Electrocardiogram: Blog illustrates value of old, but still vital cardiac test

Posted September 23, 2016 by Jennifer Huber
Categories: Health

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Stephen Smith, MD, an emergency medicine physician at Hennepin County Medical Center in Minnesota, is passionate about using electrocardiograms to save lives. He even writes a popular blog called Dr. Smith’s ECG Blog to train others to more accurately interpret them.

If you’re one of the 735,000 Americans that had a heart attack in the last year, you almost certainly had your heart evaluated with an electrocardiogram, or ECG for short, as soon as you were brought into the emergency room. The heart produces small electrical impulses with each beat, which cause the heart muscle to contract and pump blood throughout your body. The ECG records this electrical activity using electrodes placed on the skin, allowing physicians to detect abnormal heart rhythms and heart muscle damage.

On the surface, an ECG just produces a simple line graph based on technology that was invented over a century ago. So why does it still play such a vital role in the clinic? And how can a physician diagnose a heart condition from a little blip on the line? I recently spoke with Smith, who is also a professor affiliated with the University of Minnesota Twin Cities, about the importance and subtleties of interpreting ECGs.

How do you use ECGs in your medical practice?

“I work full time as an emergency medicine physician and see thousands of patients per year. In the emergency room, the ECG is the first test that we use on everyone with chest pain because it’s the easiest, most non-invasive and cheapest cardiac test. Most of the time when someone is having a big heart attack (myocardial infarction), the ECG will show it. So this is all about patient care. It’s a really amazing diagnostic tool.”

Why did you start your ECG blog?

“Every day I use ECGs to improve the care of my patients, but the purpose of my blog is to help other people do so. I write it for cardiologists, cardiologist fellows, emergency medicine physicians, internal medicine physicians and paramedics — anyone who has to record and interpret ECGs — in order to improve their training and expertise. It’s easy to interpret a completely normal ECG, but many physicians fail to look at all aspects of the ECG together and many abnormalities go unrecognized. Reading ECGs correctly requires a lot of training.

For instance, one of my most popular blog posts presented the case of a 37-year-old woman with chest pain after a stressful interpersonal conflict. She was a non-smoker, with no hyperlipidemia and no family history of coronary artery disease. Her ECG showed an unequivocal, but extremely subtle, sign of a devastating myocardial infarction due to a complete closure of the artery supplying blood oxygen to the front wall of the heart. Her blood testing for a heart attack didn’t detect it, so she was discharged and died at home within 12 hours. It was a terrible outcome, but it demonstrates how training caregivers to recognize these subtle findings on the ECG can mean the difference between life and death.

I get very excited when I see an unusual ECG, and I see several every day. In 2008, I started posting these subtle ECG cases online and, to my surprise, people all over the world became interested in my blog. In July, I had 280,000 visits to my blog and about 90,000 visits to my Facebook page. People from 190 countries are viewing and learning from my posts. And I get messages from all over the world saying how nice it is to have free access to such a high-quality educational tool. I spend about eight hours per week seeking out interesting ECG cases, writing them up and answering questions on my blog, Facebook and Twitter.”

Will ECGs ever be obsolete?

“I don’t think ECGs will ever be outdated, because there is so much information that can be gleaned from them. We’re also improving how to interpret them. The main limitation is having good data on the underlying physiology for each ECG, which can be fed into an artificial intelligence computer algorithm. An AI could learn many patterns that we don’t recognize today.

Right now I’m working with a startup company in France. They’re a bunch of genius programmers who are creating neural network artificial intelligence software. We’re basically training the computer to read ECGs better. We need many, many good data sets to train the AI. I’ve already provided the company with over 100,000 ECGs along with their associated cardiologist or emergency medicine physician interpretations. We’re in the process of testing the AI against experts and against other computer algorithms.

My only role is to help direct the research. I receive no money from the company and have no financial interests. But I do have an interest in making better ECG algorithms for better.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Project aims to improve well-being in rural Mexican communities

Posted September 20, 2016 by Jennifer Huber
Categories: Health

Tags: ,

san-miguel-peras_jshTo improve the health and well-being of people around the world, researchers must first understand what it means to be well and whether this has the same meaning for everyone.

A Stanford team at the Wellness Living Laboratory (WELL) is working to define and measure wellness by identifying the factors that help people maintain it and by testing new interventions. As announced earlier this week, they’re engaging thousands of participants from around the world, including the U.S., China and Taiwan, with the ultimate goal of optimizing everyone’s health and well-being.

Nicole Rodriguez, a research assistant with the Wellness Living Laboratory at the Stanford Prevention Research Center, recently extended this work to Mexico in conjunction with Stanford’s Community Health in Oaxaca program. This summer Rodriguez carried out a new research study with a team of Stanford undergraduates to explore the well-being of two impoverished, rural communities in Oaxaca, Mexico; I recently spoke with Rodriquez about her work.

How do you define “well-being”? Why is it important to study this worldwide?

“Well-being is about considering the whole person, where health extends beyond physical health to encompass emotional health, social connectedness, lifestyle behaviors and even factors like sense of purpose and creativity.

It’s important to consider what factors contribute to universal well-being — across cultures and socioeconomic gradients. Studying well-being helps us understand what people in diverse parts of the world care about the most and how they prioritize aspects of their lives and health. Understanding what motivates and drives people then allows for more targeted and efficient public health efforts.”

What inspired you to work in Oaxaca?

“I’ve been working with underserved Hispanic populations throughout Santa Clara County doing WELL research, and I was curious to learn more about the cross-cultural well-being in Latin American populations.

Seven years ago, I participated as an undergraduate in Stanford’s community health overseas program in Oaxaca with Gabriel Garcia, MD and Ann Banchoff. The class launched me on a career working to address health disparities among marginalized populations. This year, I returned as a program assistant to help build the research portion of the course. It was an honor to give back to the program and revisit the place and people that shaped my aspirations in medicine.”

What did the research group do in Oaxaca?

“We worked with a partnering non-profit organization, Niño a Niño, to carry out a project that would help the non-profit and community leaders better understand the community’s needs and priorities. Our group carried out a well-being study with 38 participants in San Miguel Peras and Pensamiento, two rural communities living in extreme poverty.

The first part of the study was an open-ended interview aimed at understanding individual perspectives and priorities surrounding well-being, which was modeled after the WELL measures process developed by Cathy Heaney, PhD. The second portion of the study incorporated the citizen science process developed by Abby King, PhD, which empowers community residents to capture the barriers and facilitators to their health and well-being — by carrying out a tablet-based environmental assessment, taking photos and recording audio narratives — and then engage in community advocacy. Lastly, we conducted WELL’s core well-being questionnaire that is being used on an international scale.

I think looking at well-being is especially important in low-resource settings because communities have to think carefully about how to allot and prioritize limited resources, people and time. Niño a Niño is going to use the data about community priorities to plan out its community-based efforts for the upcoming year.”

What was it like in these remote rural communities?

“Political protests and unrest across Oaxaca complicated the decision to bring the students to Mexico this summer. The city was generally calm while we were there, but we did face some shutdowns of public transportation, clinics and hospitals. I think it provided good exposure to how governmental issues can impact critical public services like healthcare.

The students also learned about community health fieldwork in marginalized and remote villages. After a rocky two-hour bus ride through muddy unpaved cliffs, we arrived in the village center. A group of children greeted our team to lead us to the family homes where we would carry out the interviews. Assuring us that the homes were close by, the children led us on an uphill scramble for about an hour to reach the families. We crossed rivers, slipped on fresh clay and mud, and held on to rocks and branches for balance as we worked our way up to the homes — while our young guides hopped gracefully through the paths.

In these rural impoverished settings, well-being was about meeting the basic necessities of daily life — having enough water in the rainwater catchment tank and enough food to put on the table. Whereas a lot of our Santa Clara County interviewees discussed issues like balancing work, personal life and health, the conversations in Oaxaca revolved around meeting fundamental necessities. Exploring issues of well-being in these communities helps us think about what is truly essential for health and well-being.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

The Opioid Crisis: Medicine X panelists explore the complexity of managing chronic pain

Posted September 19, 2016 by Jennifer Huber
Categories: Health

Tags: , , ,
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Photograph courtesy of Medicine X

Saturday’s Medicine X session on the opioid crisis focused on how best to manage the chronic pain felt by millions of Americans every day. The session engaged panelists with different perspectives, including a patient in chronic pain and physicians struggling to decide when to prescribe opioids. All the panelists recognized that opioid addiction is a serious and pervasive problem, but they also warned that proper pain management is a complex issue.

Jeanmarie Perrone, MD, professor of emergency medicine at the Hospital of University of Pennsylvania, told the audience, “I need good pain management to work in the emergency room. We need these drugs, we just need to be conscientious about it.”

ePatient Britt Johnson, a Medicine X board member and owner of The Hurt Blogger, understands this all too well. She shared her story of needing opioids to function due to severe pain from spondyloarthropathy and rheumatoid arthritis, which she’s had for most of her life.

Johnson addressed the media’s oversimplification of the issue. “Pain is not politically correct,” she said. “The media tells me that all opioids are all bad. The media makes everyone believe that I, too, am struggling with addiction. And the media lumps me in with statistics on heroin usage and overdose deaths.” She went on to say that she winds up “feeling guilt and shame for constantly experiencing pain. And I’m reminded constantly how heart breaking overdose stories are, which they are. But my story is not connected to those stories.”

Pain expert Frank Lee, MD, agreed that “we’re starting to stereotype chronic opioid patients as heroin addicts and physicians as pill pushers.” Lee described the impact of this on his practice and how it increases his risk if he prescribes a large or moderate dose of opioids to a patient. “If I just follow the CDC guidelines and tell the patient that I can’t prescribe this medication, it makes my life easier,” he said.

Lee shared a story about one of his patients who recently died. In her 70s, Mary had severe rheumatoid arthritis and three back surgeries. When he “inherited” Mary from a different pain doctor, she was on massive doses of opioids — close to 300 mg morphine daily equivalents, several times the recommended dose. “Maybe I was naïve, but I went through all the dangers of opioids. I told her, ‘We need to come down on your dose.’ She was hesitant, but she said ‘if you really need to do this, okay.’ During the next three months, we went down from almost 300 mg to about 70 mg. She ended up in the emergency room twice, because she just couldn’t take it. It hurt too much,” he said. “She cared enough to try what I recommended and I felt like I owed her the chance. We went back to the insane amount of her opioids and she did well.” However, Lee expressed his concern over what the high opioid doses did to her body.

Lee and others discussed the need to distinguish between patients like Johnson and Mary from those who are prone to opioid addiction. Sean Mackey, MD, PhD, chief of the division of pain medicine at Stanford, declared the need for more quality data on pain — through programs like the National Pain Strategy — to help identify the risk factors of the people that are more vulnerable. Cynthia Reilly, director of the prescription drug abuse project at The Pew Charitable Trusts, professed that prescription drug monitoring programs are part of the solution.

The panel agreed that another solution is to make integrated medicine options more affordable. “At the pharmacy I get a bottle of 60 Percocet for ten dollars, yet I have to pay out of pocket for massage, acupuncture, heat therapy, ice packs, cognitive behavioral therapy, pain psychologists and anything else,” said Johnson. “Opioids have the cheapest barrier to access, yet raising the price of opioids is not the answer; putting complimentarily pain therapies on an even playing field is.”

Although mostly harmonious, the panel discussion became heated near the end when a member of the audience interrupted, asking to hear more from Johnson. Feeling that she was being left out of the conversation, she said, “I’m sitting here and the discussion about the pain crisis is happening around me, when I’m right here and it could be happening with me. We could be having a real discussion here.” The panel concluded that we need to do a better job bringing everyone together with different perspectives.

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

How can technology address the health needs of aging adults? A Medicine X panel offers tips

Posted September 18, 2016 by Jennifer Huber
Categories: Health

Tags: , ,
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Photo courtesy of Medicine X

Older adults aren’t usually the first adopters of new health technologies. But wearable devices and smart phone apps could help this growing population by improving patient-provider relationships, enhancing health literacy, increasing safety and engaging patients in their own health, a panel of speakers at Medicine X said Saturday.

Moderator Frances Patmon, PhD, RN, nurse scientist at Dignity Health, began the discussion by noting, “All our baby boomers are retiring in the next five to 10 years and it’s going to be problematic if we don’t know how to care for these older adults.” She believes that it’s vital to engage and educate older patients and their families and “technology is a great way to engage the older population.”

A major topic of the session was the need to customize technology. Perry Gee, PhD, RN, nurse scientist at Dignity Health, explained that 60 percent of older adults have some kind of functional deficiency, such as impaired vision, hearing, sense of touch or memory function. “We need to consider this when we design,” he said.

Panelist Christopher Snider, Medicine X executive board member, social media strategist at Smart Patients and patient community advocate at Symplur, agreed. Both Snider and his wife live with diabetes. “I’m looking forward to getting old with diabetes with my wife who has diabetes. And our eyes and touch aren’t going to be as reliable,” he said. “Am I going to be able to hear or feel my CGM [continuous glucose monitor] when it alerts me in the middle of the night? Maybe we need an older adult model with improved technology alerts that cause a seismic shift in the house?”

Gee noted that patients need to be part of this design process. “We need to invite older adults, who are struggling, to participate in the design process — bringing them into our design labs.”

In addition to innovative design, the panelists agreed that more training was needed — for patients, families and health-care providers. Michelle Litchman, PhD, nurse practitioner and assistant professor at the University of Utah College of Nursing, explained, “It takes a lot more time to train older adults on technology. Because of dementia, we also need to involve family members and other caregivers. And we have to tailor the training for that person and consider patient safety safeguards.”

Litchman described how technology and training helped her patient Lavon, an 85-year-old woman with Type 1 diabetes and dementia who lives in an assisted-living facility. In the past, home health-care workers came in to give Lavon her insulin, but she still had a lot of glucose variability because she only needed tiny doses of insulin. So Litchman provided her with an insulin pump along with “a ton of training.” The process started with a two-week practice run using a pump dispensing saline, followed by training all of her home health caregivers and family. In the end, Lavon got a more precise dose of insulin and her dizzy episodes were greatly reduced.

Although technology can help older adults remain more independent, Gee noted that the digital divide still exists and is even more pronounced for older adults. “We need to work with people that are 75 years or older who haven’t used technology. We need to bring them to the table and learn from them,” he said.

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

On the importance of patient empowerment and open source, a Medicine X panel weighs in

Posted September 16, 2016 by Jennifer Huber
Categories: Health

Tags: ,
Core theme: Data + Devices panel with Ben West, Cedric Hutchings, Karen Sandler and Dana Lewis

Photo courtesy of Medicine X

It’s your body, so you should have access to all of your medical data, right? This morning at the Medicine X session on data and devices, I learned that liberating your own medical data — or devices — will probably not be so simple.

The conversation was started by Ben West, a software engineer and co-founder of the Nightscout Project, which supports the creation of open-source technology for people with Type 1 diabetes. He explained that he was given two computers when he was diagnosed with Type 1 diabetes 12 years ago: an insulin pump and a device that tells him how much insulin to take.

“These devices are literally in or on our bodies, so my relationship with these devices is extremely personal and intimate. And that’s true for many other patients,” he said. “But computers are programmed by people, so sometimes the computers can do the wrong thing. When something with one of these devices goes haywire — and you get a side effect because of the therapy rather than the disease — to what degree should you be empowered?” He said he believes patients should have the ability to fix or adjust the device themselves.

This launched West on his mission to reverse engineer his medical devices and develop open-source software to take control of his personal care.

Speaker Karen Sandler, JD, heartedly agreed that developing open-source software for medical devices is critical. She is the executive director of Software Freedom Conservancy, a non-profit organization that develops, promotes and defends open-source software. Her life was changed when she was diagnosed with a life-threatening heart problem and implanted with a defibrillator. “I went from someone who thought open source was cool and useful to someone who thought great open-source software was essential for our society,” Sandler said.

As a self-proclaimed “extreme geek” with technical programming experience, when her doctor gave her the defibrillator, Sandler asked, “what software does it run?” She found out that neither her doctor nor the device’s medical representative had ever thought about the software used on the device. But Sandler said she knew that all software has bugs, needs to be reliably backed up and needs to be protected from hackers.

“It’s clear that free and open-source software is better and safer over time,” Sandler explained. “If there is a problem, you don’t have to wait for the manufacturing company to admit the problem and then make and release a fix. With free and open-source software, anyone can make the fix. And that is really, really important, especially when you’re a special case.” Sandler speaks from experience: she was incorrectly shocked twice by her defibrillator when pregnant — a rare happening still in need of a technical solution. “With free open-source software, we remove the reliance on any single company and take back control,” she said.

Speaker Cédric Hutchings, co-founder and CEO at Withings, a consumer electronics company that develops health devices and apps, emphasized the importance of patient empowerment. “Empowerment is about getting insights to drive change,” he said, “ and we need to develop insights using population data.” He explained that this requires the involvement of researchers, patients, health-care providers and the community. It’s also essential to be “transparent and set expectations” with patients about how their data will be used.

Near the end of the panel discussion, moderator Dana Lewis, director of MDigitalLife, posed the question, “What is the secret sauce for the open-source community?” Perhaps not a secret sauce exactly, but the panelists said that the ability to access their personal data can help overcome a feeling of powerlessness.

However, West cautioned, “We’re intimately connected to these devices and they are on a hostile network. So when we design this kind of medical device, we need to think about it like a diplomatic pouch – something so secure and trustworthy that all your secrets in it are safeguarded.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

SLAC Summer Institute Students Envision A New Energy Frontier

Posted September 4, 2016 by Jennifer Huber
Categories: Science Education

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Photograph by Jvimal

Years ago, I worked at SLAC National Accelerator Laboratory as a graduate student on a high energy physics experiment called SLD. So it was fun to go back to SLAC to speak with former colleagues and new graduate students as they attended this year’s SLAC Summer Institute — a two-week summer school focused on how to unlock the secrets of the current Standard Model theory through new collider physics. Learn more about SLAC’s summer school in my recent news feature.

Stanford otolaryngologist champions ultrasound imaging

Posted August 31, 2016 by Jennifer Huber
Categories: Health

Tags: , , ,
Photo, of Lisa Orloff performing an ultrasound exame, by Stuart Kraybill

Photo, of Lisa Orloff performing an ultrasound exam, by Stuart Kraybill

Patients with thyroid nodules — extremely common lumps on the thyroid that are usually benign, but can be malignant — are typically sent for ultrasound imaging to evaluate the size and structure of their thyroid and nodules. A radiologist’s report is then sent to the treating physician, who discusses the report with the patient and recommends next steps.

Lisa Orloff, MD, director of the endocrine head and neck surgery program at Stanford, doesn’t follow this traditional procedure: she performs her own ultrasound exams in the office and is training other head and neck surgeons to do the same. I recently spoke with Orloff about the role of ultrasound imaging in her practice.

Why do you primarily use ultrasound imaging to diagnose head and neck disease?

“My clinical practice focuses on the surgical management of thyroid and parathyroid disease, especially thyroid cancer. In the head and neck region, ultrasound imaging has long been recognized as the ‘go to’ study if you want to evaluate the structure, size and content of the thyroid gland. What’s been recognized more recently is how great ultrasound is for most of the head and neck structures. So we’re moving into an era of ‘ultrasound first:’ See what you can see with ultrasound, and then decide if you need additional cross-sectional imaging to corroborate or complement the ultrasound findings. For patients with thyroid cancer, ultrasound is extremely useful for evaluating not only the thyroid, but the rest of the neck for aggressive features including possible metastases.

Ultrasound is a low risk, low cost and very high yield imaging study that better characterizes the details within thyroid nodules or lymph nodes; whereas, CT and MRI often rely more on size to say whether or not a thyroid nodule or lymph node is suspicious. It’s really phenomenal what you can see with modern, high-resolution ultrasound equipment.

However, ultrasound has been blamed for the recent increase in incidence of thyroid cancer, which is largely due to increased detection. Even malignant thyroid nodules can sometimes be very indolent cancers that may not require intervention, but can be monitored. A major challenge in thyroid cancer care is distinguishing potentially aggressive tumors from those that are very low risk.”

Why is it helpful to have a clinical doctor, instead of a technician, perform ultrasound?

“When used at the point of care — performed by the clinician who is taking care of the patient — ultrasound enables the treating clinician to immediately investigate and answer questions with ultrasound information, and then implement treatments. It’s sort of one-stop shopping.

There’s an invaluable connection made with the patient when the treating physician performs the ultrasound exam, while explaining findings to the patient and discussing whether and how to treat them. I think it translates into improved patient care. If I’m the one doing the ultrasound exam, I can plan and execute surgery better with first-hand knowledge of what lies beneath the surface — rather than relying on images that someone else captured. I can perform ultrasound-guided biopsies and treatments in the office. I can also judge firsthand when an intervention or even biopsy isn’t necessary.

At present, I’m the surgeon in the head and neck division who routinely uses office-based ultrasound to evaluate patients, many of whom are referred to me specifically for that reason. But my colleagues in comprehensive ENT also perform ultrasonography [ultrasound imaging], as do our fellows and residents. We’re very motivated to train the next generation of otolaryngologists so it becomes more widely practiced in the office setting. We want to reduce the need for multiple appointments and more costly or invasive studies.”

I heard you recently traveled to Zimbabwe. What did you do there?

“My department has developed a relationship with the only medical school in the country, the University of Zimbabwe. I spent two weeks this summer, mainly teaching ultrasonography to residents in both otolaryngology and surgery — introducing the concept of point-of-care ultrasound to a low-resource practice environment where this has the potential for even greater impact. Most patients there don’t have ready access to get an expensive CT or MRI scan. I think ultrasound has a particular application in that setting, because it’s inexpensive, portable, fast and so user friendly. It’s also painless and non-threatening — you can do it on kids without having to anesthetize them to stay still.

Going over there to teach was a really rewarding experience. I hope to go back soon. We were very fortunate to have ultrasound equipment loaned for teaching purposes by GE based in South Africa. My next goal is to raise funds for an ultrasound machine to equip the Zimbabwe program with this wonderful tool for their continuing use.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.


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