

Dr. Llinás: Yes, I agree. The problem with being awake is that the senses don’t allow you to think. When you have a big problem, go into a dark room, with a sign outside that says, “Please don’t disturb.”

Dr. Rosenthal: I do some of my best thinking on the treadmill. No music, no video, nothing. Just thinking.

Dr. Llinás: I’m the same way. I dream in the shower. Many of my research ideas come up in the shower.

Will it ever be possible to access other people’s dreams?Dr. Llinás: We are all condemned to live within the limit of our own cranium, but wouldn’t it be wonderful to feel what somebody else feels, to see what other people are dreaming? It won’t happen in our lifetime, but it may be possible in the future if the brain can be “wired,” perhaps with nanowires, via the vascular system.

Dr. Rosenthal: That sounds scary to me. That’s private property. People shouldn’t put probes up there.

Dr. Llinás: It is indeed private property. Nevertheless, it is possible to get there, and sadly, given the kind of beings we are, we will at some point. It may be, unfortunately, inevitable.

Q&A with Rodolfo Llinás, MD, PhD, the Thomas and Suzanne Murphy Professor of Neuroscience and University Professor, and Jane Rosenthal, MD, clinical associate professor of psychiatry and director of the Consultation Liaison Psychiatry Service

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page 6 | news & views

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A New Theory about Obesity—Straight from the Gut

In the late 1940s, animal husbandry took an odd twist.

American farmers started noticing that animals given

antibiotics grew heavier than animals that did not re-

ceive antibiotics. The discovery turned out to be an un-

expected boon for the postwar farming industry, which

faced growing demand for its livestock. In 1950, a front-

page headline in The New York Times even declared:

“ ‘Wonder Drug’ Aureomycin Found to Spur Growth

50%.” Actual gains on the farm were more modest,

ranging from 1 to 15%. Nonetheless, the practice of ad-

ministering subtherapeutic doses of antibiotics to ani-

mals quickly became the industry standard in the US,

and it remains so today.

But why would antibiotics make animals heavier?

That question has perplexed scientists for over half a

century. Now, researchers at NYU School of Medicine

have discovered evidence to support an intriguing theory:

antibiotics may trigger bacteria in the gut that step up fat

production. Their study, funded in part by Diane Belfer

and recently published in the journal Nature, suggests

that exposure to antibiotics early in life may alter the bac-

terial landscape of the gut in ways that lead to fat

gain. “By manipulating the microbial community

in the gut and its metabolic characteristics,

we can actually alter the host,” says co-author

Ilseung Cho, MD, assistant professor of medicine.

The finding also provides experimental in-

sight into the relationship between antibiotic use in

children—American children average one course of anti-

biotics a year—and the crisis of childhood obesity, which

now affects 12.2 million kids in the US.

A thicket of microbes, the human gut harbors tril-

lions of bacteria that include at least 1,000 different

species. Science has long known that antibiotics can

alter this bustling microbial community and make us

nauseated. But fat?To shed light on that question, Dr. Cho and his

colleagues examined the relationship between antibi-

otics and mice, whose guts harbor a microbial com-

munity similar to that in humans. In their experiment,

healthy mice drank water treated with low doses of

antibiotics such as penicillin and vancomycin, com-

monly administered to farm animals. After seven

weeks of antibiotic exposure, the mice had gained

roughly the same amount of weight as the untreated

mice, but the treated mice had packed on 10 to 15%

more fat. Not only did they have more fat tissue, but

they were also more likely to be hyperglycemic.

A closer look at the gut microbiome offered an

explanation. The team’s analysis showed that treated

mice harbored increased counts of microbial groups

that previously have been linked to obesity in both

mice and humans. Looking forward, the team plans to

expose mice to larger doses of antibiotics and on dif-

ferent schedules while delving deeper into the molecular

changes behind their fat gains. Eventually, Dr. Cho hopes

to expand the research to humans.

“Our hypothesis is that nature has endowed us

with a very favorable assortment of microbes that call

us ‘home,’” says Martin Blaser, MD, the Frederick H.

King Professor of Medicine, chair of the Department of

Medicine, and professor of microbiology, a senior in-

vestigator on the study. “Through our modern prac-

tices, we are disrupting this ancestral microbiome

early in life, just when developmental decisions

need to be made in our tissues. We believe that

we have been selecting for alternative developmental

pathways that are forming the seeds for obesity and

other disorders.”

Do Antibiotics Potentially Cause

Childhood Obesity? It Depends on

When They’re Given, Says Study.

The American farming industry has long relied on antibiotics to fatten up its

livestock. Now, researchers at NYU School of Medicine report that these drugs may

have a similar effect on children. In a study published in the International Journal of Obesity and supported by the NYU Global Public Health Research Challenge Fund,

investigators examined data from landmark research in the United Kingdom that had

tracked 11,532 children. After analyzing the height, weight, and antibiotic use of these

children at the ages of 7 weeks, 10 months, 20 months, and 38 months, they found

that babies given antibiotics during the first 6 months of life were 22% more likely

to be overweight at 38 months. This risk persisted even when other factors, such as

diet, exercise, socioeconomic status of their parents, and other medications given in

the first six months of life were taken into account.

The average American child now takes at least one course of antibiotics each

year, and an estimated 12.5 million American children and adolescents are obese.

How antibiotics promote weight gain remains a mystery, but the NYU study has found

that the stage of development at which antibiotics are administered matters. Infants

who received antibiotics between 6 and 14 months of life were at no greater risk of

being overweight than infants never exposed to antibiotics. One theory to explain

this is that disrupting the bacterial

colonization of the gut prior to that

period may predispose infants to weight

gain later in life. “The earliest exposure

is likely to be the greatest concern,”

adds lead author Leonardo Trasande,

MD, associate professor of pediatrics

and environmental medicine.

This idea is borne out on the

farm, where low doses of antibiotics

are commonly used to promote growth

in livestock. In fact, the earlier animals

receive antibiotics, the more weight

they tend to gain. (See “A New Theory

about Obesity—Straight from the Gut.”)

“Microbes in our intestines may play a

critical role in how we absorb calories,

and exposure to antibiotics, especially

early in life, may kill off healthy bacteria

that influence how we absorb nutrients,

and would otherwise keep us lean,”

explains Dr. Trasande. “We typically

think of obesity as being grounded in unhealthy diet and exercise, yet increasingly,

studies suggest that the epidemic is more complicated than that.”

Moreover, studies have found that children exposed to antibiotics are more likely

to suffer from asthma, skin disorders, and inflammatory bowel disease. “We’re still

learning how far the impact of the microbiome reaches and the costs of perturbing it,”

says co-author Martin Blaser, MD, the Frederick H. King Professor of Medicine, chair

of the Department of Medicine, and professor of microbiology.

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Can Some Grapes or Berries a Day

Keep the Oncologist Away?

To Bhagavathi Narayanan, PhD, associate

professor of environmental

medicine, food isn’t

just a source of

nourishment

and plea-

sure, it’s “daily

medicine.” Dr.

Narayanan says

that in her native

India, many foods are

chock-full of phytochemi-

cals, compounds that are produced by

plants, such as beta carotene, ascorbic acid (vitamin

C), folic acid, and vitamin E. Some phytochemicals have either antioxidant or hormone-

like actions. There is some evidence that a diet rich in fruits, vegetables, and whole grains

reduces the risk of certain types of cancer and other diseases. Certain phytochemicals

are believed to prevent the formation of potential carcinogens, block the action of carcin-

ogens on their target organs or tissue, or act on cells to suppress cancer development.

Two particular phytochemicals—resveratrol, found in red wine, grapes, and ber-

ries, and curcumin, the bright yellow compound found in the popular Indian spice tur-

meric—have strong anti-inflammatory effects, among other cancer-fighting benefits.

A diet rich in these substances, says Dr. Narayanan, is “like eating a little bit of aspirin

every day—but without the side effects.”

“India has very low levels of cancer,” notes Dr. Narayanan. “In the town where

I grew up, we did not even know the word. In my family, which has a lot of doctors,

we never even spoke about cancer.” Dr. Narayanan studies prostate cancer, which

occurs in 2 to 3% of men in India, whose population is more than 1 billion. This is one

of the lowest rates of prostate cancer in the world. By contrast, approximately 16% of

American men will be diagnosed with prostate cancer at some point in their lifetime.

But singing the praises of resveratrol and curcumin is one thing. Understanding

how they fight cancer and then using them to combat the disease, either as prevention or

treatment, is another. Dr. Narayanan is working on both fronts. Her lab and mice studies

have demonstrated that curcumin plus resveratrol inhibits the androgen receptor that

drives prostate cancer, and activates a transcription factor that switches on the powerful

tumor-suppressor gene p53, destroying cancer cells.

She also has worked on a method to increase the “bioavailability” of these natural

compounds to keep them in the blood and body as long as possible to fight cancer. To

that end, Dr. Narayanan and her colleagues tested a novel delivery system for curcumin

and resveratrol. In a groundbreaking study published in 2009 in the International Journal of Cancer, she demonstrated that encapsulating the compounds within a liposome

bubble can enhance their chemopreventive effect in mice. The group is now testing the

lipid agents against aggressive prostate cancer in mice. They are also collaborating with

Japanese researchers to test resveratrol-related compounds against pancreatic cancer.

While research on phytochemicals is promising, Dr. Narayanan is con-

cerned that it will not move forward until a large, long-running clinical trial is con-

ducted. “I believe that accumulating from childhood the protective benefits these

foods offer us is the best way to protect against cancer later in life,” she says.

Illustrations by Wes Bedrosian

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September/October 2012 | page 7

They seem like two friends working out together in a crowded Midtown gym. Their laughter is natural, easy, and the banter is softly sarcastic. They both favor un-orthodox workout outfits. “Ready?” asks Stephen Fischer, DPT, 34, a compact, well-toned fellow in a form-fitting polo shirt, khakis, and rubber-soled shoes. “Always,” says Florian Jay, 29, a tall, slender guy in cargo shorts and a baggy, short-sleeved shirt. Jay has transverse myelitis, a neurological disorder caused by an inflammation of the spinal cord, which has left him largely paralyzed.

“On my count,” says Fischer, flexing his knees for stabilization as he positions himself to rock back and forth enough times to enable him to lift Jay’s dead weight. On “three,” he hoists the inert, six-foot-tall, 150-pound Jay from his motorized wheelchair, cradling him firmly before gently placing him on an elevated mat. Thus begins a strenuous one-hour workout that will test the physical and emotional limits of both men.

“Our physical therapists [PTs] are trained to treat the whole person,” explains Kate Parkin, PT, DPT, clinical assistant professor of rehabilitation medicine and senior director of rehabilitation therapy services

at NYU Langone Medical Center’s Rusk Institute of Rehabilitation Medicine. “Dr. Howard Rusk founded this institute on the philosophy that rehabilitation medicine should provide all patients with care for their psychologi-cal and social needs, not just their illness or disability.”

October is National Physical Therapy Month, an occasion for Parkin to reflect on the history and growth of her profession: “Many of the methods and inter-ventions used by physical therapists today—massage, exercise, heat and cold therapy, underwater maneuvers—probably date back to Hippocrates.” But as a profession, physical therapy was born in 1917, when a special unit of the US Army Medical Department—the Division of Special Hospitals and Physical Reconstruction—de-veloped “reconstruction aide” programs to rehabilitate wounded veterans of World War I.

Each day in America, more than 120,000 licensed PTs carry on a tradition of helping people to help them-selves by treating some 1 million patients in both inpatient and outpatient settings. As of 2016, all entry-level training programs for PTs nationwide will require a doctor of physi-cal therapy (DPT) degree, reflecting not only the maturity

and professional status of the discipline, but also the enor-mous range of expertise and expanse of knowledge to be mastered when treating so many aspects of rehabilitation.

Parkin says that she’s deeply proud of all of Rusk’s 150 or so PTs, recruited from the top of their classes at training programs nationwide, but she beams when she speaks of Stephen Fischer, assistant unit supervisor in outpatient physical therapy. “Stephen is one of the most talented young managers I’ve seen,” she says. “He’s a great motivator and mentor. He so loves what he does. Most of all, his care for his patients never ends.”

Consider Florian Jay, whose spindly right leg Fischer is pushing down on with the weight of his entire body, making him sweat profusely in the air-conditioned gym. “How does that feel?” asks Fischer in a gentle tone that belies his force. “Great,” responds Jay. “A little pressure, but no pain.” Jay meets with Fischer twice a week in the airy 16th-floor gym at NYU Langone’s new Ambulatory Care Center at 240 East 38th Street to help improve his breathing, increase his range of motion, and ease his spasticity.

Jay, who lives with his father, has been confined to a wheelchair for two years. “Florian’s deficits are profound,” says Fischer. “His left side is essentially paralyzed, and any movement is slow and painstaking.” However, as long as his right hand is kept loose and open, he can still sketch quite proficiently. “I’d originally wanted to be a sculptor working with steel and iron,” says Jay, whose energy level is significantly diminished by baclofen, a drug administered to loosen his muscles.

Jay’s intensive workouts will enable him to have a pump implanted in his abdomen to deliver the baclofen in microtargeted doses into the spinal fluid. The process, called intrathecal baclofen therapy, will not only allow more normal muscle movement, but should also elimi-nate his drowsiness. Jay is psyched. “My brain works fine,” he says, “and I want to be able to use it fully. This procedure could give me my life back. I’d like to return to school. Who knows? Maybe I’ll become a PT, like my buddy here.”

The EnablersAs Empowering Partners in Care, Rusk’s Physical Therapists Help Patients Help Themselves

Stephen Fischer, DPT, shown here with one of his patients, Florian Jay, is one of some 150 physical therapists at Rusk who have been recruited from the top of their classes at training programs nationwide.

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When Elizabeth Talerman’s primary care physician told her that she’d be going to a different center for her annual screening mammogram this year, she didn’t expect much. “I figured it would be the same as it had always been,” says the 48-year-old brand strategist, who has been dutifully getting mammo-grams every year since she turned 40, although she confesses to sometimes letting things slide a little longer than that. “You go in, and you wait and you wait. And then you get the mammogram and you leave, and you wait and you wait again for someone to call you or send you a letter. I had no idea I’d be walking into something totally different.”

What Talerman walked into on July 19 was NYU Langone Medical Center’s new Center for Women’s Imaging, a dedicated street-level screen-ing facility at 221 Lexington Avenue at 33rd Street. For screening mammograms, results can be provided while you wait during weekdays. Same-day appoint-ments are available, as are evening and weekend hours. Unlike a diagnostic mammogram, a screening mammogram is for women who do not have current signs or symptoms of breast cancer. In addition to its low-dose digital technology for mammograms, the center also offers screening breast ultrasound and bone-density scans.

Shortly after Talerman entered the waiting room, she was ushered to a changing area, then escorted to a mammography room. After the imag-ing, the patient waited to receive the results. In this case, a radiologist spotted something of interest on the images that she wanted to discuss with the patient. Putting Talerman’s images up on the digital viewing monitor, the physician pointed to a white line. “This is fibroglandular tissue,” she explained. “It doesn’t show up in everyone, but it’s not a

problem, and I don’t want you to worry. Your mam-mogram shows absolutely no abnormalities.”

Talerman was relieved and delighted. “I had assumed I was healthy, but I’ve buried one friend due to breast cancer and have another who’s just had a mastectomy,” she explains. “It was wonderful not to have that hanging over my head. I walked out think-ing, ‘This is the way healthcare should be.’ ”

October is Breast Cancer Awareness Month. Given the seemingly never-ending barrage of con-fusing answers to important questions—Who should have a mammogram? At what age should you start having them? How often should you have one?—the decision to get a mammogram has become more stressful than ever. In 2009, the US Preventive Services Task Force set off a firestorm when it declared routine screening mammography to be unnecessary in women under 50. In June 2012, the American Medical Association took a stand in direct conflict with that recommendation, supporting rou-tine screening mammograms starting at age 40.

“Women have gotten mixed messages about the importance of breast cancer screening, and that’s a real negative,” says Freya Schnabel, MD, profes-sor of surgery and director of breast surgery. “While there’s some controversy about how to best serve women with mammography, there’s still no question that it’s the only test we currently have that’s been demonstrated to reduce mortality from breast cancer. A woman who wants to maximize her opportu-nity for early detection of breast cancer should have annual mammograms from age 40 on.”

Making the entire patient experience—from scheduling the mammogram, to going through the procedure, to finding out the results—easier, faster, and less stressful could mean that women stop

putting it off as an unpleasant chore. In this case, dis-couraging procrastination could save lives. “The new center provides seamless care,” notes Dr. Schnabel. “You get through the system promptly, and you get the answers you need as soon as possible.”

Says Hildegard Toth, MD, associate professor of radiology and chief of breast imaging: “It’s like scheduling peace of mind.”

For more information or to make an appoint-ment, call 212-731-5002.

Web Extra: for an article about a woman who opted for a radical form of treatment because she was at high risk for a recurrence of breast cancer, see “A Double-Barreled Diagnosis” at www.newsandviews-digital.com.

Peace of Mind—While You WaitAt NYU Langone’s New Center for Women’s Imaging, the Accent Is on Convenience

During weekdays, the new Center for Women’s Imaging can provide results for screening mammograms while the patient waits.

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Inside This Issue

The Enablers Each day in America, more than 120,000

licensed PTs carry on a tradition of helping people to help

themselves by treating some 1 million patients in both inpatient

and outpatient settings. In honor of National Physical Therapy

Month, one of Rusk’s finest describes the unique bond between

him and his patient. page 7

Believing in Your Own Brain More than 1.7 million

Americans suffer traumatic brain injuries (TBIs) each year, and

that number is rising because our aging population is more

prone to falls—the leading cause of TBI. One patient, Stephanie

Quito, is rebuilding her life with help of therapists at NYU

Langone’s Rusk Institute. page 1

A Prescription for Enhancing Patient Care As director of the Division of Pharmacotherapy, John

Papadopoulos, clinical assistant professor of medicine, heads

up a 15-member team of clinical pharmacists that’s changing

the notion—and expanding the role—of the pharmacist beyond

that of the behind-the-counter dispenser of drugs. page 3

news & views is published bimonthly for NYU Langone Medical Center by the Office of Communications and Public Affairs. Readers are invited to submit letters to the editor, comments, and story ideas to thomas.ranieri@nyumc.org.

NEW YORK UNIVERSITY

Martin Lipton, Esq., Chairman, Board of TrusteesJohn Sexton, PresidentRobert Berne, PhD, Executive Vice President for Health

NYU LANGONE MEDICAL CENTER

Kenneth G. Langone, Chairman, Board of TrusteesRobert I. Grossman, MD, Dean and CEODeborah Loeb Bohren, Vice President, Communications and Public AffairsMarjorie Shaffer, Director of Publications

news & views

Thomas A. Ranieri, EditorMarjorie Shaffer, Science Editori2i Group, Design

To make a gift to NYU Langone, please visit http://giving.nyumc.org.

Copyright © 2012 New York University. All rights reserved.

Life Is But a Dream Why do we dream? Why do some

dreams recur again and again? Are some dreams so common

that they’re almost universal? Are dreams a source of creativity?

Dr. Rodolfo Llinás, a neuroscientist, and Dr. Jane Rosenthal, a

psychiatrist, tackle these and other questions about the most

mysterious of our mental activities. page 5

For people with major physical disabilities, some of life’s simple pleasures may seem

painfully out of reach. Take, for example, the timeless summer ritual of rowing on a

breezy lake. Impossible? Not for participants in the Young Women’s Program row-

ing camp, held each July by the Initiative for Women with Disabilities (IWD) at the

Elly and Steve Hammerman Health and Wellness Center at NYU Langone Medical

Center’s Hospital for Joint Diseases.

Sixteen campers, ages 15 to 26, traveled to Meadow Lake in Queens for this

year’s five-day event. Volunteers helped to ensure that the program—sponsored by

Row New York, a nonprofit that empowers young women through competitive row-

ing—was a buoyant success.

Each morning, the campers, whose conditions range from spina bifida to

cerebral palsy, practiced their technique on land, using specially fitted ergometers.

Members of Row New York’s high school rowing team provided coaching and

encouragement. Then, it was time to hit the water in a pair of barges adapted for

cruising, racing, and aerobically enhanced fun.

Besides providing exercise and camaraderie, the camp’s most important

benefit may be to strengthen its participants’ sense of personal potential. “Rowing is

a sport in which people with disabilities can be equal with their able-bodied peers,”

says Judith Goldberg, IWD’s director. “All their lives, these girls have been told,

‘You can’t do this. You can’t do that.’ We’re showing them they can do anything.”

Goldberg should know. Born with brittle-bone disease, she became a competitive

swimmer as a young woman and rowed as part of her training.

“When we started on Monday,” she adds, “they all looked a little sleepy and

pale. By Friday, they had a glow and they were all buffed up. They looked radiant!”

Row, Row, Row Your Boat

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page 9 | news & views web extra September/October 2012

Cloak of Compassion

The White Coat Ceremony, an annual rite of passage at NYU School of Medicine, was held on August 17 for the class of 2016, signifying the beginning of their medical education and symbolically confirming their commitment to the profession of medicine. This ceremonial presentation of coats promotes empathy and compassionate service to others in the practice of medicine at the very start of medical training.

During the ceremony, 162 students were brought to the stage and, in the presence of family, friends, and colleagues, were “cloaked” in their first white coat—the mantle of the medical profession—by one of several faculty members. Together as a class, they took an oath similar to the Hippocratic Oath, stressing the importance of the doctor-patient relationship and making a compassionate commitment to medicine.

Robert I. Grossman, MD, the Saul J. Farber Dean and CEO of NYU Langone Medical Center, welcomed the new students with an in-spirational address, and at the conclusion of the ceremony, administered the Student Oath, a pledge to uphold the values of integrity, profession-alism, and scholarship.

The class of 2016, drawn from 8,351 applicants, ranges from 21 to 29 years old and is made up of 87 men and 75 women. These students hail from 26 states and Canada. While 83% of the class majored in science, 17% majored in humanities programs. The Arnold P. Gold Foundation has provided generous support for NYU School of Medicine’s White Coat Ceremony.

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extraA Double-Barreled DiagnosisFor Kelly McSpirit, the Best Treatment for Breast Cancer Was True Grit

Kelly McSpirit, 40, had just showered and was doing a breast self-exam when she felt it: a hard lump at 12 o’clock in her right breast. “I knew I was at elevated risk of getting breast cancer since it runs in my family along my father’s line. His sister had it, and so did her daughter,” says McSpirit. As a result, she had been vigilant: she had a baseline mammogram at 35 and examined herself monthly. But after the birth of her twins two years before, she be-came so busy that she simply forgot to. “Still,” she says, “I was shocked when I found the lump. Shocked, upset, and very scared.”

She and her husband, Chris Hanlon, quickly scheduled tests with local doctors in Morristown, New Jersey. “It helped that we were medically savvy,” McSpirit explains. “We had gone through several agonizing years of poking and prodding with IVF [in vitro fertil-ization] to have our twins. So while we were frightened, we knew how to face what was go-ing to be a very difficult road ahead.” The tests confirmed the presence of a small mass. “Right then,” recalls McSpirit, “I knew I needed a spe-cialist—and I wanted the best.”

That determination brought her to NYU Langone Medical Center, where she met with Freya Schnabel, MD, professor of surgery and director of the Division of Breast Surgery. Further testing revealed more bad news: not only did McSpirit have breast cancer, but she learned that she’s a carrier of the BRCA gene mutation, which puts her, as Dr. Schnabel says, in the “top bucket” of women at risk for the disease. “Such women have a 50 to 80% risk of getting breast cancer compared to 12% in the general population,” says Dr. Schnabel. Moreover, the tests re-vealed that McSpirit would be unresponsive to standard hormonal therapy.

McSpirit underwent the painful proce-dure of having an isotope-tagged dye injected

near her right nipple to identify the sentinel lymph nodes and determine the extent of the cancer. “It made me radioactive,” she explains, “so I had to stay away from my kids when all I wanted to do was hold them.” It did, however, yield good news: the cancer had not spread beyond her breast.

With limited therapeutic options, Mc-Spirit decided on the most definitive course: total mastectomies of both breasts. “It wasn’t a hard decision to make,” she says. “I needed to live, and I didn’t want to have to worry about cancer developing in the other breast.” After

the mastectomies, Nolan Karp, MD, associ-ate professor of plastic surgery and surgery, reconstructed her breasts using fat and muscle tissue from her stomach. In a later operation, McSpirit also had her ovaries removed prophy-lactically, since women with the BRCA gene

have a 15 to 40% risk of getting ovarian can-cer. Kelly’s twin sister, Laura, also carries the BRCA gene and elected to have her breasts and ovaries excised as well.

NYU Langone has mounted a multi-disciplinary effort to help and study women who, like McSpirit, are at high risk of breast cancer. This focus, says Dr. Schnabel, “has the potential to make a big impact. These women are likely to profit more than the general popu-lation. By understanding what happens with them, the hope is that we’ll be able to shed light on the bigger population with sporadic breast cancer.”

Dr. Schnabel points to a number of ques-tions begging for answers. “Only 5 to 10% of women with breast cancer have the BRCA gene. Can we get a better idea of risk in women who don’t have this mutation? Are there other genes that play a role in breast cancer? How long do people benefit from chemoprevention with tamoxifen and other drugs? What is the optimal age for such interventions?”

One of the big issues is screening. Dr. Schnabel feels that women who have the BRCA gene should start being screened about 10 years earlier than the age their closest rela-tive was when diagnosed with breast cancer. But she adds that “there are no clear guidelines for screening young women. Mammography is not that sensitive, and there is the risk of radia-tion exposure. MRIs have a role in screening BRCA carriers, but they give a lot of false posi-tives in young women.”

Kelly McSpirit, now 43 and cancer free, wholeheartedly supports NYU Langone’s endeavors. She and her family and friends have even donated $12,000 to help fund the Medical Center’s research. She knows that the results will benefit not only her, but her son and daughter, who could also be carriers of the BRCA gene.

page 10 | news & views web extra September/October 2012

A molecular model of the BRCA1 protein. Dr. Mark J. Winter / Photo Researchers, Inc.

With limited therapeutic

options, McSpirit decided on

the most definitive course:

total mastectomies of both

breasts. “It wasn’t a hard

decision to make,” she says.

“I needed to live, and I didn’t

want to have to worry about

cancer developing in the

other breast.”

web

extraA Treasure Chest Called ChildhoodBy Easing the Transition Back to School, the Hassenfeld Center Lets Kids Be Kids

In the highly competitive world of Manhattan preschool education, getting into a good elementary school is no small challenge—inter-views, tests, and letters of recommendation are all part of the process. For four-year-old Rogan Fauci, the challenge was compounded by the fact that application time coincided with the height of his chemotherapy, when steroid treat-ments often brought a sick stomach. Most days, Rogan sat with his IV drip in the bustling play-room of the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders at NYU Langone Medical Center, practicing his pen-manship and phonics with the resident teacher, Sabina Martinko. “When kids are that sick, focusing on school can be therapeutic,” says Martinko, a licensed special education teacher employed by New York City’s Department of Education to work with young patients treated at Hassenfeld each year. “It’s something that parents and children can at least control.”

Each year, about 10,000 American chil-dren are stricken with cancer, the most common diagnosis being brain tumors and leukemia. Over Memorial Day weekend in 2009, intense leg pain made Rogan inconsolable. Physicians at NYU Langone Medical Center’s Hospital for Joint Diseases detected abnormal levels of white blood cells and sent him to Tisch Hospital, where he was admitted. The next morning brought news of a devastating diagnosis: acute lymphoblastic leukemia, or cancer of the white blood cells. Rogan started chemotherapy that afternoon. “This puts your whole life in order very quickly,” explains Rogan’s mom, Kate.

Fortunately, nearly 70% of all cases of child-hood cancer can now be treated effectively, with Rogan’s chemotherapy protocol among the most successful—more than 90%.

Letting kids be kids and keeping them on track for the future during treatment is fun-damental to the Hassenfeld Center’s mission. Its Back to School Program starts soon after patients are diagnosed. In addition to emotional and educational support, the program also of-fers advocacy. “We know education law inside and out,” explains David Salsberg, PsyD, clini-cal instructor in pediatrics and rehabilitation medicine and supervisor of pediatric psychol-ogy at the NYU Langone’s Rusk Institute of Rehabilitation Medicine. “There are a lot of intricacies in getting the children physical ther-apy, occupational therapy, special accommoda-tions, or an extra set of books. We are quite successful in negotiating for special programs with the Department of Education.”

For Rogan, Dr. Salsberg obtained permis-sion from the headmasters of various schools to administer screening tests at the center, which afforded him much-needed flexibility because of the side effects. “We wouldn’t know how Rogan felt on any day until he woke up,” Dr. Salsberg explains. Once the day came for Rogan to sit for an eight-part IQ test with Laura Tagliareni, PhD, the Hassenfeld Center’s neuropsychologist, he relished solving puzzles and answering word questions. He’d known much tougher moments—lumbar punctures, sending his cat upstate to his aunt to avoid potential infection from scratches, and missing friends and birthday

parties because of his suppressed immune system. “I hate finger sticks the most,” says Rogan. “They hurt even with lidocaine.”

Rogan’s engaging, un-self-conscious man-ner and comfort with adults, even while bald, served him well on interviews. Having spoken to Dr. Salsberg and others at the center, most schools expressed little concern about Rogan’s condition. In the end, Saint David’s School, an elementary school for boys on Manhattan’s Upper East Side, which his father, Chris, had at-tended, called Rogan’s parents with good news. “ ‘We really love your son,’ they told us,” recalls Kate Fauci. “They said, ‘We’ll take care of him and get through this together.’ ”

To many young patients, a favorite part of the program is taking Hassenfeld Center staff members to school with them. At his first chance, Rogan brought Dr. Tagliareni to his kindergarten class. With a dozen boys seated before them, they took questions: Can you catch cancer? Does it hurt? Will you get better? “It was sweet,” says Dr. Tagliareni. “The boys wanted to relate to Rogan and talked about their own broken arms or legs.”

Near the nurses’ station at the center sits “the treasure chest,” a box filled with brand-new small toys. Rogan explained to his school-mates that after a painful procedure, he and his fellow patients look forward to picking out one for keeps. Rogan—now entering second grade and through with his three-year chemotherapy protocol—proudly delivered three large boxes of toys recently for the treasure chest, all gifts from his new schoolmates.

page 11 | news & views web extra September/October 2012

Rogan Fauci, with his mother, Kate, selects one of the backpacks provided by Back-to-School Blast sponsors and volunteers Harlan and Brian Saroken. Beyond the event, he benefits from Hassenfeld’s School Rentry Program, which provides patients with the emotional support they need to return to school with greater confidence.

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extraA Back-to-School SpecialAs Many of Its Patients Return to the Classroom, the Hassenfeld Center Celebrates a New Season of Hope

Several years ago, Noelia Lara spent her quinceañera—in Latin culture, the celebration of a girl’s 15th birthday, marking her transi-tion into womanhood—in the hospital, newly diagnosed with acute lymphoblastic leukemia. After that, nothing could break her heart, not even attending the annual Back to School Blast, sponsored by Harlan and Brian Saroken, at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders nine months later—even though she wasn’t going back to school. With her immune system weakened by chemotherapy, “back to school” for Lara that September meant a tutor from New York City’s Department of Education, who would appear at her Queens apartment to start 10th grade at her kitchen table. “It’s still school,” Lara said with a shrug. “It’s just at home.”

She’d attended only one month of high school when the bone pain and rash that doc-tors at first thought might be Lyme disease turned out to be worse. “Having cancer really accelerated my maturity,” she says. “I focused on my health and doing everything I could to get better, instead of my friends and what I was missing. But it’s hard—you feel alone.”

Celebrating the new school year as a community is a six-year-old tradition at the Hassenfeld Center. Along with a trivia game, a teeth-brushing demonstration from resi-dents at NYU College of Dentistry, and draw-ing lessons with staff from the Museum of Modern Art, this year’s Back to School Blast

featured a healthy breakfast display. Helping dole out the puffed millet and corn was Kahron Savage, 13, soon to be a freshman at Grand Street Campus, a public high school in Williamsburg, Brooklyn. Savage grew

so tall during his nearly two-year absence from school to treat T-cell leukemia that few classmates recognized him when he returned to eighth grade last year. He got bullied. “It’s a tough age,” says his mom, Lakiesha Jones.

“We decided to see if it would blow over, and it did. You have to give Kahron some credit for that.”

A big kid with a quick smile, Savage looks forward to a fresh start in high school, playing basketball and hopefully, after the removal of his mediport, football, too. “I am ready for the ELA [English Language Arts test] and the Regents tests and everything,” says Savage, who selected a brand-new red backpack filled with donated supplies at the party’s giveaway. (See A “Treasure Chest Called Childhood.”) “I am proud of myself for getting through everything I did to get myself better.”

For most children at Hassenfeld, that means regular lumbar punctures and count-less drug infusions. Even during the party, children slipped away to have their blood drawn, saving themselves an appointment on another day. Others moved from one activity to another with an IV pole. For Lara, now 19, at another Back to School Blast, the treat-ments are behind her. Healthy-looking, with long curly hair, she soon starts her second semester at LaGuardia Community College, working toward her dream of becoming a child psychologist for kids with cancer. “Here we never say, ‘I know how you feel,’ because we don’t know,” explains Dolli Holland, a senior social worker at Hassenfeld, who manned the reception table. “But you,” she said to Lara, “you will be able to say that.”

page 12 | news & views web extra September/October 2012

At Hassenfeld’s annual Back to School Blast, residents from NYU College of Dentistry gave teeth-brushing lessons with the aid of a hand puppet.

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