The ‘Art’ of Research in the Emergency Department
Dr. Art Pancioli at a Research Experience hosted by the American Heart Association /American Stroke Association and UCMC. Photo by Cindy Starr / Mayfield Clinic. When patients are brought into the emergency department, stricken by a stroke, epileptic seizure or other acute illness, they don’t want their doctors guessing about what to do next. But for doctors to be certain of what is best in life-threatening situations, they need data to back them up. And that means research must be conducted in the Emergency Department. The difficulty in accomplishing this, Art Pancioli, MD, said Wednesday night during a presentation at the Vontz Center for Molecular Studies, is not a matter of asking the right questions. The problem lies in figuring out how to answer them in an environment defined by urgency and the unexpected. “It’s not the what if,” he said. “It’s the how.” Dr. Pancioli is the Richard C. Levy Professor and Chairman of Emergency Medicine at UC and a member of the UC Stroke Team at the UC Neuroscience Institute, one of four institutes of the UC College of Medicine and UC Health. Addressing supporters of the American Heart Association / American Stroke Association and the UC Medical Center, he showed a picture that spoke a thousand words about why research in the Emergency Department might be a little bit challenging. “This is our world,” he said. “This is our reality. It is chaos incarnate. It is abject panic. How do you do research in this?” Furthermore, to enroll a patient in a clinical trial that might help scientists understand whether treatment A is better than treatment B, a consent form typically must be signed. Dr. Pancioli described a situation in which he asked a family he had known for only 7 minutes whether they would consent for their loved one’s inclusion in a clinical trial. He described “the level of trust that families must have to be willing to participate in research and the great appreciation and sense of duty to that patient and family that clinical researchers feel having received such trust.” Despite these hurdles, UC’s Department of Emergency Medicine is a national leader in research that tests new therapies and protocols for patients whose lives hang in the balance. And its expertise in the treatment of acute stroke played an important role in the UC Medical Center’s certification, announced yesterday, as an advanced comprehensive stroke center. The department, which includes 50 faculty members: • Produced 90-peer-reviewed publications in 2012, twice the number of the second most prolific research institution; • Is the leading enroller of study participants in the national coalition known as the Neurological Emergency Treatment Trials, a permanent research framework led by 22 large university medical centers throughout the United States; • Played an important role in the RAMPART study – named study of the year by the Society of Clinical Trials – which determined that an injection of antiepileptic medication in the muscle by paramedics was superior to delivery of the medication by IV; • Is currently participating in two additional NETT trials: POINT, which is assessing a treatment for patients who have suffered a minor stroke or transient ischemic attack; and SHINE, which seeks to provide safety data on the use of insulin-infusion therapy for glucose control in patients who have suffered an acute stroke and whose blood sugar is out of control. • Played an integral role with the UC Stroke Team in additional NIH-funded studies related ischemic and bleeding stroke, including those under the umbrella of SPOTRIAS, a global network of centers that perform research and share data in an effort to develop new therapies for stroke. Irene Ewing, RN, BSN, discusses an Emergency Department study with a guest at last Wednesday’s event at the Vontz on the UC Academic Health Center campus. The UC Department of Emergency Medicine has a long history of excellence and leadership. It developed the very first residency training program in the United States, graduating its first trainee in 1970; it was the first emergency department in the United States to become involved in acute stroke research; and it became the first stroke and neurocritical care training program for emergency physicians in the United States in 2008. Dr. Pancioli, one of the first emergency medicine specialists on the UC Stroke Team, vividly remembers his first stroke patient. “It was 1991, and we did nothing for her,” he said. “There was nothing we could do.” Today, there is much Dr. Pancioli and his team do for patients who have suffered a stroke. And there is still much more to be done. “There are not enough hours in the day to answer all the good questions we have,” Dr. Pancioli said, “even with all the good people we have.” Dr. Pancioli concluded by thanking those in attendance for their support. Without donors and tax dollars, he noted, research cannot move forward for the betterment of humankind. – Cindy Starr
It’s Destination Rabbit Hash for Sunflower Revolution 100k
Lucy Lou, Mayor of Rabbit Hash, Ky., is already getting into the spirit of the 2013 Sunflower Revolution. Photos by Cindy Starr / Mayfield Clinic. Rabbit Hash, Ky. – This bike ride is not for everyone. It is 100 kilometers long, with winding roads and hills that demand fortitude on the way up and fearlessness on the way down. But the Sunflower Revolution Fitness Festival’s 100k event on Sept. 8 is worth the price of admission for any skilled cyclist who relishes a challenging and scenic workout. The ride, which benefits the James J. and Joan A. Gardner Family Center for Parkinson’s Disease and Movement Disorders at the UC Neuroscience Institute, one of four institutes of the UC College of Medicine and UC Health, will begin and end at Washington Park in Over-the-Rhine and will feature a memorable stop in the historic bungalow of a town known as Rabbit Hash. (Visit www.SunflowerRev.org for a complete list of Sunflower events, including the 40k bike ride and 5k run/walk on Sept. 8 and the free symposium on Sept. 7 for patients and caregivers.) Rabbit Hash, a 3 ½-acre burg in Boone County, Ky., is nestled along the Ohio River at the bottom of a lush, winding road. Directly across the river is Rising Sun, Ind., and its floating casino. But here in Rabbit Hash, founded in 1831, time has long stood still. The attractions, which include a General Store, a log cabin, a Rabbit Hash Ironworks stove, and the local doctor’s office where women gave birth without epidurals, have put the site on the National Register of Historic Places. “We call it the center of the universe, because it is,” says Bobbi Kayser of the Rabbit Hash Historical Society. Bobbi Kayser with Mayor Lucy Lou and, under the bench, former mayoral contender Travis. Ms. Kayser is secretary to the town’s mayor, who, in case you haven’t heard the lore, is a dog. The current office-holder is Lucy Lou, a 5-year-old border collie with a sweet disposition and a soft fur coat. Lucy Lou enjoys swimming in the Ohio and has shown a preference for brightly colored sunflowers. She does not bark at strangers. Lucy Lou won her lifetime term in 2008 over a charismatic field that featured 10 dogs, a cat, an opossum, a miniature donkey and a human being. Because Rabbit Hash has only one permanent resident, the election was opened up to anyone and everyone. Voters paid $1 per vote and were encouraged to vote often, either at the General Store (where drinking while voting was also encouraged) or via PayPal. Votes were cast from as far away as Japan, Russia and Denmark. According to the official Rabbit Hash website, when “last call” for voting was announced, “money flew like fur.” Lucy Lou emerged victorious with more than 8,000 votes. Toby, a springer spaniel, was second; Travis the cat was third; and Higgins, the miniature donkey, was fourth. Sunflower Revolution founder Kathy Krumme, an avid cyclist and a manager at Oakley Cycles, encourages participants in the Sunflower 100k to pack money and a camera. “Although small, Rabbit Hash is full of photo opportunities and great shopping for ‘one of a kind’ treasures,” she says. “You might want to snag something cool at the Rabbit Hash General Store, such as a green-eyed stuffed kitty, and take photos of the Mayor and the amazingly decked-out motorcyclists you are likely to see!” The General Store lives up to its billing, with notions, potions and sundries that range from hand-carved canes, brooms and back scratchers, to souvenir T-shirts and sweet-smelling soaps from the South of France. Corncob back scratchers at the Rabbit Hash General Store. Ms. Kayser says thousands of visitors pass through Rabbit Hash each year, and periodic barn dances have been drawing 150 or more for live music by blues, rockabilly and old-timey groups. The town’s stores don’t generally open early on Sundays, but Ms. Kayser promised to pull a few strings so that Sunflower Revolution cyclists can fully enjoy the historic site during their stopover on the 100k. — Cindy Starr
UC Neuromuscular Program Reaches New Heights
Neuromuscular disorders specialist Hani Kushlaf, MD, in his office at the UC Academic Health Center. Photo by Cindy Starr / Mayfield Clinic During the nine months since his arrival, Hani Kushlaf, MD, has witnessed significant developments at the Neuromuscular Disorders Program at the University of Cincinnati Neuroscience Institute, one of four institutes of the UC College of Medicine and UC Health. The Neuromuscular Program has increased the number of patients served, has added diagnostic capabilities, and has established a protocol for acquiring and interpreting nerve and muscle biopsies for referred patients and those from other hospital systems. “We are adding to the neuromuscular medicine services that already exist at UC,” Dr. Kushlaf says. “I am very happy with the progress.” Neuromuscular diseases, which can be genetic, inflammatory, or autoimmune in origin, are those that affect nerves, muscles, and the neuromuscular junction. They include polyradiculopathies, peripheral nerve diseases, muscular dystrophies, ALS (Lou Gehrig’s disease), motor neuron disorders, and neuromuscular junction disorders (myasthenia gravis and Lambert-Eaton myasthenic syndrome). Dr. Kushlaf, a UC Health neurologist who sees patients at the UC Physicians’ offices in Clifton and West Chester, came to UCNI with enriched and lengthy training in neuromuscular disorders, having completed three fellowships in muscle disease and peripheral nerve disorders at the Mayo Clinic and an advanced neuromuscular medicine fellowship at Duke University. At UCNI he joined Drs. John Quinlan (Medical Director), Jason Heil, Robert Neel, Joseph Nicolas and Laura Sams. Two of the new diagnostic technologies now available at UCNI are single-fiber electromyography (SFEMG) and nerve and muscle ultrasound. SFEMG, which is offered nowhere else in the Greater Cincinnati-Northern Kentucky area, is a selective EMG recording technique that records electrical activity of single muscle fibers. It is primarily used in the diagnosis of patients with ocular myasthenia gravis and difficult-to-diagnose neuromuscular junction disease. “We carefully select patients for the test because we don’t want to do it unless it’s really needed,” Dr. Kushlaf says. “However, it is a very helpful technique. It provides a lot of information in selected patients and can be the only test that allows us to positively diagnose a neuromuscular junction disorder.” A second diagnostic tool, neuromuscular ultrasound, involves the imaging of nerves and muscles and is performed in conjunction with electrodiagnostic studies. “It is a new technique in the neuromuscular medicine world, and it is helpful as a noninvasive and cost-effective tool to look at focal nerve diseases,” Dr. Kushlaf says. During the last several months the Neuromuscular Disorders Program has also collaborated with UC Health specialists in surgery and pathology to establish a streamlined method for acquiring nerve and muscle biopsies. “If a physician has a patient who could benefit from a nerve or muscle biopsy, we are happy to offer a consultation,” Dr. Kushlaf says. “We can see the patient in clinic, perform a biopsy and provide a second opinion. Or, we can interpret a biopsy that is sent to us.” Looking ahead, Dr. Kushlaf, an Assistant Professor of Neurology and Pathology, is hoping to secure two additional components of a program that is moving steadily toward a more national stature: 1) a fellowship for physicians who have completed their general residency training in neurology; and 2) the ability to participate in multi-site clinical trials that study new medications and therapies for patients. To join the national network of elite institutions that conduct clinical trials, Dr. Kushlaf says, the program first needs to establish a cohort of patients with every neuromuscular disease. “If, for example, we have a number of patients with motor-neuron disease and a number with myasthenia gravis, we would be available as a site to enroll patients in multi-center trials of therapies for those conditions. And we really have arrived at that stage.” Establishing a critical mass of patients affected by specific neuromuscular diseases is challenging, Dr. Kushlaf says, because many of the diseases in neuromuscular medicine are rare. An institution with 10 patients enrolled in a study, he says, could have the largest number of patients of any study site in the country. Next on the agenda for Dr. Kushlaf and his colleagues is the annual Muscular Dystrophy Association Camp, which will be held for children June 30 through July 6 at YMCA Camp Campbell Gard in Hamilton, Ohio. The Neuromuscular Disorders Program physicians will be on call 24-7 to provide guidance to on-site medical staff or travel to the camp if needed. — Cindy Starr
Summer Reading Recommendations from Our Neuroscience Team
Research shows that vacations are good for your health! Your heart will thank you for getting away from work and its accompanying stresses. For many people, one of the most enjoyable parts of a vacation is indulging in a good book. If you haven’t read a book yet this summer and you’re not sure where to start, here are recommendations from specialists and associates at the UC Neuroscience Institute, one of four institutes of the UC College of Medicine and UC Health. Some are related to neuroscience and education, while others are not. All have value in their ability to inspire or enlighten. Joseph Broderick, MD, Research Director, UC Neuroscience Institute, and Albert Barnes Voorheis Professor & Chair, UC Department of Neurology Unbroken, by Laura Hillenbrand. “A great and compelling real-life story of a true World War II hero.” Thinking, Fast and Slow, by Daniel Kahneman. “This is the best book about how and why we make decisions in our daily life by a Nobel Prize winner in behavioral economics. I paraphrase my experience of this book as ‘Reading slow and thinking deep.’ ” John M. Tew, Jr., MD, Clinical Director, UC Neuroscience Institute, and Professor of Neurosurgery, Radiology & Surgery Whole: Rethinking the Science of Nutrition, by T. Colin Campbell. “Whole is the successor to The China Study (by T. Colin Campbell and Thomas M. Campbell II). “Both books are rather complex and require a deep appreciation for the theory of why there is such resistance to the plant nutrition concept. Whole provides the insight into the industrial-business resistance to the life-changing opportunity that plant-based nutrition can provide.” Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity, and Disease, by Robert H. Lustig. “This is another good summer read. Most people should be familiar with the publications of Dean Ornish, whose work is readable and transformative.” Michael Privitera, MD, Medical Director of the UC Epilepsy Center and Professor of Epilepsy Another thumbs up for Thinking, Fast and Slow, by Daniel Kahneman. “This is my choice for summer reading for the academic neuroscientist. This is a very readable book that uses psychological research to show us how we think and make decisions, most of the time without realizing it. His insights on undetected biases are interesting and helpful when understanding decisions that range from personal to professional. His simplified construct of System 1 and System 2 is appealing, although I believe there is much more complexity in the brain and mind.” Henry Nasrallah, MD, Professor of Psychiatry and Behavioral Neuroscience and Director of the Schizophrenia Program at UC In Search of Memory: The Emergence of a New Science of Mind, by Eric R. Kandel, MD, Nobel Prize Laureate in Medicine in 2000. “This is a wonderful and inspiring autobiographical book by one of the premier neuroscientists of our time. It is full of insights about life and clues of what it takes to achieve greatness. I invited Professor Kandel to deliver a special lecture last October and, for the first time in years, it was a full-house, including the balcony.” Ravi Samy, MD, Associate Professor of Otolaryngology and Director of the Adult Cochlear Implant Program at UCNI On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry, by John Toussaint, MD, et. al. “This is a great book on lean / kaizen principles to improve the quality of healthcare while reducing costs.” Rekha Chaudhary, MD, Assistant Professor of Medicine and Neuro-Oncologist at UC Brain Tumor Center: The Alchemist, by an allegorical novel by Paulo Coelho, first published in 1988 and translated into more than 50 languages. “This is an inspirational book for any new journey.” Cal Adler, MD, Associate Professor of Psychiatry & Behavioral Neuroscience and Co-Director of the Mood Disorders Center at UCNI Darkness Visible: A Memoir of Madness, by William Styron. The book grew out of a lecture given at the Department of Psychiatry at Johns Hopkins University School of Medicine. “It is an insightful description of the author’s depression, even if it’s not entirely complimentary toward psychiatrists.” Keith Herrell, Public Information Officer for UC Department of Neurology and Rehabilitation Medicine and the Department of Psychiatry and Behavioral Neuroscience The Center Cannot Hold, by Elyn R. Saks, Professor at University of Southern California Gould School of Law. “Carol Tamminga, MD, mentioned this 2007 book during her Nasrallah Lecture May 15. Subtitled, ‘My Journey Through Madness,’ it’s a well-written memoir by a woman who has lived with schizophrenia throughout her life—even while attending Vanderbilt University and Yale Law School, studying in Oxford and teaching law classes. I found her repeated efforts to avoid medication particularly interesting. Ultimately, she came to terms with her medication, combined with talk therapy.” An Unquenchable Thirst: Following Mother Teresa in Search of Love, Service, and an Authentic Life, by Mary Johnson, former Missionaries of Charity nun. “As Sister Donata, wearing a white and blue sari, American Mary Johnson spent 20 years with the famed Missionaries of Charity order founded by Mother Teresa. This 2011 memoir is a fascinating behind-the-scenes look at life as a Missionaries of Charity nun, with plenty of glimpses of the great woman herself (who comes out unscathed but apparently operating on automatic pilot at times). If you’re looking for dirt, you’ll find it: jealousies, backbiting and predatory sexual behavior are part of life in the order. Still, Johnson’s journey of self-discovery is a compelling one well worth the read.” Cindy Starr, communications specialist and contract employee, UC Neuroscience Institute Far From the Tree: Parents, Children and the Search for Identity, by Andrew Solomon, Lecturer in Psychiatry at Cornell University. “Andrew Solomon presents a compendium of stories, statistics and insights about children who are nothing like their parents and the ‘horizontal communities’ they strive to find. Chapters explore children and their families who live with autism, dwarfism, disability, deafness, Down syndrome and schizophrenia. Additional chapters probe the lives of families whose children are prodigies, criminals and the product of rape. I will never see families who confront
Use Your ‘Street Smarts’ to Avoid Facial Trauma
David Hom, MD, Director of Facial Plastic & Reconstructive Surgery, on the UC Academic Health Center campus. Photo by Cindy Starr / Mayfield Clinic. By David Hom, MD The topic of facial trauma has been in the news recently as members of the media have told the story of Chris Byrd, whose nose was bitten off during an altercation after a night out with friends. The story had a favorable ending, however, because our surgical team was able to reconstruct the young man’s nose and give him a chance to move on to a more normal life. Without doubt, Mr. Byrd’s story is one of the more dramatic examples of facial trauma, which we treat at the University of Cincinnati Neuroscience Institute and UC Health. But Mr. Byrd, who was injured in July 2012, also illustrates the rise in facial trauma injuries that my colleagues and I see during a period known as “trauma season,” which begins in April and extends into October. Facial injuries double during this time, and in a typical week I may see 6, 8 or even 10 cases of traumatic facial injury. The most common of these injuries are broken noses, jaws and cheekbones, accompanied by multiple facial lacerations. If cuts are deep, they can injure the facial nerve, causing the inability to close your eyes, lift up your eyebrows, wrinkle your nose, smile and frown. Such injuries can involve physical pain and disfigurement as well as mental anguish for the patient and family. Some facial injuries, caused by flying elbows on the basketball court or misjudged fly balls on the baseball field, are true accidents. But facial injuries caused by vehicular accidents and altercations are often the result of unawareness, arrogance or carelessness, and all of us can reduce our chances of suffering a potentially life-changing facial injury by taking a few common sense precautions. Where altercations are concerned, physicians can almost predict the setting: the individual is leaving a premises at night and is in a parking lot. In the scenarios we see most often, these altercations are random acts that occur when the perpetrator or victim has been drinking or when the victim is talking on a cell phone, texting or walking alone. Distracted by the phone, the victim becomes oblivious to his or her surroundings and fails to intuitively recognize the warning signs that something bad is about to happen. Drinking, texting, talking, walking alone: these all add up to vulnerability. Meanwhile, many facial injuries that are caused by motor vehicle accidents also have a common thread: a left-hand turn. Picture yourself making a left-hand turn at an intersection: cars are coming toward you, and you can see cars waiting impatiently behind you in your rear-view mirror. People want you to hurry, and you want to comply. The traffic breaks, you start to turn and there – suddenly — is a pedestrian walking across the street. Because left-hand turns carry more risk than may be apparent, drivers should always exercise caution when turning left, and pedestrians should remain vigilant, even if they are crossing in accordance with the traffic signal. I’ve seen it both ways recently: a patient (pedestrian) who had been hit by a commercial truck, and a patient (driver) who made a left-hand turn in front of an oncoming car. Speed is another factor in facial trauma. As speed limits increase, the severity of facial injuries goes up. Facial surgeons praise the shoulder harness and airbags, which have kept thousands of faces from crashing against dashboards and windshields. But high impacts can still result in facial injury – especially when drivers and passengers are unbelted. If a facial injury does occur, specialists in trauma surgery, neurosurgery, plastic surgery, oral maxillofacial surgery, ophthalmology and otolaryngology at the UC Medical Center and UC Health work in a comprehensive manner, because an injury to the face can also cause trauma to the brain, eye and neck. Rehabilitation can be lengthy, both physically and psychologically, and these injuries may also require the services of occupational and physical therapists. Clearly, an ounce of prevention is worth the months of cure that facial trauma requires. As you and your loved ones enjoy the warm weather and the outdoor pleasures that go with it, use your “street smarts.” Be aware of your surroundings, especially at night. Don’t use your phone as you’re walking to your car at night. Obey speed limits, avoid difficult left turns when possible and, if you must turn left, focus on what’s in front of you and not on the impatient driver behind you. * * * David Hom, MD, is Professor and Director of Facial Plastic & Reconstructive Surgery in the Department of Otolaryngology-Head & Neck Surgery, at the University of Cincinnati and a facial plastic and reconstructive surgeon at the UC Neuroscience Institute and UC Health.
Scholar Probes New Brain Cancer Pathway with $50k Grant from AANS Section on Tumors
Kazutaka Sumita, MD, PhD, a fellow in the Department of Hematology-Oncology, in his lab at the Vontz Center for Molecular Studies at UC. Photo by Cindy Starr / Mayfield Clinic. Kazutaka “Kazu” Sumita, MD, PhD, knows how to meet a challenge. He earned his doctoral and medical degrees at Tokyo Medical & Dental University and then trained to become a brain surgeon. To date, he has performed more than 1,300 surgeries, including a particularly terrifying one. When the Higashi nihon daishinsa –the Great East Japan Earthquake — struck off the Pacific coast of Tōhoku in 2011, triggering the deadly tsunami, Dr. Sumita was performing an endovascular treatment. The lights went out and all power was lost for an hour, but he managed to finish the operation safely and save his patient. Dr. Sumita, a post-doctoral fellow in the Division of Hematology-Oncology and a researcher at the Brain Tumor Center at the UC Neuroscience Institute and UC Cancer Institute, today faces an equally big challenge: He has been awarded a $50,000 grant — the American Association of Neurological Surgeons (AANS) Section on Tumors/Brainlab International Research Fellowship — to pursue a novel laboratory study of malignant brain tumors. The grant allows a foreign neurosurgeon to perform clinical, translational or basic research in the field of neurosurgical oncology in a clinical and/or laboratory setting within the United States. Details of Dr. Sumita’s work will be published in a scientific report in a couple of years. He is targeting an energy pathway that enables malignant primary and metastatic brain tumors to grow and spread. More specifically, he is studying phosphoinositide signaling. Phosphoinositide is a cellular messenger that plays a role in controlling cellular activities such as growth and proliferation. Once cells have lost control of phosophoinositide signaling, the risk for disease, particularly cancer, increases. “We are looking for pathways that are important for the survival of brain cancer cells,” Dr. Sumita said. “We want to identify these pathways so that we can stop the growth of primary brain cancers (such as glioblastoma) as well as metastatic brain tumors. The pathway we are now discovering is a new signaling pathway; it will be a sensational finding, and when we interfere with this pathway, we expect to see a decrease in tumor growth. “Right now we do not understand how it is happening or what molecular mechanism is making it slow down. The fellowship will enable us to decipher the cause.” Atsuo Sasaki, PhD, Assistant Professor in the Division of Hematology-Oncology at UC and Dr. Sumita’s scientific mentor, said Dr. Sumita “is likely to discover the central energy status” in cancer cells that have changed from normal brain cells. “This is an important component of tumor therapy,” he said. “Ideally, we do not want to kill normal cells during treatment, yet this is a major problem with chemotherapy. People suffer side-effects because the therapy also acts on normal tissue. What Dr. Sumita has found is the clue for a brain tumor-specific energy pathway, or energy utilization pathway. We think that this pathway is linked to the phosphoinositide signaling pathway.” If such a pathway could be targeted with medication, the researchers said, it would give doctors a way to combat cancer cells without harming healthy cells. Physician-scientists like Dr. Sumita bring a valuable perspective to the study of disease. They can seamlessly introduce the important clinical questions into the laboratory and then test the lab findings in Phase 1 clinical trials. If successful, Phase 1 trials can ultimately lead to a clinically relevant therapy. “Kazu believes that basic science will help him find a way to cure patients suffering from brain tumors, trauma or neurovascular disease,” Dr. Sasaki said. “During his clinical work he had many patients who suffered from malignant brain tumors. Surgery helps, but it is not a complete solution. He is pursuing this training to find a cure for brain tumors. “His aspirations are high,” Dr. Sasaki continued. “He is a really dedicated researcher and clinician, and you see him at the lab almost 24-7.” “We have a great clue,” Dr. Sumita said. “We want to understand this pathway in a year or two. No other researchers are looking at this pathway. We want to be the first.” — Cindy Starr
Calming the Brain the Night before a Big Event
Who among us hasn’t had the dreaded experience of trying to fall asleep the night before a big exam, presentation, competition or other nerve-wracking event? The harder we try to relax and fall asleep, the louder the seconds tick by. And the more we worry that we’re losing precious sleep time, the more elusive the all-important “good night’s sleep” becomes. Well, maybe a “good night’s sleep” isn’t as important as we think. And maybe we are just setting ourselves up for failure by believing that it is. “The two things you can’t do by trying really hard are sleep and sex,” says Scott Ries, MSW, LISW, Associate Professor and Administrative Director of the Mood Disorders Center at the University of Cincinnati Neuroscience Institute, one of four institutes of the UC College of Medicine and UC Health. “If I go to bed saying I have to do something, and I’m worried that I am not going to do it, then I am going to activate the threat center in the brain, and my brain is not going to want me to sleep. “So the better approach is to say, ‘Yes, it would be great if I could get a good night’s sleep; but if I don’t, it’s not the end of the world.’ ” The good news, Mr. Ries says, is that most of us can function after not sleeping well for a night or even two. All parents have experienced times when they were up all night with a sick child but then were able to get through the next day. Perhaps most famously, Charles Lindbergh crossed the Atlantic in a single-engine airplane after not sleeping the night before. So even if a really good night sleep is optimal, you are more likely to get one if, paradoxically, you do not care whether you get one. “You can’t force yourself to sleep,” Mr. Ries says. “It’s something that relies on your being able to let go. Think of all the times when you fall asleep at night when you’re reading a book or watching television or attending a dinner party. You can barely keep your eyes open, because you are not trying to sleep. And then, the night before something big, you go to bed and think, ‘I have to get a good night’s sleep!’ And that worry begins to ruminate in your mind. Plus you are worrying about the stressful event that you will be facing tomorrow. So you already have one worry, and now you’re adding another one. Your brain is going to alert itself to a problem out there, and it is going to try to keep you awake.” Mr. Ries stresses that his comments apply to people who normally don’t have trouble falling asleep and do not suffer from serious sleep disorders, which include obstructive sleep apnea and sleep disruptions caused by medication side effects, medical conditions (such as asthma, thyroid disease or heart failure), neurological conditions (such as epilepsy, stroke or Parkinson’s disease), and psychiatric disorders (such as anxiety and depression). At the same time, he says, all of us can benefit from good “sleep hygiene,” the act of creating an environment that maximizes our chances for a restful sleep. “You want to be in an environment that is relatively cool, quiet and dark – meaning that you don’t have the TV on or a glowing alarm clock looking at you,” Mr. Ries says. Jennifer Rose Molano, a neurologist and sleep specialist with UCNI’s Memory Disorders Center, explains that sleep is regulated by two main processes: 1) our circadian rhythm, or internal clock; and 2) the buildup of the sleep drive throughout the day. “It’s a combination of those two things that help us stay awake during the day and fall asleep at night,” she says. “Our sleep drive is highly influenced by what we do during the day,” Dr. Molano continues. “The two things that can influence our sleep drive at night are caffeine or taking prolonged naps in the afternoon. If people drink a lot of caffeine in the afternoon or if they take a one- or two-hour nap during the day, their body is a little bit confused when they try to go to sleep at 10 or 11 at night. Their body is getting a mixed signal; it doesn’t understand why it’s supposed to go to sleep.” Cal Adler, MD, Associate Professor of Psychiatry and Co-Director of the UC Mood Disorders Center, says that ideally people should establish good sleep hygiene well in advance of exams, presentations and other stressful events. “Students may benefit from following a regular sleep schedule,” he says. “Falling asleep the night before an exam or other stressful event is easier if a pattern of going to sleep at a regular time has already been established.” Dr. Adler also offers these recommendations: • Avoid caffeine after noon the day before the event/exam. • Light exercise can be helpful, but don’t overdo it. • Don’t overeat the evening before. • Listening to relaxing music can be helpful; hard rock might not be a good choice. • A shower or bath is sometimes helpful. • If you can’t sleep, don’t try to fill the time with further studying. It can be helpful to go to bed even if you don’t think you are going to be able to fall asleep. People facing a stressful event should not give in to the temptation to take medication unless it has been prescribed by a physician, Mr. Ries says. He also does not recommend drinking alcohol, which “may help you fall asleep but will not necessarily help you stay asleep.” Dr. Adler adds that while some people find over-the-counter medications helpful, the night before a big event is not the time to try them out. When Mr. Ries has trouble sleeping, he gets out of bed and walks – in the dark – to another quiet place in the house. “I’ll sit quietly in the dark, and usually one of the
UCNI’s Mission to Educate in High Gear This Week
Jim Eliassen, PhD, Associate Director of the Neuroscience Graduate Programand Professor of Psychiatry, asks a question during the annual Nasrallah Lectureon Schizophrenia. Photos by Cindy Starr / Mayfield Clinic. The University of Cincinnati Neuroscience Institute’s mission has three components: patient care, research and education. The third part of that mission was on proud display this week as multiple neuroscience disciplines and centers of excellence staged premier lectures and presentations. From brain metastasis to multiple sclerosis to schizophrenia to rare movement disorders, the topics of the educational sessions were designed to intrigue and inspire clinicians, researchers and supporters to continue pressing forward in new directions at the UC Neuroscience Institute, one of four institutes of the UC College of Medicine and UC Health. What do dandelions and brain metastases have in common? Ronald Warnick, MD, Medical Director of the UC Brain Tumor Center, spelled out the problem of brain metastasis in stark terms at the fourth annual Wine Tasting Celebration at the Myers Alumni Center Tuesday night on the UC campus. This year, 170,000 people will be diagnosed with a brain metastasis in the United States alone, and the problem is increasing because people increasingly survive cancer. Whereas only 50 percent of cancer patients lived five years in 1975, 70 percent do so today. Lung cancer, breast cancer and melanoma are the most likely cancers to metastasize, or spread, to the brain. Dr. Warnick explained brain metastasis with an analogy to seed and soil. Just as a dandelion’s seeds break away, blow in the wind and land in the soil, a lung or breast cancer’s cells break off and spread through the bloodstream and settle in another part of the body. And just as dandelions sprout anew in fertile, nutrient-rich soil, cancer cells take root as new tumors when they settle in the brain. James Driscoll, MD, PhD, of the UC Brain Tumor Center The source of nutrients, Dr. Warnick said, is healthy brain cells. With the help of funding generated by the 2012 Wine Tasting event, James Driscoll, MD, PhD, and his research team looked at how normal brain cells are providing nutrients to the invading cancer cells and causing uncontrolled growth, Dr. Warnick said. “A signal called micro RNA is stimulating the tumor cells to grow uncontrollably, while activating a force field that protects the cancer cells from chemotherapy. The result is a brain metastasis that is growing rapidly and is resistant to our common therapies.” Dr. Driscoll’s next step was to introduce a suppressor that blocked that micro RNA signal, thereby preventing the cancer cell from receiving nutrients from healthy brain cells. This, in turn, caused the cancer cells to wither and die, like dandelion seeds that land on dry, barren soil. Dr. Driscoll is now testing the therapy in an animal model. If successful, it could lead to a phase I clinical trial for brain metastasis in early 2014. Dr. Warnick closed his remarks by thanking the Brain Tumor Center’s supporters. “Your generosity and support last year allowed us to do this cutting-edge research, and your support tonight will allow us to take on the next promising avenue of research.” What is plaguing our patients with rare movement disorders? The Unusual Movement Disorders Marathon Symposium drew more than 150 neurologists, residents-in-training and experts from six countries Wednesday evening at the Cincinnati Club in downtown Cincinnati. The event was directed by Alberto Espay, MD, Research Director at the James J. and Joan A. Gardner Family Center for Parkinson’s Disease and Movement Disorders and a neurologist at UC Health. Symposium Director Alberto Espay, MD, of the UC Gardner Center During the symposium 12 professors each presented one of the most challenging cases of their careers, and a group of three internationally known specialists (pictured above) with no prior knowledge of the cases then discussed them and worked to arrive at the correct diagnoses and optimal treatment plans. The heart-rending cases, illustrated by video, depicted once-healthy people struggling with ruinous symptoms that included cognitive decline, shaking, rigidity and freezing of gait. The cases were also staggeringly difficult, in some cases stumping the panel. They demanded knowledge of genetics, pathology, neurology and physiology, and they illuminated the profound difficulties that can confront a neurologist who is working independently. Among these, there was a rare case of galactosemia and a singular case of “slowly progressive” rapid-onset dystonia parkinsonism (RODP). (Only 50 cases of RODP have been recorded since 1993.) There was a syndrome precipitated by legionella, the pathogen that causes Legionnaires disease. Another case presentation, which had bedeviled doctors at a leading center for four years, was just recently solved with an observation from a neurologist from another center. The event, endorsed by the Movement Disorder Society and likely to be repeated in the future, was supported by educational grants from Merz, Ipsen, Allergan, USWorldMeds, Athena diagnostics, Medtronic and UCB. Dr. Carol Tamminga, the 2013 Nasrallah Lecturer, and Dr. Henry Nasrallah of the UC Mood Disorders Center What is the role of the hippocampus in schizophrenia? Carol Tamminga, MD, Professor and Chairman in the Department of Psychiatry at the University of Texas Southwestern Medical School and a longtime leader in the field of schizophrenia, presented the 2013 Nasrallah Lecture Wednesday at UC. Schizophrenia is a brain disease whose “bizarre and almost unbelievable symptoms,” in Dr. Tamminga’s words, have driven her quest to answer the question: “How can a brain do that?” For the last 15 years she has focused her attention on the hippocampus, a small area of the brain that is “the size of your little finger” and that plays a role in synthesizing experiences into coherent memories. The brain has two hippocampi, one on each side, and within the hippocampi are “little stations that perform unique tasks and have unique functions,” she said. “We rely on the hippocampus, which is highly plastic, to learn something new.” People with schizophrenia have alterations in parts of their brains, including the hippocampus, which appear to contribute to psychosis (hallucinations, delusions or other
The Cruel Duality of Bipolar Disorder: Creativity and High Risk
Henry Nasrallah, MD, Course Co-Director of the 3rd AnnualMood Disorders Symposium. Photo by Cindy Starr / Mayfield Clinic. What did Abraham Lincoln, Winston Churchill, Leo Tolstoy, Virginia Woolf and Jimi Hendrix have in common? And what condition do Judy Collins, James Taylor, Kitty Dukakis, Kay Jamison and Catherine Zeta-Jones also share? The answer is bipolar disorder, a mood disorder characterized by periods of high energy, euphoria or irritability, and sleeplessness followed by periods of depression. The condition was the topic of Saturday’s third annual Mood Disorders Symposium, a continuing education event that was held at UC Health Drake Center. The event was sponsored by the Mood Disorders Center at the UC Neuroscience Institute, one of four institutes of the UC College of Medicine and UC Health; the Department of Psychiatry and Behavioral Neuroscience; and the Center for Clinical & Translational Science & Training. Henry Nasrallah, MD, Professor of Psychiatry and Behavioral Neuroscience and Vice Chair for Education and Training, said the topic was a fitting one for May, which is national Mental Health Awareness Month. April and May represent the peak suicide months of the year, and 15 to 18 percent of people with bipolar disorder will die of suicide if they go untreated. “Bipolar disorder can make a person more creative and productive, and there are many examples of high-achieving people with bipolar,” Dr. Nasrallah said. “Georg Friedrich Händel wrote the Messiah in two weeks during a manic episode. But the condition is also disabling. Bipolar disorder has one of highest associations with suicide in medicine.” Stephen Strakowski, MD, explained the neurobiology of bipolar disorder. Stephen Strakowski, MD, the Stanley and Mickey Kaplan Professor and Chair of the Department of Psychiatry and Behavioral Neuroscience and Vice President of Research for UC Health, said bipolar disorder is a brain disease. “It is not caused by bad parenting or the environment; it is caused by genetics,” he said. Fortunately, many treatments for bipolar disorder exist, including longstanding medications (e.g., lithium), newer mood stabilizers and antipsychotics, various types of interpersonal and family-focused therapy, transcranial magnetic stimulation and electroconvulsive therapy. Bipolar disorder exists on a spectrum, Dr. Nasrallah said, and a recent survey of 100,000 people suggests that it affects 3.7 percent of the population. People with bipolar I suffer severe depression and mania (disabling extreme moods) and may be hospitalized for both. People with bipolar II have less dramatic periods of “hypo-mania” and are hospitalized only for major depression. “Bipolar patients are the ones who are reading four or five books at the same time,” Dr. Nasrallah said. “They typically are not diagnosed until the mania interferes with their job or they are hospitalized.” Treatment is vital because a brain bathed in cortisol – a stress hormone – can undergo serious changes. Although bipolar disorder cannot be diagnosed with brain imaging, brain imaging studies have revealed specific characteristics in the bipolar brain. Several imaging studies, but not all, have shown that the amygdala appears to develop abnormally in untreated patients with bipolar disorder. “The amygdala, which processes our fight-or-flight reactions to fear, is smaller than normal in children and enlarged in adults with bipolar disorder,” Dr. Strakowski said. “The developmental process in the amygdala has gone awry.” At the same time, the ventricles, reservoirs where fluids are exchanged, spread and grow larger, reflecting a loss of surrounding brain tissue. “These patients lose white-matter connections, the connecting neuronal pathways, in the brain,” Dr. Strakowski said. “We worry that the efficiency of these networks is degrading.” Brain imaging of people with bipolar disorder reveals heightened activity in the amygdala and prefrontal cortex, where executive function resides. “Our hypothesis is that the prefrontal cortex is over-working to control an over-activated amygdala,” Dr. Strakowski said. “The brain is compensating at baseline, struggling to maintain a dysfunctional emotional regulatory system. During mania, the amygdala loses prefrontal control, which leads to wild emotional swings.” Glutamate, an excitatory neurotransmitter, is elevated in people with bipolar disorder, as is lactate in the brain, reflecting abnormalities with energy management “at a very deep cellular level,” he said. Other general points of interest from the symposium included: Only 20 percent of people with bipolar disorder have been diagnosed, and the average person with the condition will suffer for eight years before receiving a correct diagnosis. The average age at onset is 18 to 24 years, although children have also been diagnosed with the condition. Sixty percent will initially be diagnosed with depression. Bipolar disorder is equally common in men and women, while unipolar depression is much more common in women. In families with strong heredity, the onset of bipolar disorder may occur earlier with successive generations. After April and May, October brings the second-highest wave of suicides. Researchers theorize that the light-dark change triggers mania, which leads to suicide. A lethal combination of “depressive thinking, combined with the energy to do something about it,” results in these tragedies, Dr. Strakowski said. “We need to keep a close eye on patients at those times.” Medications for bipolar disorder can include a host of unpleasant side-effects and can be challenging for patients. A collaborative partnership among health care providers and caregivers and family can maximize the potential for recovery, said Cal Adler, MD, Associate Professor of Psychiatry and Behavioral Neuroscience and Co-Medical Director of the UC Mood Disorders Center. Catherine, a social worker, shared her story of recovery. Catherine, a survivor of bipolar disorder who is now a social worker, said that therapy, medication, family support and a consistent work and sleep schedule were all part of her recovery. Melissa DelBello, MD, Professor of Psychiatry and Behavioral Neuroscience and Co-Medical Director of the UC Mood Disorders Center, said some data suggest that omega 3’s will help some depressive symptoms. Even if they fail to do so, they can help counteract risk factors like weight gain, a side-effect of some medications. When to switch doctors? A patient should switch if he or she does not like his or her physician and should not fear
At Telestroke’s First Anniversary, 40 Lives Touched in Lawrenceburg
Opeolu Adeoye, MD, demonstrates the telestroke robot at the University of Cincinnati Medical Center. Photo by Cindy Starr / Mayfield Clinic. As Dearborn County Hospital in Lawrenceburg, Ind., prepares to mark its one-year anniversary with the UC Health Telestroke Network next Tuesday on the eve of Stroke Awareness Month, hospital President and CEO Roger Howard could not be more pleased with the initiative’s success. “We have had just over 40 patients brought to our hospital who were candidates for the stroke protocol,” Mr. Howard said this week. “That’s 40 patients who may have been treated differently a few years ago. It is not a huge number, but one is a huge number if you’re the one. The program has changed 40 lives – 40 families — in this community.” The UC Health Telestroke Network, an initiative that includes the Comprehensive Stroke Center at the UC Neuroscience Institute, enables physicians from the UC Stroke Team to “examine” stroke patients long-distance with the help of robots. UC Health launched the program in March 2012, with one robot placed in the UC Medical Center’s Emergency Department and another in the Neuroscience Intensive Care Unit. By early May 2013, UC Health will have seven official telestroke affiliates, including West Chester Hospital. Opeolu Adeoye, MDDirector, Telestroke Program Opeolu Adeoye, MD, Director of the Telestroke Program at UC Health and Interim Director of the Division of Neurocritical Care, described the telestroke program as an outstanding success. “The introduction of telestroke genuinely adds a dimension that allows us to improve upon the care we have been delivering,” he said. “We hope this model in stroke serves to expand the services we are able to deliver to communities in the Greater Cincinnati region.” Stroke is a leading cause of severe adult disability and the fourth leading cause of death in the United States. Time is precious when a stroke occurs, as brain cells lacking oxygen begin to die. People who have suffered an ischemic stroke — one caused by a blood clot — can reduce or eliminate their risk of death and disability through early treatment and the administration of the tPA within 3 to 4 ½-hours of the onset of the stroke’s first symptoms. At the same time, this drug does carry a risk: a small minority of patients will experience bleeding in the brain. A patient who avoids unnecessary administration of tPA therefore avoids that risk. Pamela Kimmel, RN, BSNTelestroke Program Manager The telestroke robots can play a critical role in expediting evaluation and treatment of patients in hospitals in rural or outlying areas. The robots enable audio-video communications in real time between a patient and clinician at a distant site and a UC Stroke Team member (with laptop) wherever he or she is at the time. The Stroke Team physician can interview the patient and observe while the patient performs simple tasks, such as touching his or her nose or repeating words or phrases. The physician also will be able to confirm or rule out facial droop and will even be able to see the size of the patient’s pupils. Ultimately, this co-evaluation by the community hospital’s emergency department and the Stroke Team specialists determines whether the patient should receive care at the outlying hospital or should be transferred to the UC Comprehensive Stroke Center for tertiary treatment. Of the 40 stroke patients who were treated at Dearborn County Hospital in the first year of the telestroke program, 17 were transferred to the UC Medical Center. At the opposite end of the treatment spectrum, telestroke can also help determine when less is best. Telestroke Program Manager Pam Kimmel, RN, BSN, noted that the very first telestroke patient would have received tPA based on the phone conversation shared between physicians. But after the Stroke Team physician examined the patient remotely, he determined that the stroke was not as severe as originally thought, and tPA – with its small but inherent risks — was therefore not administered. Roger Howard, President & CEODearborn County Hospital Mr. Howard said that once the telestroke program was instituted at Dearborn County Hospital, the changes were almost instantaneous. “The first huge change it made for us was to give our emergency room staff, physicians and nurses a tremendous amount of support,” he said. “When you are a rural or outlying hospital, you may not have that extra little bit of backup that can help reinforce your initial decisions.” The extra support – a virtual second opinion – was also greatly appreciated by patients and their families, Mr. Howard said. “We have worked with the UC Medical Center for years, but the telestroke program really brought this to the forefront, and it let patients know they are in good hands. They can see the doctors online, can hear them participating in their care. It gives the families of our patients a very good feeling that there is a team of healthcare workers there to help them, and not just one solo physician, working on their behalf.” Mr. Howard said the program had changed the public’s perception of the hospital, which supports 78 beds, 20,000 annual emergency room visits, and 150,000 annual out-patient visits. “The partnership with UC Health brings us up in stature as a place that can take care of you a little better when you come through our doors,” he said. “Every other month I conduct a local town hall meeting at one of our outlying communities. During these meetings I talk to people about the hospital and healthcare in general. Approximately 75 to 100 people attend, so it’s a good way for Dearborn County Hospital to deliver new information and also find out what people are thinking. “I bring up the topic of stroke and our affiliation with UC Health and the stroke protocol. The talks have enlightened the community and raised awareness about where people should go and – more importantly –when they should seek help. We have worked through our local EMS teams and city councils to