Week 8: Mayo Clinic Sleep Center

August 8th, 2012

Parker Emrich ’13, Dr. James Culbertson Fellow in Neurology and Medicine

As this week began I really started to get into the tempo of independent CAP scoring and only managed to finish one very heavily fragmented sleep record. Part of the reason that it took so long was because I had to manually re-score every event the previous team labeled one at a time which slowed down the re-scoring process significantly. Thankfully on Tuesday, I figured out a feature of the program that Dr. Erik didn’t know about that allows us to rename all of events in a sleep record from one event name to another so I was able to re-score the entire sleep record in broad strokes first and then go through visually to correct whatever mistakes the broad strokes missed such as CAP events that they did not score at all last summer, CAP events that they did score that we would not by the new rules and guidelines, and checking each event visually to make sure that it has been properly assigned the correct subtype that represents its particular morphology, amplitudes and frequencies. In some part thanks to this new found feature, I managed to bulldoze my way through five records in a day on Tuesday, although I think I went into a hyperfocus state slightly and that really helped my work efficiency.

Wednesday morning was spent reading three articles and then breaking from my article reading to go to the General Internal Medicine grand rounds seminar being presented by John B. Bundrick about a variety of clinical pearls. Clinical pearls is a concept that,as I understand it, is used to refer to little shortcuts, smart tools or tactics and similar things that most internists and other physicians may not have picked up in their practice. Basically the idea of clinical pearls presentations is to disseminate useful nuggets of information to physicians that may not have encountered them in their practice and, in this purpose, it serves to reinforce the Mayo Clinic’s strong belief in the continuing education of its medical professionals. Additionally, because the clinical pearls are usually fairly simple and succinct, the information presented in these seminars tends to be much more accessible to people with less formal medical education such as myself. By way of example, one of the things I will definitely be remembering from Wednesday’s seminar is that the presenter recommended ipratropium and oxymetazoline nasal sprays as the most effective treatment for the relief of the nasal symptoms of the common cold and that the most common and simple way to check for basic symptoms of carpal tunnel syndrome is to check for hypalgesia of the median nerve in the hand by checking the sensitivity of the pointing finger compared to the pinky finger. If there is reduced sensation in the forefinger that has been shown to be indicative of carpal tunnel syndrome. He was also one of my favorite speakers that I have had the pleasure and opportunity to listen to during my stay at the Mayo Clinic. He had a wonderfully conversational and pleasant tone and speaking manner. He had a few of the physicians around me tearing up in laughter at his witty repartee. His presentation went a little over the designated times but I am fairly certain no one really minded. His talk was informative, fun, and engaging, a combination that teachers everywhere aspire to as a gold standard of seminars.

After the Wednesday seminar, I went back to the reading room where we do all of our scoring and work and I delved back into CAP scoring in an effort to get as much of our CAP re-scoring done as I was able in my limited time left here in Rochester. I managed to finish re-scoring a few more records before Wednesday ended and I picked up where I left off on Thursday morning. However Thursday afternoon, after 3 pm at least, was devoted to our group getting together to do the final discussion of articles that I will be present for and afterward, Dr. Erik and I had a lovely discussion and debriefing of my time here. I was very happy to hear that he enjoyed my company and my insights and my hard work. I absolutely loved my time here, it was such a special experience and such a tremendous learning experience for me about how research is done and about many of the realities of practicing physicians.

Week 7: Mayo Clinic Sleep Center

August 1st, 2012

Parker Emrich ’13, Dr. James Culbertson Fellow in Neurology and Medicine

This week began on a Tuesday for me after a long week of relaxing and working out. One of my secondary goals for the summer was to get in the habit of having a part time work out routine so that I can stay in shape better and that plan has been succeeding fantastically. I have found a wide variety of workout routines online that I have been able to do in my apartment whenever I have time. We spent Tuesday afternoon working with Dr. Erik on figuring out a new scoring method for the arm leads in the RSWA scoring montage because the standard method for RSWA scoring was being confounded by the presence of regular cardiac artifacts due to the placement of the electrodes for the arm lead. Unfortunately until Dr. Erik can convince the sleep lab technicians to use a different electrode arrangement for measuring the arm muscle activity, we are stuck with the cardiac artifacts. Thus we crafted a more visual based technique for identifying RSWA segments overlaid over cardiac artifact or between cardiac events, and this new technique appears to work much better, although it might suffer from some lost precision.

Completion of the Gold-er standards allowed us to complete remediation for both CAP scoring and RSWA scoring so we can start working completely independently on scoring patients polysomnograph recordings. Wednesday was spent finishing remediation for CAP and RSWA Gold Scoring by checking our own scorings against the newly polished Gold-er standard for both. For CAP scoring, this was relatively simple although time consuming simply due to the length of the CAP sections on the Gold-er standard. The idea was simple: rescore the CAP sections using the newly clarified rule structures that we had been discussing and typing up as we reviewed Jonny’s and my CAP scorings and then compare our rescored CAP scorings against the newly polished and revised Gold-er standard. For RSWA scoring, the final remediation process went very quickly with us only having to rescore any particular leads that we didn’t perform adequately on amongst the three EMG leads in the montage (Left arm, left leg and chin). I had to rescore the chin lead because I had missed some tonic episodes (tonic episodes of RSWA being periods of muscle activity that are at least double the background voltage of that lead that last at least fifteen seconds of a given thirty second epoch) and the presence of tonic events changes how we score phasic events in the same mini-epochs (three second periods). Everyone had to rescore the left arm lead because of our new techniques and guidelines for scoring RSWA in that lead, although the new guidlines made it much easier and it took no longer than twenty or thirty minutes for each person to rescore the arm.

Once we had finished remediation, I immediately set to work reviewing and rescoring PSG recordings that were scored last summer when they were using a different set of criteria to distinguish between the A1, A2 and A3 subtypes of CAP segments. Generally, they used A2 far more often than we are using it this year and they were severly underscoring A1 segments. Continuing to push through CAP recordings of patients with moderate to severe obstructive sleep apnea (OSA), it was remarkable to note how many micro-arousals and periods of wake after sleep onset (WASO) that these patients experienced. Seeing how fragmented their sleep was, I started to understand why OSA can be such a fatiguing sleep disorder.

It struck me this week that I am going to be leaving this wonderful place soon. I am really going to miss everyone I have been working with. The atmosphere was always pleasant and jovial and even the long tedious process of CAP scoring was brought to life by Dr. Erik’s commentary on various portions of sleep macroarchitecture and answering every question that he was able to throughout my experience here.

Week 6: Mayo Clinic Sleep Center

July 31st, 2012

Parker Emrich ’13, Dr. James Culbertson Fellow in Neurology and Medicine

As the sixth week of my lovely stay at the Mayo Clinic Sleep center began, we were continuing to work on the remediation of our CAP Gold standard scorings and RSWA Gold standard scorings. It has been taking an enormously large amount of time to fully go through one of my fellows students and my CAP scorings due to the length of sleep time that we scored and the number of problematic segments that we have had to stop and discuss during review of both my scoring and Jonny’s scoring on the CAP Gold standard. After finishing looking through two whole sets of student’s scorings, Dr. Erik decided that that was probably enough to reforge the Gold standard of CAP into the Gold-er Standard, partially because of the number of edits we had already made, and because of the amount of time we had sunk into reviewing just two of the whole sets. Overall, we spent most of Monday, Wednesday and Thursday reviewing CAP scorings, and eventually, RSWA scorings. Thankfully, the RSWA scorings took much less time to review. By the end of reviewing the RSWA Gold standard, Dr. Erik had come to the conclusion that he needed to rework our scoring criteria for the arm lead of the RSWA PSG montage. We resolved to finish that and discuss it next Tuesday when he was back from his conference that he was heading to over the weekend starting on Friday and ending on Monday.

On Tuesday afternoon, we were scheduled to begin working on learning how to score sleep stages on an intracranial EEG study that is being performed by another research group that Dr. Erik has agree to help. We met with Dr. Amit and Dr. Erik to learn the intricacies of reading the new montage of leads used for this study and the scoring program that this research group has had to build from the ground up to avoid some annoying data exportation problems. We did not end up being able to learn much however because the program is still in its infancy and was having significant problems with its saving and scoring protocols. The problem currently is that when they score sleep stages of a recording and then save and exit, when they reload that saved scoring file the 30- second segments that they previously saved are not being time-locked properly so they are “moving” around the recording. It was interesting nonetheless to see a different montage of cranial EEG leads and what sort of patterns and morphology the waveforms took in different stages of sleep on those leads. It simultaneously made me feel intelligent and knowledgeable and showed me just how little I really know about even this subject that I have been studying all summer. Honestly, that sensation only served to further enhance my certainty that medicine and its related fields are really what I enjoy and want to continue learning about alongside my continued love of studying psychology.

Week 5: Mayo Clinic Sleep Center

July 23rd, 2012

Parker Emrich ’13, Dr. James Culbertson Fellow in Neurology and Medicine

My fifth week at the Mayo Clinic passed very quickly as our activities picked up a bit. Monday was spent, with the exception of the seminar that I will discuss later, scoring REM Sleep Without Atonia (RSWA) segments on the RSWA Gold Standard that, like the CAP Gold Standard, was intended to make sure that our scorings of REM epochs for RSWA segments was decently reliable within our group. RSWA scoring is about finding segments in REM sleep epochs in EMG readings with sufficient muscle activity to be scored as RSWA. RSWA scoring generally goes faster than scoring CAP segments although the rules for scoring RSWA are more specific, and seem to result in more difference of opinion on exactly where the segments start and end, than the rules for CAP scoring are.

On Tuesday, we met with Dr. Erik to discuss the articles we were reading last week on variation in CAP subtype rates amongst Narcolepsy-Cataplexy patients and about CAP subtypes rates and their effects on cognitive functioning after either a partial or complete sleep deprivation condition. After we finished discussing the articles, we transitioned to discussing and typing up some preliminary aims and hypotheses for the CAP research we are going to be performing this summer (and that will probably continue to be performed for at least another summer or two). At the end of the discussion, Dr. Erik semi-assigned research topics to each of the four of us. I picked to research neuropsychological behavioral tests of cognitive impairment and their relation to sleep deprivation to see if I might be able to find a test that we could use or that at least might inform our understanding of the tests we are already using to measure cognitive impairment derived from partial sleep deprivation.

Wednesday, Thursday, and Friday were spent finding and reading research articles or working with Dr. Erik on RSWA scoring remediation. Basically the idea of RSWA scoring remediation is that we sit down at two computers and look at one person’s scoring and compare it side by side with the “Gold Standard” and we discuss what was different between the two and the person in question can either stand their ground against the Gold standard or choose to rescore in accordance with it. However, as we kept going with it, it became fairly obvious that the “Gold standard” was really more gold-plated because we kept finding places where Dr. Erik was willing to change it because he believed we either found something they didn’t previously or because he agreed that something that was scored on the “Gold Standard” was not really an event.

Friday’s seminar was titled “Epilepsy Rewired” and it focused on reviewing the 2010 epilepsy classification guidelines and what the changes in the guidelines reflect about seizure classification, epilepsy etiology, and epilepsy syndrome classification today. Wednesday had a seminar on stemcells but unfortunately it was full by the time we got there so we didn’t go. But this week’s seminar that had the strongest effect on me was Monday’s. Monday’s seminar was a memorial for a Dr. Burton Sandok. He was a member of the Neurology department at the Mayo Clinic and had at one point been the department chair for seven years. He was a major advocate for the need for the existence of a medical school as part of the Mayo Clinic to help fulfill its role as a teaching institution and he served as the Dean of the Medical school for seven years from 1991-1998, and in many ways, he helped turn the Mayo Medical School into the highly competitive and successful school it is today. I never knew him but as I sat listening to people who had known him talk, I couldn’t help but feel that I was witnessing the passing of a man who had had a tremendous impact on these people and likely on his field of medical interest, namely stroke/cerebrovascular disorders. For all that I heard about him, he sounds very much like a man that I wish I had had an opportunity to meet.

Week 4: Mayo Clinic Sleep Center

July 12th, 2012

Parker Emrich ’13, Dr. James Culbertson Fellow in Neurology and Medicine

This last week was an odd one indeed thanks to the Fourth of July celebrations in the middle of the week. I worked my normal hours on Monday, Tuesday, and Friday, but Wednesday and Thursday were off for the Fourth. Monday and Tuesday were spent with the group reading articles on the variation in CAP subtype rates amongst Narcolepsy-Cataplexy patients and articles about CAP subtypes rates and their effects on cogitive functioning after either a partial or complete sleep deprivation condition. These articles were intended to provide a small basis for our later discussion of the aims and hypotheses for our study of CAP amongst partial sleep deprivation conditions.

Wednesday and Thursday were kind of odd because of the lack of work. So I woke up around when I usually do on weekdays and spent the days either wandering Rochester, cleaning my apartment or reading some of the articles that I had printed off at the end of my Mayo hours on the subject of the neurophysiological basis and background of ADHD, a
subject which has always been in my list of scientific interests. At the end of the day on Wednesday, I decided to go out for a night walk just to enjoy the (relatively) cool air and I happened to stumble across the middle of a fireworks display. I watched for about 20 minutes and then decided to head back to my appartment to cool off (I made the mistake of thinking it might be miraculously chilly outside so I had brought a sport coat). As I got back to my apartment, I looked out my main window and noticed another fireworks display on the
opposite side of downtown Rochester. So I got to watch two sets of fireworks this year which is new to me. It was kind of odd because earlier that day I had actually wished that there would be a fireworks display visible from my apartment.

Friday was a slow day with only myself and one of my compatriots, Alora, showing up to work (the other two being still on vacation). Erik had allowed us any amount of the week off that we wanted, but I wanted to get everything I could out of my time here so I opted for a shorter vacation time. Friday’s lunch seminar was on the topic of movement disorders with a specific focus on Deep Brain Stimulation as well as a few other treatments as a method of relieving many of the tremors and stiffness of Parkinsons Disease.

Week 3: Mayo Clinic

July 4th, 2012

Parker Emrich ’13, Dr. James Culbertson Fellow in Neurology and Medicine

This week was busier than the last. On Monday, I went to a Clinical Pathology Conference (CPC), which is an explorative look at the possible diagnoses that would have fit a particularly challenging or interesting clinical case. A variety of possible diagnoses were discussed and each was weighed pros versus cons in terms of its likelihood as an explanation for the patient’s symptoms. The final diagnosis was CADASIL syndrome (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) which I knew next to nothing about at the time. This prompted me to do a little research on it. Apparently it is theorized to be caused by mutations on the Notch 3 gene on chromosome 19 and is a common form of hereditary stroke disorder. The primary pathology of CADASIL is progressive degeneration of smooth muscle cells in blood vessels caused by the accumulation of Notch 3 at the cytoplasmic membrane of vascular smooth muscle cells. Besides the lunch seminar, Monday and Tuesday were spent reading the articles and preparing for our group discussion on Tuesday afternoon.

The readings were centered on the pathphysiology and outcomes and the possible links with alpha-synuclein degenerative disorders, of REM sleep behavior disorder (RBD). RBD is primarily about the presence of dream enactment behavior during the sleep cycle. Dream enactment behavior is caused when the patient’s brain fails to properly, or completely,  implement the skeletal muscle atonia that is an important part of REM sleep. Because of this lack of atonia, patients are still partially or fully capable of motion and often end up hurting themselves (falling out of bed or hurting their limbs) or their sleeping partners (kicking or punching them accidentally). Typically, patients with RBD report being able to remember their dreams in vivid detail later and their dream mentatin usually contains a theme of being chased or protecting themselves or loved ones from some attacker or threat. I think my favorite part is the fact that usually the sleeping partner can speak, with remarkable accuracy,  about the subject matter of the dream because of how clear the actions of the patient are when they are enacting them.

Wednesday was spent scoring more of the most recent CAP study we are performing, either alone or with the group on occasion. The lunch seminar was education about the healthcare deficits that exist in our present system for American Indians, Native Americans and Alaskan Natives. Both due to underfunding and some unwillingness amongst the population to use the federally provided healthcare for these groups, they have significantly poorer health outcomes in an overall view.  Thursday and Friday were spent working on the Gold Standard of CAP scoring and a variety of the Mayo Clinic mandated training modules. The Gold Standard of CAP scoring is Dr. St Louis’ is about scoring the prechosen segments of various patients’ sleep studies and then comparing my scoring to the composite scoring of Dr. St Louis and two other colleagues of his. The comparison is intended to make sure that everyone here at the Sleep Center is scoring CAP with a decent amount of reliability between our scorings. After I finished the Gold Standard on Thursday, I set to work completely all of the Mayo training modules which took me a lot less time than the rest of my compatriots who had been working on it all day. I think that a good portion of the reason I finished the IRB training modules so quickly was due to my previous experience with the ethics and standards of ethical practice for research with human subjects that was thoroughly taught in a few of my psychology courses at Cornell, including Research Methods and Counseling and Clinical Psychotherapy to name a few. While we did go to the lunch seminar on Friday, it was a bit too highly technical for me to catch all of it. The main subject matter was taking a close in-depth look at the neuroimmunological  causes and effects of Neuromyelitis Optica (NMO). It seemed like it would have been interesting if I had a background in the relevant literature but sadly, I did not so I listened intently and picked up as much as I could. What I did pick up was mainly related to the possibility that NMO worked partially through causing demyelination of the neurons in certain portions of the brain.

Week 2: Mayo Clinic Sleep Center

June 25th, 2012

Parker Emrich ’13, Dr. James Culbertson Fellow in Neurology and Medicine

In my second week of my fellowship at the Mayo Clinic, I got a hang of the work schedule. In the morning, the other summer students and I focus on reading the articles that Dr. St Louis assigns us as readings to prepare us for the next group discussion. For last week we were reading articles on normal sleep patterns, standard sleep architecture, the effects of sleep deprivation and the R&K scoring criteria for the stages of sleep as well as the American Academy of Sleep Medicine’s scoring criteria. To me the most interesting part of this set of readings was the definitions for what kinds of sleep architecture are present in each of the stages of sleep, such as alpha, beta, theta, and delta waves as well as vertex waves, sleep spindles, K-complexes and sawtooth waves. Then on Thursday, we met with Dr. St Louis and the other research assistants to go over what we had read and discuss any questions that had come up during the reading. We score Cyclic Alternating Pattern (CAP) polysomnograph (PSG) studies and REM Sleep without atonia (RSWA) PSG studies during the mornings and afternoons. Later in the day, Dr. St Louis comes by and works with us on our scorings and working on improving the summer students interrater reliability on our scoring techniques. Later on in week three, I will be taking our lab’s standardizing test to see if my scoring techniques show a sufficient reliability to ensure that my scorings are accurate to the standard set by the other physicians working with Dr. St Louis. A lot of the research that we are doing this summer is based off of our scorings of the length and placement of CAP segments and RSWA segments. A couple of times a week there are lunch seminars held by physicians and residents on various subjects. Last week I went to two of them, one on Wednesday and one on Friday. Wednesday’s seminar was on clinical pearls in gastroenterology and it was absolutely fascinating and really highly technical. The Friday seminar was much more accessible due in part to its focus on diagnosis, and treatment of chronic headache disorders.  The next set of readings we are doing are focused on REM sleep behavioral disorder (RBD) and its comorbidity with the alpha-synucleinopathy family of neurodegenerative disorders such as idiopathic Parkinson disease (PD), Lewy body disease (LBD), and multiple system atrophy (MSA) amongst others.

Week 1: Mayo Clinic Sleep Center–Rochester, Minn.

June 21st, 2012

Parker Emrich ’13, Dr. James Culbertson Fellow in Neurology and Medicine

Welcome to my blog where I will be happily posting about the exploits of my Fellowship experience at the Mayo Clinic under Dr. Erik St. Louis. I arrived at around 3:15 pm on last Monday the 11th, met Leslie, the student housing coordinator who is assisting me with my apartment and then carted everything upstairs to my wonderful little apartment where I am staying for the duration of the fellowship. I was connected with Leslie Wallenfeldt by Allie Good who is the wife of Dr. Good who is a family friend and the doctor who delivered my brother. After moving in, my mother and I went out for a tour of Rochester, courtesy of the Goods. We drove around for about 20 minutes with Allie pointing out the important buildings and a little bit of information about each of them. The overall Mayo Clinic complex is rather massive. After the tour of the city and some red wine in their treehouse gazebo extension, my mother and I said goodbye to the Goods and trundled off to go do some last minute supply shopping to outfit my apartment with food. My first night ended with setting up my apartment, or at least starting to. I decided to put off most of it for the next couple of days.

On the second day of my Rochester experience, I had a morning appointment at St. Mary’s to have a drug test and a TB test performed as part of my pre-employment screening. It went by very quickly and efficiently and then I was on my way. For lunch, my mother and I went around the corner from my apartment building and ate at a wonderful little Alsacian bistro called Jasper’s. The conversations going on around us were something else. Only in a city this full of medicine and medical professionals does polite lunch conversation include the phrase “…and by then I was oozing blood…” followed by gentle laughter from both parties. I enjoyed the food so much that my mother got me a gift card for the bistro so that I can eat there a few times before the end of my fellowship. The rest of the evening was spent getting my mail room key and finishing setting up my apartment.

The rest of the week, except for Friday, was spent getting my apartment fully set up and reading my personal copy of the DSM-IV TR and the book that Julie Barnes was so nice as to send to me “At the Bench: A Laboratory Navigator.” However, Friday was my first day of the Fellowship. I met with Dr. St Louis at 1 PM and I was introduced to a little of what I would be doing for the time being. I joined the other three summer students who were working on scoring CAP sections of a person’s sleep data. I hit the ground running pretty well but I was still confused for a little while. But after my orientation, this Monday and working with my fellow students afterward until 4:30 PM I am feeling much more confident about my understanding of what we are doing and some of the possible implications of our research.



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