NYUTHE MAGAZINE OF NEW YORK UNIVERSITYPHYSICIAN SCHOOL OF MEDICINE SPRING 2014 TAKING IT ON FAITH Community-based programs are reducing the burden of hypertension in minority populations

PLUS THE MYSTERIOUS CHANNELS BETWEEN BRAIN CELLS HIGH-TECH VESTS FOR THE BLIND THE FUTURE OF FACE TRANSPLANTATION Help Us Make Dreams Come True

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New York University Martin Lipton, Esq. Chairman, Black-owned Board of Trustees barbershops in the John Sexton President city are neighborhood centers for healthcare Robert Berne Executive Vice President outreach. for Health • NYU Langone Medical Center DEPARTMENTS Kenneth G. Langone Chairman, Board of Trustees 02 From the Dean Addressing Health Disparities Robert I. Grossman, MD Dean and Chief 03 News From Medicine Executive Officer • A Surprising New Role for Kathy Lewis Immune Cells in the Brain Senior Vice President • DNA’s Surveyors Communications • A Virus Exerts Unusual Control and Marketing Over Its Host Cells • NYU PHYSICIAN 24 Faculty Conversation Steven B. Abramson, MD COVER STORIES Dr. Eduardo D. Rodriguez, Anthony J. Grieco, MD the new chair of plastic surgery, Editors, Science Taking It on Faith discusses face transplantation. and Medicine In churches, barbershops, and other

gathering places around New York 6 26 Faculty News Marjorie Shaffer City, researchers at the Center for Editor Dr. Jef Boeke Joins NYU Langone as Healthful Behavior Change are • Director of New Institute for Systems Genetics partnering with lay advisers to bring Nicole Dyer Dr. Ruth Lehmann Named Contributing Editor down soaring rates of hypertension • in minority populations. Chair of Cell Biology Sherry Zucker By Bryn Nelson • Dr. Andrew D. Rosenberg Appointed Print Production  Chair of Anesthesiology Coordinator The Spaces In Between • Dr. Edward Fisher Awarded Segal Savad Design Charles Nicholson’s pioneering Memorial Lectures Art Direction 14 studies of the slender channels • Dr. Rodolfo Llinás Honored around brain cells could lead to better Nancy E. Sherman drug delivery and new treatments for Copy Editor 28 Medical Education neurodegenerative diseases. Dr. Steven Abramson, chair of the Department • By Nicole Dyer of Medicine, revives a beloved teaching ON THE COVER: ILLUSTRATION BY tradition: Saturday morning rounds. LYNDON HAYES Stick Shift Driven by his own battle with a vision- 30 Patient Story 20 destroying disease, Dr. John-Ross Solving a case of facial paralysis by tapping Rizzo is devising better alternatives to into a nerve from the tongue. the white cane for the blind. By Kenneth Miller 32 Obituary David S. Baldwin, MD ILLUSTRATION BY LYNDON HAYES BY LYNDON ILLUSTRATION

NYU PHYSICIAN SPRING 2014 1 MESSAGE FROM THE DEAN & CEO

HYPERTENSION BY THE Addressing NUMBERS Health Disparities Hypertension among minority populations, particularly 42.6% African Americans, is devastating. High blood pressure killed Percentage of adult black men nearly 52 out of 100,000 black men in the United States in in U.S. with hypertension 2009, for example, triple the mortality rate for white men. The statistics are almost as dire for black women. The condition claimed about 38 lives out of 33.4% 100,000 black women, more than 2.5 times the Percentage of rate for white women. adult white men These appalling disparities, tracked by the in U.S. with hypertension American Heart Association in its latest survey, have long been a source of great frustration. How can healthcare providers engage minority communities to reduce the burden 47% of hypertension? In this issue of NYU Physician Percentage of magazine, the extraordinary work of Dr. Gbenga adult black women Ogedegbe, who founded the Center for Healthful in U.S. with hypertension Behavior Change at NYU Langone Medical Center, provides at least a partial answer. He and his colleagues have established community-based programs that enlist the help of lay health advisers in churches, barbershops, and other gathering places in New York City. 30.7% Dr. Ogedegbe’s work reveals how creative thinking about an intractable Percentage of adult white women healthcare problem can lead to new approaches with possibly lasting in U.S. with hypertension results. The two other features in this issue of the magazine also showcase creative thinkers seeking answers to pressing health problems and scientific conundrums. One story explores the work of Dr. Charles Nicholson, a pioneering neuroscientist whose exploration of the spaces between nerve cells in the brain has yielded some astounding insights. Another describes 69% The percentage of all the innovative work of Dr. John-Ross Rizzo, who is inventing low- and high- people who have their first tech successors to the cane for the blind. He himself suffers from an incurable heart attack and have blood disease that is destroying his eyesight. pressure higher than 140/90 Altogether, these inspiring stories reveal how tenacity, ingenuity, and creative insight can make a significant contribution to improving healthcare and our understanding of the human condition. That, after all, is a large part of our mission. $51 BILLION Estimated direct and indirect U.S. costs of hypertension in 2009

Sources: National Health and Nutrition Examination Survey (NHANES), DEAN & CEO ROBERT I. GROSSMAN, MD American Heart Association

NYU PHYSICIAN PHOTOGRAPH BY 2 SPRING 2014 JOHN CARNETT

NEWS FROM MEDICINE

A Surprising New Role for Immune Cells in the Brain Dan Littman

Researchers reveal that the cells are Wen-Biao Gan important for learning and memory. Christopher Parkhurst Microglial cells are best control of microglial functions. agent, in this case, the cancer understood as neuronal Researchers inactivate or drug tamoxifen. bodyguards of the brain and express specific genes in the With the ability to target spinal cord that patrol for microglia of these mice. “Before microglia specifically, the chemical that cements neuronal cellular debris and pathogens. our mice were generated, researchers found that mice connections. “We typically For Wen-Biao Gan, PhD, and there never was a good way to with diminished microglia associate BDNF with neurons,” his colleagues at the Skirball specifically change the genetic populations experienced Dr. Gan says. “But we know that Institute of Biomolecular expression and function of difficulty growing dendritic microglia secrete it too, and that Medicine at NYU Langone microglia or control their spines, the treelike extensions it plays an important part in the Medical Center, however, the chemical signaling without of neurons that connect to formation of synapses.” question that has propelled affecting related cells elsewhere other neurons and facilitate the The next step is to determine their work for the past decade in the body,” Dr. Gan explains. passage of information across precisely how microglia shape is not what microglia do when Previous studies in mice synapses, the junctions at which synapses. Do microglia interact things go wrong, as in disease, have shown that manipulating neurons meet. with other cells to do the job? Or but rather what the cells do a number of genes expressed In healthy mice, tests of maybe there are other chemical when things go right. in microglia disrupts the motor skills, such as balancing signals they secrete that In teasing out the function development and function of on a spinning rod, alter somehow influence neurons. of microglia in the healthy the central nervous system. neuronal connections. “When “It’s all possible,” Dr. Gan says. brains of mice, Dr. Gan and Yet none of these studies has you learn, you make new “We just don’t know, but we plan his team are overturning proved conclusive, since such synapses,” says Dr. Gan. But to find out.”• —NICOLE DYER common assumptions about target genes also express the microglia-deficient mice microglial function and offering themselves in related cells showed much-reduced growth compelling evidence in support elsewhere in the body. of new synapses. So did mice Microglia carrying a specific of the emerging idea that these The new mouse model—the unable to produce brain-derived gene glow red; others carry immune cells, far from being just product of a collaboration neurotrophic factor, or BDNF, a a fluorescent yellow protein. defensive sentries, play a pivotal with Dan Littman, MD, PhD, role in learning and memory. the Helen L. and Martin S. “People once believed that Kimmel Professor of Molecular microglia just sat around in Immunology—overcomes this healthy brains and became limitation. Dr. Littman and functional only in the presence of Christopher Parkhurst, an MD/ diseases,” says Dr. Gan. “Now we PhD student who is the first know that’s not true.” (In 2005 author of the Cell paper, turned Dr. Gan and his team discovered to a sophisticated genetic- that microglia cells move engineering tool that could constantly in healthy brains.) either remove or express specific In their latest study, genes in microglia using an published recently in Cell, the enzyme called Cre recombinase. scientists created a powerful The researchers could activate tool to study microglia: the first this enzyme at very precise genetically engineered mouse points in the animal’s life by model that affords precise administering an inducing IMAGE COURTESY OF DR. WEN-BIAO GAN WEN-BIAO OF DR. COURTESY IMAGE

ILLUSTRATIONS BY NYU PHYSICIAN LEANDRO CASTELAO SPRING 2014 3

NEWS FROM MEDICINE

DNA’s Surveyors New findings suggest how molecules collaborate to repair damaged DNA.

All organisms, from bacteria Evgeny Nudler to humans, face a near- constant onslaught of DNA Venu Kamarthapu damage from ultraviolet light, chemicals, and other sources. Life depends on the ability journal Nature, offer clearer of cellular repair specialists insights into how the repair to find and fix this damage process works and, most before it leads to a host of dire important, how it might be consequences, such as cancer, corrected when it goes awry. recurrent infections, and “Better repair means fewer Vitaly Epshtein premature aging. mutations, which also means Scientists only partially slower aging and lower rates understand how these repair of cancer and many other crews do their jobs. Recently, pathologies,” Dr. Nudler says. Our health largely depends however, Evgeny Nudler, PhD, According to the study, on how well DNA is repaired. a Howard Hughes Medical DNA repair appears to rely Investigator and the Julie on a close association between Wilson Anderson Professor RNA polymerase and a protein these pauses or arrests are subjects of molecular biology.” of Biochemistry, and his team called UvrD. Researchers the result of backtracking,” Why do RNA polymerases filled in some significant have long known that UvrD Dr. Nudler says. “So UvrD pulls transcribe most of our gaps in our comprehension of plays a major role in mending the polymerase backward, in genome, converting vast the process. The researchers damaged bacterial DNA. the opposite direction from the stretches of DNA to RNA, have long studied RNA Inherited defects in the gene way that it normally goes.” when only a tiny fraction polymerase, an enzyme encoding the human analog By doing so, the study of those resulting RNA that copies DNA into RNA of UvrD, a protein known as suggests, UvrD and a second transcripts will ever prove as it slides along tracks of XPB, have been implicated collaborator, called NusA, useful? That extensive activity, double-stranded DNA. This in a range of devastating and help expose damaged DNA he says, makes far more RNA, in turn, contains all of incurable disorders linked to sites lodged beneath the sense if the polymerase is the information needed to compromised DNA repair. polymerase. The two partners simultaneously patrolling construct cellular proteins. A powerful biochemical then recruit a team of other our chromosomes for DNA Their latest study, supported technique developed by Dr. proteins to patch up the DNA damage and ensuring that its by Timur Artemeyev, suggests Nudler’s lab pointed to the tracks before the polymerase associates help with repairs. that the key to successful DNA unexpected connection between continues on its way. Led by study co-authors repair is a sort of construction UvrD and RNA polymerase. Dr. Nudler says the new Vitaly Epshtein, PhD, and Venu supervisor able to literally Even more surprisingly, a series findings also offer a possible Kamarthapu, PhD, postdoctoral pull the polymerase backward of experiments suggested that justification for a puzzling fellows in Dr. Nudler’s lab, the to point out hidden sites of UvrD brings RNA polymerase phenomenon known as group’s research is dramatically damaged DNA that need to be to a grinding halt at frequent pervasive transcription, expanding that list of potential fixed. The mechanics of this intervals along the helical which he calls “one of the polymerase collaborators. • backtracking, reported in the track of DNA. “We proved that most enigmatic and debated —BRYN NELSON NYE / PHOTOTAKE S. LINDA

NYU PHYSICIAN 4 SPRING 2014

A Virus Exerts Unusual Control Over Its Host Cells Ian Mohr CMV’s tactics could shed light on cancer and other conditions.

With 230,000 letters of DNA, into functional proteins. cytomegalovirus is bigger Most viruses subvert a host than any other virus known cell’s normal protein-making to infect humans. It’s also apparatus, globally suppressing remarkably common, infecting normal production and forcing up to 80 percent of adults in the cell to manufacture only the United States. For years, viral proteins. Dr. Mohr’s lab however, researchers deemed discovered that CMV uses this viral giant an infrequent a different strategy: Instead troublemaker that caused of shutting down all regular disease mainly in babies and production by the host, in adults with weakened the virus reprograms the immune systems. entire cell and selects which Increasing evidence suggests cellular proteins can still be that the virus may be more manufactured. In this way, dangerous than previously the virus blocks the synthesis thought. Recent studies, in of many proteins but actually fact, have investigated the stimulates the production of This colorized electron possibility that CMV might thousands of others. micrograph reveals human protein production. The virus herpesvirus-5, commonly assist in the formation of some In the translational system, known as CMV. shut down its host’s ability to types of brain tumors. cells recruit molecular engines produce proteins involved in In a recent study in Cell known as ribosomes to decipher growth and immune defense. Reports, Ian Mohr, PhD, instructions embedded within surprising,” Dr. Mohr says. But This made sense, but CMV professor of microbiology, and RNA transcripts for protein the revelation, he adds, fits with infection also turned up the members of his lab have now production. “Clearly, the virus the growing body of research production of other host found that unlike other viruses, has the capacity to manipulate linking CMV to gliomas, a kind proteins capable of limiting CMV exerts far more selective this code, and it may be a of brain tumor. viral growth, a seemingly control over the cells it invades, powerful tool to help teach us Some scientists have counterproductive strategy. a technique that helps it how different RNA transcripts speculated that the virus might Perhaps, Dr. Mohr flourish. “There’s a large extent are selected for translation by promote inflammation or speculates, some host of this micromanaging,” Dr. ribosomes,” Dr. Mohr says. other conditions that can spur defenses can still evade the Mohr says. “Something like this Deciphering this code could cancer and atherosclerosis. viral takeover and rise to the really hasn’t been seen before.” have profound implications Alternatively, CMV’s occasion. Alternatively, CMV Moreover, the precision of its for understanding how other micromanagement might lead may be lengthening its own tactics, he says, may offer new diseases can hijack protein to cellular dysfunction and reproductive cycle to avoid clues about how viral infections production. For example, the eventually to disease. killing the cell too soon and and diseases such as cancer can researchers found striking For their study, led by burning itself out before it commandeer a fundamental similarities between proteins graduate student Caleb has a chance to reproduce biological process known as whose production increases McKinney, the researchers and spread. By biding its time translation, which lets cells turn after CMV infection and infected lab-grown human within the cell, the virus might information stored in DNA and proteins up-regulated within cells with CMV and then gain the upper hand over the

JAMES CAVALLINI/SCIENCE SOURCE CAVALLINI/SCIENCE JAMES encrypted in messenger RNA cancer cells. “That was very examined the changes in long run. • —BRYN NELSON

NYU PHYSICIAN SPRING 2014 5 TAKING IT ON

In dozens of churches, barbershops, and other gathering places around New York City, NYU FAITHLangone Medical Center researchers at the Center for Healthful Behavior Change are partnering with lay advisers to bring down soaring rates of hypertension in minority populations. BY BRYN NELSON • ILLUSTRATION BY LYNDON HAYES

The brick façade of Bethel Gospel materialize. It slowly hardens arteries, Tabernacle is glowing red in the evening weakens vessels, and reduces blood flow and oxygen through increasingly narrow sun as a dozen parishioners gather for a lesson passageways in the kidneys, eyes, heart, on better living. While a gardener waters the and brain. Then, with a sudden blockage, clot, or burst vessel—and often a heart shrubs and flowers behind a low wrought-iron attack, a stroke, or kidney failure— fence enclosing the churchyard in Jamaica, hypertension makes itself known. Often too late. Queens, three volunteer leaders are tending to Like many primary care physicians, Dr. the physical health of their fellow congregants in Ogedegbe has witnessed the devastating a nearby Sunday school classroom. consequences of untreated high blood pressure. “I found very early on that by the time we see patients in primary care The summer evening begins with a (CHBC). Launched in 2008, the CHBC has practices, their disease is far advanced,” he Scripture reading, a prayer, and a chorus reached out to at-risk residents in dozens says. “They have chronic kidney disease, or of Amens. Then the teachers take turns of churches, mosques, senior centers, they’ve already had a heart attack or heart leading their students—all over the age barbershops, beauty salons, and other failure. Some have had a stroke.” of 50 and all diagnosed with high blood neighborhood centers around New York Although many of the consequences pressure—through a carefully scripted City with programs like FAITH. At their of hypertension can be prevented with session about increasing their physical heart, nearly all of the center’s projects medication and more healthful lifestyles, activity and improving their diets. After focus on reducing health disparities by far too few of the necessary interventions taste-testing a relatively low-calorie mix helping minority populations adopt lasting ever reach minority communities. Dr. of pure pineapple juice and club soda, lifestyle changes. Ogedegbe recalls meetings held by an the class learns how to read nutrition The time-intensive strategy depends ecumenical council brought together labels and choose healthful drink upon training church members, barbers, by the New York City Office of Minority options. A woman in a white head scarf and other leaders to be trusted partners Health in 2005. Faith leaders from around readily admits that she had never before in carrying out the studies. Early signs the city talked about the most pressing considered the total carbohydrate content suggest that the CHBC’s investments could health issues facing their communities, when comparing labels. be paying off. If successful, they could form and hypertension dominated almost every “Thank God for this class!” she exclaims. the basis for broader outreach efforts in discussion. Again and again, Dr. Ogedegbe Similar sentiments are ringing out in 32 minority communities across the United heard the frustration of leaders who were churches throughout the five boroughs, States. The CHBC is part of NYU Langone’s desperate for help. “I thought, ‘We’ve got to where parishioners are enrolled in a recently inaugurated Department of do some studies that allow us to evaluate National Institutes of Health–funded study Population Health, dedicated to bringing alternative approaches to providing care called FAITH (Faith-Based Approaches in research advances for improving health and reducing the burden of hypertension in the Treatment of Hypertension). During into everyday use among people at high minority populations,’ ” he recalls. a 12-week course, congregants learn how risk. “Too often we fail to consider shifting In 2009, hypertension killed about 52 to adopt a more healthful lifestyle, and lay the focus beyond the healthcare delivery out every 100,000 black men in the United advisers follow up for an additional three system to where people live their daily States—triple the mortality rate for white months to help participants identify and lives—at home, school, work, and places of men. The stark disparity, tracked by the overcome any remaining barriers. “At the worship,” says Marc Gourevitch, MD,MPH, American Heart Association, was nearly end of the study, we’ve empowered the chair of population health. as pronounced among women: high blood churches to take this on themselves so that pressure claimed 38 out of every 100,000 it can be sustainable. That’s the beauty ● ● ● black women that year, more than 2.5 times here,” says Gbenga Ogedegbe, MD, MS, the rate for their white counterparts. MPH, professor of population health DOCTORS CALL HYPERTENSION the To close the gap, Dr. Ogedegbe says, and medicine. “silent killer.” clinicians must overcome the mistrust, Dr. Ogedegbe directs NYU Langone’s High blood pressure can undermine poor communication, and other barriers Center for Healthful Behavior Change the body for years before any symptoms that have long prevented many minority

NYU PHYSICIAN 8 SPRING 2014 Dr. Gbenga Ogedegbe and Dr. Antoinette Schoenthaler

patients from seeking out and staying with lifesaving care. Increasingly, he and Like many primary care physicians, colleagues at the CHBC are convinced Dr. Ogedegbe has witnessed the that the answer lies in an approach that is quickly gaining momentum: bringing more devastating consequences of personalized preventive lifestyle strategies untreated high blood pressure. directly to community settings.

● ● ● uses positive peer pressure to improve just a few weeks. From that pool, the THE IMMENSE POPULARITY of blood pressure in at-risk populations, program identified four churchgoers competitive weight-loss shows like The implemented jointly by the New York whose blood pressure was so high that Biggest Loser in predominantly black City Department of Health and Mental they were at imminent risk of a heart attack churches may be one way to boost Hygiene and the CHBC, enrolled nearly or stroke. CHBC researcher Antoinette

PHOTOGRAPH BY JOSHUA BRIGHT BY JOSHUA PHOTOGRAPH participation. A city-wide program that 200 participants from five churches in Schoenthaler, EdD, MA, assistant

NYU PHYSICIAN SPRING 2014 9 From left, lay health advisers Ena Davis, Azerean Cameron, RN, and Princess Ramos, RN, in front of Beth Gospel Tabernacle in Jamaica, Queens.

professor of population health and spend more time with family, for example, patients to rely on their own problem- medicine, says that initial screening was may be more inclined to take his blood solving skills or on the past experience of critical in helping the congregants receive pressure medicine if he associates that friends and family. immediate medical care. change with improving his chances of “We’ve learned that heart disease is a In 2002, Dr. Schoenthaler joined Dr. celebrating a milestone anniversary or very treacherous disease for the patients Ogedegbe’s team to address a crucial seeing a relative graduate from high school. in our study. They’re very scared of it, question: what prevents so many To gain the trust of her study subjects, but they really use symptoms as a guide patients from taking lifesaving drugs? Dr. Schoenthaler moved closer to the clinic to determine whether or not to take Recent surveys by the U.S. Centers for so that she could develop stronger ties with their medications,” Dr. Schoenthaler Disease Control and Prevention have the community. For a new project, she is says. If they feel symptoms, the patients underscored the problem. Although comparing personalized care to standard take the drugs. If the symptoms persist, black respondents were more aware of care in helping 148 high-risk Latino patients however, many consider the medication their high blood pressure than whites with uncontrolled hypertension stick to insufficient and seek relief through on average, they were significantly less their medication regimen. “Rather than just herbal remedies and alternative likely to have it under control. using the evidence base that’s published and treatments like garlic and vinegar—a At a community-based clinic in Long then developing an intervention, we wanted practice that is even more pronounced in Island City, Dr. Schoenthaler began to to hear from the patients themselves: what’s African American communities. chip away at this conundrum through getting in the way?” she says. Well-intentioned interventions, says Dr. one-on-one motivational interviewing. Schoenthaler, can be further complicated The counseling technique, adapted ● ● ● in minority communities by a pervasive from clinical psychology, aims to change mistrust of medications and healthcare unhealthful habits by aligning personal ACCORDING TO FEEDBACK she providers and by fatalistic beliefs about values with behavioral adjustments to has received from focus groups, poor unchangeable health outcomes. The achieve specific goals. A man who wants to communication with doctors often leads CHBC’s researchers have found that

NYU PHYSICIAN 10 SPRING 2014 many minority patients never admit to “Too often we fail to consider shifting the being depressed but instead view it as a normal consequence of life. Likewise, the focus beyond the healthcare delivery researchers say, blacks and Latinos are system to where people live their daily less likely to rank a sleep disorder as an important contributor to poor health, to lives–at home, school, work, and places of report having a sleep disorder, or to be evaluated for one. Yet obstructive sleep worship,” says Marc Gourevitch, MD,MPH, apnea, which is too often dismissed as chair of population health. little more than noisy snoring, has been strongly linked to hypertension.

● ● ●

MORE THAN A FEW of the community- based advisers in CHBC’s projects have Pill Bottles and Birth Dates become beneficiaries as well. Ena Davis, an administrative assistant at Bethel FOR HER STUDIES ON MEDICATION ADHERENCE, Dr. Schoenthaler Gospel Tabernacle, who coordinated often uses an electronic pill bottle with a microchip embedded her church’s involvement in FAITH in the cap, called an eCap. As a proxy tracking whether and when and serves as one of three leaders, says patients are taking their hypertension drugs, the chip records the time she’s been gratified by the enthusiastic whenever the bottle is opened. A more advanced system measures the response from her adult pupils. She’s also bottle’s weight from the bottom and can tell whenever a pill has been taken her weekly lessons to heart after her added or removed. If there’s no change in weight, the patient receives doctor told her that her cholesterol was a text message reminder to take the medication. climbing. “What I was reading to them, But technology can sometimes create problems of its own, I would go home and say, ‘I need to do especially among minority populations that are inherently mistrustful this.’ Not because I had hypertension, but of doctors and drugs. Dr. Schoenthaler abandoned an even more because I wanted to be healthy,” she says. sophisticated wireless system after the plug-in electronic hub that “Not only was I helping someone else, I captured pill bottle data occasionally short-circuited outlets in patients’ felt like I was helping myself.” homes. Even worse, its blinking lights convinced many participants that Increasingly, the city’s barbers are their privacy was being invaded. “Our primary measure of adherence also feeling empowered. Before Joseph was causing patients to drop out,” says Dr. Schoenthaler. Her team Ravenell, MD, MS, joined NYU Langone quickly switched to less intrusive technology. in 2008, he and his colleagues in For a separate study called Keep on Track: Insights for Community Dallas taught barbers at black-owned Health, staff and congregants at predominantly black churches can barbershops how to measure blood access password-protected electronic dashboards that show how pressure and counsel hypertensive enrolled individuals are faring in reducing their blood pressure. The customers to seek medical care. After project, a partnership with the New York City Department of Health 10 months, significantly more men and Mental Hygiene that has received funding from the federal in those shops had their high blood Agency for Healthcare Research and Quality, has already enlisted pressure under control than in shops hundreds of congregants. where customers received only printed Here, too, however, Dr. Schoenthaler learned that technology can educational materials. lead to unanticipated privacy concerns. “We learned early on that In New York, Dr. Ravenell, assistant people don’t want to give their birth date—that’s one of the registration professor of population health and criteria,” Dr. Schoenthaler says. Fortunately, the researchers resolved the medicine, and founder of the Men’s Health issue by asking the electronic dashboard designers to make the birth Initiative at the CHBC, has expanded that date optional. —Bryn Nelson barbershop-based outreach to include colon

PHOTOGRAPH BY KARSTEN MORAN PHOTOGRAPH cancer screening. Black men in the United

NYU PHYSICIAN SPRING 2014 11 States, he says, have higher colon cancer “Our reception has been remarkable. death rates than any other subgroup, largely due to a lack of timely screening. We actually have churches and During free events at about 90 black- barbershops calling us to see owned barbershops throughout New York City, Dr. Ravenell and a team of whether or not they can participate researchers, community health workers, and coordinators are recruiting men for in the study,” Dr. Ravenell says. separate hypertension and colon cancer screening studies. The two randomized controlled trials, collectively known as the Multi-Intervention Study to Improve CRC Screening and to Enhance Risk often portrayed as being apathetic about our on to the initiative. Before NYU Langone Reduction in Black Men, or MISTER B, health. But across the age spectrum that we began holding free screening events at will test the effectiveness of the center’s have encountered, people are very willing the shop, owner Jay Green says some of targeted approach. to get their blood pressure checked and talk his customers had never had their blood “One of the things that’s been surprising about these issues.” pressure checked. is just how interested men are in their In 2010, Jay’s Barbershop in Harlem was But men tend to listen to their barber, health,” Dr. Ravenell says. “I think we’re one of the first neighborhood shops to sign he says. Starting a conversation about hypertension can then open the door to discussing other healthful behaviors, such as which foods to eat or avoid. Green, who serves on the project’s community advisory board, discovered that he too had high blood pressure and stood to benefit from the Can Storytelling Save Lives? health initiative. “I stopped putting salt on my food, I drank more water, and now I try LAST YEAR DR. OGEDEGBE RECEIVED A $12 MILLION GRANT to exercise a little bit,” he says. “I think it’s a from the National Institutes of Health to create the Center for great program, and it’s helped a lot of dads Stroke Disparities Solutions in New York City. The center, a collaboration in the community.” with eight other medical centers and healthcare organizations, is focused The CHBC is also recruiting men from on reducing disparities in the city’s minority population, with a particular about 80 predominantly black churches emphasis on preventing recurrent stroke. for a related study. “Our reception has One innovative research project is using storytelling in churches as a been remarkable. We actually have way to improve stroke literacy rates among both blacks and Latinos. In churches and barbershops calling us to African American churches, professional storytellers will present narrative see whether they can participate in the tales about stroke patients, emphasizing the telltale symptoms and the study,” Dr. Ravenell says. Combined, the importance of calling 911. Afterward, each congregation will hear from two projects have provided free screening an actual stroke survivor. and information to more than 6,000 black In Latino churches, the storytelling will take the form of a professionally men and enrolled more than 1,000 in acted telenovela, a limited-run melodrama similar to a soap opera that is the ongoing research. “That’s one of the wildly popular on Spanish-language television. things we’re most proud of—the service For both projects, researchers will measure the congregants’ stroke aspect of what we’re doing, which is literacy rates before and after the live presentations. The events will really necessary for us to accomplish our be filmed, and twelve-minute DVDs distributed to church members. Six research aims,” he says. months later, the researchers will conduct a follow-up survey to determine CHBC researcher Girardin Jean-Louis, whether improved stroke literacy—delivered here in story form—can be PhD, professor of population health retained within a community. —Bryn Nelson and psychiatry, and a behavioral sleep specialist, is adopting similar tactics to study how untreated sleep disorders can

NYU PHYSICIAN 12 SPRING 2014 Jay Green, the owner of a barbershop in Harlem, gets his blood pressure checked by Dr. Joseph Ravenell.

exacerbate health disparities in minority At Bethel Gospel Tabernacle, the dozen no one had ever shared with them. populations. Health educators are helping FAITH study participants laugh and joke Princess Ramos, RN, another volunteer to steer minority patients toward testing with each other but readily admit to less- adviser at Bethel and a registered nurse at and treatment for sleep apnea and other than-healthful meals or minimal exercise. Kings County Hospital Center in Brooklyn, disorders in one project. Another relies on Again and again, they encourage each other says she’s been amazed at the congregants’ the expanding network of barbers to recruit to take small steps. readiness to incorporate those new lifestyle peer educators. “If the barber tells me, ‘Hey, Azerean Cameron, RN, a volunteer lessons into their daily regimens. “It just this snoring thing you’re talking about, you adviser at the church and a quality makes me feel good that they’re actually should go get a sleep test done,’ I’m going to assurance manager at New York Methodist putting them into practice,” she says. go,” Dr. Jean-Louis says. “Why? Because I Hospital in Brooklyn, says later that the During one particularly well-received trust this guy. He’s helped me in the past.” project has been a welcome extension of the outing to a local supermarket, the class health tips her pastors have long shared studied nutrition labels and picked out ● ● ● from the pulpit. One important lesson is more healthful alternatives to their normal that change does not happen overnight. options. “I think it opens the eyes of ALTHOUGH THE CHBC RESEARCHERS “You can’t just expect someone who’s been everyone, participants as well as leaders, cannot yet say whether stronger ties, deeper eating the same way for many years to stop to see that the choices we make, in fact, can trust, and newly acquired knowledge will and change their ways,” she says. “It’s a make a change,” Ramos says. lead to lasting behavioral changes, the process.” Even so, Cameron says her pupils By opening their ears to the need for positive feedback from participants has have regularly told her how thankful they that change, they may be helping to finally

PHOTOGRAPH BY JOSHUA BRIGHT BY JOSHUA PHOTOGRAPH given them reason for optimism. are to learn nutrition and exercise facts that loosen the grip of a furtive killer. •

NYU PHYSICIAN SPRING 2014 13 14 for 15minutes orso, andthen mysteriously disappears. The slowly spreads across hisvisual field, obstructing his vision when abright orb oflight suddenly pierceshisview. The light has just arrived at hisoffice at NYU Langone Medical Center Nicholson, PhD, professorofneuroscience andphysiology, winterdreary weather makes itfeelmorelike Monday. Charles COLD,IT’S A channels ignoredby aroundbraincells.Long molecular biologists, Charles Nicholson hasdevoted hiscareertostudying theslender his pioneeringresearch is now opening new avenues of inquiry that couldleaddelivery tobetterdrug andnew treatments for damp Friday morninginManhattan, butthe in between neurodegenerative diseasesandbraincancer. the spaces the spaces SPRING 2014 NYU PHYSICIAN BY NICOLEDYER you any harm,”hesays. typically ensue. “You recover from itquickly, and itdoesn’t do without theclassic headache andincapacitating painthat suffered fromamercifullybenignsilent migraine, anaura complains; he’s oneofthelucky ones. disruption isalways andinconvenient unnerving buthenever Since theearly 1980s, Dr. Nicholson hasperiodically

PHOTO BY SASHA NIALLA; INK DIFFUSION ISTOCKPHOTO Dr. Charles Nicholson measures the ions that move between brain cells in much the same way that he would measure the diffusion of ink in water. His knowledge of migraine auras is based on more than personal experience. Coincidentally, he has spent his career studying their physiological roots in the slender channels of fluid that weave between brain cells, called the extracellular Bucking decades- space, or ECS. A veritable microenvironment brimming with long trends that put neurons proteins, polymers, and electrically charged molecules—ions like sodium, calcium, potassium, and chloride—these channels at the center of the known help conduct electric current from one neuron to the next. universe, Dr. Nicholson has Migraine auras are thought to arise when something disrupts beaten a lonely, persistent path the diffusion of ions in the channels. As when a circuit breaker is flipped, electricity stops flowing into the cells and the brain can to understand what happens no longer function properly. “We’re almost certain that migraine not inside neurons, but rather auras result from ionic imbalances,” he explains. If ion shifts in the spaces between brain cells can cause around them. visions, what else can they do? Science is only just beginning to understand their clinical significance. Bucking decades-long trends that put neurons at the center of the known universe, Dr. Nicholson has beaten a lonely, persistent path to understand what happens not inside neurons, but rather around them. implications for the treatment of neurological disorders. With duel degrees in neuroscience and mathematical physics, The Rochester scientists spent weeks with Dr. Nicholson he has done more over the past four decades to model, measure, learning his trademark technique to measure the volume of the and map the ECS than perhaps any other scientist. Along the extracellular space. They also relied on his software—now used way he has authored more than 150 peer-reviewed papers and in labs throughout the world—to analyze the measurements. cultivated many of the brightest minds working on the ECS today. “We were constantly sending Charles data,” says lead author Yet his research remains underappreciated and Maiken Nedergaard, MD, PhD, codirector of the Center for underestimated, his colleagues say. “The work he does is not Translational Neuromedicine at University of Rochester Medical understood by most people,” says Rodolfo Llinás, MD, PhD, Center. “His technique has had a huge impact on our research.” a longtime mentor of Dr. Nicholson, and the Thomas and Eva Syková, MD, PhD, director of the Institute of Experimental Suzanne Murphy Professor of Neuroscience and University Medicine in Prague, has also collaborated closely with Dr. Professor in the Department of Neuroscience and Physiology. Nicholson. The researchers first met at a conference in the Czech “It’s mathematically complicated; it’s deep. Yet it’s beginning to Republic in the early 1980s, when the Czech government, then flourish because molecular biologists can no longer ignore the Communist, forbade Dr. Syková to leave the country. “Charles extracellular spaces.” made several trips to my lab during that time,” she recalls. His Accumulating evidence—much of it built on techniques software (which she still uses today) has helped her team discover a pioneered by Dr. Nicholson—suggests the ECS is far more link between changes in diffusion across the ECS and brain-tumor than just cellular padding. As essential to brain function as the malignancy. “We can now use diffusion for diagnostic purposes,” cells it supports, the ECS holds vital clues not just to migraine she wrote in an e-mail. “For example, the extent of a patient’s headaches and visual auras, but also to better drug delivery and operation can be modified according to the degree of malignity of a new treatments for neurodegenerative diseases, brain cancer, tumor, which can be recognized from diffusion parameters.” and stroke, among other conditions. It isn’t surprising that Dr. Nicholson’s name commands a Last October a group of researchers at the University of special reverence among those familiar with his work. Dr. Llinás Rochester Medical Center made international headlines with calls him the “world authority in his field.” Dr. Nedergaard, a paper co-authored by Dr. Nicholson and published in Science who has collaborated with Dr. Nicholson since the late 1980s, that showed the ECS expands by a remarkable 60 percent considers him “one of the giants of neuroscience.” Robert G. during sleep, allowing cerebrospinal fluid to more readily flush Thorne, PhD, a former postdoctoral fellow of Dr. Nicholson’s, away toxins, such as the sticky clumps of protein known as who is now at the University of Wisconsin–Madison School beta-amyloid plaques that accumulate between brain cells during of Pharmacy, marvels at Dr. Nicholson’s enduring influence. Alzheimer’s disease. The findings offer the first direct evidence “There are a lot of attractive findings published in the best for a long-held hypothesis that nightly dips into unconsciousness journals that wind up on the scrap heap of history,” Dr. Thorne allow the brain to cleanse itself, an idea that holds broad says. “Charles’s work withstands the test of time.”

NYU PHYSICIAN 16 SPRING 2014 ● ● ●

Charles Nicholson’s interest in neuroscience began 45 years ago with alligator brains. In 1965 he had just left a post at the Atomic Energy Authority in England, where he had been applying his physics degree to help the government agency understand the energy inside stars. “I had always been torn between physics and biology,” Dr. Nicholson says. Growing up in southwestern England, the only child of an accountant and a homemaker, he gravitated toward physics simply because it kept him amused. “I spent a lot of time by myself,” he says. He often retreated to the basement to noodle with radio sets and electronics. “I wanted to know how the world worked and I thought physics was probably the best way to do that,” he says. Yet Dr. Nicholson never imagined himself at a university. It was only when he serendipitously encountered a government initiative to encourage more students to pursue higher education that he made his way to college, becoming the first person in his family to do so. There, he fell in love with An electron micrograph of a rat brain shows the mathematical physics but received little encouragement. convoluted network of fluid-filled channels (red) that weave between brain cells. In humans, these When his physics adviser told him he had no future in extracellular spaces account for 20 percent of the academia, he went to work for the government. But the work brain by volume. felt suffocating, so he decided to pursue a PhD in his other area of interest, biology. ● ● ● Fortuitously, his doctoral adviser happened to work closely with the eminent physiologist Sir John Eccles, who shared the In 1970, after the AMA Institute closed, Dr. Llinás and Dr. Nobel Prize in physiology in 1963 for his role in elucidating Nicholson, along with about 10 other researchers, moved as a the electric circuitry of nerve cells. Dr. Eccles, then at the team to the University of Iowa. There, Dr. Nicholson expanded American Medical Association’s Institute for Biomedical his research to small catfish and took serious interest in the Research in Chicago, needed a graduate student with sharp electric currents that flowed between brain cells. mathematical skills to help him model the cerebellum, an It was also in Iowa that the young researcher began wrestling ancient brain region at the base of the skull just above the with a question that would shape the rest of his career: What brain stem, which coordinates voluntary body movements. was carrying the electric current between brain cells? At the Dr. Nicholson soon found himself in Chicago, thrilled by time, it was understood that negatively and positively charged the opportunity to apply his mathematical mind to the field ions move in and out of brain cells, creating voltage spikes or of biology. However he had no idea what a cerebellum was. “action potentials” that send current zipping down a cell’s long, If he wanted to model it, he realized he would need to see slender projection called an axon. As the current exits the cell, it one, and that’s where the alligators come in. Here, too, enters travels through the extracellular space to complete the electric Dr. Llinás, a leading expert on the electric circuitry of the circuit. But precisely which chemicals were carrying the current cerebellum who worked for Dr. Eccles. Dr. Llinás wanted to and how? understand the evolutionary origins of the cerebellum and No microscope on earth was yet powerful enough to peer studied alligators because they were among the closest living inside the mysterious channels between brain cells, but Dr. relatives of the dinosaurs. “We handled them with caution,” Nicholson reasoned he could draw an indirect picture by Dr. Nicholson recalls. measuring the molecules that move through them. Happily, When Dr. Eccles left the AMA Institute in 1968, Dr. he had at his disposal a recent invention called the ion- Nicholson stayed on to work with Dr. Llinás and finish his selective microelectrode, a glass sensor small enough to dip PhD in Chicago. “An eight-month visit to the United States between cells. Still widely used today, the sensor works like turned into 45 years,” he says, his British accent still evident. a kind of ion trap, using a liquid membrane at its tip to allow For the two researchers, those early days in Chicago were the passage of a specific ion. As an ion flows through the sensor,

IMAGE COURTESY OF DR. CHARLES NICHOLSON OF DR. COURTESY IMAGE beginning of a lifelong friendship. a sophisticated voltmeter measures the electric charge. The

NYU PHYSICIAN SPRING 2014 17 resulting measurement gives an indication of the chemical’s ● ● ● concentration in real time: The greater the voltage, the stronger the concentration. Finding the right molecules to study diffusion in the ECS “You put a tiny amount of liquid in the tip that binds the ion soon led to another critical insight. In 1981 Dr. Nicholson you’re looking at,” Dr. Nicholson explains. “The trick is to find published a landmark paper in the Journal of Physiology (his the specific liquid membrane and get it to stick in the tip.” most frequently cited one today) that showed how a modified It was while using the ion-selective microelectrode in version of a classic physics principle, called the diffusion catfish that Dr. Nicholson began to notice that sometimes equation, could predict how ions move through the ECS. Dr. the voltage in the ECS would just disappear. He suspected Nicholson likens diffusion to a cocktail party: “If you herd the disappearance was connected to a poorly understood people into a corner, they will eventually disperse throughout phenomenon called spreading depression. Discovered by the room. No one wants to be crowded.” Brazilian biologist Aristides Leão in 1944 while researching The trick was to mathematically account for two factors. epilepsy in rabbits, spreading depression refers to a wave of One was the concept of hindrance or tortuosity, which refers electrical disruption in the brain. Like a rolling brownout, the to the winding, random path that ions take as they diffuse condition knocks out electricity cell by cell, restricting blood through extracellular space. Like the person at a cocktail party flow as it spreads and possibly causing migraine auras like trying to find the restroom in an area crowded with tables, an those that occasionally strike Dr. Nicholson. ion inevitably bumps into obstructions as it travels, zigzagging But what caused the electrical imbalance in the first place? randomly from point A to point B. “Tortuosity is one of Through meticulous sensor adjustments, Dr. Nicholson and Charles’s most important concepts,” says Dr. Llinás. “The his first graduate student, Richard Kraig, now a professor at distance between two points is rarely a straight line.” the University of Chicago, discovered the source was a massive The other factor was the size, or volume, of the space increase in extracellular potassium ions, along with decreases in through which the ions move. Taking into account these two sodium and chloride ions. “Other people had suggested some of parameters, tortuosity and volume fraction, Dr. Nicholson this, but no one had measured it,” Dr. Nicholson says. developed a mathematical formula that, in conjunction with The finding offered compelling evidence for a small but the new TMA probe applied to anesthetized rodents, was growing suspicion that the extracellular space had profound able to do what no microscope could: accurately measure clinical consequences. “People tend to forget that the nervous the volume of brain tissue occupied by the ECS in real time. system is a system and not just a bunch of neurons,” Dr. By his calculations, the space accounted for a startling 20 Llinás says. percent of the brain. The figure was initially met with skepticism. In the 1960s, ● ● ● esteemed Harvard Medical School scientist Sanford L. Palay, pioneer of the electron microscope and former chief of After six years at the University of Iowa, the British native neurocytology at the National Institutes of Health, used his bid adieu to the heartland and headed east. In 1976 Dr. high-powered scope to arrive at an estimate of just 5 percent. Llinás and his team, including Dr. Nicholson, moved to While Dr. Palay’s estimate was widely accepted, it gnawed NYU School of Medicine, where Dr. Llinás became chair of at Dr. Nicholson. He suspected something was off. As with the neuroscience department. the German research, that something turned out to be a Settled in New York, Dr. Nicholson began to dig deeper into technical oversight. In order to see the spaces between brain the mystery of how ions diffuse through extracellular space. cells beneath an electron microscope, Dr. Palay had to first When a prominent group in Germany made a splash with one euthanize the rodents he was studying and then fix the of the first calculations of ionic diffusion through the ECS, brain samples in formaldehyde. But killing the animal cut Dr. Nicholson suspected a subtle but serious flaw in their off the oxygenated blood flow to the brain, causing cells to technique. For starters, they were using potassium ions to swell, which in turn reduced the volume of the ECS. And make their measurements. Potassium, Dr. Nicholson realized, the formaldehyde procedure dehydrated the brain samples, disappears into cells nearly as soon as it enters the ECS. “This further shrinking the ECS. was confounding their results,” he recalls. Dr. Palay defended his technique for years. “He finally So he developed a better probe, using a small molecule admitted to me on a bus at a conference that my estimate was called tetramethylammonium, or TMA, that resists cellular probably right,” Dr. Nicholson says. The 20 percent figure still uptake, and got a very different answer, the right one as it holds today, although the work of the University of Rochester turned out. “It was a very exciting time,” he recalls. team in slumbering rodents adds a new twist.

NYU PHYSICIAN 18 SPRING 2014 Unlike conventional fluorescent tags, quantum dots come in a variety of sizes, allowing the researchers to explore how big a molecule can be before it stops moving through the ECS No microscope altogether. Another advantage is that the dots could be coated on earth was yet powerful with an electrically neutral chemical, which would keep them from reacting with other molecules in the ECS. “It’s a beautiful enough to peer inside the tool,” Dr. Thorne says. mysterious channels between Moreover, Dr. Thorne devised a way to view the dispersal brain cells, but Dr. Nicholson of the dots in living, anesthetized rats, using what’s called a cranial window, which is essentially a tiny sunroof implanted reasoned he could draw an in the skull that affords a view into the living brain. “It’s indirect picture by measuring becoming increasingly clear that the physiological state of the animal has a big effect on the ECS,” he says. the molecules that move Using this modified form of integrative optical imaging, through them. along with quantum dots about 35 nanometers in diameter, the researchers discovered the width of the extracellular channels to be about 40 to 60 nanometers, one seventeen- hundredth the diameter of the average human hair, and twice ● ● ● as wide as the previous estimate. “We overturned decades of dogma that said the ECS was about 20 nanometers wide,” By the late 1990s, Dr. Nicholson had turned his attention to the Dr. Thorne says. After all, how could a 35-nanometer-wide diffusion of larger molecules like albumin, dextran, growth dot squeeze through a 20-nanometer-wide channel? Their factors, and other proteins in the ECS. It was a particularly resulting paper, published in The Proceedings of the National important line of inquiry for drug delivery. Even if an Academy of Sciences in 2006, has become a citation classic. oversize molecule could penetrate the blood-brain barrier, the selective membrane that keeps pathogens in the blood ● ● ● from contaminating the brain, it would still need to squeeze through the extracellular channels to reach its target. A chunky One could measure the success of a scientist by tallying up medication aimed at brain tumors would never make it. the number of papers published, honors bestowed, grants No one had yet figured out a way to track and measure earned. At 72, Dr. Nicholson has plenty of all of those. But he so-called macromolecules, but Dr. Nicholson and his also has something even more telling: the trust, respect, and long-time colleague Lian Tao, PhD, soon came up with a admiration of a large circle of accomplished collaborators who solution. In 1993 they developed a breakthrough technique credit part of their own success to his techniques, software, called integrative optical imaging. It took advantage of and intellectual support. Two members of the NYU School of newly invented fluorescent tags that could make certain Medicine faculty—Mitchell Chesler, MD, PhD, and Margaret macromolecules glow under a microscope. The researchers Rice, PhD, both professors of neurosurgery and physiology loaded the tagged molecules into a miniaturized dropper and and neuroscience—trained with Dr. Nicholson. “We all benefit used a short pulse of nitrogen to disperse them into the ECS. from Charles’s techniques,” Dr. Thorne says. Then they used a fluorescence-detecting microscope and But it’s not just about his technical savvy. Dr. Nicholson’s digital camera to photograph the molecules as they spread generosity and humility have also made a lasting impression out like a cloud of ink in water. Dr. Nicholson and Dr. Tao on his colleagues. Dr. Nedergaard, lead author of the recent wrote software to quantify the cloud dispersion. Science paper, remembers calling Dr. Nicholson a few years ago But the technique had its limits. For one, it relied on brain to tell him that her group had found evidence of convective slices bathed in a physiological solution; these were living flow in the extracellular space during sleep. Unlike diffusion, tissue as opposed to the fixed slices used by Dr. Palay, and so flowing particles move like a river, directed by some external the ECS was preserved, but the blood flow was absent. Plus, the force. “We had never seen that in the extracellular space before,” fluorescent tags were only available for certain size molecules. Dr. Nicholson recalls. Although the idea surprised him and In 2002 Dr. Thorne, a postdoctoral fellow in Dr. Nicholson’s challenged existing notions of the ECS, he dove in to help. “He lab at the time, suggested quantum dots, man-made nanoscopic was really excited and supportive,” Dr. Nedergaard says. “It’s crystals that glow under ultraviolet light. A new door opened. never about him, it’s about the research.” •

NYU PHYSICIAN SPRING 2014 19 Dr. J. R. Rizzo shows how CumbaCane, a low-tech successor to the old-school cane, could help avoid obstacles or changes in terrain without swinging. Driven by his own battle with a vision-destroying disease, Dr. John-Ross Rizzo is devising better alternatives to the white cane for the blind.

BY KENNETH MILLER • PHOTOGRAPHS BY JOHN ABBOTT

FOR THOUSANDS OF YEARS, blind people have used NYU Langone Medical Center’s Rusk Rehabilitation—those sticks, staffs, or canes to navigate the pedestrian world. flaws are a source of intense and very personal, frustration. Such devices have changed little over the millennia, The 32-year-old physician suffers from an incurable disease except to become more uniform. In 1921, as motor traffic that is gradually destroying his eyesight. At present, he’s became a growing peril, a Briton named James Biggs, hobbled by severe tunnel vision, cataracts, and difficulty who’d lost his sight in an accident, painted his cane white adjusting to changes in lighting; stepping from sunshine to alert drivers; by the 1940s, that color had been adopted into shadow or vice versa can leave him entirely sightless for almost everywhere. During World War II, a veterans minutes at a time. You might not guess any of this watching rehabilitation specialist in Pennsylvania, Richard Hoover, him stride around the hallways of the Ambulatory Care developed a new technique using a long white cane to Center at NYU Langone Medical Center. Dr. Rizzo, who prefers probe the path ahead; by sweeping it from side to side, to be addressed as J.R., is friendly and voluble, and talks the user could better detect obstacles and drop-offs. The enthusiastically about the topics that obsess him. He has a black “Hoover method” became the universal standard and belt in karate, and in familiar surroundings he moves with remains so to this day. an athlete’s confidence. On city streets, however, he proceeds Yet even lightweight modern canes are relatively slowly—and despite his caution, he stumbles at least once a day. primitive instruments. They can miss up to 50 percent Eventually, he knows, he’ll need a white cane of his own. of tripping hazards, such as potholes, curbs, or uneven Before that happens, he’s determined to create a better sidewalks, and the constant swinging can cause damage to alternative. “My mission is to make a commercially viable the back, shoulder, elbow, and wrist. For John-Ross Rizzo, product and get it into users’ hands,” he says. “I’m not going MD—clinical instructor and associate research scientist at to rest until that’s done.”

NYU PHYSICIAN SPRING 2014 21 THE FIRST SIGNS of Dr. Rizzo’s illness emerged in early childhood. Growing up in northern New Jersey, he loved to “The dearth of climb trees, practice martial arts, and explore his suburban mobility devices neighborhood. But after sunset, while the other kids kept playing, he would retreat to the sidelines or run home. for people with In a dimly lit movie theater, he’d cling to his mother as they headed for their seats. By the time he reached his visual handicaps teens, his parents had begun to wonder why their son was very upsetting was so uncomfortable with darkness. A peripheral-vision test provided a hint: the boy scored so poorly that his to me.” pediatrician thought he must have fallen asleep. “I said, ‘The test was boring, but I swear I was awake,’ ” Dr. Rizzo recalls. “That’s when we knew something was seriously wrong.” For the next year, he bounced from one specialist to another, undergoing endless diagnostic procedures. The was very upsetting to me.” In his spare time, he began verdict arrived when he was 15: choroideremia, a rare sketching ideas for gadgets that could fill the gap. inherited disorder that destroys capillaries in the choroid By 2012, Dr. Rizzo had been appointed chief resident; he (the layer just beneath the sclera, or white of the eye) and joined the faculty later that year. In addition to his teaching in light-sensitive tissue in the retina. Carried on the X duties, he became codirector (with Tamara Rusk, MD) of chromosome, the disease strikes an estimated 1 out of Rusk’s new Residency Research Program and founding 50,000 to 100,000 people—almost exclusively males. The director of the Visuomotor Integration Lab, which studies how first symptom is usually impaired night vision; over the brain injuries affect hand-eye coordination. He also started a years, a patient’s visual field narrows and his visual acuity company called Tactile Navigation Tools to turn his sketches diminishes until by his 50s or 60s, he’s completely blind. into products that could make the traditional cane obsolete. The diagnosis plunged Rizzo into a deep depression. Within a few months, however, he’d transformed his ● ● ● misfortune into a driving force. He began devouring ophthalmology textbooks and interviewing eye doctors OTHER INVENTORS have pursued that goal for decades, to learn more about choroideremia and related disorders. with little success. Since the 1960s, a small number of canes Soon, he decided to become an ophthalmologist himself. or handheld obstacle detectors using sonar or lasers have hit Although his worsening vision made reading a challenge, the market, but none took off commercially; they were too he graduated from NYU (magna cum laude) with a BS in bulky and difficult to operate to justify their high cost. Only neuroscience and earned his MD (with honors) at New York recently have advances in microelectronics and computer Medical College. When it came time to choose a specialty, technology made a truly user-friendly sensor-equipped however, he learned that his ailment put his intended cane a practical possibility. Few such gadgets, however, profession, which requires good eyesight, out of reach. have reached the manufacturing stage, and they remain After another period of mourning, he settled on a field that dauntingly expensive. addresses a broader range of disabilities: physical medicine Dr. Rizzo and his team—including business partner Todd and rehabilitation, also known as physiatry. Hudson, PhD, a computational neuroscientist at the NYU Dr. Rizzo began his residency at Rusk Rehabilitation in Center for Neural Science—are developing both high- and 2009. While conducting research in areas ranging from low-tech successors to the old-school cane. Their most basic exercise-induced kidney damage to how the brain plans device is the CumbaCane, which has two legs angling out movement, he treated patients as a physiatrist at several from the lower portion of the shaft, each with a small wheel hospitals affiliated with Rusk, including the New York mounted on springs. (The extensions are collapsible, like an Harbor Veterans Affairs Medical Center. “I was seeing vets umbrella.) The wheels roll along the ground, a body-width coming back from Iraq and Afghanistan with all kinds of apart, allowing the user to detect obstacles or changes in injuries,” he recalls. “If they lost a limb, the government terrain without the need for swinging. At a planned price of would pay for a $50,000 robotic prosthesis. But if they lost less than $100, this product would be affordable to a large their sight, we gave them a stick. I said, ‘This is insane.’ The proportion of the estimated 4 million Americans—and 150 dearth of mobility devices for people with visual handicaps million others worldwide—who are visually disabled. “It

NYU PHYSICIAN 22 SPRING 2014 doesn’t have to be plugged into an outlet,” Dr. Rizzo notes, A lightweight vest would incorporate various sensors and other components “so it can be used anywhere on the planet.” seen in the model above. Drs. Rizzo The digital version of the cane, the Deyenamic, was and Hudson named their prototypes inspired, in part, by Dr. Rizzo’s studies of the natural world. Edgar and Ethyl. “Animals with poor vision have some amazing navigation methods,” he says. “Paddlefish can sense electric fields; snakes use thermal imaging; bats echolocation.” He also took a cue from auto-industry research into driverless cars, which use typically use just one kind of sensor and transmit vibrations combined input from a variety of sensors to avoid collisions. to the handle. But transforming the vision into reality The Deyenamic will be fitted with technologies such as LiDAR will be a complex process. The CumbaCane is in its third (light detection and ranging) laser, infrared and ultrasound, prototype; Deyenamic and Eyeronman are in earlier stages each of which functions best under a different environmental of gestation. Dr. Rizzo is busy filing patents, raising capital, condition and will supplement the others. Dr. Rizzo’s company and refining his designs. He expects to bring the devices to is also developing a lightweight vest, the Eyeronman, market within the next two years. containing similar sensors. These devices, used together or That would be an ambitious aim for any inventor- separately, will be connected wirelessly to an undershirt entrepreneur, let alone one with a severe disability. But made of e-textiles, fabrics that can seamlessly incorporate those who know Dr. Rizzo have little doubt that he’ll make microprocessors and other components. Data transmitted his deadline. “I constantly forget he’s visually impaired,” from the cane or vest will trigger actuators in the shirt, creating says Dr. Hudson. “Nothing gets him down. Whenever we vibrations whose position and intensity will correspond to have a setback, he drives right through it. It’s that way with the direction and proximity of obstacles. “It’s an intuitive everything in his life. He just sets his mind on the goal and platform,” says Dr. Rizzo. “If the object is on your left, you feel a keeps on going.” tickling on your left side. If it’s taller, you feel it higher up. If it’s For Dr. Rizzo, there’s no time to waste. “I’m trying to make shorter, you feel it lower.” people with a specific weakness as strong as possible,” he This system is designed to provide more precise and says. “There’s nothing else I’d rather work on. This is my detailed information than existing electronic canes, which raison d’être.” •

NYU PHYSICIAN SPRING 2014 23 FACULTY CONVERSATION

Face to Face The new chair of the Department of Plastic Surgery discusses the present and future of face transplantation. BY GARY GOLDENBERG

The surgeon in charge of this groundbreaking procedure was Eduardo D. Rodriguez, MD, DDS, then affiliated with the University of Maryland Medical Center. Dr. Rodriguez brought to the operating table a rare combination of skills in oral and maxillofacial surgery, plastic and reconstructive surgery, and reconstructive microsurgery. He recently joined NYU School of Medicine as chair of the Department of Plastic Surgery, director of the Institute of Reconstructive Plastic Surgery, and the Helen L. Kimmel Professor of Reconstructive Plastic Surgery.

What brings you to NYU School of Medicine? I thought I would stay at the University of Maryland and Johns Hopkins Hospitals for a long time, but then one of the giants of craniofacial surgery, Joseph McCarthy, decided to step down as chairman of plastic surgery at NYU. The opportunity to take the helm of this internationally recognized center of excellence was the ultimate dream.

What is your vision for the department? Dr. Eduardo D. Rodriguez One goal is to push forward with surgical innovation in tissue N 1997 Richard Norris of Hillsville, Virginia, suffered an accidental engineering and tissue transplantation, shotgun wound that nearly obliterated his face. Despite multiple including limb transplants as well as reconstructive surgeries, he remained terribly disfigured and had face transplants. I would also like to trouble talking and breathing. His life took another dramatic turn in explore the potential role for transplants 2012, when a large team of medical experts rebuilt his eye sockets, in the pediatric population. Ultimately, upper jaw, teeth, and tongue, plus the nerves, muscles, and skin of his it comes down to limiting the morbidity face, using bone and soft tissue from a 21-year-old man who had died in associated with long-term immune a car accident. Today, Mr. Norris, now 39, can venture outside without suppression. One of the great benefits Idrawing stares and ridicule. of being at NYU is that we have the More than two dozen people around the world had undergone a face transplant resources to address every aspect of this before this 36-hour operation at the R Adams Cowley Shock Trauma Center in issue, from the basic science questions to Baltimore, but none was as complex as Mr. Norris’s. the ethical questions.

NYU PHYSICIAN PHOTOGRAPH BY 24 SPRING 2014 JOHN ABBOTT How close are you to doing face transplants “Advances in How did your peers receive this initiative? here at NYU Langone? There were many naysayers. They We are already organizing the team. immunosuppression reasoned that these patients are In fact, we just performed our first and surgical medically stable and the potential for transplant simulation rehearsal [in techniques made face death is high, so why risk their lives. January 2014], using cadavers. It far exceeded my expectations. We can't transplantation possible. How did you respond? begin evaluating any patients until we We also had a great Yes, these people are stable, but receive formal IRB [Institutional Review clinical need, as all they are extremely disfigured and Board] approval, however, there are cannot lead normal lives. Advances plenty of patients who would like to be these injured soldiers in immunosuppression and surgical considered as candidates. were coming back from techniques made face transplantation Iraq and Afghanistan.” possible. We also had a great clinical You assembled a team of 150 medical need, as all these injured soldiers were specialists for Mr. Norris’s case. Are you coming back from Iraq and Afghanistan. recruiting staff from outside the institution for the upcoming surgery? What turned you around? What criteria do you use for selecting Most of the key elements already exist Toward the end of my fellowship, when potential face transplant candidates? here: the surgeons, the anesthesiologists, I was applying to medical school, there First, they have to have a deformity the radiologists, the psychiatrists, the were some individuals who felt I didn’t that cannot be treated by conventional nurses, the speech pathologists, the have the intellectual capacity or the work measures. Second, we look at their nutritionists, the social workers, the blood- ethic to go to the next level. That was a psychologic state and their level typing specialists, just to mention a few. good awakening. More than wanting to of commitment. Compliance with prove them wrong, I wanted to prove to treatment—especially with taking Could you tell us a little about your myself that I could do it. immunosuppressant medications—is background? absolutely key. I was born and raised in Miami. Both Why did you decide to study medicine? of my parents were Cuban émigrés. I enjoyed oral surgery, but I wanted to Are there limits to the age difference between An interesting bit of family history able to do even more and did not want to donor and recipient? What about gender? is that my father fled Cuba at the feel limited. I can point to a particular I would not consider transplanting a beginning of the Castro revolution. He incident: a patient who had breathing 60-year-old’s face onto a 20-year-old. But then enlisted in the Bay of Pigs invasion, troubles after a surgical procedure. He there are no specific limits. As for gender, during which he was wounded and held needed a tracheostomy, but I wasn’t it’s not unreasonable to transplant a prisoner until he was eventually released trained to do one. The surgical airway female face onto a male. The cosmetic following a negotiation. team got there in time, but it was touch result would probably be acceptable, and go. I felt helpless and I didn’t want to and it would broaden the potential You hold a degree from NYU College of be in that situation ever again. donor pool. But I don’t know if it would Dentistry as well as a degree in medicine work the other way, male to female; from the Medical College of Virginia. What How did you become involved in face just because of facial hair, I would not influenced your initial career path? transplantation? support it. I had good role models: an uncle who was About 10 years ago, I came to the a physician and a close friend’s father who realization that there was only so much How do you prepare a donor’s family for the was a dentist. I was torn between the two, we could do for patients with what possibility of seeing their loved one’s face on but ultimately, I decided that I liked how we call central facial injury. We could another person? dentists had more control over their lifestyle. improve their deformities, but we could In the Richard Norris case, the family never re-create certain parts of the face. was counseled beforehand through Were you studious from an early age? Around that time, the chair of surgery the organ donor system that this could Educationally, I was a bit of a late bloomer. at the University of Maryland asked happen—especially since we anticipated I always wanted to learn more, but it me to participate in an Office of Naval substantial media coverage. But I don’t wasn’t until my fellowship in oral and Research grant looking at the possibility know if you can fully prepare anyone maxillofacial surgery that I really became of facial transplantation as a treatment for for this, especially a parent who has committed to my studies and my future. disfigured soldiers. lost a child. (Continued on page 27)

NYU PHYSICIAN SPRING 2014 25 FACULTY NEWS

JEF BOEKE APPOINTED DIRECTOR OF INSTITUTE FOR SYSTEMS GENETICS RENOWNED GENETICIST JEF BOEKE, Dr. Boeke’s team will use the latest PhD, DSc, has been appointed director tools and insights from human genetics, of the newly established Institute for systems biology, computational science, Systems Genetics at NYU Langone and biological engineering. “It’s a major Medical Center. Dr. Boeke, a member of initiative to bring together this level the National Academy of Sciences, joins of expertise under one roof,” says Dr. NYU Langone from the Johns Hopkins Boeke, who aims to recruit 12 to 15 faculty University School of Medicine, where he members within the next few years. served as professor in the Department of The link for the Institute for Systems Molecular Biology and Genetics and the Genetics is: http://research.med.nyu.edu/ Department of Oncology. He also founded systemsgenetics. the High Throughput Biology Center, Dr. Boeke is a pioneer in the emerging chromosome ever built,” says Dr. Boeke, who an interdisciplinary research facility field of synthetic biology, designing will expand on this work at NYU Langone. that leverages automation to rapidly microorganisms to produce novel “We have shown that yeast cells carrying test millions of chemical, genetic, and medicines, raw materials for food, this synthetic chromosome are remarkably pharmaceutical compounds. and biofuels. His research focuses on normal. They behave almost identically At NYU Langone Dr. Boeke will the genome of Saccharomyces cerevisiae, to wild yeast cells. Only they now possess oversee a new hub for modern genetics commonly known as brewer’s yeast. new capabilities and can do things that wild research. “It’s the only institute in the In late March, Dr. Boeke and a team yeast cannot.” world with the words ‘systems genetics’ of international researchers announced Dr. Boeke is a native of New Jersey. He in the title,” Dr. Boeke says. Spurred by the synthesis of the first fully functional graduated from Bowdoin College in Maine the advent of automated DNA sequencing yeast chromosome. The achievement, in 1976, earned his PhD in molecular in the 1990’s, systems genetics puts a published in Science, affords researchers biology at Rockefeller University in 1982, high-tech twist on genome analysis, an unprecedented opportunity to explore and was a postdoctoral fellow in the tapping data-processing techniques genetic interactions and functions central laboratory of celebrated biologist Gerald to map the vast networks that connect to biology and human health. R. Fink at the Whitehead Institute/ genes, proteins, and other molecules. “It’s the most extensively altered Massachusetts Institute of Technology.

as an Alpha Omega Alpha graduate innovative educator, developing CHAIR OF ANESTHESIOLOGY of the State University of New York simulators for teaching ultrasound- ANDREW D. ROSENBERG, MD, Upstate Medical Center. He trained guided regional anesthesia. His research professor of anesthesiology and at NYU Langone as a resident, chief focuses on regional anesthesia, outcomes orthopaedic surgery, has been appointed resident, and cardiac anesthesiology in orthopaedic anesthesia, neurotoxicity the Dorothy Reaves Spatz Chair of the fellow before joining our faculty as of local anesthetics and antiseptics, and Department of Anesthesiology. Previously, a cardiac anesthesiology attending infection control. Dr. Rosenberg had served as chief of physician in 1984. He served as chair of Dr. Rosenberg succeeds Thomas J.J. anesthesiology at the Hospital for Joint the Department of Anesthesiology at HJD Blanck, MD, PhD, who stepped down as Diseases (HJD) and executive vice chair of from 2000 to 2006, when HJD merged the Dorothy Reaves Spatz, Chair of the Department of Anesthesiology. with NYU Langone. the Department of Anesthesiology last A graduate of Cornell University, Dr. Dr. Rosenberg is a leader in June to devote himself to research at Rosenberg earned his medical degree orthopaedic anesthesia and is an our institution.

NYU PHYSICIAN 26 SPRING 2014 NEW CELL BIOLOGY CHAIR cells to the developing ovary and testis In March Dr. Fisher delivered The 24th RUTH LEHMANN, PHD, the Laura and and the mechanisms that control the Annual Dennis Memorial Lecture in Isaac Perlmutter Professor of Cell Biology quality of germ cells as they mature into Cardiology at the Baylor College of and director of the Skirball Institute of egg and sperm to assure the health of the Medicine/Texas Heart Institute and the Biomolecular Medicine and the Helen L. next generation. annual Frank H. Tyler, MD, Honorary and Martin S. Kimmel Center for Stem Dr. Lehmann succeeds David Sabatini, Endowed Lecture in Medicine, University Cell Biology, has been named chair of the MD, PhD, who joined NYU School of of Utah School of Medicine. Department of Cell Biology. Medicine in 1972 to become chair of the Dr. Fisher, who is also professor Dr. Lehmann joined the faculty of Department of Cell Biology, and in 1975 of pediatrics and cell biology, and his the School of Medicine in 1996 and has was named the Frederick L. Ehrman colleagues have developed models of received numerous prestigious honors Professor of Cell Biology. He stepped atherosclerosis regression that have throughout her career, including election down after nearly 40 years of illustrious revitalized this area. They have adapted to the American Academy of Arts and leadership and scientific achievements HDL particles to carry imaging agents and Sciences, the National Academy of in the fields of organelle biogenesis and therapeutics into atherosclerotic plaques. Sciences, and the European Molecular intracellular protein traffic. Biology Organization. She has also been DR. LLINÁS HONORED a Howard Hughes Medical Institute EDWARD A. FISHER AWARDED RODOLFO LLINÁS, MD, PHD, the investigator. In 2011, she received EDWARD A. FISHER, MD, PHD, MPH, Thomas and Suzanne Murphy Professor the Conklin Medal of the Society for the Leon H. Charney Professor of of Neuroscience, received the Ragnar Developmental Biology, which recognizes Cardiovascular Medicine, who directs Granit Lectureship in Neuroscience extraordinary research and mentoring. both the Marc and Ruti Bell Program in awarded by the Nobel Forum, Karolinska Dr. Lehmann studies germ cells, the Vascular Biology and the Center for the Institutet in December. only naturally occurring immortal cells Prevention of Cardiovascular Disease, Dr. Llinás is a world-renowned in our body, as they differentiate into was honored last year as the George neuroscientist who pioneered sperm or egg and can give rise to a new Lyman Duff Memorial lecturer, among magnetoencephalography, a highly organism. She is interested in the signals the most longstanding and prestigious of sensitive, noninvasive technology for that specify and guide migrating germ the American Heart Association awards. measuring the brain’s electrical activity.

Continued from page 25 much sensation Richard now has comes up to NYU Langone for follow-up (Faculty Conversation with Dr. Rodriguez) throughout his face. Because of the care. He can receive all of the services he The Norris case was a great success, but is there scarring, we weren’t able to connect any of needs in our comprehensive program, anything you would do differently next time? the sensory nerves. The donor nerves were treatments like speech and physical The recipient’s side of the operation took laid in proximity to the recipient nerves, therapy, dental care, and periodic blood longer than we had anticipated. Extensive and somehow they connected. We’re work and biopsies to test for rejection. scarring made it difficult to identify looking into how that happened. anatomical structures. We delayed the What do you say to people who say that face final separation of the donor’s face as How committed was Mr. Norris to transplants are too costly? long as possible. But there were patients this operation? They are costly. But you have to keep in waiting for the donor’s other organs, so we Richard was so courageous. Even at mind that without a transplant, these had to separate the donor’s face and place the last minute, we gave him every patients would still undergo several major it in a cold preservative solution. No one opportunity to abort the operation. He reconstructive surgeries—at no small really knows how long this can be done wanted to do this. He always had—and expense. And they will never be quite without affecting the long-term function of still has—this commitment to helping right. In that light, a single corrective the tissue. Next time, we’d probably begin others by pushing this work forward. procedure—a face transplant—isn’t much the recipient’s operation a bit earlier. more costly overall. Not only that, it Now that you’ve relocated, are you still in could dramatically reduce the patient’s Were there any surprises? touch with Mr. Norris? physical, emotional, and psychological Perhaps the biggest surprise was how We still have a very close relationship. He stress, which is no small benefit.•

NYU PHYSICIAN SPRING 2014 27 MEDICAL EDUCATION

Stopping the Clock on Saturday Morning Reviving one of NYU School of Medicine’s most beloved teaching traditions, Dr. Steven Abramson, chair of the Department of Medicine, rounds with residents during off-peak hours. BY GARY GOLDENBERG

FORTY YEARS AGO, Dr. Steven leadership of Saul Farber, MD, the School’s Abramson, freshly graduated from longtime dean and chair of the Department Saturday morning rounds Harvard Medical School, arrived at of Medicine, who was hailed as one of the with Dr. Abramson (right), and Dr. Brandon Oberweis, chief resident, NYU School of Medicine to begin his most respected physicians in the country and other residents. internship in medicine. He was delighted and a master educator. A compassionate to be at NYU Langone Medical Center, physician and tireless teacher, Dr. Farber the patients and the deep responsibility of the one of the nation’s top-ranked academic personally led hospital rounds on Saturday physician as a professional entrusted with medical centers, and looking forward to mornings, taking advantage of these quiet their care. These peripatetic off-peak rounds his clinical training at Bellevue Hospital hours to delve deeper into the art and eventually passed into history, but not from Center, NYU’s major teaching affiliate and science of bedside care. memory. When Dr. Abramson, who as chief America’s oldest public hospital. These rounds, which included medical resident spent many a Saturday morning at Like many residents, the young man students as well as residents, became Dr. Farber’s side, was appointed chair of the was drawn to the extraordinarily diverse legendary for the pearls of wisdom Dr. Department of Medicine in March 2013, one patient population and inspired by the Farber imparted. The focus was always on of his first actions was to revive the tradition

NYU PHYSICIAN PHOTOGRAPHS BY 28 SPRING 2014 JOSHUA BRIGHT of Saturday morning rounds, this time to have safety considerations. include NYU Langone’s Tisch Hospital and A decade ago, New York the Manhattan VA Medical Center, NYU’s State passed a law limiting other primary teaching hospitals. a resident’s workweek “One reason we brought back Saturday to 80 hours, reasoning morning rounds was to slow down the clock that fatigued doctors-in- at the bedside for trainees, if only for a few training—who perform hours,” Dr. Abramson says. “Because of the lion’s share of inpatient the changes in hospital care, including the medical care—put patients focus on managing acute problems with in jeopardy. comorbidities in the outpatient setting, “When I was a resident, inpatient care gets telescoped. Too often, we worked through the clinical questions that get addressed the night every third become what, how, where: What is the day, in addition to our patient’s diagnosis requiring admission? daily shifts,” recalls How do we treat it? Where does the patient Dr. Abramson. “It was go next? But in some sense we focus less on exhausting, but it did the important why. have its advantages both “For example, if the admitting diagnosis for learning and for the is deep venous thrombosis, why is there continuity of patient care. a thrombosis, why do the platelets clot At night, we could set aside excessively in this patient? Asking the 20 to 30 minutes here and why question not only leads to a deeper there to talk about this understanding of the patient’s illness that X-ray or that EKG. Those may alter therapy, but also reminds us quiet evening moments for of how little we often understand about learning are uncommon in disease mechanisms and how much the new shift-driven restrictions on ward being a departmental chair, is steeped in research remains to be done,” he adds. duty, but I think Saturday rounds is a step administrative responsibilities. Saturday And the why can make all the difference. in the right direction.” morning rounds, he says, keep him in “On a recent Saturday morning at Bellevue,” Dr. Abramson is also concerned that touch with the clinical side of medicine. Dr. Abramson recalls, “we visited a newly more and more hospital rounds have “Rounding with residents gives me insights admitted patient, Mr. K.—hungover, moved from the bedside to the conference into their daily lives,” he says. “It also makes disheveled, uncommunicative, relegated room, a nationwide trend. It can be more a clear statement that the chief of medicine to the status of a homeless alcoholic— efficient to discuss cases in a conference cares enough about what’s happening on admitted for head trauma post-fall, and now room. But without that hands-on the wards to come in on the weekend.” awaiting placement and being observed perspective, we’re losing something. The Brandon Oberweis, MD, senior chief for the inevitable delirium tremens. But as focus becomes discussion, rather than the resident in internal medicine, appreciates we started talking to him, we noticed his patient. We need to combine both.” the effort. “Having the chair of medicine tattoo of an Army insignia. When I asked “Over the years,” Dr. Abramson round with residents on Saturday morning him about it, his face lit up. It turned out continues, “we’ve created a host of courses really emphasizes the approachability he had been a paratrooper in Vietnam and and programs in medical humanities and of the senior faculty,” he says. “Also, it’s later fell on hard times. Digging deeper, the bioethics, which are vital in preparing tremendously helpful for us to see the way team began to see the patient not as Mr. K, physicians for practice. But when you’re a highly experienced physician like Dr. a street person, but as an individual with a resident working nonstop for 8 or 10 Abramson interviews a new patient and a life history, a veteran with perhaps an hours, you can lose sight of all that. We generates a differential diagnosis.” undiagnosed case of post-traumatic stress need to reinforce these lessons at the After four decades on the front lines, all of disorder, a possible explanation for his bedside at every opportunity.” it spent at NYU Langone, Dr. Abramson has current condition.” As senior vice president and vice his own stories to tell, his own wisdom to If the economics of healthcare have dean for education, faculty and academic share. And now, like his onetime mentor, he put a crimp on residency training, so too affairs, Dr. Abramson, in addition to has a weekly opportunity to pass both on. •

NYU PHYSICIAN SPRING 2014 29 PATIENT STORY

Who Are You If You Can’t Emote? Solving a case of facial paralysis by tapping into a nerve from the tongue.

BY AMY ENGELER FOR ANTON DOLCE, the dull When Dolce awoke, he learned that injury, viruses, even Lyme disease—to headaches and light-headed moments while his nerve remained intact, it had know that the suffering goes beyond were all too easy to dismiss. He even been stretched during the surgery. Only vanity and health concerns. “So much of came to appreciate the ringing that time would tell whether the resulting who we are is in our facial expressions,” developed in his right ear after he turned paralysis was temporary or permanent. says Dr. Roland. “It’s what gives us 60—the rhythmic whoosh sounded like “The doctors were very hopeful that the personality and makes us human. With the crashing waves of his childhood on nerve would come back over the next few a flaccid face that is unable to express the Long Island shore. So it was with months. I was hopeful too,” Dolce says. emotion, it can be difficult to feel whole.” shock when Dolce, 64, an architect and But his paralysis persisted. Dolce tried The surgical technique, performed mechanical engineer, learned that these to stay calm as he looked into the mirror. 45 times at NYU Langone since 2003, mild symptoms came not from age and On the paralyzed side of his face, the cheek calls for grafting the damaged facial noisy construction sites but from a golf drooped like that of a jowly old man. The nerve into a healthy one from the tongue, ball–size brain tumor lodged behind his right eye, open and unblinking, looked essentially plugging it into a new power right ear, growing dangerously close to startled. His right lip sagged sadly. “When source. In the past, the tongue nerve his brain stem. Like about 2,000 other I tried to smile,” he says, “it just looked might be weakened or sacrificed for people in the United States that year, like I had gas.” Upbeat and gregarious by the added nerve, but Dr. Roland and Dolce was diagnosed with an acoustic nature, Dolce became too self-conscious colleagues found a way to loosen the neuroma, a slow-growing tumor of the to go anywhere other than job sites. He facial nerve from around a salivary gland nerve that carries sound from the inner ear to the brain. Although such a cancer will not spread outside the nerve, it can crush surrounding nerves and structures “So much of who we are is in our facial as it grows. expressions,” says Dr. Roland. “It’s At the same time that removing the tumor promised to prevent further damage what gives us personality and makes and perhaps save Dolce’s life, it risked us human. With a flaccid face that is injuring his facial nerve, which passes out of the brain stem and close to the ear before unable to express emotion, it can be it divides into seven branches to control the difficult to feel whole.” muscles on the side of the face. Surgeons J. Thomas Roland Jr., MD, the Mendik Professor of Otolaryngology and chairman of the Department of Otolaryngology, ate in private, unable to close his mouth, near the jaw and extend its length by 3 and John George Golfinos, MD, chair of and remained home if his wife went out. to 5 centimeters. The extension allowed the Department of Neurosurgery, worked “My friends tell me I don’t look like a freak them to graft the nerves together without carefully over eight hours in August 2012 show,” he said, “but I feel like one.” tension, thus increasing the odds that to extract the growth and untangle it When electrical tests on the nerve both nerves would function. from the facial nerve, which had become showed no activity beyond the brain The surgery presented Dolce with some wrapped around the tumor like ribbon on stem 12 months after surgery, Dr. Roland unusual but surmountable challenges. a gift. After several decades of experience proposed a nerve graft, using a technique Until his brain adjusted to the rerouted with this delicate surgery, Drs. Roland and he had pioneered at NYU Langone nerves, he might need to think of chewing Golfinos are able to preserve facial nerve 12 years earlier. He had seen enough in order to grin. But Dolce was eager to try function in 19 out of 20 acoustic neuroma patients with facial paralysis—from anything to regain his smile.

cases, better than the nationwide average. tumor removal, Bell’s palsy, traumatic “I can deal with an eye that doesn’t LEIGHTON BY SCOTT ILLUSTRATION

NYU PHYSICIAN 30 SPRING 2014 blink,” he said. “But to be able to smile again would be fantastic. If they can fix my mouth, I’ll be happy.” To ensure the best possible outcome, Dr. Roland recruited the help of facial plastic surgeon Matthew White, MD, assistant professor of otolaryngology- head and neck surgery. On the day of the operation, performed in early November, Dr. White began by implanting a gold weight on Dolce’s right eyelid to help it close. Then he lifted his eyebrow and pulled a tendon from his upper jaw down to the edge of his mouth—a facelift technique that would balance both sides of his face and help him control his lips. “I told him, ‘Don’t make me look like Joan Rivers,’” Dolce recalls, jokingly. When Dr. White finished, Dr. Roland took over and moved the intra-temporal facial nerve down to the hypoglossal (tongue) nerve and grafted the facial nerve to half of the tongue nerve, using tiny sutures under the lens of a microscope. Dolce emerged sore and bruised but thrilled with the results. For starters, he no longer looked angry. With symmetrical eyebrows and a mouth curved upward he appeared cheerful. Able to smile passably and show his teeth, Dolce felt his old personality returning. “My friends say I’m 80 percent better,” he says, “and the nerve hasn’t even kicked in yet to do the rest of the job.” As the nerve fully heals over the next year, sensation should first return to The facial nerve relays messages from the brain to most of the 43 the eye and work downward through muscles in the face. Dr. J. Thomas Roland Jr. modified a surgical the nerve branches toward the chin. technique to re-establish facial muscle innervation and movement by grafting the temporal facial nerve onto the nearby tongue nerve, “In nine months I’ll ask him to push also known as the hypoglossal nerve, which acts as a surrogate his tongue to the roof of his mouth,” Dr. power source. One key to success is locating the graft below a Roland explains. “If I see something junction of nerves near the jugular vein, called the ansa hypoglossi, (circled in above inset), a kind of switchboard that connects dozens moving in his midface or eye, I will know of nerves originating in the neck with the tongue nerve. A graft that he’ll get an acceptable result.” • above this junction might not be as effective.

NYU PHYSICIAN SPRING 2014 31 OBITUARY

Dr. David S. Baldwin

DAVID S. BALDWIN, MD, professor symptoms have resolved, Dr. Kimmel says. forerunner of cyclophosphamide, to emeritus in the division of nephrology, and In an editorial published in 1977 produce remissions of symptoms caused former director of the division, died in his in the American Journal of Medicine, by kidney damage. sleep December 23, 2013, at his home in Dr. Baldwin challenged medical wisdom The son of Russian Jewish immigrants, New York City. He was 92. that strep-induced damage to the glomeruli David Baldwin was born in Rochester, New For half a century this meticulous resolved after acute symptoms abated. York, and raised with two older sisters in bench scientist and beloved physician His follow-up of such patients over 10 to an orthodox home. He attended college and trained scores of kidney specialists at 18 years showed that the hallmarks of the medical school at the University of Rochester. NYU Langone Medical Center. He studied disease—blood and protein in the urine, In 1940 he met Halee, his wife of 68 years. In and documented the natural history of high blood pressure, impaired renal 1947, after a residency in St. Louis, the couple virtually all forms of glomerular disease, function, and hardening or scarring of the moved to New York City. Early in his career, in which infections like strep throat and glomeruli—either persisted or recurred Dr. Baldwin worked a second job as a staff bacterial endocarditis or conditions such as in most patients even years later and, in physician at the New York Times, according diabetes and systemic lupus, impair renal some cases, progressed to kidney failure. to Daniel Baldwin, one of his four sons, who function by damaging the glomeruli, the “His ideas, based on patient observations fondly recalls how a boyhood interest in tiny blood-filtering units of the kidney. confirmed in the lab in the 1970s and ’80s, classical music led his father to take him to hear Paul L. Kimmel, MD (’76), a researcher are at the forefront of nephrology today,” a live string quartet in the studios of WQXR, with the National Institute of Diabetes and Dr. Kimmel says. then owned by the New York Times Co. Digestive and Kidney Diseases, remembers Another of Dr. Baldwin’s former “He was the person I turned to for advice his former teacher as a “charming man,” students, Jerome Lowenstein, MD (’57), when I had important decisions to make,” polite and engaging, who treated his professor of medicine, later became his Daniel says. “He was a great listener, students and residents as his equals. colleague and then his patient. Still later, which I’m sure contributed to his skill as a Dr. Baldwin was the first to establish that their roles reversed. The two met in the mid- diagnostician.” acute disease can continue to damage 1950s, when Dr. Lowenstein was a third- Dr. Baldwin could cut a rug with his wife the kidneys even after clinical signs and year medical student. “He had just gotten at dinner dances, too, and he loved Hydrox out of the Army a few years before. There cookies as much as he did a well-made was only about a 10-year age difference, but martini. Although he had worked mornings Dr. Baldwin and his wife, Halee he seemed very much my senior,” on the weekends when his children were Dr. Lowenstein says. still living at home, on Sunday afternoons In those early days, few he would take his sons for a drive through physicians made careers in adult Central Park, then open to auto traffic. “It kidney disease because no treatment was a big deal,” Daniel says. “He allowed us existed. Dr. Lowenstein recalls that to listen to rock stations, the Beatles.” Dr. Baldwin came to NYU Medical An avid reader throughout his life, Center because he “wanted to study Dr. Baldwin in later years turned to with Homer Smith, MD, a giant in drawing in his spare time. He retired at renal physiology.” At the time, “a age 82 in 2004. Two years later he and lot of textbooks described the signs Halee created a fellowship fund in and symptoms of kidney disease nephrology at the School of Medicine. but little was written about the He is survived by his wife; four sons course of the disease.” Dr. Baldwin and three daughters-in-law, Neil and his “wrote and published papers that wife, Roberta, Andrew and his wife, Susan, describe every form of glomerular Daniel and his wife, Nancy, and James; seven disease—an extraordinary body of grandchildren, Nicholas, Allegra, Seth, information,” Dr. Lowenstein says. Laura, Matthew, Joshua, and Julia; and two He was also among the earliest great-grandchildren, Levi and Emily. • clinicians to use nitrogen mustard, a —AUBIN TYLER

NYU PHYSICIAN 32 SPRING 2014 Change Change Change Change Change Change Change Change Change the world…

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