clevelandclinicmagazine

Transcription

summer 2009
Music meets
medicine p.28
What research
means to you p.12
Connecting
withautism
Innovative ways to break through
p.20
World Cuisine
by Chef Zachary Bruell
One World. Infinite Possibilities.
Open Seven Days,
Weekday Happy Hours 4pm-6pm,
Chef’s Table, Free Valet Parking
216.707.4045 for reservations
Visit us online at www.tbl45.com
Table | 45
at the InterContinental Cleveland
9801 Carnegie Ave. Cleveland, Ohio 44106
contents
volume 6 issue 2 • summer 2009
p.20
p.00
p.00
p.12
COVER STORY
20
Connecting With Autism
At the newly expanded Center for Autism at
Cleveland Clinic Children’s Hospital, innovative
behavioral training is bringing children like Joey,
Jonathan and Ronnie out of their shells.
FEATURES
12 The Next Breakthrough
Scientists search for tomorrow’s medical innovations in
today’s labs. Find out what research will mean to you and
your health in the not-so-distant future.
28 Healing Notes
p.28
Doctors and therapists with firsthand experience have
long touted the medical benefits of music. Now, science
is proving them right.
Cover photograph: Marge Ely
cleve la n d c lin ic .o rg/c c m
contents clevelandclinic.org/ccm
Advisory Board
M. Bridget Duffy, MD
Chief Experience Officer, Professional Staff Affairs
Departments
Tanya Edwards, MD, MEd
Director, Center for Integrative Medicine
firstword
p.40
3 Benefits Beyond Measure
Cynthia Galbincea
Executive Director, Division of Marketing,
Communications and Planning
Exploring the past and future
of medical research.
A. Marc Gillinov, MD
Thoracic and Cardiovascular Surgery
medicinechest
philanthropia
4 Building a Better Transplant
34A Magnetic Attraction to Research:
Thomas F. Peterson Jr.
4 Easy on the Eyes
5 Acid Reflux Relief
5 Anatomy 101: The Esophagus
6 Can the Bee Gees Save Lives?
6 Scrimping on Scripts
35One Physician, Two Chairs:
Leonard Calabrese, DO
36The Future of Vascular Surgery:
Len Stuart
37Meeting Nursing Needs:
Stanley Shalom Zielony
Grahame Kidd, PhD
Neurosciences, Lerner Research Institute
Carol L. Moss
Chairman, Institutional Relations and Development
Ellen Rome, MD, MPH
Head, Section of Adolescent Medicine
James Young, MD
Chairman, Academic Department of Medicine
Physician Director, Institutional Relations
and Development
Editorial and design
onthehorizon
40 Brain Booster Built for Two
40 Pinpointing New Immune Disease
41 The Nose Knows
2
41 Detecting Invisible Damage
asktheexperts
42Statins in the Spotlight:
Steven Nissen, MD, and
Leslie Cho, MD
mystory
p.4
livinghealthy
44 Opening My Heart
Former football star Paul Hanna thought
he was as fit as could be. An executive
health physical showed otherwise — and
may have saved his life.
7 Small Steps, Big Change
Taking the stairs is just the start.
p.44
ccprofile
8 Saving Face
Maria Siemionow, MD, PhD, and her
team made medical history in December
2008 when they performed the first face
transplant in the United States.
Kathryn DeLong, Editor
Cori Vanchieri, Senior Medical Editor
Chris Blose, Managing Editor
Kim Caviness, Senior Editor
Elizabeth Lear, Director, Development Communications
Laura Greenwald, Senior Manager, Creative Services
Ginny Reardon, Project Manager
Glenn Pierce, Art Director
Ali Southworth, Photo Editor
Brenda Waugh, Production Artist
Editorial, Design and Project Management
Questions, comments and subscription requests:
Cleveland Clinic Magazine
The Cleveland Clinic Foundation / AC 322
Institutional Relations and Development
9500 Euclid Ave.
Cleveland, OH 44195
[email protected]
Cleveland Clinic Magazine is a biannual publication of
The Cleveland Clinic Foundation. Copyright © 2009
Cleveland Clinic. All rights reserved. Reproduction or use
without written permission of written or pictorial content in
any manner is prohibited. Printed in the United States. The
magazine accepts no unsolicited manuscripts, photography
or artwork. Cleveland Clinic realizes that individuals would
like to learn more about its particular programs, services or
developments. At the same time, we fully respect the privacy
of our patients. If you no longer wish to receive materials
containing this information, please write to us at Cleveland
Clinic Magazine, The Cleveland Clinic Foundation/ AC 322,
9500 Euclid Ave., Cleveland, OH 44195. This publication is
for informational purposes only and should not be relied
upon as medical advice. It has not been designed to replace
a physician’s medical assessment and medical judgment.
Always consult first with your physician about anything
related to your health.
diagnosischallenge
10 Off Balance
Josephine Vagell struggled with steps and
memories until a neurologist pinpointed
her perplexing condition.
clevela nd clinic magaz i n e
Cleveland Clinic is proud to support the Forest S
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firstword
Benefits beyond
measure
A letter to our
readers from
Delos M. Cosgrove,
MD, CEO
Pierre Arsenault/Masterfile
and President
M
edical research is one of the great success stories of our time. Thanks to better
healthcare resulting from medical research, the life expectancy of the average
American has increased by 30 years in the past century. Infant mortality
has decreased by 95 percent, and deaths from infectious disease have been
virtually eliminated. Some of this increase in longevity can be traced directly
back to Cleveland Clinic. The work of Cleveland Clinic scientists such as Irvine Page, PhD,
and Harriet Dunstan, PhD, combined with the clinical breakthroughs of F. Mason Sones,
MD, and Rene Favaloro, MD, in the 1950s and 1960s launched the modern era of heart and
hypertension care, leading to a drastic decline in mortality from heart diseases.
In addition to giving us longer lives, medical research and better healthcare have improved
the quality of our lives. The concept of “old age” continues to be redefined upward, and most
Americans can look forward to being active and productive well into their 70s and 80s.
In 2000, the Lasker Foundation published the results of a study by several economists
estimating the monetary value of the longevity resulting from better healthcare. They
concluded that from 1970 to 2000, increased life expectancy added $57 trillion to the
economy. The report states, “Improvements in healthcare account for 50 percent of the
gain in the standard of living in the last 30 years.”
Clearly, medical research was a great social investment in the 20th century. But what about
today? In our economic climate, should medical research continue to be a priority?
To answer that question, I would point to “The Next Breakthrough” in this issue of Cleveland
Clinic Magazine. In this article, you’ll meet a few of the 200 staff physicians and scientists
at Cleveland Clinic’s Lerner Research Institute who are tackling some of the most difficult
problems in health and medicine. Led by Chairman Paul DiCorleto, PhD, Lerner Research
Institute investigators are preparing new treatments and cures for cancer, diabetes and
coronary artery disease. You’ll also meet some of the outstanding Cleveland Clinic clinicians
who are perfecting the next generation of devices and techniques to treat and cure these
devastating conditions.
For despite the great advances we’ve made, heart disease and cancer are still the leading
causes of death in our society. With our aging and overweight population, we’ll see an
explosion of new cases of diabetes, heart disease and other associated disorders in the very
near future. Reducing deaths from these diseases even slightly would have an enormous
financial benefit to our society. One study estimates that only a 10 percent reduction in
mortality from cancer and an equal reduction in heart disease deaths would have a value
of almost $10 trillion to current and future generations.
Better healthcare arising from medical research has driven extraordinary gains in longevity
and quality of life. The economic value of these gains far surpasses their comparatively
modest cost. But all economic advantages are insignificant compared with the human and
emotional benefits of medical research. Who can put a price on one life saved, a family
preserved or the ability to enjoy life and work restored? These are benefits beyond measure.
3
medicinechest
Building a better
4
he small intestine hosts a horde of white blood cells to fight
germs. For patients who need an intestinal transplant, those
infection fighters also can cause their bodies to reject their
new organ.
When Cristiano Quintini, MD, and colleagues performed
the first small intestine transplant on an adult patient in Ohio in June
2008, it was the result of several steps forward. Only about 200 intestinal
transplants are performed worldwide each year, says Dr. Quintini,
Surgical Director of Cleveland Clinic’s Intestinal Transplant Program,
and about 65–70 percent of recipients are alive after one year. That
success rate has improved in recent years because of better patient
monitoring after surgery and improved immunosuppressive drugs to
block the body’s rejection response.
“These drugs are giving us a much safer window in the first four or
five months, when rejection risk is highest,” Dr. Quintini says. Better
antibiotics also can keep infection in the bowel from spreading to
the bloodstream.
The majority of patients who need a small bowel transplant have
had surgery for other bowel conditions, such as Crohn’s disease, that
leave them with too little small intestine to absorb nutrients and
fluids. Others have a small intestine that no longer works properly,
or they have a type of tumor that prevents proper function. Most are
unable to eat or drink, and some experience constant nausea. They
receive nutrition through an intravenous (IV) line, which in some
cases can lead to liver failure, thrombosis and IV line infections. Over
time, their options run out.
Dr. Quintini has performed five transplants to date. He says patients
who undergo the procedure before they have gotten too sick have a higher
success rate, particularly if their livers are still healthy. They are more
likely to return home — and return to eating — than those for whom
transplant is a last resort.
“Timing is extremely important,” Dr. Quintini says. “We’re hoping
to create an awareness in the surgical and medical community not to
wait to refer these patients until they’re at the end.” — Chris Blose
Easy on
the eyes
D
iabetes is the leading cause of blindness
among American adults. Sixty-five thousand
patients develop the most sight-threatening
form of diabetic retinopathy each year. Early
detection of the blood vessel damage that
causes diabetic retinopathy is crucial to prevent damage and vision loss, yet only about half of diabetics get
the annual recommended eye exam, says Rishi Singh,
MD, a retina expert with the Cleveland Clinic Cole
Eye Institute.
Many people say they don’t have the time to schedule yet another doctor’s appointment. Dr. Singh’s
solution is to place screening cameras in the primary
care office, so there’s no need for a separate trip to
the optometrist or ophthalmologist. The easy-to-use
cameras take high-resolution images of the eye and
don’t require special eye drops or medications. Each
photo session lasts only a few minutes.
“This type of photography is incredibly sensitive
and specific for detecting disease,” Dr. Singh says.
The photos are sent electronically to Cleveland
Clinic’s Cole Eye Institute, where a team of doctors
evaluates them within two business days and makes
any needed referrals to specialists. Since the program
began in January 2008, Cole Eye Institute physicians
have evaluated photos from more than 1,000 patients.
Other diseases also include eye-related complications. Dr. Singh hopes to use the cameras to look
at the veins and arteries in the eye to help detect
the high blood pressure in the eye that leads to
glaucoma, another major cause of vision loss. “This
could become an essential portion of determining
someone’s wellness,” he says. — Nancy Volkers
Pipes: Marvy!/CORBIS; Iris: Ellen Martorelli/Getty Images
T
transplant
Acid reflux
M
relief
ore than 60 million Americans experience heartburn at
least once a month. But just because it’s common doesn’t
mean it’s normal, says Gary W. Falk, MD, in Cleveland
Clinic’s Department of Gastroenterology and Hepatology.
“If you have it regularly, look for causes. Don’t tolerate it.”
Heartburn has little to do with the heart; its name comes from
the burning sensation of stomach acid surging up into the throat.
Normally, muscles around the top of the stomach keep stomach acid
where it should be, but in people with acid reflux, these muscles relax
when they shouldn’t.
Nearly nine of every 10 people with persistent acid reflux find relief
with medication, according to Dr. Falk. Over-the-counter medications
that block acid production may help some people; if they don’t, he
recommends a doctor’s visit. If not treated, long-term acid reflux can
damage the esophagus and even increase the risk for cancer of the
esophagus. Also, late-night heartburn can lead to sleep deprivation,
which affects health and quality of life.
Dr. Falk is seeing an increase in heartburn complaints, due in part,
he says, to the nation’s growing waistline. “Obesity is a risk
factor,” he says. “We can help people with medications, but
one of the most important things someone can do is
lose weight.”
This is not an easy undertaking, and Dr. Falk
knows it. His clinic staff reviews weight loss options
and talks to patients about removing obvious triggers (such as
certain foods, late meals or too much coffee). Medications are part of
the discussion, as well. — Nancy Volkers
illustration: John Hersey; ICE: Diamond Sky Images/Getty Images
Anatomy 101:
5
The ESOPHAGUS
The esophagus has one function: to carry food from the throat down to the stomach. This
10-inch tube gets plenty of chances to flex its muscles.
When you swallow, the esophagus’ opening, or upper sphincter, relaxes to let food pass; at
the same time, the voice box pulls forward and upward to prevent food from going down the
“wrong pipe.” After that, involuntary muscle contractions push food downward like a wave.
Glands produce mucus to keep things moving smoothly. Another sphincter at the bottom of
the esophagus closes once the food passes into the stomach; if it fails to close properly, stomach acid can leak upward and eventually damage the lining of the esophagus.
The esophagus is not straight, but sword swallowers take advantage of the fact that it’s also
not rigid. They train their bodies to fight the gag reflex and relax involuntary muscles, and the
sword straightens the esophagus on the way to the stomach. But these daredevils run the
risk of tearing the esophagus’ lining and causing internal bleeding. In other words, don’t try
it at home. — Chris Blose
medicinechest
Can the
Bee Gees
save lives?
D
isco is so 1970s. But one
dance-fever classic can be
a lifesaver. The Bee Gees’
“Stayin’ Alive” has the
perfect number of beats
per minute — approximately 100 — for
performing CPR (cardiopulmonary
resuscitation), according to a study from
the University of Illinois.
Focusing on an up-tempo tune during
CPR makes sense to Lynn Pagliaccio, a
physician’s assistant in the Emergency
Department at Cleveland Clinic. She says
many people don’t push hard enough
or fast enough to force blood to where it
needs to go.
“Stayin’ Alive” also sticks in people’s
minds, whether they want it to or not.
“So it’s a handy reminder of the key
to performing CPR — push hard and
push fast — and this added confidence
might encourage people to step in when
needed,” Ms. Pagliaccio says. “This is
important, since starting CPR early
greatly increases chances of survival.”
6
The beat goes on
Don’t like disco? Ms. Pagliaccio has a CPR-friendly song for you:
Help Is on Its Way, Little River Band
Quit Playing Games (With My Heart), Backstreet Boys
Love Will Keep Us Alive, Eagles
Yeah, Usher
That’s Amore, Dean Martin
Hemera Technologies/Jupiter Images
— Tom Burroughs
Faced with rising drug
costs and a failing
economy, Americans
are scrimping on their
medications.
More than half of
people recently polled
by the Kaiser Family
Foundation reported
using some form of costcutting measures, such as
skipping doses of prescription medicines, not filling
prescriptions in the first
place or splitting pills.
“People are on medications for a reason, so
skipping or going without
Splitsville
them can cause serious
Splitting is fine for some
health problems,” says
pills, says Ms. Leonard,
Mandy Leonard, Pharm.D.,
but not these:
Assistant Director of Drug
l Extended-release pills
Information Services and
Formulary Management at
lP
ills coated to
Cleveland Clinic. “People
protect the stomach
worried about costs should
l Powdered capsules
talk with their physicians
l Gel capsules
about alternatives, including switching to generics
lP
ills containing
or reducing the number of
multiplemedications
medications they’re taking.”
She says splitting pills can
be a good option; many medications can be prescribed in large enough doses that they can be cut in
half to make the supply last longer. Some common
medications — including cholesterol-lowering statins and drugs used for treating high blood pressure
and depression — may be candidates for splitting,
Ms. Leonard says. But she cautions that some pills
should not be split (see “Splitsville”). Always talk with
a physician or pharmacist about which pills can be
split safely.
A pill splitter — available for less than $10 — is
the best tool for the job, rather than a knife or other
sharp object. Having trouble splitting pills? Get help
from a pharmacist or family member.
— Tom Burroughs
photoillustration: Michael Northrup
Scrimping
on Scripts
livinghealthy
Small Steps, Big Change
Big Cheese Photo/Jupiter Images
When Elizabeth Ricanati, MD, was growing up,
she and her family loathed climbing stairs.
To avoid extra trips to the second floor of
their home, they never went up the stairs
empty-handed, she recalls. They’d carry as
much as possible each trip.
“Now, I make multiple trips up the stairs — on purpose,” Dr. Ricanati says.
This 180-degree turn in her mindset came about over time as she realized the importance of
incorporating small, positive changes in her daily routine. “There’s a lot of emerging data that
shows you don’t need to work out in the gym for 45 minutes a day. You can get in your exercise
10 minutes here, 10 minutes there,” she says. Current recommendations set a goal of 10,000
steps a day.
Fitting in those 10,000 steps doesn’t come easily, she acknowledges. “You have to work at it
in our culture. But the little things add up — walk around the kitchen table, or up and down the
stairs of your home.”
The result can be a big boost in wellness, a popular, broadly defined buzzword in healthcare
today. “There’s physical wellness, there’s emotional wellness, there’s spiritual wellness,”
Dr. Ricanati says. To her, the essence of wellness is “wrapped into happiness and contentment
and being in control.”
As Medical Director in charge of disease reversal for Cleveland Clinic’s Wellness Institute,
Dr. Ricanati oversees the Lifestyle 180 program, which teaches patients with chronic diseases
how to take charge of their health. Those who change their diets, start exercising and practice
stress management have better outcomes than those who don’t, Dr. Ricanati’s team has found.
For example, “there were 24 participants in the first two pilots this past fall,” she says. “Some
were able either to avoid starting prescription meds, decrease their dose of prescription meds
or actually discontinue their prescription medications.” These were the patients who, based
on what they learned in the program, made new choices in their everyday lives: switching from
white pasta to whole wheat, for example, or stopping a few times a day to close their eyes and
take a few deep breaths.
Dr. Ricanati has a “drawerful of studies” showing the impact that lifestyle choices have on
disease. In 1999, the Lyon Diet Heart Study was the first to conclude that a Mediterranean diet
(rich in fruits, vegetables, fish and olive oil) reduced the risk of a second heart attack in patients
with heart disease, for example. Other studies have shown similarly impressive results from
diet modification.
Data from these and other studies went into the creation of Lifestyle 180, which is based on
the premise that you can help prevent disease, stabilize it and, arguably, even reverse it. “Our
society has high rates of largely preventable disease, so let’s prevent it,” Dr. Ricanati says.
It’s all about making different choices, she adds. “You don’t have to make a career out of
wellness to make a difference in your life.” — Kathryn DeLong
Changing
Course
Want to achieve a higher level
of wellness? Elizabeth Ricanati,
MD, recommends a few small but
beneficial lifestyle changes:
• Eat three meals a day, and don’t
skip any. “The most unhealthy
patients I’ve seen are the ones who
skip breakfast.”
• Take three deep breaths before you
start each meal “to be mindful of the
moment, to actually smell the food,
to be thankful for the meal you are
about to enjoy.”
• Eat a few raw almonds or walnuts
a day. “They’re loaded with hearthealthy omega 3s and protein.”
• When dining out, if you’re going
to eat bread, ask for olive oil to
replace the butter. “Or, better yet, ask
for veggies.”
• Work with your doctors to make
sure you’re up to date on your preventive healthcare (mammograms,
prostate exams, etc.).
• Wear a pedometer and aim for
10,000 steps a day.
• Take a break. “Close the door, sit
down and take some deep breaths.
If you can do that, you’re giving
yourself a great, great gift.”
7
ccprofile
Saving Face
Maria Siemionow, MD, PhD, and a team of 30 specialists
made medical history in December 2008 when they
performed the first face transplant in the United States.
The 22-hour operation, the most complex and extensive
to date, transplanted 80 percent of the patient’s face from
a cadaver. Dr. Siemionow, Director of Plastic Surgery
Research at Cleveland Clinic, says this surgery was 20 years
in the making.
 When
did you first start thinking about performing a
face transplant? Back in Poland, I cared for children
with burned hands. Most also had burned faces. I
performed surgery on their hands and had some sort of
a subconscious idea that it was possible to reconstruct
their hands and maybe their faces. My interest in
composite tissue transplants, such as hand, face or limb
transplant, developed over the years.
8
 How
many people have disfigured faces? It’s very
difficult, really, to estimate, because we do not see them.
They are hiding. Some wear masks. Some go out when
there are not many people in the street. It’s difficult to
live without a face.
 What
obstacles do they encounter? They can be
missing lips or eyelids, or a nose. They can have
difficulty breathing. Imagine that you have a hole
instead of a nose, and you can’t take a shower because
the water will go directly into your throat. You have no
mouth and you cannot even use a straw because you
have nothing to hold it with, so you have to have a feeding tube to eat. You don’t smell anything.
are the most common causes of disfigurement?
The major causes of disfigurement include car
accidents, burns, gunshots, work-related injuries
and tumors. We don’t consider cancer patients for
transplants at this point because they will need lifelong
suppression of the immune system, which could cause
cancer to recur.
TK
Kenneth Baehr
 What
“The most important part is, who is the patient? The patient
is not a defect. The patient is a person. This is more
important than the technical aspects of the surgery.”
Everyday Milestones
Today, the recipient of the face transplant at Cleveland
Clinic can do things we take for granted, but that she
could only dream of before her December surgery.
She has reached important milestones. She can smell
things now, and she has managed a partial smile. Her
nerves are still in the process of regeneration, and her
facial muscles are being re-educated during physical
therapy. She has tasted a hamburger and enjoyed a
cup of coffee — two things she couldn’t do before
the operation.
The patient, who was discharged from the hospital in
early February, has avoided immune rejection, which
is among the biggest risks of a transplant. She is taking
three antirejection medications and antibiotics.
 Why
are hand and face transplants called “composite”
surgery? Unlike a kidney transplant, which only involves
kidney tissue, composite transplants are constructed
from many tissue types. The hand has skin, bone,
muscles, nerves. The face is even more complex because
of the small muscles for upper eyelids, lower eyelids,
upper and lower lips.
 There
are limits to the amount of skin and tissue you
can transplant from one part of a patient’s body to
another. Is this the reason for transplanting tissue from
human donors? We do not have in our body skin of such
pliability, nor do we have an extra nose or ear on the
side. There is limited surface area of skin you can use
to reconstruct a face. My research shows that to cover
a face, you need about 1,200 square centimeters of the
skin in one piece. It needs to be vascularized, meaning
that it has a supply of arteries and veins. The biggest
amount of skin that we can get from our entire back will
cover about 50 percent of the full face with scalp.
 What
kind of matching is done between patient and
donor? Well, you have gender to consider matching,
because you don’t want a woman to have to shave her
face. And you have to match the race because of the skin
tone and color.
 Are
the technical and physical issues most important?
There’s more than that. It’s emotional, psychological,
psycho-immunological and social. The most important
part is, who is the patient? The patient is not a defect.
The patient is a person with feelings and a family
and social interactions and problems. This is more
important than the technical aspects of the surgery.
To have the right patient is to understand what the
problems are and where the patient is with his or her
feelings. Does the patient want the procedure, or is
maybe someone in the family pushing them to have
a procedure? Is the patient a compliant patient or
noncompliant? Is the patient a candidate who will take
lifelong immunosuppressants or have doubt about that?
 What
risks do these patients face from a lifetime of
immunosuppressant drugs? The risks are the same
exactly as for kidney transplants, liver transplants,
heart transplants. Possible side effects include severe
infections and diabetes. Some patients can develop
cancers, such as lymphoma. That has not happened
yet in any of the composite tissue transplant patients,
and the longest follow-up of a hand transplant from a
cadaver donor is more than 10 years.
 What
is next? I hope to introduce into transplant
surgery, possibly this year, my protocol for tolerance
induction, where patients won’t need lifelong
immunosuppression or at least will have a reduced need.
It will apply to all patients with solid organ transplants, as
well as to composite grafts such as face transplants.
— Interview by Howard Wolinsky
Maria Siemionow is also Head of Microsurgery Training at
Cleveland Clinic.
9
diagnosischallenge
Off Balance
Josephine Vagell remembers the day she fell and broke her left foot while
walking into her garage. It was nearly three years ago; she was 71. Walking and keeping
her balance took great effort.
“The patient said she had a problem with balance, and her husband mentioned that there
had also been a memory problem,” Dr. Mordes
recounts. He conducted a series of tests to narrow
the possibilities, because the symptoms could
indicate conditions as varied as Alzheimer’s,
Parkinson’s and ministrokes.
In Dr. Mordes’ office, Ms. Vagell failed a memory
screening test, but just barely. She also showed
some wavering in a test of heel-to-toe walking.
“She wasn’t as steady as she should have been,”
Dr. Mordes says. An MRI revealed no evidence of
strokes, but it did show enlargement of the cavities
heavy ...
“You can’t imagine the difference between
the person
I was
before and the person
I was after.”
She lost balance and couldn’t walk ...
TK
michael Northrup
10
“I was shuffling my feet. My legs felt very heavy,
and then I started to develop a loss of balance,” Ms.
Vagell recalls. At first, she leaned on her husband,
Ted, for support, but after her fall she began using a
cane and then a walker. Her doctor in Jupiter, Fla.,
sent her to a variety of specialists to try to diagnose
and treat her condition.
She saw an arthritis doctor and then underwent
physical therapy for several months, followed by
acupuncture. She also visited a cardiologist, an
internist, a podiatrist and an occupational therapist over the course of more than two years, all
without success.
“By that time, I was really desperate. I was getting depressed,
because I couldn’t walk,” Ms. Vagell Her legs felt
recalls. “I couldn’t do anything the
way I wanted to. I avoided friends;
I just wanted to stay home. There
was no joy in my life.”
In June 2008, Mr. and Ms. Vagell
had lunch with Shannon Curley,
Managing Director of Development
at Cleveland Clinic in Florida, to
which they had previously donated.
“She was watching the way I was
walking,” Ms. Vagell recalls. After
Ms. Curley got back to her office,
she called Ms. Vagell, saying, “I
think I’d like you to see a neurologist from my office.”
This was the first time someone had suggested she consult a
neurologist. “I was happy to try anything at that point,” she says. At Ms.
Curley’s suggestion, she made an
appointment with Cleveland Clinic
neurologist Marvin Mordes, MD.
in Ms. Vagell’s brain, with no tumor or other obvious cause. Dr. Mordes hypothesized that Ms. Vagell
might have normal pressure hydrocephalus (NPH),
a blockage and buildup of the cerebrospinal fluid
that flows throughout the brain.
An MRI doesn’t pick up the fluid, so a separate
test was necessary. In 40 years of medical practice,
Dr. Mordes had seen only 20 to 30 cases of NPH, so
it was a long shot.
“I sent her to our hospital facility in Weston for a
test that involved withdrawal of a fairly large volume
of spinal fluid,” Dr. Mordes says. The goal was to
relieve fluid pressure on the brain. At the hospital, neurosurgeon Badih Adada, MD, withdrew an
ounce of fluid.
Ms. Vagell was required to lie still for more than
six hours following the spinal tap, but at the end of
that time, she knew that Dr. Mordes had made the
right call. “When they said I could get up, I got off
Her memory was deteriorating ...
the bed and almost ran to the bathroom,” recalls
Ms. Vagell, who could barely walk when she entered
the hospital. She also scored much higher on a
memory test.
Ms. Vagell’s instantly improved walking, balance
and memory confirmed Dr. Mordes’ diagnosis of
NPH. He knew that excess fluid would build up
again, so he ordered a permanent shunt for the
patient. Dr. Adada inserted a tube in Ms. Vagell’s
brain to constantly drain excess spinal fluid into
her abdominal cavity. The procedure took place in
August 2008.
“You can’t imagine the difference between the
person I was before and the person I was after they
took the fluid away from my brain,” Ms. Vagell says.
She’s back to seeing friends, going to restaurants
and movies, and cooking. She has even played some
golf; she swings her clubs with a steady stance.
11
— Harvey Leifert
Her doctor wondered about excess fluid ...
TK
=?
By Brian Vastag
Eileen Newman* was a typical 21-year-old college student.
She went to class. She worked. She studied late and often ate on the go. Then she started
feeling thirsty — really thirsty. “Unquenchable,” she says. “I felt so dehydrated.”
Ms. Newman was diagnosed with type 1 diabetes. Early in the disease, the immune
system, for reasons unknown, attacks insulin-making cells in the pancreas and destroys
them. Thirst is one of the first signs that the pancreas can no longer produce enough
insulin to regulate the body’s glucose levels.
*The patient asked that her name be changed.
female figure: Colin Andersen/Jupiter Images;test tube and beaker: Charles O'Rear/Corbis
b
Finding
tomorrow’s
innovative
treatments
in today’s
top labs
breakthrough
13
It’s like trying to
divine the recipe
for the perfect chocolate chip cookie by surveying a cupboard full of
ingredients and throwing them into a bowl one by one. Baking that way
leads to a lot of inedible cookies, but with enough perseverance, one
magic batch may arise.
“To treat human diseases, we have to understand the root
causes. And to understand the root causes, we have to understand
how cells work, how proteins work, how genes work, how the
machinery of our bodies works,” Silverstein explains. “Then we
can define targets to fix.” In type 1 diabetes, the target is already
well known: the insulin-making cells of the pancreas, called islet
cells or beta cells. At Cleveland Clinic, several research groups are
exploring ways to replace them.
Repair and Replace
“We know if we have the cells, we can actually cure the disease,”
says Jan Jensen, PhD, Director of Diabetes Research in the Department of Stem Cell Biology and Regenerative Medicine at the Lerner
Research Institute. Dr. Jensen points to islet cell transplants,
pioneered by researchers at the University of Alberta, Canada, in
2000. In this procedure, surgeons extract islet cells from donor
organs and implant them into the abdominal veins of patients.
But, as with whole-pancreas transplants, a shortage of donors
renders the procedure out of reach for large numbers of patients.
And, after three to five years, the implanted cells often fail as they
are destroyed by the immune system.
Sharon Grundfest-Broniatowski, MD, sees a way around both of
these problems. The Associate Professor of Surgery at the Cleveland
Clinic Lerner College of Medicine is developing an artificial pancreas
filled with insulin-producing islet cells from pigs. “Pigs have cells
that produce insulin very similar to human insulin,” says Dr.
Grundfest-Broniatowski, who performed the first human pancreas
transplant at Cleveland Clinic in the mid-1980s. The woman who
received the organ has lived without insulin injections for more than
20 years.
The artificial pancreas encapsulates pig cells inside a special
membrane. Covered with extremely tiny pores, the membrane
allows oxygen and other nutrients to flow in and insulin and other
digestive proteins to seep out. Crucially, the membrane protects the
pig cells from the immune system, which would otherwise identify
them as foreign and destroy them. Made with advanced polymers,
the membrane was developed by materials scientist Joseph
Kennedy, PhD, and colleagues at the University of Akron, Ohio.
MedicalRF.com/Getty Images
14
Her days became a rigid schedule of frequent insulin injections
and skin pricks to check her blood glucose levels. The routine
quickly wore on her.
After a year, Ms. Newman decided to see another endocrinologist and was referred to Cleveland Clinic. She was switched
to an insulin pump, a pager-sized device she wears that delivers a steady stream of insulin. She still needs to check her blood
glucose readings and dial up the right dosage on the pump, but
she no longer chafes under a tightly timed regimen. “It really,
really frees up your lifestyle and schedule,” Ms. Newman says of
the pump, developed by researchers in the 1980s. “It’s made a
huge difference in my life.”
Now 31 and living in a suburb of Cleveland, Ms. Newman
has avoided many of the complications that can accompany
type 1 diabetes. But a decade after her diagnosis, she worries.
Later in the disease, toxic acids can build up in the blood and
cause blindness, kidney failure, nerve damage and accelerated
hardening of the arteries. Early death from heart attack or stroke
is not uncommon. She’s looking for work now and is concerned
that her “preexisting condition” will make her less appealing to
potential employers.
“You have your ups and downs, and some days are harder than
others,” Ms. Newman says, her voice trailing off. “If they could
ever find a cure …”
Between 1 million and 2 million people in the United States live
with type 1 diabetes, with about 30,000 new cases diagnosed each
year, according to the National Institute of Diabetes and Digestive
and Kidney Diseases.
That’s why, in laboratories around the world, researchers are
working on new ideas for treating both type 1 diabetes and type
2, in which the body stops responding to the insulin it produces.
They’re doing the same for cancer, heart disease and other
killers large and small. It’s this basic research — the painstaking
process of learning how cells and molecules function and what
goes wrong with them during disease — that drives all advances
in patient care, says Roy Silverstein, MD, who holds the Jan
Bleeksma Chair in Vascular Cell Biology and Atherosclerosis at
Cleveland Clinic’s Lerner Research Institute.
bypass made better
In 1967, a revolution in heart care was born at Cleveland
Clinic. That year, surgeon René Favaloro, MD, pioneered
heart bypass surgery. Today, the operation, which reroutes
the heart’s blood flow around potentially fatal blockages, is
the most commonly performed surgery in the United States,
annually benefitting more than 400,000 people.
But 40 years ago, surgeons scoffed. “A lot of people
were extremely skeptical as to whether this was the right
thing to do,” says Joseph Sabik, MD, Chair of Thoracic and
Cardiovascular Surgery at Cleveland Clinic.
In the 1970s and 1980s, though, three large studies
vindicated the operation, showing that it extends life in
patients with severe blockages.
Two advances made bypass surgery possible. In the
early 1960s, Cleveland Clinic’s Mason Sones, MD,
invented angiography — pictures of the chest that highlight
blockages. “These were the road map the surgeons
needed,” Dr. Sabik says. Then, Dr. Favaloro removed a
vein from a patient’s leg and used it to shunt blood around
coronary blockages.
Eventually, heart surgeons noticed that the leg veins
tended to close up after several years. So a new generation
of Cleveland Clinic surgeons improved on cardiac bypass
surgery once again, this time by using arteries from the
chest wall. These vessels have proved to be a better longterm option for patients.
Now, Dr. Sabik and his colleagues are taking the next
step: minimally invasive cardiac bypass surgery. Instead of
slicing a large incision down a patient’s chest and prying
open the sternum, surgeons can operate via a three- to
four-inch incision between the ribs. New technologies, such
as metal connectors that plug the new vessels into the
old without extensive stitching, may someday render the
surgery safer and less traumatic, Dr. Sabik explains.
“If you look at heart deaths per year, they’re going
down,” he adds. “There’s no doubt bypass surgery has
played a very important role in that.” — B.V.
15
There’s one strategy that holds the promise to beat back all cancers:
Starve them.
Molecular Pantry
Like Dr. Grundfest-Broniatowski, Dr. Jensen is committed to
finding a cure for type 1 diabetes. But instead of heading to the
barnyard for his beta cells, he’s betting on embryonic stem cells as
a source. If he can strike on the right molecular recipe to turn the
versatile embryonic cells into insulin-makers, he will have a nearly
bottomless source of patient-helping cells. “If you have that, you
take care of the [pancreas] supply problem,” Dr. Jensen says.
But finding the right recipe is proving tricky. Dr. Jensen and
other researchers have spent years studying how the pancreas
grows. As a baby develops in the womb, various growth factors
trigger blank-slate cells to sprout into the whole range of
tissues — nerves, muscles and so on — that make up the fully
formed infant.
Dr. Jensen is trying to re-create this process for the pancreas.
To that end, he has a molecular pantry stocked with 25 growth
factors, and he’s searching for the right combination to reliably
grow beta cells from embryonic cells. It’s like trying to divine
the recipe for the perfect chocolate chip cookie by surveying a
cupboard full of ingredients and throwing them into a bowl one
by one. Baking that way leads to a lot of inedible cookies, but with
enough perseverance, one magic batch may arise. Dr. Jensen is
convinced he’ll achieve it.
“The problem is a complicated one,” he says. “So the solution
is going to be complicated too. But I think we’re attacking it the
right way.”
He envisions eventually inserting beta cells grown from
embryonic cells into a membrane like the one Dr. GrundfestBroniatowski is working with. That would protect the cells
from the autoimmune attack that touches off type 1 diabetes.
“Encapsulation and stem cells might go hand in hand,” he says,
“and the cells represent the cure.”
Starving Cancer
In the search for cures, progress against cancer has been steady
over the past decades, with occasional spectacular successes. In
2001, a new drug called imatinib (Gleevec) became available for
patients, changing a diagnosis of chronic myelogenous leukemia
from a death sentence into a chronic but nonfatal illness for
many patients.
Imatinib came about after researchers discovered the precise
molecular breakdown that occurs in this specific type of leukemia
and then designed a drug to fix it. Many cancer researchers continue
to pursue similar cancer-specific tactics. But there’s one strategy that
holds the promise to beat back all cancers: Starve them.
In the 1970s, Judah Folkman, MD, a Harvard University
researcher, established that all tumors lay down new blood
vessels as they grow. Without these vessels to bring in oxygen
and nutrients, the tumor starves and dwindles. Dr. Folkman
dedicated the rest of his life to figuring out how to stop this
process, called angiogenesis.
Nearly 30 years later, the first drug to block angiogenesis
became available for cancer patients. Called bevacizumab
(Avastin), the drug lengthens survival time for patients with
Siri Stafford/Getty Images
16
Dr. Grundfest-Broniatowski hopes to test the system in
patients within five years. “We haven’t proved this is feasible
yet in humans, and we’ve got a ways to go,” she says. “But
we’ve got some promising results from some of our initial
experimental animals.”
The artificial pancreas is now traversing the tricky middle
ground of the three phases of medical research. The first stage
is laboratory-based discovery, where biologists, chemists
and other scientists strike on a new idea for fixing the broken
machinery of cells and tissues. Next is translational research,
in which researchers typically use laboratory model systems of
human disease to devise practical improvements for patients (see
“Bench to Bedside”). Finally, there’s clinical testing in patients,
which is also done in distinct phases. In all, it’s a long road, but
one that any new treatment must travel to prove its safety and
effectiveness, says Paul DiCorleto, PhD, Chairman of the Lerner
Research Institute.
b ench to b e d s id e
Translational research has been
drawing more attention from
researchers and funding agencies, says
Lerner Research Institute Chairman
Paul DiCorleto, PhD. The National
Institutes of Health has poured
hundreds of millions of dollars into a
new program to buttress translational
research at top institutes around the
country, including Cleveland Clinic.
And three years ago, the Cleveland
Clinic Lerner College of Medicine
launched one of the first programs
in the country devoted to training
a new generation of translational
researchers. The students, training
to earn their PhDs, choose a disease
to focus on and then spend time with
clinicians and patients to understand
the day-to-day issues involved with
that disease. The goal, says Martha
Cathcart, PhD, Professor of Molecular
Medicine and director of the program,
is to prepare scientists with the knowhow to push projects out of the lab
and into patient care. — B.V.
17
Statins have made a big difference,
but we need to make another
18
idney cancer, which had been notoriously difficult to treat. “Drugs
k
that target angiogenesis have dramatically changed the way we
treat the disease, and it’s certainly helping patients live longer,”
says Brian Rini, MD, who helps run clinical trials with bevacizumab
and other anti-angiogenic drugs at Cleveland Clinic.
But bevacizumab and several similar drugs also carry a serious
drawback. Because of how they work, they can damage normal
blood vessels. Recent studies show the drugs can cause strokes.
And many tumors, for unknown reasons, fail to shrink in the face
of the drug.
Enter Tatiana Byzova, PhD. In 2000, the researcher in Cleveland
Clinic’s Department of Molecular Cardiology found another
means for blocking angiogenesis: a critical communications
signal that tumors broadcast to nearby tissues. By silencing this
signal, the tumor can’t call on new blood vessels. As an important
bonus, blocking the signal doesn’t harm normal blood vessels
the way bevacizumab can.
After nearly a decade of work, Dr. Byzova has developed a handful
of molecules — potential drugs — that jam the signal at the source.
In laboratory animals, the drugs reverse the course of cancer. “We’ve
tried it on melanoma, breast cancer, prostate cancer,” Dr. Byzova
says. “The tumors stop growing, and they regress.”
In 2007, Dr. Byzova founded a company, AngioQuest, to push
the drugs into human trials and, she hopes, into hospitals across
the country. She’s now trying to raise funds for this last, crucial
stage of turning a laboratory discovery into a potentially lifesaving treatment.
“I believe it’s going to be much better than anything that’s
available right now,” she says. “The new drugs we’re developing
affect all types of tumors.”
down the road
Sometimes, participating in research is as easy as giving blood.
Over the past several years at Cleveland Clinic, some 15,000
patients with heart disease have donated vials of the red stuff
to help researchers understand and defeat the leading cause of
death in the United States.
The goal, says Dr. Silverstein, is to improve on statins, the drugs
that have dramatically reduced the burden of heart disease since
their introduction, reducing the risk of having a heart attack by
about a third.
“Statins are probably now the most widely used class of drugs in
the world, other than aspirin,” Dr. Silverstein says. “And they have
dramatically changed the natural history of coronary disease.”
Statins, such as simvastatin (Zocor) and atorvastatin (Lipitor),
were developed after the discovery that a high level of so-called
bad cholesterol, or low-density lipoprotein (LDL), is a major
risk factor for heart attack and stroke. When LDL leaches into
the arteries lining the heart, plaques can form and narrow the
arteries, effectively starving the heart and triggering blood clots.
Statins help lower circulating levels of LDL.
“By understanding how cells work, how genes work,
we’ve developed drugs that have changed human life,” says
Dr. Silverstein, speaking of statins.
LDL leaches into cells after it becomes oxidized, meaning after
oxygen molecules latch onto it. An important discovery made
at Cleveland Clinic — with the help of all those donated vials of
blood — was that a specific protein in white blood cells causes
LDL oxidation. This led to the development of a Food and Drug
Administration-approved blood test, called CardioMPO, that can
help predict who’s at risk for heart attacks.
As a follow-up, Cleveland Clinic researchers are now working
on how to stop LDL from going bad by blocking free oxygen
from attaching to it. While development of such drugs is early,
Dr. Silverstein hopes they will someday improve on statins.
After all, heart disease is still the number one killer. “Statins
have made a big difference, but we need to make another
threshold leap.”
Those threshold leaps drive long-term goals for researchers
dealing with many different diseases and create hope for patients
such as Ms. Newman. “Discoveries may not translate into patient
care tomorrow or next week; it may be five years from now,” says
Dr. DiCorleto. “But it’s the discoveries today that will lead to
improved health down the road.” n
3D4Medical.com/Getty Images
threshold leap.
Do you take better care of this body…
than your own?
Schedule your 50,000-mile checkup at Cleveland Clinic today.
In just one day, our Executive Health experts will have you on the road to better health.
For more information or to make your appointment, visit www.clevelandclinic.org/executivehealth,
or call 800.223.2273 ext. 45707.
connecti
20
Ronnie Cable, who was nonverbal when he
came to the Center for Autism, raises his hand
to answer a question in class.
ing with
autism
21
By Benjamin Gleisser
Innovative
behavioral
training is
bringing
children
like Joey,
Jonathan
and Ronnie
out of
their shells.
Today Joey Timco looks at his teacher as
she’s talking, an improvement for a child who
previously did not respond to others.
joey
was a dimple-chinned baby who
attracted attention whenever his mother, Melanie Timco, took him to the
supermarket. Other mothers cooed over the 1-year-old nestled in
the shopping cart. But Joey never responded to the playful overtures.
“I used to tell them, ‘Oh, he just woke up from his nap,’ ” Ms. Timco says.
“He was a very unresponsive baby. We knew something was going on.”
Like most parents, Melanie and Joe Timco were afraid to acknowledge
that something was wrong with their firstborn child. The toddler was
given to fits of repetitive hand-flapping. At age 3, Joey hid beneath the
dining room table when visitors stopped by and refused to move until
they left the house. He screamed when his pediatrician and others tried
Photography by Greg Ruffing
to touch him. At home, he incessantly played with trains.
jonathan
now “can pick up on our sadness
and happiness. Sometimes he laughs in response to our laughter,”
says his mother. “That’s such a wonderful sound.”
22
The Timcos’ fears were realized when Joey was diagnosed
with autism just before his fourth birthday. Melanie, a middle
school assistant principal, and Joe, a seventh-grade social studies
teacher, knew Joey would face challenges in a public school
setting. What kind of education would he receive?
“We had a hard time trying to picture where our son would
be in 10 years,” Ms. Timco recalls.
Autism is mystifying; its causes are not known, though
researchers are beginning to pinpoint the genes involved in
this brain development disorder. According to the Centers for
Disease Control and Prevention, autism occurs in one in every
150 births, and boys are four times more likely to be diagnosed
with autism than girls. The Autism Society of America calls it the
“fastest growing developmental disability” and projects that by
2013, treating the 1 million to 1.5 million autism sufferers in the
United States will cost between $200 billion and $400 billion a
year. H
owever, the group adds, the cost of lifelong care could be
reduced by two-thirds with early diagnosis and intervention.
The Timcos chose intervention by enrolling Joey in the Lerner
School for Autism at Cleveland Clinic Children’s Hospital in
Shaker Heights, Ohio. The school practices the Applied Behavior
Analysis (ABA) treatment of behavior modification. Within six
months, the Timcos noticed a change in Joey’s behavior.
“Last Christmas, for the first time ever, Joey hugged people,”
Ms. Timco says. “We were all moved to tears. He [started]
conversations with his relatives.”
Now 5, Joey plays soccer with other kids at the community
recreation center, although he still requires a high level of
support from the adults around him.
Before the 1960s, children with autism were often considered
impossible to educate, and schools focused on trying to curb the
children’s bizarre and aggressive behavior by isolating them from
the group or sending them to the gym to work off hostile energy.
Today, autism specialists, including those at Cleveland Clinic’s
Center for Autism, find great success using ABA and other
behavior modification models to help children not only stop
aggressive and self-destructive behavior, but also develop social
skills, confidence and feelings of self-worth.
Rewarding the Positive
Children with autism typically display three characteristics:

difficulty with communication, repetitive actions that can be self-
Joey Timco develops his social skills with teacher Deanna Sampson
during the Center for Autism’s after-school program for children with
high-functioning autism or Asperger’s syndrome.
Jonathan Kiernan works on math and penmanship by counting colored blocks and writing down amounts with a teacher’s help.
injurious (such as slapping body parts) and socially challenging
behaviors, such as temper tantrums. In addition, many children
have low muscle tone and problems with fine motor skills.
In the 1960s, autism researchers began looking for ways to
teach children with autism, and in 1987, O. Ivar Lovaas, PhD, a
clinical psychologist at the University of California, Los Angeles,
reported that the approach he devised, Applied Behavior Analysis,
resulted in improvements and even recovery among children with
autism. Doreen Granpeesheh, PhD, founder of the Center for
Autism and Related Disorders in Tarzana, Calif., worked with Dr.
Lovaas on that early study.
“Using behavior modification in the form of intensive ABA,
47 percent of the students in our study recovered, meaning the
child’s IQ reversed to normal, he displayed normal adaptive
skills and was able to move into a mainstream educational
environment,” Dr. Granpeesheh says.
Behavior modification works on the following principle: A
behavior followed by a reinforcing stimulus — a reward — boosts
the likelihood of that behavior occurring in the future. However,
Dr. Lovaas’ method moved beyond simple behavior modification.
It became a structured teaching program involving a series of
small lessons that built upon each other to achieve a goal. Correct
responses and behaviors were rewarded, and negative responses
were ignored.
The key to educating children with autism is enabling them
to communicate, Dr. Granpeesheh says. And their greatest
reward? Pleasing their parents, she adds. “Normally developing
kids want positive reinforcement from their parents. They care
about making their parents happy. But kids with autism aren’t
really aware of what their parents are feeling; they don’t make eye
contact and can’t read their parents’ expressions. When children
with autism begin to communicate with their parents, they begin
to develop an internal awareness.”
Once children become confident in their communication
skills and their aggressive or self-injurious behavior dissipates,
Dr. Granpeesheh says, you can teach them just about anything.
Cleveland Clinic’s Center for Autism uses this approach.
Combining ABA-based behavior modification with education to
help children learn social interaction skills encourages them to
become self-confident and develop compassion for others.
mastering skills
The Center for Autism opened in 2000 with six children in a
single room at the Children’s Hospital Shaker campus. In May
2008, the school moved into its new space, the Debra Ann November
Wing (see “A More Perfect World,” page 27), with 100 full-time
students, from infants to 23-year-olds. The student-teacher ratio
is nearly 1:1, and the school calendar runs 219 days a year.
Toddlers concentrate on mastering skills such as toilet
training, socialization and language acquisition, while older
students focus on reading, writing, activities of daily living and
vocational training.
No matter which skills are being taught — from reducing selfinjurious behavior to applying for a job — ABA is the foundation
of learning, says Leslie Sinclair, Director of Cleveland Clinic’s
Center for Autism.
“We are all motivated by token economies,” Ms. Sinclair
explains. “When you go to work, you get a paycheck. You display
such-and-such behavior, you get a token. That token — and
it doesn’t even have to be something physical — becomes the
reinforcement.”
Some tokens are universal, such as a snack or a beverage.
Others are more individual — listening to music, riding a bike,
going outside — because each student is motivated by different
rewards. When a new child comes to the Center for Autism,
his family members, caregivers and others close to him fill out
reinforcement surveys, which give the staff insight as to what will
inspire the youngster to want to perform his tasks.
“Once we have the list, we apply the rewards strategically,”
Ms. Sinclair says. “If the child goes for a whole morning without
23
Ronnie
started looking at his parents after six months in the
program. “That was big,” his father says. “It was like seeing the light at the end
of a tunnel. Now, he’s reading — not a novel, but he’s sounding out words,
doing addition and a lot more things that we never thought we’d see.”
24
hitting himself, and we know he likes going outside, one of the
teachers will say something like, ‘You’ve done very well. C’mon,
let’s take a walk.’ ”
The center’s staff uses ABA programs such as Differential
Reinforcement of Alternative Behavior, where children are given
a different behavior to compete with a behavior that needs to be
reduced. For example, if a child is slapping himself, he is given
something more pleasurable to do with his hands, like playing
with Play-Doh. Under this approach, the child chooses to engage
in the more pleasurable behavior. A second program is Direct
Reinforcement of Incompatible Behavior, where the child is given
a behavior that makes it impossible to engage in the undesirable
behavior — so, if the child body-rocks, she is asked to walk on a
treadmill, since rocking is impossible while walking.
The incentive is really twofold, Ms. Sinclair adds. The children
not only get rewards, but they also see that their actions have
pleased someone.
“I think all of our children want to do a good job, but they have
been given some wiring that’s pretty faulty,” Ms. Sinclair says.
“When many of them come to us, they seem so nonresponsive.
But once we give them a new way to approach and see the world,
they start to light up. They want to show you what they can do. It
really builds their confidence.”
Parents get daily sheets that track the child’s improving behavior
and note how many challenging acts the child displayed. Parents
are then urged to continue rewarding good behavior at home.
During the fall 2008 semester, 58 of the school’s 100 students were
on active behavioral reduction plans. After 130 days, those plans
resulted in a 95 percent reduction in challenging behavior.
As children mature, they are encouraged to monitor their
own behavior.
“I’ll meet kids in the hall at the end of the day who say, ‘Guess
what? I only repeated myself three times today!’” Ms. Sinclair
says. “And I’ll say, ‘Great job! How many times did you used to
repeat yourself?’ ‘Three hundred times!’ ”
This type of self-awareness also generates another level of
All of the students love their weekly swim time. “They’ll do anything to get in the water,”
says Leslie Sinclair. Ronnie Cable glides in the pool with teacher Sharon Griffin.
understanding, creating empathy in children who once
displayed flatness in emotion. Ms. Sinclair offers this anecdote:
“I was in the hallway at dismissal and noticed a 16-year-old
student crying softly to herself. I put my arm around her and
asked what was wrong. I looked toward the therapist, who said
that they’d been watching the movie Wall-E [a movie about a
robot who lives alone on a deserted Earth]. I asked her if the
movie made her sad. She said yes, and I asked why. ‘Because
Wall-E is lonely.’ Coming from a person with autism, that was
so moving for me — that she could empathize with his loneliness
was amazing. In our world, this is what we’ve been working
toward and waiting for. It was pure grace.”
Because of successes such as this, the Center for Autism
formed the Cleveland Clinic Autism Consulting Group to help
other healthcare systems and agencies start their own autism
centers. Providing everything from staff training to ideas on
building design, the Autism Consulting Group helped start an
autism facility for the Freeman Health System/Ozark Center
in Joplin, Mo., and is consulting with the Highlands Regional
Medical Center in Prestonburg, Ky. In addition, Ms. Sinclair is the
editor of Autism Spectrum Disorder: A Supplemental Curriculum, a
soon-to-be-published guidebook for autism teachers containing
more than 250 step-by-step exercises and programs that teach
children with autism adaptive behavior and daily living skills.
Eye Contact
Ron Cable, a magistrate in the Summit County (Ohio) Domestic
Relations Court, was skeptical about what the Center for Autism
could do for his son Ronnie when he first met Ms. Sinclair.
Ronnie, who was diagnosed with autism when he was 2 years
old, wouldn’t look at or talk to his parents; instead, he often
sat by himself in a corner of the house and made bizarre
vocalizations. He screamed when his mother, Irina, tried to take
him outside. He was also obsessed with the television, sitting
inches away from the screen when it was turned on and playing
with the cable when it was off.
Ronnie uses words, sign language and a computer-generated voice program
to communicate.
Placing Ronnie in a preschool was a disaster. “The teachers
didn’t know what to do with him, so they essentially put him
in a room by himself,” Mr. Cable remembers. “We knew that if
we didn’t do something to help him, he would someday end
up institutionalized.”
When Ms. Sinclair told the Cables that the Center for Autism
could help Ronnie, the couple was hopeful, and enrolled him
at age 5. After six months, they noticed the first change: Ronnie
started looking at them.
“That was big,” Mr. Cable says. “It was like seeing the light at
the end of a tunnel. Now, he’s reading — not a novel, but he’s
sounding out words, doing addition and a lot more things that
we never thought we’d see.”
Ronnie, now 11, has been at the Center for Autism for six
years, and Mr. Cable credits ABA for his son’s turnaround. The
Cables use the ABA’s system of rewards at home, too. “Ronnie
likes to be rewarded, but we don’t reward him every time he does
something,” he says. “Ronnie understands the concept of why
we give him rewards and why, sometimes, there are things that
you just have to do. ABA will always be part of his life.”
Pediatric psychologist Thomas Frazier, PhD, directs the
research program at the Center for Autism, where staff
continually assess and improve the program. For Dr. Frazier,
the research is personal: His 5-year-old son, Sean, has autism.
“Autism is a passion for me because of my son, but I was
involved in helping children long before he was born,” he says.
“About 10 percent of my patients have symptoms of ADHD
[attention deficit/hyperactivity disorder] or milder forms of
autism, and I saw how tough that was on their families, and how
tough that was on the child. It made me want to understand the
neurobiology behind autism.”
Dr. Frazier’s research has led to a new way of screening
children for autism, which places more emphasis on social
communication and repetitive or stereotyped behaviors as the
core characteristics of the disorder. This work was published in
the Journal of Autism and Developmental Disorders in 2008.
25
“Once we give them a new way to approach and see
the world, they start to light up.They want to show you what they can do.It really builds their confidence.” – Leslie Sinclair
Three other children in the program — Evan and Christopher on this page, and Sean on the opposite — enjoy daily gym time and practice handwriting, counting and spelling.
The Center
for Autism
minimizes
distractions
so students can
focus on learning.
Pediatric psychologist Julie Knapp, PhD, coordinates the
center’s diagnostic and clinical programs. One of the most
popular is the Social Thinking Program for Children with High
Functioning Autism/Asperger Syndrome. The program teaches
youngsters how to apply the social skills they’ve learned at the
Center for Autism in a real-world setting. The highlight of the
program is a six-week summer camp experience, complete with
rock climbing, swimming, hiking and sports.
“The children work on social skills such as greeting peers,
developing friendships, and how to deal with conflicts and
compromise,” Dr. Knapp says. “Each child is placed with a
behavioral coach, and their goal is to work on generalizing
social skills they learned in order to develop friendships and
understand another’s perspective.”
The aim of the program is not just to make a new friend,
but also to understand what friendship entails: listening and
empathy. These same concepts are stressed at the Center for
Autism, and elementary school teacher Shirley Kiernan has seen
the resulting behavior developing in her son, Jonathan, 12, who
has attended the school for one year.
Jonathan received good marks in public school, but Ms. Kiernan
attributes those good grades to her being a teacher and working
with him. However, his self-injurious behaviors in school —
like whacking his chin until it was bright red — concerned the
Kiernans. “When he became excited, the teachers let him go to
the gym and swing or ride on a scooter until he calmed down,”
she says. “My husband and I realized that if we didn’t get him
into a program that addressed autism, we would lose him.”
The Kiernans noticed an improvement after one month at
the Center for Autism. Jonathan stopped hitting himself. But
the most welcome change, Ms. Kiernan says, was that Jonathan
became incredibly sensitive to his parents.
“On days we drive through traffic, sometimes he’ll ask me, ‘Is the
traffic too heavy?’ Or, ‘Are you sad, Momma?’ ” Ms. Kiernan says. “He
can pick up on our sadness and happiness. Sometimes he laughs in
response to our laughter. That’s such a wonderful sound.” n
A More
Perfect World
To some children with autism, fluorescent light bulbs are threatening
objects. The hypersensitive children experience the pulsating current
as a screaming noise. So, when it came time to design the new
educational space for Cleveland Clinic’s autism programs, Director
Leslie Sinclair insisted that incandescent bulbs be used in the facility.
The $8-million, 24,000-square-foot Debra Ann November Wing,
which houses the Lerner School for Autism at Cleveland Clinic, opened
in May 2008. Ms. Sinclair helped design the facility.
“I’ve been teaching kids with autism since 1982,” says Ms.
Sinclair, who greets students at the school’s front door every morning.
“Back then, autism was the poor stepchild of the educational
environment, and I often had to work in a basement or a closet.
I used to wonder, in a perfect world, what would I need to educate a
child with autism?”
Her answer: Children with autism tend to fixate on visual p
atterns,
so design elements stress neutrality. The hallways, ceilings and floors
are completely beige. Classrooms are beige, with subtle accents of
turquoise or coral. Plush carpeting at the entrance dampens the
acoustics for noise-sensitive children, and student lockers are made
of plastic, so there are no thunderous echoes if a locker door gets
slammed in frustration. Special heating and air-conditioning systems
minimize machine noise and air circulation sounds.
Classrooms are modular, because many children with autism
don’t learn well in big, open spaces. The Early Childhood Program
area, for infants, toddlers and preschoolers, has a number of small
classrooms, including several that have a toilet stall, so youngsters can
learn toilet training as well as language skills. The modular primary and
middle school areas are designed to resemble classrooms in a typical
school. The space for high school students contains an apartment-scape
where older students are taught daily living skills, along with career
planning. These students also have access to treadmills in the exercise
area. Parents can visit the media room to remotely watch their children
in the classroom. — B.G.
27
28
healing
notes
Doctors and therapists
with firsthand experience
tout the medical benefits
of music. Now, science is
proving them right.
By Pam Smith O’Hara
Illustrations by Calef Brown
isa Gallagher has been a board-certified
music therapist for nearly two decades. Roaming the halls of Cleveland Clinic’s palliative care unit, keyboard in tow, she brightens the
lives of critically ill patients every day. She’ll sing a hymn, play a jazz riff or cut loose on her own rendition of “Margaritaville.”
She knows music’s therapeutic value personally as well as professionally. In 2007, Ms. Gallagher, at age 41, was diagnosed with
breast cancer. She used her own medicine, music, to help her through a lumpectomy and 31 radiation treatments.
Strapping on her headphones and settling into one of her favorite new-age tapes helped Ms. Gallagher overcome anxiety during
several presurgery procedures. “I had to use my music to get through that,” she says. “When it was time for surgery, the nurses offered
to give me something to calm me down, but I didn’t need it.”
29
The study of “neuromusic”
is an active field of research made possible by
modern imaging technologies such as MRI, PET scan and MEG.
30
Throughout radiation and recovery, relaxing melodies kept
her focused and calm. Pianist Jim Brickman’s songs were her
constant companion.
Since ancient times, music and medicine have intertwined.
Priests of the Abydos Temple, the center of medicine in ancient
Egypt, used chants and rhythms to treat illnesses. Now, doctors
worldwide are moving the field of music therapy from superstition to science. Research is beginning to reveal how a musical
approach can help in a wide variety of illnesses (see “Putting
Music to the Test,” page 31). And in 2008, an international symposium in Austria, co-created by Cleveland Clinic and the Cleveland
Orchestra, brought together a panel of experts who discussed
and explored the intersection of music and neuroscience, the
impact of music on health, and social implications of the musicbrain connection.
“Musicians were talking to scientists and clinicians, and many
new ideas and collaborations were being generated,” says organizer Ali R. Rezai, MD, Director of Neurological Innovations
who holds the Jane and Lee Seidman Chair of Functional Neurosurgery at Cleveland Clinic. “You could feel the energy; it was like
popcorn popping.”
Prescribing Music
Cleveland Clinic neurologist Kamal Chémali, MD, a conservatorytrained pianist, specializes in neuromuscular diseases and the
autonomic nervous system. He says the study of “neuromusic”
is an active field of research made possible by modern imaging
technologies such as functional MRI (magnetic resonance
imaging), PET (positron emission tomography) scan and MEG
(magnetoencephalography). Now researchers can observe the
parts of the brain responsible for body movements, sensory
perception, coordination, cognition, mood and anxiety. And they
can see which parts are working during a particular activity. They
can also reveal differences between a normal brain and one with
underlying problems.
Oliver Sacks, MD, neurologist and Columbia University professor, explores the importance of the union of music and the brain
in his book Musicophilia: Tales of Music and the Brain (Knopf,
2007). “Music therapists have known for decades that music
works therapeutically — it works for people with Parkinson’s,
Alzheimer’s, autism and many, many other conditions. But it is
only in the last few decades, with the new techniques of brain
imaging, that we have been able to study exactly how this happens on a neural level,” Dr. Sacks wrote in an email.
“I expect and hope that music therapy will become a
therapeutic option at every hospital over the next few years,”
he continued. “It is not only efficacious for many, many patients
— it is extremely cost-effective, and it contributes to the quality
of life for all of us.”
The most immediate clinical application of neuromusic, Dr.
Chémali says, is music therapy. “And yes, we do prescribe music
therapy in neurological and palliative medicine,” he says. The
goal of palliative medicine is to relieve suffering and improve
quality of life for people facing serious illness. He prescribes
Mozart twice a day for 20 minutes — with headphones — for
patients with chronic pain or with disorders that have not
responded well to classical treatments. Dr. Chémali says Mozart’s
music is pleasant, well balanced and easy to like, though he
sometimes chooses other composers.
Music therapy is not limited to a certain type of music. “We
are not at the stage where we can say that rock and roll works on
one part of the brain and classical music works on the other,” Dr.
Chémali says. “We are still learning.”
Therapy can involve a drum alone, a guitar, chords of a familiar
song that the patient likes or the tapping of a rhythm on a hand or
foot. Sometimes having the patient play or sing along proves beneficial. It’s important to find out what the patient likes to listen
to. “In therapy, preferred music is almost always the best music,”
says Dr. Chémali.
In 1994, Ms. Gallagher collaborated with the Cleveland Music
School Settlement, one of the largest community music schools
in the country, to bring music therapy to Cleveland Clinic. Since
then, it has become a standard part of care in the palliative
medicine unit and other areas of the hospital. Music therapy is
also used to help patients recovering from radiation therapy or
chemotherapy, as well as during some surgical procedures and
with pain and anxiety management.
Ms. Gallagher and her colleagues have published studies
assessing the effect of music therapy on patients with advanced
disease. Their 2006 study published in Supportive Care in Cancer
Putting Music
to the Test
Researchers have begun to perform rigorous studies on
music’s impact on health and are finding positive effects
on stroke recovery and other neurological diseases, as
well as influences in areas of the brain involved in
anxiety and relaxation, mood, creativity and memory.
Here are a few examples:
• Cancer patients taking chemotherapy who received
20 minutes of live music therapy reported a greater
than 50 percent drop in anxiety in a 2007 study at
Florida State University. A control group receiving no
music reported an 11 percent increase in anxiety.
•Stroke patients who listened to music two hours a
day for two months after the stroke had stronger
improvements in verbal memory and focused
attention than patients who listened to books on
tape or nothing, according to a 2008 study from the
University of Helsinki, Finland. Improvements held
even six months after the stroke. The music-listening
group experienced less depression and confusion,
as well.
•In patients with an average of six years of chronic
pain, listening to music reduced their pain by up to
21 percent and depression by up to 25 percent,
according to a 2006 study by researchers at
Cleveland Clinic and Case Western Reserve University. The control group had slightly higher pain at
the end of the study.
•Surgery patients who listened to recorded music on
headphones had a four-fold reduction in postsurgical
pain compared with a control group that received
no music, according to a 2005 study at Hong Kong
Polytechnic University.
31
Awakening the
Senses
Iva Fattorini, MD, believes that fine art and music make good
medicine. That’s why, as Executive Director of Cleveland Clinic’s
new Arts & Medicine Institute, she is infusing the hospital environment with the energy and vitality of the arts.
Dr. Fattorini joined Cleveland Clinic as the Director of International eHealth, a role in which she helped connect international
patients to Cleveland Clinic physicians. Spending time with these
patients and their families, she realized the importance of providing ways to reduce their stress and bring them hope.
“We want to awaken the soul of the hospital so people can
feel it,” Dr. Fattorini says.
She’s already well on her way. Just like visiting an art museum,
visitors are able to pick up a wand at the front desk and take
an hour-long, self-guided audio tour of the prints, paintings and
sculptures on display throughout Cleveland Clinic. Music therapy
is offered to patients to decrease pain, relieve stress and aid in
the recovery of speech and gait after a stroke. Art therapy is being
introduced to heart patients, cancer patients and children. And on
New Year’s Eve, the institute brought a live broadcast of the New
York Philharmonic’s performance at Lincoln Center into the rooms
of patients and onto a big screen in the lobby.
Artist and sculptor Roger Powell was among the crowd that
night as he awaited word on his brother-in-law’s heart valve
replacement. He and his nephew, sketchpads in hand, made
pen-and-ink drawings of the lobby. The two had spent part of
their day on the rooftop of the Sydell and Arnold Miller Family
Pavilion enjoying the panoramic views of the city, attending a
meditation class and enjoying a chamber music concert, part of
the institute’s “Concerts in the Sky” series.
Mr. Powell was wowed. “All of this builds the human spirit by
giving hope, making people smile.”
Other hospitals and universities across the country also realize the importance of the spirit of their institutions. Betty Haskin,
an arts coordinator at Duke University Medical Center and a staff
member of the Health Arts Network at Duke (HAND), is setting
up a display in the Touchable Art Gallery for visually impaired
patients. She says such programs remind patients that they have
a life outside their disease and reminds them of their humanity.
Dr. Fattorini and her colleagues are implementing new ideas.
The institute supports research on the effects of the arts on
the human body, both in and out of the hospital setting, and
will continue collaborations with local, national and international organizations to promote the marriage of medicine and
the arts. “I’d like to see a day when the fine and performing arts
in all their energy would be an integral part of every hospital,”
she says. — P.S.O.
“We are essentially listening to the music of the brain,
the symphony of the mind.
You can hear it firing. It’s like Morse code.”
analyzed the impact of music on 200 patients with advanced
illness. The therapists used a variety of scales to record pre- and
post-music scores. For the majority of patients, music therapy
reduced anxiety, pain and shortness of breath and improved
mood, facial expressions, ability to move and the ability to talk.
On her rounds, Ms. Gallagher sees music work every day. If a
patient is agitated or unresponsive, Ms. Gallagher may start playing at the tempo of the patient’s breathing and then slow it down.
The patient’s breathing begins to ease as well.
Doctors Join In
Dr. Chémali doesn’t find Ms. Gallagher’s results surprising. He
began playing for his patients years ago as a medical student in
Lebanon. “I saw the joy,” he says. “From that point on, I became
a believer in the power of music and, most importantly, in the
healing power of music.” Studies continue to prove him right.
These days, he cheerfully corrals his Cleveland Clinic
colleagues to bring music to patients. He’ll play piano duets
with pulmonologist Loutfi Aboussouan, MD. Richard Lederman,
MD, PhD, an accomplished violinist and a neurologist who treats
the medical problems of musicians, joins in.
At the annual Doctor-Patient Music Connection, doctors and
patients play chamber music together with members of the
Cleveland Orchestra, the Cleveland Institute of Music and international artists from the Conservatory of Paris. It’s a good way to
spread awareness among musicians of the therapeutic benefits of
music and to enhance patient-doctor relations, Dr. Chémali says.
“Patients see doctors wearing a different hat and using a different
type of talent to serve them.”
In June 2008, Cleveland Clinic hosted A Concert/Symposium
on Music and the Brain in 4 Acts, featuring experts in the field
of neurology and music. This gathering was a prelude to the
international symposium hosted by the Cleveland Orchestra and
Cleveland Clinic. In August 2008, musicians, physicians, music
lovers and scientists from around the globe descended on
Salzburg, Austria, birthplace of Mozart, for a first-ever exchange
at the Salzburg International Music Festival.
The program focused on music’s impact on the brain — and
on society and philosophy. Cleveland Orchestra Music Director Franz Welser-Möst led the symposium with Dr. Rezai. “I felt
like a little child in a toy shop,” says Mr. Welser-Möst. “Being an
amateur in the study of the brain, it is fascinating to learn more
about what happens with our emotions. Brain specialists can now
locate where and what is happening. But we are still trying to find
out how.”
“Franz is interested in the philosophy and social aspects
of music in life,” says Dr. Rezai. “I am more interested in the
multidimensional influence of music on the nervous system.”
By combining his interests with colleagues at Cleveland Clinic’s
Arts & Medicine Institute (see “Awakening the Senses,” page 32),
Dr. Rezai is trying to advance the science of how music affects
the brain, as well as develop ways in which music can help treat
disorders and improve overall health.
Though he is not a musician, Dr. Rezai explores those connections every day. In the operating room, he evaluates the electrical
activities of the human brain using tiny microphone wires to
listen to the electrical signals between neurons.
“We are essentially listening to the music of the brain, the symphony of the mind,” he adds. “You can hear the fantastic activity
of the human brain.” He and the team play various musical pieces
to study the influence of music on the brain’s neurons. Dr. Rezai
says that Cleveland Clinic scientists and the Cleveland Orchestra
are the only group in the world studying the influence of musical
rhythm, melody and types of music on the brain by recording the
sounds of neuron activity.
The Cleveland Clinic team also plans to image brains of
patients and healthy individuals —musicians and nonmusicians — while they listen to music. “We will take pictures
of the brain and see how it interfaces with the music,” Dr. Rezai
explains. Mr. Welser-Möst has agreed to have his brain
scanned. Learning about the impact of music on the healthy
brain may help researchers learn how to further activate the
brain of someone with a stroke who cannot move or better
coordinate the movement of someone with Parkinson’s
disease, Dr. Rezai adds.
He also hopes these studies will help determine how the
components of music affect the emotions, memory, energy level
and wellness.
“The human brain is under a lot of stress in these times,”
Dr. Rezai explains. Everyday demands — cell phones, email,
meetings, responsibilities, expectations — can take a toll. “Everybody needs more sleep, more rest and more music,” he says. n
33
philanthropia
All stories by Elaine DeRosa
A Magnetic
Attraction
to Research
Thomas F. Peterson Jr.
Steve Travarca
34
T
homas F. Peterson Jr. has been interested in science and
inventing ever since he was a young boy. He is most at
home in a laboratory setting, particularly his own home
lab, with its collection of antique scientific instruments.
These include a glass fluorescent tube from the 19th
Mr. Peterson’s interest in science and technology began in his
century that reads “God Save Queen Victoria” and an authentic
childhood when he played at the workbench where his father,
Brush arc light similar to those that first lit Cleveland’s Public
founder of Preformed Line Products Co., designed and built
Square in 1879. He also is proud of his collection of nearly 4,000
models of his own inventions. The younger Peterson earned
books, many about the Earth’s magnetic and electric fields. This
his first patent at the age of 9 for a perpetual calendar he
particular passion generated several patents, including one for an
fashioned with materials including a flashlight battery and a
instrument that measures the electrical charge of seawater.
cardboard tube.
Mr. Peterson’s lifelong interest in scientific research and
A Cleveland resident, Mr. Peterson donated a two-photon
innovation has led to his recent $5 million gift creating the Thomas microscope to the McGovern Institute for Brain Research at
F. Peterson Jr. Center for Heart-Brain Research, a part of Cleveland
Massachusetts Institute of Technology (MIT), which he attended.
Clinic’s Earl and Doris Bakken Heart-Brain Institute. The center,
He is a member of MIT’s Corporation Development Committee
directed by Marc Penn, MD, PhD, implements, funds and manages
and its Leadership Council at the Koch Institute for Integrative
the institute’s research program on cardiovascular and nervous
Cancer Research, and he is establishing collaborative research
system disorders.
between MIT and Cleveland Clinic. He created an endowment
Mr. Peterson’s gift also is motivated in large part by personal
to fund the Thomas F. Peterson Jr. Conservator position in the
experiences. His mother had Alzheimer’s disease, his wife
MIT Libraries, and he serves the Bakken Library and Museum of
had multiple sclerosis and one of his children suffers from
Electricity in Life in Minneapolis as a trustee and member of its
schizophrenia. His wife, Jessie, passed away from colon cancer that library and finance committees.
went undetected largely because nerve damage from MS masked
His friendship with Earl Bakken, a founder of Medtronics and
her symptoms.
developer of the first wearable artificial pacemaker, reinforced his
“I realized that I might be able to do something about mental
interest in heart-brain research.
and neurological illnesses by supporting research,” says
“Earl called me at the house, delighted,” Mr. Peterson recalls.
Mr. Peterson, who was himself a patient at Cleveland Clinic.
“He said there have been two great events in the past year. One
“Cleveland Clinic saved my
was a celebration held in his
life twice, once with five-way
honor at the renovated movie
heart bypass surgery in 1996
Mr. Peterson’s firm, Motion Picture Sound Inc., recorded and edited soundtracks for
theater where, as a boy, he had
and again in September 2008,
films and television. For two decades, the studio was a focal point of the Clevelandseen the original Frankenstein
with laparoscopic colon cancer
area movie industry. Film reviewers watched advance screenings there, and film
movie, which motivated him to
surgery. Following my recent
directors reviewed daily rushes of movies shot in the area, including The Deer Hunter;
use electricity to save lives. The
surgery, I received a clean bill
Those Lips, Those Eyes; and the perennial favorite A Christmas Story.
second was when he heard
of health.”
about my gift.”
One Physician,
Two Chairs
Leonard Calabrese, DO
The Classen Chair will enhance such opportunities, he says. It
supports research and graduate education programs in osteopathic
medicine at both South Pointe Hospital, a Cleveland Clinic hospital,
and Cleveland Clinic.
“At South Pointe Hospital, we are bringing in some of the finest
Cleveland Clinic teachers from various areas of medicine, and
we have launched several research projects,” he says. “One is in
osteopathic manipulative medicine and fibromyalgia, which we
hope to make a national research project. We’re also conducting a
long-term study into empathy in healthcare.”
Dr. Calabrese says he is excited about what this research will
mean for patient care. “Everybody in this country wants to have a
relationship with their physicians,” he says. “They want to be heard.
They want to know that their doctor can stand in their shoes, even
just for a moment.”
Foundation Support
Richard J. Fasenmyer Foundation
Steve Travarca
A
s the first and only Cleveland Clinic physician to hold
two endowed chairs, Leonard Calabrese, DO, understands
the importance of philanthropy. He has seen what it can
do for medical research and education.
Dr. Calabrese, of the Rheumatic and Immunologic
Disease Department, has held the R.J. Fasenmyer Chair in Clinical
Immunology since 1999. In 2008, he became the first to hold the
Theodore F. Classen, DO, Chair in Osteopathic Research and Education.
“The two chairs are hand-in-glove,” Dr. Calabrese says. Having
both chairs will allow him to blend allopathic (traditional) and
osteopathic (holistic) medical practices to train the next generation
of physicians, he says.
“As medical technology has advanced in the past 20 years, we have
increased the distance between patient and physician,” Dr. Calabrese
says. “In osteopathic medicine, we say that caring must always
inform competence.”
The Fasenmyer Chair has helped him make great strides in his
research and education efforts, he says. “It was the initial stimulus
for me to explore initiatives in HIV, hepatitis C and autoimmune
diseases,” he says. “A decade ago, I was seeing patients full time.
I had tons of research ideas but little outlet to exercise them. The
Fasenmyer Chair allowed me to engage in research and education in
the context of care, and to grow them up around me.”
Since 1991, the Richard J. Fasenmyer Foundation has
committed more than $6.5 million toward the work of
Dr. Calabrese. It established the R.J. Fasenmyer Chair in Clinical
Immunology in 1999, and the Richard J. Fasenmyer Center for
Clinical Immunology in 2005. A new $1.5 million gift for an
education center allows for increased Fasenmyer Center
staffing and expanded community outreach, research and
education efforts.
“The education center will help fulfill Richard Fasenmyer’s
dream that the Cleveland Clinic take a leadership role in the
area of immunology research,” says John Baechle, CEO of RJF
International and a Director of the Foundation.
Mr. Fasenmyer, who passed away in 2002, was a Cleveland-area
industrialist who founded RJF International Corp.
Brentwood Foundation
In 2008, the Brentwood Foundation committed $5.5 million to
establishing the Theodore F. Classen, DO, Chair in Osteopathic
Research and Education to help further research and enhance
graduate education programs in osteopathic medicine at South
Pointe Hospital and at Cleveland Clinic.
“We seek opportunities to carry out our mission of promoting
good care by preventing illness and promoting wellness,” says
Roger Classen, DO, Brentwood Foundation President. The graduate
program at South Pointe is affiliated with Ohio University’s College
of Osteopathic Medicine.
“This gift will allow us to enrich the osteopathic medicine
graduate education program and expand research in this unique
area of medicine,” says Fred DeGrandis, President and CEO of
Cleveland Clinic’s Regional Hospital System.
35
philanthropia
The Future of
Vascular Surgery
Len Stuart
36
Considered one of the “100 greatest TV shows of all time” by
Entertainment Weekly, the show ran for eight years and helped
make stars of alumni Short and Moranis, as well as John Candy
and Catherine O’Hara.
Mr. Stuart’s gift to Cleveland Clinic will accelerate the training
of future vascular surgeons, placing them on a faster track in
their own careers.
“We’re excited about this, the first chair in vascular
surgery,” says Dr. Clair. In the past, vascular surgeons had
five years of training in general surgery and only two years in
vascular surgery as a subspecialty. Now, they will be trained
right out of medical school with five years exclusively in
vascular surgery.
More specialty training means better patient care down the
road, Dr. Clair says.
“This program will be a dramatic improvement, affecting
surgeons’ ability to treat peripheral vascular disease,” he
says. “Much of what we do now is very far afield from general
surgery, with technologies that are not adequately addressed
in a general surgery training program. Because we’ll be one of
the first 12 places in the country to train people this way, this
chair will enhance our ability to recruit top students.”
Neil Lantzy
A
Canadian entrepreneur who built a small bingo
supply company into a multinational gaming and
entertainment business has turned his energy toward
shaping the future of vascular surgery.
Len Stuart also had a hand in building Second City,
the training ground for many famous comedians, including
Martin Short and Rick Moranis. His latest, more serious,
endeavor began when the resident of the Bahamas came to
Cleveland Clinic for heart care a few years ago, on the advice of
Cleveland business associates and friends.
It quickly became his home base for healthcare. “No matter
where I am in the world, Cleveland Clinic is where I’m coming for
my medical care,” he says. He speaks highly of his physicians and
of Francine Pate in Global Patient Services, who facilitates
his visits.
In appreciation, Mr. Stuart is supporting the Len Stuart
Distinguished Chair in Vascular Surgery, the department’s
first endowed chair. His surgeon, Daniel Clair, MD, Chairman
of Vascular Surgery and professor of surgery with Cleveland
Clinic’s Lerner College of Medicine, will be the first
chair holder.
Mr. Stuart says he admires his Cleveland Clinic physicians’
dedication to their work. He can relate to their drive to excel.
While attending Alberta College in Edmonton, Canada, he was
elected president of the 3,000-member student body. At 19, he
took a job as a shipping clerk at Bazaar & Novelty, eventually
becoming the company’s owner. Beginning with a single
printing press and three employees, he expanded the Bazaar,
Novelty and Bingo King brands until his business was the largest
manufacturer of bingo supplies in North America. By selling
primarily to distributors who resell the company’s products to
nonprofit and governmental organizations to use for fundraising
events, he helped turn community bingo games into significant
revenue sources for government and charity.
Mr. Stuart was equally successful in the entertainment
industry as a major shareholder and co-chairman of Second
City, a performance theater for promising new comedians, and
executive producer of SCTV, a Canadian sketch comedy show.
Meeting Nursing
Needs
Stanley Shalom Zielony
Don Gerda
S
tanley Shalom Zielony of Garden City, N.Y., sees himself as
a problem solver. In 1967, the Israeli émigré proposed an
innovative idea to the publishing industry that brought
him financial success: mailing scientific journals and
magazines by air rather than ground transportation.
“I created a new international mail system for 80 percent of
scientific journals, all the major publishers. It was a brand-new
industry,” he says.
Now, Mr. Zielony, President of Publications Expediting Inc.,
is making a major gift to Cleveland Clinic’s Nursing Institute in
hopes of addressing some other problems: a nursing shortage,
the soaring cost of higher education and rising unemployment.
His gift establishing the Stanley Shalom Zielony Center for Nursing
Education is expected to help more than 1,000 Cleveland Clinic nurses
pursue their undergraduate and advanced nursing degrees.
“Given the recession in Cleveland and the general economic
downturn in the United States, I thought this was the perfect time to
support a program dedicated to the recruitment and training of a new
generation of young nurses,” he says. The program also trains nurses
interested in advancing within the profession. “I hope that many
individuals will be interested in supporting this project,” he says.
Mr. Zielony’s gift will be important to Cleveland Clinic’s
recruitment and retention efforts, says Debra Albert, MSN, MBA,
Chief Nursing Officer and Chairman of the Nursing Institute for
Cleveland Clinic. “We are so grateful to Mr. Zielony for his generous
gift to help educate the current and next generation of nurses.
Cleveland Clinic is dedicated to our nurses, a group of highly skilled
and compassionate individuals who foster an environment of
healing hospitality, innovation and high-quality patient care.”
The gift is unusual, says Michelle Dumpe, PhD, RN, Associate
Chief Nursing Officer for Nursing Education and Professional
Practice Development at Cleveland Clinic. “This gift clearly
sets us apart as nurses,” she says. “It speaks to our value and
relevance, not only here, but for nurses practicing anywhere.”
Nurses receiving tuition support from the new center can
attend the school of their choice while acquiring additional
skills for new positions, especially in the areas of greatest need,
Dr. Dumpe says. “Right now, those areas are nurse practitioner,
clinical nurse specialist, nurse educator and nurse manager. We
also need nurses with baccalaureate degrees in nursing.”
Seventy percent of Mr. Zielony’s gift will support tuition, and
30 percent will support other Nursing Education initiatives,
including the Nursing Institute’s simulation lab. “We are among
the very few academic medical centers with such a lab,” Dr. Dumpe
says. “About 1,300 nurses each year, new and current employees,
come to the lab, where we train them on new technology.”
In 2003, Mr. Zielony was awarded an honorary doctoral degree
by Technion-Israel Institute of Technology in Haifa, Israel, for
his accomplishments in the publishing industry. Also a strong
supporter of Technion, a major engineering and medical
education institution, he is passionate about his gift to Cleveland
Clinic nurses and the opportunity to give back to his adopted
country by supporting education.
“The philosophy behind my philanthropy is quite simple,” he
says. “I came to the United States as a poor immigrant with little
formal education. This country afforded me an opportunity to
succeed beyond anything I could have imagined. I am hopeful
that my support of the Center for Nursing Education and other
educational programs will create similar opportunities for others.”
Critical numbers
• The Council on Physician and Nurse Supply estimates the United States
may lack as many as 200,000 physicians and 800,000 nurses by the
year 2020.
• More than 1,000 Cleveland Clinic nurses working on undergraduate and
advanced degrees will be helped by scholarships through the Stanley
Shalom Zielony Center for Nursing Education.
• There are 4,772 nurses on Cleveland Clinic’s main campus.
• Each year, about 1,300 nurses are trained in the Nursing Institute’s
simulation lab.
37
MOVING HEALTHCARE
F
FORWARD
At Cleveland Clinic, we’ve opened the doors to the future of healthcare.
Last fall, we introduced two new buildings that will further enhance our
abilities to provide leading patient care, research and education.
To keep advancing, we need your support — because the help you give
now will make a difference in the care we give in the future.
To support the campaign for
Cleveland Clinic, please visit
clevelandclinic.org/giving.
onthehorizon
Brain
40
n 2003, Jay Alberts, PhD, rode a tandem bike across Iowa with
Parkinson’s patient Cathy Frazier to raise awareness and money.
After countless pedal pushes and a few serendipitous strokes of
handwriting, the trip would yield even bigger results.
When Ms. Frazier signed a birthday card for a friend during the
trip, Dr. Alberts noticed that her writing was clear and neat, unusual
for patients with the brain disorder. In fact, all of her motor skills
seemed to improve. In 2006, another ride with a different patient produced similar observations, including a decrease in tremor.
“After seeing that, I knew I had to follow up with a real preliminary
study,” says Dr. Alberts, Assistant Staff in Biomedical Engineering at
the Lerner Research Institute.
In that study, published in April 2009 in Neurorehabilitation and Neural Repair, five patients rode with a trainer on a stationary tandem bike,
and five rode solo for an eight-week training period. The patients riding
in tandem experienced a 35 percent improvement in motor skills and
upper extremity function, far better than the soloists. Those improvements were still evident four weeks after they stopped pedaling.
“To me, this points to a real change in central nervous system function,” Dr. Alberts says. He theorizes that “forced exercise” — so called
because tandem riding helps the patients pedal much faster than they
could on their own — improves the flow of signals from the brain to
the rest of the body. Now, Dr. Alberts and colleagues are using functional MRI imaging to observe those changes as patients cycle.
They also are developing a motor-driven cycle so future test participants — and, possibly, future patients — can achieve the same
benefits when riding solo. — Chris Blose
Pinpointing
New Immune Disease
W
hen siblings are born with the same
disease, chances are good they inherited it from their parents. But finding the cause, a faulty gene passed
from generation to generation, can
be daunting.
In 1996, Lerner Research Institute scientist Tatiana
Byzova, PhD, learned of a brother and sister who
had severe bleeding, frequent infections and other
immune problems. “It was nothing like any other
disease,” Dr. Byzova recalls. She suspected it was a new
genetic disease.
Genetic diseases are caused by changes in the letter
code, or sequence, of genes. Such changes garble the
instructions for producing proteins. So Dr. Byzova and
her colleagues began a painstaking 12-year analysis of
the proteins in the two siblings’ blood cells to search
for abnormalities.
They found one: KINDLIN-3. This protein allows cells
to communicate and carry out normal functions, such
as fighting off infections.
The gene that encodes the KINDLIN-3 protein had
a tiny change in its sequence. The siblings had inherited two faulty copies, one from each parent. Thus,
they could not produce any normal KINDLIN-3. The
researchers published their findings in the March 2009
issue of Nature Medicine.
Dr. Byzova and colleagues have devised a genetic test
for the gene mutation so that doctors can diagnose the
disease. “There are probably many more patients with
this disease,” she says. With an accurate diagnosis in
hand, doctors will be able to choose the right treatment:
a bone marrow transplant. The two siblings were given
bone marrow transplants, and both are now fine.
— Laura Bonetta
Tandem Bike: Till Gottbrath/Photolibrary; chromosomes on a cellular surface: 3D4Medical.com/Getty Images
booster
built
for two
I
The
nose
knows
Detecting
damage
E
— Siri Carpenter
Dog nose: GK Hart/Vicky Hart/Getty Images; soldier's head: Jose Luis Pelaez Inc/Photolibrary; uniform: Creatas Images/Jupiter Images
S
niffing out disease? Dogs have
been known to do it. Now
Cleveland Clinic researchers are
testing an electronic nose that
can discern lung cancer’s distinctive chemical signature from a person’s
breath. Doctors need a way to detect lung
cancer early, before it causes irreparable
damage. Today, fewer than 15 percent
of patients are able to be cured, often
because the disease is not found
early enough.
Peter Mazzone, MD, MPH, a physician
in the Respiratory Institute, and a team
of researchers are asking volunteers to
breathe into a hand-held sensor for five
minutes. The chemicals in a person’s
breath activate an array of dots, which
change color in particular patterns
depending on the combination of chemicals present. An earlier version of the
device could distinguish people with and
without lung cancer with up to 73 percent
accuracy. “That was encouraging, but not
accurate enough to be clinically useful,”
says Dr. Mazzone, who developed the
device with Cleveland Clinic colleagues.
This spring, his group will also begin
testing patients’ breath with an advanced
mass spectrometer, a machine that analyzes the chemical makeup of whatever
compounds it detects. The researchers
hope that either the electronic nose or
the mass spectrometer, or the combined
results of both instruments, will help them
pin down a unique signature for lung
cancer with high accuracy. “If we could
detect lung cancer at an earlier stage,”
Dr. Mazzone says, “we could save lives.”
invisible
ven if a soldier walks away
from a bomb explosion
apparently unscathed, he
may have sustained hidden
damage to the brain. About
1 in 10 soldiers come back from Iraq
and Afghanistan with undetected
damage, according to Cleveland Clinic
neuroscientist Stephen M. Rao, PhD.
The energy transmitted from a blast
can cause damage to brain tissue,
resulting in traumatic brain injury
(TBI). In some cases the damage is too
small to detect. “Soldiers with mild
TBI don’t always show abnormalities
on conventional CT or MRI scans,”
Dr. Rao says.
But the damage is real. A soldier
might have trouble concentrating and
sleeping, frequent headaches and
mood swings months after the explosion — symptoms that may also have
other causes, such as depression.
“When soldiers come back from
battle with lingering problems, it
is not always clear what these are
related to,” says Dr. Rao, who is collaborating with researchers at
Baylor College of Medicine in
Houston to bring clarity with
specialized imaging methods.
With a $1.4 million grant from
the U.S. Department of Defense,
they have launched a brain imaging study in 120 individuals — soldiers who survived a bomb explosion
and civilians who suffered a concussion
in a car accident or fall.
The study uses two types of magnetic resonance imaging (MRI).
One method, called functional MRI,
measures brain activity when a person
performs a task in the scanner. The
other, called diffusion tensor imaging, measures the integrity of nerve
fibers that connect parts of the brain.
“These advanced imaging techniques
provide a new window for visualizing
the damage caused by a mild TBI,”
Dr. Rao explains.
He hopes to be able to help doctors
diagnose mild TBI in soldiers and use
the techniques to determine whether
a particular treatment — for example,
attention exercises or medication to
stimulate brain activity and memory —
is working. — Laura Bonetta
41
asktheexperts
Statins in the Spotlight
There’s more to heart disease than cholesterol.
If you’re getting older but your cholesterol is low, there’s no need to worry about heart
disease, right? Wrong, according to a new study of people with admirable cholesterol
numbers but high readings on a less-familiar test that measures inflammation, called
C-reactive protein (CRP). The study’s good news is that statins can help. Two Cleveland
Clinic experts share their views on the study, called JUPITER, and the role of statins.
In the JUPITER study, people who were taking 20 mg
daily of the statin Crestor (rosuvastatin) had half the risk
of heart attack and stroke compared with those taking a
placebo pill. Have these results changed how you treat
your patients?
 STEVEN
NISSEN, MD: It’s absolutely essential that we integrate this information into our practices. People with minimal
risk factors in the older age group — men over 55 and women
over 60 — with elevated CRP should be treated. Now I’m testing
more patients.
Steve Travarca
42
 LESLIE
CHO, MD: We’ve been using CRP for a long time,
feeling that high CRP in patients with normal cholesterol
levels deserves more aggressive cholesterol control. This study
confirms that.
Is it wise to put apparently healthy individuals on a medication for the long term, or does it turn out that these people
aren’t as healthy as they seemed?
 DR.
CHO: They were probably not so healthy. The population in
JUPITER was older — early 60s, overweight — and 40 percent had
50 percent reduction in risk. We don’t have evidence that in this
population lifestyle changes will produce a 50 percent reduction.
Until we see a sustainable approach to lifestyle, we have to go
where the data lead us.
Are there downsides to using statins?
 DR.
NISSEN: A diabetes risk caught our attention in this study,
but it was a very small effect, and since cardiovascular events
were reduced, the benefit was overwhelmingly in favor of therapy.
We sometimes see elevation in liver enzymes, but no patient has
experienced liver failure from statins. The more relevant concern
is the patients who experience muscle pain and weakness, and,
very rarely, rhabdomyolysis, a breakdown in muscle, which can be
serious. For those patients, we try a different statin, or occasionally, we’ll use other therapies, which are not nearly as effective.
“drugs are a supplement, not
a substitute, for a healthy
lifestyle. Losing weight helps reduce C-reactive protein
(CRP). Exercise can lower CRP. Smoking increases CRP.”
— LESLIE CHO, MD
Is one statin as good as the next?
 DR.
CHO: The answer is patient-specific. To get bad cholesterol
down and CRP down, some patients require the most potent
statin and others need just a little bit of a low-potency statin. The
most potent agent will get you there faster. But a lot of patients
can’t take the most potent medication.
 DR.
How do statins lower risk for heart attack and stroke?
NISSEN: This study tested only one potent statin at a specific dose, 20 mg. We don’t know if the same results would have
come from a less-potent or generic statin. That said, for patients
who have to pay for their own medication, where cost is an issue,
a generic statin is better than none.
 DR.
What’s the message from the JUPITER study?
metabolic syndrome, a precursor to diabetes. They weren’t thin
40-year-olds, as some news stories reported.
NISSEN: That’s the $64,000 question. Many of us believe
that lowering cholesterol is one mechanism. Statins lower lowdensity lipoproteins (the bad cholesterol) and raise the good,
high-density lipoproteins. They lower triglycerides a little and
lower inflammation, so CRP goes down. We don’t know how
much of the benefits come from each of these effects.
Are lifestyle changes worth pursuing first, before going
to medication?
 DR.
CHO: Absolutely. For me, drugs are a supplement, not a
substitute, for a healthy lifestyle. Losing weight helps reduce CRP.
Exercise can lower CRP. Smoking increases CRP.
 DR.
NISSEN: I’d be the first to tell you that everyone ought to
have a healthy lifestyle, eat low fat, exercise. But JUPITER didn’t
look at that. Everyone on the study got dietary counseling, then
half got statins and half didn’t. Those taking statins had nearly a
 DR.
CHO: Get your cholesterol levels checked, know your risk
factors and try to modify them. This is a great study to bring out
the importance of CRP. Get your CRP checked. The message is:
Become proactive. You bring it up with your doctor. Get your
questions addressed.
 DR.
NISSEN: You don’t see a lot of studies with a 50 percent
reduction in morbidity and mortality. That’s a pretty dramatic
result. I frankly think the result should get everyone’s attention.
— Cori Vanchieri
Steven Nissen, MD, is Chair of the Robert and Suzanne Tomsich
Department of Cardiovascular Medicine at Cleveland Clinic. Leslie Cho, MD,
is Director of Cleveland Clinic’s Women’s Cardiovascular Center and Section
Head, Preventive Cardiology and Rehabilitation in the Tomsich Department
of Cardiovascular Medicine.
43
mystory
BY PAUL HANNA, as told to Cleveland Clinic Magazine
Opening My Heart
I was 48 years old and in great shape when I went
44
I wasn’t expecting the diagnosis I got. I had no symptoms, no
illness, nothing. I worked out at least four or five days a week. I’ve
always been a hard charger, a type A personality. I have a very
successful business, Blue Technologies, and I never got sick to the
point where I had to miss work. I thought of
myself as invincible.
“I’m probably like most men: We don’t get medical I had several tests, including a CT scan.
care until it’s too late or there’s a problem.”
At the end of the day, Dr. Raul Seballos told
me I had a large aortic aneurysm. It was a weakness in the wall of
a source of great confidence and comfort, told me about several NBA
the aorta, the major artery that carries blood from the heart to the players, a hockey player and others who’ve had a full recovery.
rest of my body. I almost fell out of my chair. When I’d done the
The morning of the surgery was a very emotional time. I kissed
stress test, they told me I had the heart of a 29-year-old athlete.
my wife and four children goodbye. I wasn’t sure I was going to
Without that CT scan, they would not have found the aneurysm.
see them again. The first couple of weeks after the surgery were
Dr. Seballos was very reassuring and immediately got on the
pretty hard. I got out of the hospital in three and a half days and
phone and lined me up with the surgeon, Dr. Lars Svensson. Two
wasn’t supposed to drive for six weeks. My wife drove me to work.
weeks to the day of the diagnosis, I had open-heart surgery to
She made sure I didn’t work full days.
repair the aneurysm. If they hadn’t caught it, the weakened artery
I had had some knee surgery from my sports days, so I knew
wall would probably have ruptured, and that’s very often fatal.
how important it was to follow the program for recovery. Walking
It turned out that a genetic disorder caused my aneurysm. My
was key in the beginning. My wife and I walked every day together.
mom and my mom’s mom both had an aortic aneurysm that
It was a great way to reconnect with her.
ruptured. My grandmother died of it. I never thought I was at
I’m 49 now, and thanks to Cleveland Clinic I carry no baggage
risk for the same problem — that it was a genetic issue — until
from that surgery, other than the scar on my chest. I’m running,
I talked to the doctors. My mother and grandmother were both
doing the elliptical, weight training. Six weeks after surgery, I
heavy smokers, and I’d always attributed it to that. But I didn’t
went bonefishing in the Bahamas. In September, I shot a bear in
smoke and didn’t have high blood pressure.
Manitoba, Canada. I’m close to 100 percent, doing everything I
My aneurysm was 5.9 centimeters, the
was doing before the surgery.
size of a billiard ball; there was no option
Now I believe there’s a bigger mission for me than just being
but surgery.
successful in business and enjoying my life. I’ve always done
It was frightening. Obviously,
charity work in the community, and I’ve always been fond of helpwhen you have open-heart surgery
ing children, because I had wonderful parents. But I stepped that
at 48 years old, it is an extreme,
up in a big way during my recovery.
life-changing event. I spent probably
I’m probably like most men: We don’t get medical care until
every night searching the Internet,
it’s too late or there’s a problem. I want people to know
looking for people who’d gone
that with good healthcare and a positive attitude, the
through this, and I couldn’t find a lot
human body can overcome a lot, because I experiof information. Dr. Svensson,
enced it. — Interview by Marina Krakovsky
Greg Ruffing
to Cleveland Clinic for an executive health physical
in March 2008. The last time I’d had a physical was in
1986, when I was in training camp with the Cleveland
Browns. None of my business partners — guys I’m
very close to — even had a regular doctor, and neither
did I. I figured the physical would be a good opportunity to get a baseline, so the four of us went together.
FridAy FirEWOrkS
SAturdAy GivEAWAyS
SuNdAy kidS FuN dAy
2009 EVENT AND GIVEAWAY SCHEDULE
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Memorial Day, “I Am IN the Tribe”
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Fill The House for The Diversity
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presented by Medical Mutual
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m All Fans
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n All Women
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for Shoes and Clothes for Kids
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House of Cleveland
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Sept 30
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ArE yOu iN thE tribE?
These are
the hands of
the future.
The hands of University School
student Yefe Soriano, Class of
2016. Since his family could
remember, Yefe has talked
about and aspires to become a
brain surgeon.
Yefe’s gift for academic achievement isn’t the only
thing we value about him. “Yefe is kind, creative,
hard working and has a great sense of humor,” says
his 5th grade teacher, Laura Pickwick. “He excels in
creative writing due to his active imagination. He
is our expert at the art of origami and is always in
search of bigger challenges.”
University School’s distinct educational framework,
built around the way boys learn best, immerses them
in a rich curriculum that captures their imagination
while building critical thinking and analytical skills.
At University School, we believe in challenging students
to stretch their minds and chase their dreams. By
believing in every boy’s personal pursuits, we know
the best plan for tomorrow rests in the hands of people
like Yefe and his classmates – today.
F O R B O Y S G R A D E S K -1 2 w i t h t w o c a m p u s l o c a t i o n s i n G r e a t e r C l e v e l a n d 2 1 6 - 8 3 1 - 2 2 0 0 w w w . u s . e d u