Archive for April 2017

California bill aims for later school start times to protect teens’ health

April 19, 2017

Odds are that you’re feeling tired when you read this. More than one in three American adults don’t get enough sleep on a regular basis, and studies show sleep deprivation is an even greater problem for teens. This poses a public health risk — inadequate sleep is linked to chronic diseases like hypertension, diabetes, depression, obesity and cancer.

“Society has not prioritized sleep,” Rafael Pelayo, MD, a clinical professor in psychiatry and behavioral sciences with the Stanford Center for Sleep Sciences and Medicine, told me. “Teenagers need more sleep than adults, so they are more vulnerable. Biologically teens tend to go to sleep later than when they were younger, but the schools start earlier. Teens should get close to 9 hours of sleep, but they get 7 hours or less.”

This epidemic of sleep deprivation among teens prompted California Senator Anthony Portantino (D-Glendale) to introduce Senate Bill 328, which would require middle and high schools to start no earlier than 8:30 am. Currently the average school start time in California is about 8 am, and some schools have a “zero period” that starts as early as 7 am.

“It is an extra 30 minutes or more every morning for the entire school year,” Pelayo said. “The later start time lets teens and families know that sleep is valued and respected by society. School districts that have changed their school start times have had demonstrable improvements in the health of the students.”

According to the American Psychological Association, studies have shown that starting the school day no earlier than 8:30 am increased attendance rates, grade point averages, state assessment scores, college admission test scores, student attention and student-family relations. They also found a decrease in disciplinary action, students sleeping during class and student-involved car accidents.

Such evidence inspired Pelayo to testify today in Sacramento in support of SB 328. He also rallied support among professional organizations and he plans to present letters of support from the American Academy of Sleep Medicine and the California Sleep Society, of which he is a board member.

Despite the evidence demonstrating the harm of sleep deprivation in teens, there are arguments against the bill. Opponents argue that school start times should be determined locally and that starting school later will be inconvenient. It is also viewed by some as a school policy issue rather than a health issue, Pelayo said.

Nonetheless, Pelayo believes the effort is important:

“Too many families end the day with an argument about bedtimes and homework and start the day with an argument about getting up in time for school. Twenty-five percent of teenagers self-report falling asleep in class and the actual number is likely higher. If a first or second grader fell asleep in class, the teachers would notify the parents since it is so unusual, yet for teens it is a daily occurrence. If this many teenagers were not getting enough food it would be a national crises, but since it is sleep it is ignored. Teens that wake up alert are healthier and do better both academically and in sports.”

The California bill comes at a time of heightened national awareness about teen sleep. Pelayo is speaking at the first national conference on school start times, which will be held in Washington DC later this month.

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

Clinical guidance on genetic testing: A Q&A

April 18, 2017

 

Earlier this month, an FDA ruling gave 23andMe permission to market its personal genetic tests for 10 diseases, including Parkinson’s and late-onset Alzheimer’s.

But with the increase in genetic testing at home and in clinical settings comes challenges. What do physicians do with all of these data? And how do they evaluate the validity and clinical utility of genetic tests?

To tackle these questions and others, the National Academy of Medicine formed a committee to provide guidance. I recently spoke with one of the committee members, Sean David, MD, DPhil, an associate professor of medicine at Stanford, about the committee’s new recommendations and report.

What inspired you to participate in the NAM Committee on the Evidence for Genetic Testing?

“The National Academy of Medicine consensus reports have high impact on national health policy and practices, so I jumped at the chance. In our work at Stanford, we struggle with advising patients on which genetic tests to recommend, which ones to order when requested by a patient and how to interpret results from the many direct-to-consumer genetic tests. We need guidance and a framework for making these decisions. The NAM committee addressed this challenge.

Years ago, I had a patient bring in a whole stack of direct-consumer whole genome sequencing results that showed her genetic risks for different illnesses. She asked me to interpret it for her, but there was far too much for me to consume during our brief office visit. And it was unclear what criteria to use when evaluating these tests. There’s been a rapid increase in the development of genetic tests with thousands of commercially available tests, but limited evidence regarding their validity for diagnosing disease and improving patient outcomes.”

What was the committee’s mission?

“Our charge was to examine the relevant medical and scientific literature to determine the evidence base for different types of genetic tests, as well as recommend a framework for decision-making regarding the use of genetic tests in clinical care.

This is the first consensus report on this topic. Although it was designed for the Military Health System, it should still be applicable to both military and civilian populations and may set benchmarks for private insurance companies. The report also encourages different agencies to cooperate and create a clinical data repository of evidence-based genetic testing decisions, which will be available to everyone. I think someone needs to do this to set the standard. Once that’s been done, at least we’ll have something we can all use as a benchmark.”

How can this decision-making framework help guide clinical practice?

“The decision framework can be used by physicians to determine which genetic tests are really ready for prime time in the clinic. For example, we know that if people are tested based on their family history and found to be at high risk for hereditary breast or ovarian cancer, they can have interventions that will improve their survival and outcomes. By using the decision framework, a physician can come up with a quick triage decision that it’s a ‘yes’ test for someone with several family members with breast and/or ovarian cancer, and one that really all providers should know about.

Other genetic tests like tests for Alzheimer’s aren’t as clear. For instance, there could be a genetic test for a particular rare form of early onset Alzheimer’s associated with a particular mutation. If someone has that mutation, he may have a very high risk of early onset Alzheimer’s disease. Do we screen people for that? It will depend on the clinical testing scenario. If someone has family members who developed Alzheimer’s in their 40s, then it might be a good diagnostic test. Whereas, there might be another genetic test for associated risk of dementia where the causal relationship with Alzheimer’s may not be established. That’s an issue of clinical validity. So we might not offer that test routinely — to avoid giving patients information that might be misleading and might even cause some harm.

In addition, ethical, legal and social implications of genetic testing are important. For many patients — including parents of children with undiagnosed rare diseases — genetic testing may help end a diagnostic odyssey. Oftentimes geneticists will order whole genome testing without testing for something specific. There may be thousands or even millions of different genetic markers that are tested with the hope that they’ll find something that leads to a diagnosis. Evidence of clinical utility may be lacking in scenarios like these, but taking into account the value of tests to patients and their families is important — the context matters. There needs to be a certain amount of clinical judgment, and the committee isn’t saying anything against this.”

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

Sick people are worse for the environment, a study shows

April 13, 2017

Photo by ryan harvey

Environmental degradation is widely recognized to contribute to human illness. However, little research has been done to investigate the impact of human illness on the environment. This is a critical question particularly for the millions of people around the world who depend on natural resources for food and income while coping with high burdens of infectious diseases.

When people are sick, they often alter their use of natural resources in ways that harm the environment, according to a new study reported in the Proceedings of the National Academy of Sciences.

Specifically, the researchers examined how illness influenced fishing practices in the community around Lake Victoria, Kenya, which has high rates of HIV and other illnesses. They interviewed about 300 households several times over 16 months, collecting and analyzing data about household fishing habits and mental and physical health. They found that healthy people are better for the environment.

“Studies suggest that people will spend less time on their livelihoods when they are sick, but we didn’t see that trend in our study. Instead, we saw a shift toward more destructive fishing methods when people were ill,” said lead author Kathryn Fiorella, PhD, a postdoctoral scholar at Cornell University, in a recent news release.

The study found that sick fishermen were less likely to legally fish in deep waters or overnight to target the more sustainable mature fish. Instead, they used destructive fishing methods that were concentrated along the shoreline — such as using a beach dragnet that captures a high proportion of juvenile fish and disturbs shallow fish breeding habits.

Basically, sick fishermen just wanted to get their catch quickly with less energy. They were focused on their short-term goal and not worried about depleting the fish stock.

In light of this study, the authors suggest that institutions and organizations focused on protecting the environment may need to more deeply consider the health of communities. The paper concludes, “Our study emphasizes the importance of considering health, governance, and ecosystems through an integrative lens.”

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

New imaging study investigates role of dopamine in migraine attacks

April 7, 2017

Many people suffer from migraines —throbbing, painful headaches that last up to 72 hours and are often accompanied by nausea, vomiting and sensitivity to light and sound.

Although not fully understood, an imbalance in a brain neurotransmitter is thought to contribute to migraines. The neurotransmitter, dopamine, is a chemical in your brain that affects your movements, emotions, motivations and sensory perceptions, including the ability to modulate pain.

Now, researchers at the University of Michigan have shown that dopamine levels in the brain fall during a migraine attack relative to their baseline level between attacks, as reported in a recent news release.

The research team performed two PET scans on different days to study eight migraine sufferers during a spontaneous migraine and in between attacks, comparing their brain activity and dopamine levels with and without a headache. On average, these patients were 27 years old and experienced migraines about six times per month. The scientists also imaged eight healthy adults, comparing migraine sufferers to controls.

They found that dopamine levels in the brain fluctuated, temporarily reducing during migraine attacks. They also found that the study participants were more sensitive to non-painful stimuli, such as warmth applied to the forehead, during a migraine.

“With this study, we better understand how dopamine is related to the suffering during a migraine attack,” said Alex DaSilva, DDS, DMedSc, assistant professor of dentistry and of the Center for Human Growth and Development at the University of Michigan, in the video above. “Lower dopamine levels mean you are more sensitive to pain and stimulation. Second, lower dopamine levels also inhibit your behavior. You want a dark room. You want to avoid social interactions.”

In their paper, the researchers call for additional studies to confirm the results and evaluate how they can be used to develop more effective migraine therapies.

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

On addiction, psychiatric disorders and primary care: A Q&A with a Stanford clinical psychologist

April 6, 2017

Photo by Eric Norris

Resolving America’s opioid crisis is clearly more difficult than just saying “no” to opioid use.

A key complication is that many opioid addicts also have mental health issues, said Mark McGovern, PhD, a professor of psychiatry and behavior sciences who joined Stanford in January. McGovern’s research focuses on patients with both psychiatric and addiction disorders. I connected with him via email.

What inspired you to focus on patients with both psychiatric and substance use disorders?

“In my personal experience and clinical practice, it seemed obvious that many people who had a problem with alcohol or drugs also had a mental health issue, whether it was depression, anxiety or something else. When I entered the world of research, the epidemiological and clinical prevalence data verified my anecdotal experience. About 70 percent of patients with a diagnosis of a drug or alcohol disorder have another psychiatric disorder. And of those with a psychiatric disorder, approximately 50 percent have had a substance use problem at some point. Ironically, our mental health care system, including our education and training programs, are organized as if people have one or the other problem but not both. It turns out that if a person has both types of disorders, their life outcomes are significantly worse. This struck me as an enormous health-care disparity.”

How do you treat these patients?

“I spent the past 20 years designing interventions that address these ‘co-occurring disorders’ within the same treatment course. We worked with systems of care — including large organizations, counties, states, tribes and nations — to reconfigure services to provide integrated care. These efforts included the use of both psychotropic and addiction medications, integrated combined therapies, and changes in attitude, philosophy, organizational structure and financing.

We need to address these behavioral health issues in both primary care and specialty settings.

Common problems such as depression, anxiety, alcohol and drug use disorders are ubiquitous in primary care settings. As with any medical condition, early intervention before disease progression results in better outcomes. Further, most people with these conditions don’t seek specialty care, but typically do see their doctor for other problems or routine health-care visits. Unfortunately, substance use disorders typically aren’t screened for in primary care, and they are currently addressed in only the most obvious and severe cases. People at Stanford are just beginning to develop an innovative ‘unified model of behavioral health integration’ that fully addresses the complex array of behavioral health conditions.”

How do you use addiction medications?

“Before I arrived at Stanford, I was at Dartmouth where I consulted with the states of northern New England — Vermont, New Hampshire and Maine — to combat the opioid addiction epidemic, including heroin and prescription narcotics. There are three FDA-approved medications for opioid addiction: methadone, buprenorphine and naltrexone. Unfortunately, even though they are very effective, these medicines are not widely available to people with opioid addiction. We worked most closely with physician practice groups across Vermont to prescribe buprenorphine and naltrexone and deliver high quality care. For example, we used learning collaboratives to engage physicians, improve access to buprenorphine and reduce the variability between different doctors. Overdose death rates in all New England states except Vermont have continued to rise, whereas Vermont’s has decreased since 2015. And the number of Vermonters receiving addiction medications has grown from 800 in 2013 to close to 5000 today.

I remember meeting my patient Bobby (a pseudonym) who was a general contractor with a successful business. He injured his back in 2004 and was prescribed Percocet for pain by his primary care physician. Gradually, he noticed that he needed more medication to get the same pain relief, emotional relief and stress reduction. Over time, Bobby shuffled from doctor to doctor to obtain opioid prescriptions allegedly for his family members. He transitioned to heroin by 2006. Prior to his opioid addiction, Bobby had no history of illegal activities and no substance problem. Bobby’s wife did some online research and learned about addiction medications. They were both drawn to the possibility of buprenorphine because he might be able to get it from a ‘regular doctor’ without going to rehab and ruining his business. Bobby was seen in our clinic and responded extremely well to the medication, and discontinued his use of other opioids. Interestingly, he said that he still had occasional pain but it was more important to be ‘functional than pain free.’”

What advice do you give to trainees?

“When educating medical students, psychiatric residents and fellows and clinical psychology interns at Stanford, I advise them to:

  • Understand addiction as a chronic medical condition that has its basis in the brain, even though its manifestations radiate across the person’s life, relationships and world.
  • Empathize with the person who is suffering with this condition, who may not be able to accept or describe it clearly, but who is nonetheless struggling to control It’s not their choice; it is not their ‘Plan A’ in life.
  • Know that effective treatments are available, and that you can provide them.
  • Have high hopes that recovery is possible for patients with addiction.”

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

Low-cost “magic box” could decontaminate water in rural communities

April 4, 2017

Photo by Shawn

More than a billion people drink water that is contaminated and can spread deadly diseases such as cholera, dysentery, hepatitis A, typhoid, polio and diarrhea.

Most contaminated water could be purified by adding hydrogen peroxide, which safely kills many of the disease-causing organisms and oxidizes organic pollutants to make them less harmful. Hydrogen peroxide disinfects water in a similar way as standard water chlorination, but it leaves no harmful residual chemicals. Unfortunately, it’s difficult to make or obtain hydrogen peroxide in rural settings with limited energy sources.

Now, researchers from Stanford University and SLAC National Accelerator Laboratory have developed a portable device that produces hydrogen peroxide from oxygen gas and water — and it can be powered by a battery or conventional solar panels. You can hold the small device in one hand.

“The idea is to develop an electrochemical cell that generates hydrogen peroxide from oxygen and water on site, and then use that hydrogen peroxide in ground water to oxidize organic contaminants that are harmful for humans to ingest,” said Christopher Hahn, PhD, a SLAC associate staff scientist, in a recent news release.

First, the researchers designed and synthesized a catalyst that selectively speeds up the chemical reaction of converting oxygen gas into hydrogen peroxide. For this application, standard platinum-mercury or gold-plated catalysts were too expensive, so they investigated cheaper carbon-based materials.

Next, they used their carbon-based material to build a low-cost, simple and robust device that generates and stores hydrogen peroxide at the concentration needed for water purification, which is one-tenth the concentration of the hydrogen peroxide you buy at the drug store for cleaning a cut. Although this device uses materials not available in rural communities, it could be cheaply manufactured and shipped there.

Their results were recently reported in Reaction Chemistry and Engineering. However, more work needs to be done before a higher-capacity device will be available for use.

“Currently it’s just a prototype, but I personally think it will shine in the area of decentralized water purification for the developing world,” said Bill Chen, first author and a chemistry graduate student at Stanford. “It’s like a magic box. I hope it can become a reality.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine. For more details, please read my SLAC news release.


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