Week 13: Mayo Clinic

August 21st, 2013

Katlyn Arndt ’15, Brent Fellow in Neurology and Medicine

I can’t believe that my time at Mayo Clinic is already over! This summer has given me so many opportunities to learn about research and the medical field. The knowledge and skills I have gained from this fellowship will help me succeed in the future, both academically and professionally.

During my last week, I was able to help out with the data entry for our survey-based epilepsy project. We are using a program called REDCap, which stands for Research Electronic Data Capture. This web-based tool allows us to collect and track the data from our surveys. It took about 25 minutes to enter the data for each survey we have received back. After I entered at least 10 surveys into the database, we were able to complete a “mini” data analysis. Although this was a small population number, we were able to see the general trends of the data. It looks like we will have some great things to work with!

There are many people I would like to thank who made this experience possible. First and foremost, I would like to thank Dr. Erik St. Louis for being a wonderful mentor. His knowledge and guidance helped me through this summer. I learned so much about the field of neurology and sleep medicine from him. A big thank you to all the research assistants (Dave, Stu, Paul 1, and Paul 2) who guided me through our research and provided great company. In addition, I would like to thank Maia and Grace, the other student summer interns, who I could not imagine this summer without. Finally, I would like to thank the Cornell Fellows program and my advisor, Craig Teague, for supporting me academically and financially throughout this whole experience.

I plan to continue working on some of our research throughout the fall. I will continue scoring CAP for our sleep deprivation project and eventually help with the writing process of this paper. In addition, I will return to Rochester during one of the block breaks in the fall semester to help with the data analysis for our survey-based epilepsy project. Although I was not able to complete a project this summer, I am excited to continue working on them and to see their outcomes.

Dr. Erik St. Louis and I

Dr. Erik St. Louis and I

The other student summer interns and I

The other student summer interns and I

“Today the only thing that is permanent is change.” -Dr. Charlie Mayo

Week 12: Mayo Clinic

August 13th, 2013

Katlyn Arndt ’15, Brent Fellow in Neurology and Medicine

This week we finished sending out our surveys and even received some back in the mail. I was very excited when I found out the first Epilepsy survey was returned! So far, we have received about 10 Epilepsy surveys and 30 Parkinson’s Disease surveys back. We are currently working on setting up a database so we can begin the data entry process for the Epilepsy survey. Since the Parkinson’s Disease survey is part of a multi-center study, we will not do anything further with them. We will be sending them to Montreal, where they will be analyzed.

Throughout this whole process we have gotten a lot of phone calls, so I’ve had the opportunity to interact with some of the patients. There were a couple mistakes found in the surveys,  which is disappointing because I proofread them multiple times. This was bound to happen, however, in a 40-page document. In addition, some of the patients called inquiring why they received a survey because they have never been diagnosed with Epilepsy or Parkinson’s Disease. In some cases, the patients were in denial that they had this diagnosis, which made the situation very delicate. In other cases, some of the patients had a diagnostic code in their record by accident. Either way, talking to these patients was a great learning experience. One particular phone call that I really enjoyed was a patient who called to let us know that our survey was impressive and that she really enjoyed it. It was nice to see that all of the hard work I put into the surveys has paid off!

I have continued to work on our sleep deprivation CAP study, however, it has been very time consuming. Unfortunately, I will not be able to finish scoring all of the records before my fellowship is over. My goal is to have at least 30 out of 50 records completed before I am done. We may have the chance to begin analyzing the data before I leave, since the subjects are their own controls. We will be comparing the difference between the control nights and the sleep deprived nights based on total CAP rate, CAP subtypes, and other factors.

This week, Grand Rounds was a little different. The presentation was about Walter DeWitt Shelden, the “Father of Mayo Neurology”. It was very interesting to learn more about the history of Mayo and how the Neurology section at Mayo was started. In addition, one of the grandchildren was present to share his memories and experiences with Shelden.

“The sciences bring into play the imagination, the building of images in which the reality of the past is blended with the ideals for the future, and from the picture there springs the prescience of genius.”-Dr. Will Mayo

Week 11: Mayo Clinic

August 7th, 2013
Katlyn Arndt ’15, Brent Fellow in Neurology and Medicine
This week we continued to work on the CAP analysis for our sleep deprivation study. We have approximately 20 out of the 50 records analyzed thus far. Our goal is to have all the records analyzed before my last week here, so I can help with the data analysis. This is what I will be spending most of my days doing during my last couple weeks here. I’m starting to go a little crazy looking at brain waves all day, however, each record gets a little bit easier as I gain more experience.
image-2Thankfully, some of the days have been broken up by putting our surveys together.   We have had an intense assembly line going, which included stapling, putting multiple labels on paperwork, stuffing envelopes, labeling envelopes, sealing envelopes, etc.    In addition, everything has to stay completely organized to ensure that the names and ID numbers match on all the paperwork. We were able to knock out our Parkinson’s Disease and REM Sleep Behavioral Disorder survey in about two hours, since there were only 250 subjects. Our epilepsy survey, however, has 1000 subjects, so it will take a couple days to complete that. We won’t receive many surveys back before I am done, so hopefully I will be able to come back in the fall for a few days to help with the data analysis. The picture to the right is of some of my colleagues and I working on putting the surveys together.MayoWeek11This summer I had the opportunity to meet some amazing, talented students from all over who were completing research through the Student Undergraduate Research Fellowship (SURF) program at Mayo. Unfortunately, their program ended this week, but had a great last week together. The past weekend we participated in a volleyball tournament through the Mayo Graduate School. Our volleyball team, pictured in the top left, was named “Kidney Stones”. Although we didn’t win, we had a great time playing and interacting with some of the graduate students. We celebrated our last days together by eating a home cooked meal. One student from Sweden, who is very passionate about cooking, made us some delicious shrimp tacos (shown in the picture to the bottom left). Being able to meet these other students has been one of the highlights of my time here in Rochester. It has given me the opportunity network with other undergraduates and share our experiences with each other.
“The man of science in searching for the truth must ever be guided by the cold logic of facts, and be animated by scientific imagination.” - Dr. Will Mayo

Week 10: Mayo Clinic

July 29th, 2013

Katlyn Arndt ’15, Brent Fellow in Neurology and Medicine

This week I hit the ground running with the CAP analysis for our sleep deprivation study. We have five subjects who have completed the study so far. We will analyze five nights of sleep deprivation and five nights of normal sleep as a control. This means that we have to analyze 50 records in the next few weeks. Considering each record takes approximately one day, we have a lot of work to get done in a short amount of time. Hopefully with all the student interns working on the project, we will be able to get it done. Once we finish scoring all the records, we will analyze the data to see if their is a difference in the amount of CAP between the sleep deprived state and the control state. In addition, the subjects completed many cognition tests while in the sleep deprived state, so we will be able to analyze the relationship between CAP and cognition.

I also continued to work on my individual project, which is the Epilepsy survey. Everything is approved and finalized so now we are starting the mailing process. This survey is HUGE and we are sending it to about 1,000 patients. After a quick calculation, I realized that we need to print ~40,000 pages. Thankfully, Mayo’s media services will print everything for us for free. We are expecting to get the printed copies early next week. Then, we have the exciting job of labeling each survey packet and stuffing them into mailing envelopes.

On Wednesday, I attended Medical Grand Rounds. The topic was “Why Scientists and Physicians Inhibit Scientific Advances”. It was an interesting presentation about how we ignore or deny facts that challenge our basic assumptions. Essentially, it’s something we have never heard of, so it can’t be true. The presentation was very interactive and enjoyable.

To finish out the week, I attended a barbeque at Dr. St. Louis’ house. It was great to spend time with everyone outside of the lab and enjoy some delicious food! And of course there were some neurology jokes thrown into the conversation. Two of the research assistants in our lab will be beginning medical school at the University of Minnesota next week, so it was a great way to send them off.

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“The keynote of progress in the 20th century is system and organization, -in other words, ‘teamwork.’”-Dr. Charlie Mayo

Week 9: Mayo Clinic

July 22nd, 2013

Katlyn Arndt ’15, Brent Fellow in Neurology and Medicine

After being at the Mayo Clinic for over nine weeks now, I have gotten into a routine. This is what a typical day in the lab looks like:

Screen Shot 2013-07-22 at 8.15.27 PM My day begins by walking from my apartment to work through the skyway/subway system at Mayo. The picture to the left is the lobby of the Gonda building, in which I work in. This is one of the main patient buildings at Mayo and it is gorgeous! There are marble floors and walls, large open windows, and many paintings and sculptures by famous artists. Many times there is someone playing the piano or singing, which is nice to hear first thing in the morning.

Screen Shot 2013-07-22 at 8.38.42 PMAfter making my way to the 17th floor of Gonda, I met my lab in our office. Here we discuss any updates on our current projects and decide on the agenda for the day. Unfortunately the office is tiny, so the other student interns and I work in a different area. It’s a little hard to cram six or more people in an office meant for two. The picture to the right is the reading room where we spend most of our time. Here we work on our scorings and have group meetings with Dr. St. Louis.

At least three times a week, we have grand rounds or a sub-speciaility conference during lunch. These are great opportunities to learn about medicine as well as get some free food! On days that we do not have grand rounds or a conference, my lab and I eat lunch together in our office. We usually relax during our lunch break by watching a couple episodes of a television show. I am so thankful that I have a great group of people to work with everyday!

Nothing particularly exciting happened this week, however, I continued to work on my RSWA and CAP scoring. I have now passed the Gold Standard for both RSWA and CAP, so I can work on my projects independently as well as help out with projects lead by the research assistants in my lab. One of the medical students in our lab is working on a project which studies the correlation between RSWA and patients with multiple system atrophy (MSA). MSA is a progressive neurodegenerative disorder which causes problems with movement and balance. So far, this study has shown that MSA patients have a lot more tonic muscle tone, which is muscle tone that is at least 15 seconds in duration. The tonic muscle tone, however, makes the scoring much more difficult, so it takes more time to score these records.

Dr. St. Louis presented some of the work our lab has done regarding REM sleep behavioral disorder at Friday’s sub-speciality conference. It was nice to see some of the results of the work I’ve done this summer. Also, it was the first conference I’ve been to at the Mayo Clinic where I understood everything that was said. It’s amazing how much I’ve learned about sleep medicine and neurology this summer.

“It is a great thing to make scientific discoveries of rare value, but it is even greater to be willing to share these discoveries and to encourage other workers in the same field of scientific research.” – Dr. Will Mayo

 

 

Week 8: Mayo Clinic

July 16th, 2013

Katlyn Arndt ’15, Brent Fellow in Neurology and Medicine

I am thankful I had the opportunity to shadow a Physician Assistant (PA) and Nurse Practitioner (NP) on the Sleep Medicine floor this past week. After Cornell, my goal is to attend a PA program. For those of you who don’t know, a PA is a mid-level healthcare professional who practices medicine under the supervision of a doctor. PAs take medical histories, conduct physical examinations, diagnose and treat patients, and prescribe medications. This opportunity was a great way to explore the medical field and interact with patients. In addition, I was able to use some of the background knowledge I’ve gained from my fellowship while shadowing.

Both days of shadowing were similar. In the morning, we began in the reading room to go over the sleep studies that were conducted the night before.  After reviewing the sleep study, the patient was diagnosed and a treatment plan was formulated. The rest of the day was spent seeing patients. When a patient has a sleep study, they come in for a follow-up appointment the next day. In addition to these follow-up appointments, we also saw patients for consultations. These patients have already had an oximetry test which screens them for obstructive sleep apnea (OSA). OSA occurs when there is complete or partial blockage of the upper airway during sleep. If their oximetry test is abnormal (too many drops in oxygen levels), they are recommended to have a sleep study to be formally diagnosed with OSA. OSA is thought to be a “scapegoat” because of its many associated comorbidities. For example, OSA can lead to high blood pressure, high levels of hemoglobin, low levels of testosterone, etc.  Patients come to the Sleep Medicine floor hopeful that sleep apnea treatment will solve all of their problems.

One of the amazing things about the Mayo Clinic is that people come here for treatment from all over the world! In just the two days I shadowed, three out of the fifteen patients I saw were from different countries. These patients, however, present a challenge with the language barrier. Mayo Clinic offers great resources such as interpreters and language lines. On the first day of shadowing, the patient spoke Nepali. Since an interpreter was not available for this language, we had to use the language line. This required using an interpreter over-the-phone. On the second day,the patient required an Arabic interpreter for which one was available. I think the examination with the interpreter went better than the examination using the language line, mainly because the was more personal interaction with the patient. In addition, this was a great experience to see how different cultures can affect a patients decision for medical treatment.

Overall, this has been my favorite week at Mayo Clinic thus far. I loved interacting with patients! In addition, I was able to ask the PA I worked with a lot about her career and her schooling. It is great to hear the perspective of someone who has already been in my shoes. As well as shadowing, I have also been researching PA programs. I finally have a “short list” of 35 programs that I am interested in attending. My goal is to narrow this list down to approximately 15 schools. As I become more familiar with the medical field through my everyday interactions in this fellowship, I think it will be easier to decide which PA program will be right for me.

“There are two objects of medical education: To heal the sick, and to advance the science.” – Dr. Charlie Mayo

Week 7: Mayo Clinic

July 8th, 2013

Katlyn Arndt ’15, Brent Fellow in Neurology and Medicine

This week went by quickly, considering we only had a three-day week. Most of this week was dedicated to completing the CAP gold standard. The CAP gold standard consists of 120 epochs compiled from different subjects. In order to pass, you must have over 80% concordance with the gold standard. The purpose of the gold standard is to ensure that our scorings are reliable. Now that I have passed, I can begin scoring records on my own. We have a lot of subjects we need to tackle by the end of the summer!

My favorite project this week was finalizing the questionnaire for our survey-based epilepsy study. We have two versions of the questionnaire: one for controls and one for epileptic patients. After making a final decision for which measures to include, I proofread and formatted the 39-page questionnaire. We also did a sample size calculation to estimate how many surveys we need to send out. Our sample size calculation showed that we need at least 300 patients. We are expecting a response rate of 20-30%, since the questionnaire is so long; therefore, we will be sending the questionnaire to 1500 epileptic patients. Now, we are waiting for the IRBs approval of our modifications. Hopefully, we will begin to mail out surveys next week.

I really enjoyed the neurology Grand Round this week. The speaker presented on identifying biomarkers for Alzheimer’s Disease through metabolomics. Metabolomics is the study of chemical processes involving metabolites. This method can compare disease state to control state and can be easily translated from animals to humans. Using Ultra Performance Liquid Chromatography (UPLC) and Time-of-flight mass spectrometry (TOFMS), a blood sample can be analyzed. This technique detects which metabolites are present and which pathways are most active. Currently this technique can only detect 22% of metabolites, however, once the other 80% of metabolites are identified, this technique has a lot of potential. I love learning about the cutting-edge advancements in science and how they are being applied clinically.

To celebrate the 4th of July, I spent the weekend at my family cabin on Mille Lacs Lake in Minnesota. The weekend was filled with waterskiing, tubing, and many card games.  It was a great way to spend time with my family and relax.

 

My cousin and I tubing on Mille Lac Lakes during the 4th of July weekend. What a great way to let loose and relax!

Week 6: Mayo Clinic

July 1st, 2013

Katlyn Arndt ’15, Brent Fellow in Neurology and Medicine

This week was pretty exciting because I had my first interaction with a patient. I was invited to observe Dr. St. Louis give a neurological examination to a patient participating in our sleep deprivation study. The patient was staying at St. Mary’s Hospital, which is the other Mayo Clinic campus in Rochester about five minutes from downtown. While on the bus ride over, I was able to have a great conversation with Dr. St. Louis. He told me about his experience working at University of Iowa as well as his trips to Mount Vernon to eat at the Lincoln Cafe. In addition, we talked about the physician assistant profession. Although I want my career to be patient focused, I would love to do clinical research. At the moment, there are no physician assistant programs with a PhD track like there is for medical school, but this may be something that develops in the future. It was great to have Dr. St. Louis’ input since he does both patient care and clinical research.

The sleep deprivation study our lab is completing is very interesting. Patients stay in the hospital for 21 days: 3 days of normal sleep, 14 days of deprived sleep, and 4 days of recovery sleep. During the deprived sleep stage, patients only get four hours of sleep per night. In addition to recording the EEG, the patient also completed different cognitive tests to test the affects of sleep deprivation. The patient we were seeing was over halfway through the deprived sleep stage, but the nurses were concerned with his balance. As a precaution, Dr. St. Louis was called to make sure the patient was okay from a neurological stand point. It is amazing how much he could discern from simple tests, such as having the patient walk in a straight line or hold their arms out straight. It was a great learning experience. Later this summer, we will be scoring CAP from the EEGs of the patients who undergo this study, so it’s cool to be able to see the other side of the research.

In addition to the normal conferences I attend, Mayo Clinic offers student seminars in order to introduce students to different medical fields and illustrate current research occurring in those fields. This weeks seminar focused on biomedical engineering, which is the advancement in health care treatment. Mayo Clinic prides itself in always being on the edge of medical advancement. Over 100 years ago, Dr. Henry Plummer developed the “unit record” at Mayo Clinic, which kept all of a patient’s record in one file. This type of record was the first of its kind and quickly became the standard of medical record keeping around the world. Recently, Apple published an article about the Mayo Clinic’s use of an iOS application that allows health providers to access the electronic medical record from an iPad of iPhone, order medications, etc. Mayo Clinic also offers a patient app, allowing them to view their own medical record and contact their physician.

The doctor speaking at the seminar explained his current research regarding spinal cord injuries. Many times, spinal cord injuries result in paralysis, which can also decrease the function of the diaphragm. Through this research, it has been shown that brain-derived neurotrophic factor (BDNF), a secreted protein which encourages the growth and differentiation of new neurons and synapses, increases the recovery of the diaphragm by signaling throughtropomyosin related kinase receptor subtype B (TrkB). By delivering BDNF into the spinal fluid, the BDNF/TrkB signaling increases, enhancing the recovery of the diaphragm. By enhancing the gene expression of TrkB.FL gene, the BDNF increase. Although this research does not correlate directly to what I am researching in my lab, it is interesting to learn how Mayo is advancing healthcare in different areas of medicine. In addition, these seminars allow me to apply knowledge I have learned in Cornell classes such as Cell and Molecular Biology.

“The sciences bring into play the imagination, the building of images in which the reality of the past is blended with the ideals for the future, and from the picture there springs the prescience of genius.”-Dr. Will Mayo

 

Week 5: Mayo Clinic

June 24th, 2013

Katlyn Arndt ’15, Brent Fellow in Neurology and Medicine

This past month has gone by so quickly – I can’t believe I am almost halfway done with my experience. I have learned so much these past few weeks and I cannot wait to apply my new knowledge as we delve deeper into our projects these next couple months. One project I am particularly excited about is the sleep-epilepsy survey project. The aim of this study is to analyze sleep disturbances in adult patients with epilepsy and to determine whether these sleep disturbances affect the quality of life of the patient. This past week I did a lot of literature review on the subject and met with Dr. St. Louis to finalize the measures. The survey is approximately 30 pages, containing different scales that measure insomnia, sleep apnea, quality of life, seizure severity, depression, etc. This project has allowed me to learn about research design and the execution of a study.

After a week of working on one CAP study as a group, we finally finished! When attempting to analyze the data in HypnoLab (the software we use), however, the file containing our data was completely erased. Thankfully, the IT department had a backup of the file from the day before, so we only had to re-do about three hours of work. Next week, Dr. St. Louis is setting us free to start scoring CAP studies on our own. The CAP studies we are scoring are from epileptic patients. It is thought that the amount of CAP increases in the presence of certain sleep disorders, such as epilepsy. In addition, CAP can trigger epileptic events. Later on this summer, we will also study the correlation between CAP and sleep deprivation.

During my free time, outside of work, I have been enjoying the beautiful weather by running outside. Rochester has an extensive trail system, covering over 85 miles. It’s nice to be able to escape to nature, while still having the luxury of living in the heart of downtown. In addition, I have been researching physician assistant schools and studying for the GRE. There are so many resources at the Mayo Clinic, so I hope to take advantage of them. In early July, I will be shadowing two physician assistants that work in my department.

A view of downtown from one of the running trails in Rochester.

A view of downtown from one of the running trails in Rochester.

“See things for yourself; reading alone is not enough.” – Dr. Will Mayo

Week 4: Mayo Clinic

June 17th, 2013
Katlyn Arndt ’15, Brent Fellow in Neurology and Medicine
 In the mornings, the other summer students and I continue to practice our RSWA scoring skills in order to prepare for the Gold Standard test. After we complete the Gold Standard test, our scorings will be considered reliable to use in the studies. After a week of experience with RSWA scoring, I have been exposed to a variety of patients. Every now and then I come across segments that I am not sure about, but I am getting much more comfortable scoring by myself.
The afternoons are spent with Dr. St. Louis. This week we delved into the subject of Cyclic Alternating Pattern (CAP). CAP, which can be seen in an EEG lead during non-REM sleep, represents unstable sleep. To be considered CAP, the waves must be 1/3 greater in amplitude than the background. We can also classify CAP into three subtypes: sleep preserving (A1) and sleep fragmenting (A2 and A3). We have been learning how to conceptualize CAP by scoring a case together as a group. CAP scoring can be much more subjective than RSWA scoring, so it is important that we are all on the same page. CAP scoring can be tedious but hopefully it will get faster once we are more familiar with the process.
This figure illustrates the different subtypes of CAP.

This figure illustrates the different subtypes of CAP (Parrino et al, 2012).

I attended two Clinical Pathology Conferences (CPC) this week. These conferences provided great insight into how challenging cases are diagnosed. The conference begins with a description of the case including past medical history, lab results, etc. Then, a clinician presents their opinion on the diagnosis while demonstrating their process of reasoning. First, the clinician, through a process of elimination, decides which types of diseases to consider. From this, they discuss possible diseases that fall under these types. They determined the probability by assesing the symptoms for and against the particular disease. After the clinician decides on a final diagnosis, a pathologist reveals the final diagnosis.  After completing a biopsy, both cases were diagnosed as Central Nervous System (CNS) lymphoma. In the conferences I attended, both clinicians made an incorrect diagnosis, however, I think this shows the importance of collaboration in medicine.
“No one is big enough to be independent of others” – Dr. Will Mayo
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