Archive for September 2016

New simulations may guide future brain surgeries

September 30, 2016

A team of researchers, led by Ellen Kuhl, PhD, a Stanford professor of mechanical engineering, is developing a new simulation tool to help guide surgeons to more safely relieve brain swelling.

Brain swelling can be caused by a trauma, such as a stroke, tumor or traumatic brain injury. This swelling builds up pressure inside the skull that can lead to brain damage or death, so surgeons sometimes perform a decompressive craniectomy — removing a large portion of the skull to allow the brain to mushroom out. But the surgeons need to know where and how big to cut the skull, which is no easy task.

A recent news release explains,

“… The shape of the brain is essential to its function. It consists of billions of fragile filaments, called axons, bundled together in purposeful patterns. When parts of this amalgam bulge out, axons stretch and shear. Surgeons currently rely on experience to limit the collateral damage that might occur when dire circumstances force them to perform a decompressive craniectomy.

‘This is a new tool to help surgeons decide where and how big to make the hole, by giving them a way to visualize the effects of the procedure on the brain tissue,’ Kuhl said.”

Kuhl is working with Johannes Weickenmeier, PhD, a postdoctoral research fellow at Stanford, and Alain Goreily, PhD, a professor of mathematics at the University of Oxford, to create mathematical models based on magnetic resonance brain images. These simulations will predict how an injury affects specific parts of the brain — showing the predictions on a color-coded brain map, with extreme damage in red, mild damage in green and minimally affected areas in blue.

The team then used these maps to “play what-if scenarios to illustrate how skull openings of different sizes in different regions affect the axons inside the brain,” the news release states.

The researchers plan to work with neurosurgeons to improve their new simulation tools, hoping one day to allow neurosurgeons to accurately peer beneath the skull and make more informed surgical plans.

Video courtesy of Stanford University.

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

‘Eat a bleeping Dorito’: An elite runner and Stanford medical student addresses disordered eating

September 29, 2016

megan-e1475000985163-300x300Somehow, Megan Deakins Roche balances her roles as a fourth-year Stanford medical student, wife, athlete on the Nike trail running team and, according to her Twitter profile, an ice cream connoisseur. Balance is an underlying theme of her recent article on disordered eating in Trail Runner Magazine.

Disordered eating isn’t quite the same thing as an eating disorder. Many people suffering from disordered eating do not meet the criteria of eating disorders, which are psychiatric illnesses. However, the abnormal thoughts and behaviors of disordered eating can lead to serious health problems, including developing an eating disorder. Both disordered eating and eating disorders can affect people of any size or gender.

Roche writes:

“We live in a culture of fad diets and fad exercise philosophies. You can choose to be gluten-free, vegan, Paleo or even fruitarian. You can log 120 miles a week on Strava, do CrossFit until you pee blood or do hot yoga until your core temperature and skin texture resemble a Thanksgiving turkey.

Some of these actions have become socially acceptable. Heck, some have made champions. So how do we draw the line? When does disciplined eating morph into disordered eating, and when does disordered eating slip into a life-threatening disorder?”

She explains that it is important to understand the warning signs of disordered eating, which can include:

  • Chronic yo-yo dieting
  • Fasting or skipping meals regularly
  • Avoiding social events where food is served
  • Rigid compulsive exercise routines
  • Self esteem that is highly based on body weight
  • Preoccupation with food, body and exercise that causes distress

Roche gives the example of Kara Goucher, who overcame disordered eating as a collegiate runner before competing in the 2008 Olympics in the 10k and the 2012 Olympics in the marathon. In a video, Kara describes the moment she realized she had an eating problem. While on a date with her boyfriend (now husband) Adam Goucher, he offered her some Doritos as a snack since she was too hungry to wait for dinner. When Kara repeatedly refused the chips, Adam said, “Eat a bleeping Dorito” — a now oft-repeated quote among elite runners.

Roche focuses her piece on the pervasiveness of disordered eating within the running community, which often associates weight loss with faster times. She argues that trail running requires strength and resilience, whereas disordered eating weakens musculoskeletal strength and increases the risk of stress fractures, soft-tissue overuse injuries and depression.

“These issues are common for runners, and confronting them head-on is the best way to get healthy and stay healthy long-term,” she says in her piece. She later adds, “The only way for us to squash the stigma (and possibly save running careers and even lives) is to practice consistent empathy, as individuals and as a unified community.”

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

For rehabilitation, team-based approach provides best care, Stanford resident writes

September 28, 2016

As a medical student at Harvard, Shara Yurkiewicz, MD, worked in both inpatient acute hospitals and rehabilitation hospitals. The striking differences between these two environments inspired her to become a resident in Stanford’s Physical Medicine and Rehabilitation program.

In a recent opinion piece in the AMA Journal of Ethics, Yurkiewicz argues that the “patient care collective” structure of the rehabilitation setting provides more comprehensive and holistic patient care than the traditional “physician-centered” structure. In a patient care collective, a patient’s entire health-care team — physician, physical therapist, occupational therapist, nurse, speech pathologist, psychologist and case manager — work as equal team members. We recently discussed her piece, and her experiences, via email.

What inspired you to write this opinion piece?

“As a medical student, I had spent most of my time in a traditional inpatient hospital setting. When I did several rotations at a rehabilitation hospital, I was introduced to a less hierarchy-driven and more collaborative style of care. This style was particularly well-suited to the rehabilitation environment, where a patient is working with various team members for several hours each day. Encouraging open dialogue among team members, in an environment that nurtures this sort of crosstalk, is a healthier and happier place to work. Though each team member has clearly defined roles, there is less fear about upsetting a hierarchy should one member have questions or concerns… as a medical student I found this approach refreshing. By writing this opinion piece, I want to let others know that while a strict hierarchy may work for some situations, in the particular environment where I practice and where patients recover, a less hierarchy-driven approach works remarkably well too.”

Is it feasible to use this collaborative model in an acute hospital setting to provide patient-centered care?

“I think care in an acute hospital setting can be both patient-centered and physician-centered. The difference is in the care priorities. Patients sick enough to be hospitalized are quite sick. First and foremost, their safety is paramount, even if it comes at the expense of their comfort. This may mean more frequent blood draws than a patient finds comfortable. This may mean keeping a patient with strict fall precautions in bed, even though he or she desires to exercise.

I think that the physician plays the central role on the health-care team because patients interact with fewer clinicians on a daily basis and their acute medical problems generally overshadow their functional or social ones. However, in my experience, there is still a good amount of cross-talk among physicians, nurses and social workers. The most useful part of the interdisciplinary relationship for me was knowing that the nurses are at the bedside for far longer periods of time than the doctors are. I depended on nurses to tell me about both acute and subtle changes in a patient’s medical condition. It’s an ongoing conversation, and the patient remains at the center.”

How do you balance science writing with the demands of residency?

“I’ve been writing since I can remember, and I joined the Yale Scientific Magazine on a whim during my freshman year in college. I also interned at Discover magazine during college and then at the Los Angeles Times as a science reporter through the AAAS Mass Media Fellowship. After I completed medical school, I worked as a medical reporter for MedPage Today while I applied for residency. Those were full-time positions that would be too difficult to maintain while also being a medical student or resident. But the desire to write remains. On the first day of medical school, I began a blog entitled This May Hurt a Bit to document my thoughts and feelings on the medical training experience. I’ve continued to blog and also to freelance for various media outlets since then. Balancing being a resident and writing isn’t easy. I write when I am inspired, when I have the time, or even better — both. Sometimes the time stamps on my writing appear at strange hours, which further reflects that!”

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

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

September 23, 2016

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

September 20, 2016

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

September 19, 2016
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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

September 18, 2016
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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.


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