Departments
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By Dana Fischetti
It's a Friday morning and another not-so-typical day at the office for U of L physicians Larry Cook '64A, '68M and Christine Cook '71M, '75MER. Between departmental meetings and personnel matters, Larry, chair of the Department of Pediatrics, is checking the progress of a patient in the neonatal intensive care unit at Kosair Children's Hospital. Christine, an associate professor in obstetrics and gynecology, is performing an in vitro fertilization in the Fertility Center at Alliant Medical Pavilion, offering hope to a couple desperate to conceive a child.
For the Cooks, life revolves around the practice of medicine. Both are skilled physicians who are comfortable working in the arena of high-tech medicine. But it is their "high touch" approach that makes them great doctors. Whether explaining a procedure to the family of a critically ill infant or advising an infertile couple on treatment options, they recognize that everyday occurrences in their professional lives can be major emotional traumas in the lives of their patients. While the Cooks specialize in different fields, they share a common interest in using their medical knowledge to help people improve the quality of their lives. During their years at U of L, each has made that interest a reality.Extracorporeal Membrane Oxygenation
In his specialty area of neonatology, Larry Cook has focused on the treatment of heart and lung conditions in newborns. One of his major areas of clinical research has been in the use of Extracorporeal Membrane Oxygenation (ECMO), a heart-lung bypass treatment for newborns suffering from respiratory failure of a reversible nature.
Through the use of surgically placed tubes, ECMO diverts blood outside the body into a bypass system. For several days or weeks, the system replaces the functions of the baby's heart and lungs, allowing them to recover and heal. One of the earliest ECMO centers in the world, U of L began using the procedure in 1985. Since then, U of L physicians have treated more than 500 critically ill newborns with this technology. The university has had a major role in its evaluation and is one of the largest contributing institutions to a national registry of children undergoing ECMO. "It's been a dramatically successful program, with survival rates in excess of 80 percent," says Cook. "U of L was a pioneering center in the definition of qualifying criteria for ECMO. We've established with some precision which babies will die without ECMO and which babies will survive without ECMO.
"We also have a wonderful high-risk infant follow-up program, in conjunction with the state Division of Maternal and Child Health, which has allowed us to follow the progress of children for up to 10 years after ECMO. Our data has helped assure the medical community that in excess of 80 percent have excellent neurologic and intelligence outcomes, or what we call 'intact survival.'"Even with such a high success rate, Cook and his colleagues are conservative when it comes to the use of this technology. ECMO is a highly invasive and risky procedure, and babies are placed on it only if they have an 85 percent chance of dying without it and all other forms of treatment have been unsuccessful.
The newborn is surgically placed on ECMO, which requires the sacrifice of one of the carotid arteries providing blood flow to the brain. The baby's blood must also be anti-coagulated, creating the risk of a fatal hemorrhage. That risk necessitates around-the-clock monitoring by two nurses.
"ECMO is extremely expensive and emotionally challenging to caretakers and families," says Cook. "In the early days of its use, it was especially difficult because we didn't know what the outcome would be. Today, we know there are hundreds of children alive and well as a direct result of ECMO, but we still apply this technology with significant respect for its complexity."
Recently, U of L doctors have begun using inhaled nitric oxide as an alternative treatment. Historically, many babies needed ECMO because of high blood pressure in the lungs. That pressure can sometimes be lowered with nitric oxide, avoiding the risks of ECMO.
Treatments such as ECMO and inhaled nitric oxide, originally used in neonatal intensive care, are now being used to treat older children suffering from heart and lung failure, Cook says.
"That's true of a lot of critical care technology," he says. "Much of it has originated in newborn intensive care. Neonatologists have a little bit of engineer in them. We're fascinated with the convergence of medicine and technology."
Treating infertility in men
While Larry Cook's discipline requires a bit of the engineer, Christine Cook's specialty of reproductive endocrinology requires a bit of the detective. Much of her clinical research has been in the use and evaluation of treatments for infertility.
Recently, she worked with Douglas Darling, assistant professor in biological and biophysical science; Arnold Belker, clinical professor of surgery in urology; and Mary Fallat, assistant professor of surgery, on the genetic causes of and specific treatments for male infertility.
"Historically, men have not received much attention in the area of infertility," Cook says. "Donor insemination was the only option. But now we're using new procedures to help couples conceive."
One procedure, intra-cytoplasmic sperm injection, involves the use of a microscope to insert single sperm into single eggs, which are then implanted in the woman's uterus. "This procedure has a 45 percent successful pregnancy rate on the first try," says Cook. "This is helping men who historically had absolutely no chance of being biological fathers."
More than 100 intra-cytoplasmic sperm injections are performed at U of L each year, but Cook estimates that several hundred men in the Louisville area could benefit from it. Its $7,000 cost is prohibitive to many, she says, and insurance companies rarely cover it.
"There is an ongoing debate over whether or not the right to reproduce is really a right," Cook says. "It's a complicated issue. There are too many people in the world, but there is also a biologic imperative in most of us to reproduce. I wouldn't want to live without my children, so I understand how important this issue is to my patients."
Another relatively new procedure, which is inexpensive and low-risk, is intrauterine insemination, which involves the insertion of the man's sperm high in the uterus with increased access to the fallopian tubes, where fertilization takes place.
Cook is reporting the results of intrauterine inseminations at U of L as part of the nation's largest published series of inseminations. She has found it particularly effective in cases of unexplained infertility.
"In 25 to 30 percent of the couples we see, we can't find a cause for the infertility," she says. "For a long time, artificial insemination was their only option. But we've found that about 20 percent will get pregnant if they do the intrauterine inseminations for three or four months."
Cook says that working with couples experiencing infertility involves much more than diagnosing and treating the problem. Infertility is an intensely emotional issue that requires a great deal of compassion on the part of the physician.
"The experience of infertility treatment can be isolating and disruptive of work and family life," she says. "It's becoming more comfortable for people to discuss, but there are still many people who keep it a secret. Part of my role is to help them through that stress and isolation."
Evaluating hormone replacement therapy
Although Cook says treating couples with infertility has been fulfilling, she decided last year to step down as director of the In Vitro Fertilization Program to devote more time to another research interest, the use of hormone therapy to treat the symptoms of menopause.
She is involved in an ongoing study to evaluate bone loss in women between ages 35 and 50. Using a urine test, Cook measures the presence of a collagen byproduct that indicates a loss of bone density. She then monitors participants to see if hormone therapy or the use of birth control pills will stop the bone loss.
"It's particularly important that we quantify the application of hormone treatment and its effects," Cook says, "because there are concerns about breast cancer development in women taking estrogen for an extended period of time."
Part of the purpose of Cook's research is to provide physicians with data to better manage hormone therapy and minimize the risk of cancer. She is particularly excited about setting up a center for the study of menopause, which will give her the opportunity to do more clinical trials and provide improved care.
"Seventy-five percent of post-menopausal women are not on any kind of hormonal treatment," she says. "We need to evaluate the health problems specifically linked to low estrogen levels."
Cook says the center will also provide the opportunity to study non-pharmacologic treatments, such as exercise, diet, vitamins, minerals, and herbal or homeopathic remedies.
"We'll have a lot of patient candidates for clinical trials," says Cook. "We'll be able to spend more time on research and treatment and less time recruiting people for studies."
An "exciting and satisfying" profession
The Cooks found their way to the medical profession, and to U of L, through separate paths.
Raised in rural Pennsylvania, Larry accepted a scholarship to U of L instead of going to the U.S. Military Academy at West Point, and stayed for medical school. At U of L, he worked with Billy Andrews, then a young assistant professor, who established the first newborn intensive care unit in Kentucky.
"I became fascinated with these little people," he says. "I knew I wanted to pursue neonatology as my specialty."
Christine grew up in Oregon, received her bachelor's degree in microbiology from Oregon State University, and came to U of L for medical school. As an undergraduate, she worked in the maternity ward of a local hospital, and found she enjoyed the work. But pursuing a medical degree in obstetrics and gynecology did not prove to be as pleasant.
"Back then, all the faculty were men," she says. "Only three percent of ob/gyn residents in the country were women, and there were no others here. There were only five other women in my medical class, out of 100. That was tough, but I can be fairly stubborn and I felt it was the right thing for me to do."
The Cooks met in 1971 when Larry returned to U of L to do a fellowship in neonatology and Christine was an intern. They married in 1973.
During their years at U of L, the Cooks have kept up with two hectic professional schedules while raising three children, Kirk, 29, Larry's son from a prior marriage; Brian, 22; and Amelia, 20. None have chosen to pursue a medical career, which is just fine with the Cooks.
"What's important is to enjoy the work you do," says Larry. "That's a luxury Christine and I have had in being able to combine research, teaching, and being practicing physicians. We're fortunate to be in a profession that makes every day exciting and satisfying. I hope our children will have that, too."
DEPARTMENT OF PEDIATRICS
Where Children Come First
Larry Cook, chair of the U of L Department of Pediatrics, speaks with pride as he takes a visitor on a tour of the Kosair Charities Pediatric Center.
In addition to department offices, the building houses the Child Evaluation Center, which evaluates and treats children with developmental, genetic, and learning disorders. The center brings a unique atmosphere to the building, with its colorful walls, bright waiting room, and the sound of children's voices in the halls.
"It's a constant reminder of the reason we're all here, which is to improve the lives of children," says Cook. "We are blessed to have this facility, particularly right across the street from Kosair Children's Hospital, the 15th largest children's hospital in the nation and the teaching site for the Department of Pediatrics."
The building's completion in 1996 brought most of the department's faculty together in one location, creating an environment conducive to research and collaboration.
"We've had some wonderful research programs in our department," Cook says, "but research has not been a dominant influence in the past. The emphasis of the Challenge for Excellence, as well as our new facilities, are creating a research culture in pediatrics."
That culture will grow stronger with the opening of the Baxter Biomedical Research Building, under construction nearby. The Pediatric Research Institute, with office and lab space for researchers, will occupy an entire floor. Two new endowed chairs have also been funded, which Cook says will provide the opportunity to bring in "anchor" researchers with strong track records.
"We have always had outstanding clinical programs," Cook says. "Now we are adding a growing strength in basic research."
The beneficiaries of that research will be the children of Kentucky, who depend on U of L for the highest quality in pediatric care.
