A look at the cigarette epidemic in China

Image by Dimhou

The imagery of a cuddly panda bear has often been used to sell tobacco products in China. So a new book that examines China’s cigarette industry seems aptly titled: Poisonous Pandas: Chinese Cigarette Manufacturing in Critical Historical Perspectives.

The book brings together an interdisciplinary group of scholars — including Stanford editors Matthew Kohrman, PhD, a professor of anthropology, and Robert Proctor, PhD, a professor of history. Together the team has investigated how transnational tobacco companies have worked to triple the world’s annual cigarette consumption since the 1960s. They focus on the China National Tobacco Corporation, which currently produces forty percent of cigarettes sold globally.

In a recent Freeman Spolgi Institute Q&A, Kohrman discusses how he got involved in this work. “When I began my ethnographic fieldwork on tobacco in China, I initially studied mostly consumer behavior. But I quickly realized that focusing solely on cigarette consumption, without considering the relationship between supply and demand, was like studying obesity while ignoring food,” he says.

Kohrman explains that cigarettes have become the single greatest cause of preventable death in the world today and the problem is getting worse. “Instead of declining as we would expect based on our impressions living here in California, the number of daily cigarette smokers around the world is projected to continue climbing,” he says. In particular, he explains the big tobacco companies are targeting less-educated people from lower- and middle-income countries.

Kohrman does offer some hope in light of the Chinese government’s recent initiatives to restrict tobacco advertising and smoking in public places. But he says that there is a lot more work to do.

“The road towards comprehensive tobacco prevention in China is going to be a long one,” Kohrman concludes.

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

Advertisements

Inherited Neanderthal genes protect us against viruses

Image by Claire Scully

When Neanderthals and modern humans interbred about 50,000 years ago, they exchanged snippets of DNA. Today, Europeans and Asians still carry 2 to 3 percent of Neanderthal DNA in their genomes.

During contact, they also exposed each other to viruses. This could have been deadly for the human species since Neanderthals encountered many novel infectious viruses while living for hundreds of thousands of years outside Africa. Luckily, the Neanderthals’ immune systems evolved genetic defenses against these viruses that were passed on to humans, according to a study reported in Cell.

“Neanderthal genes likely gave us some protection against viruses that our ancestors encountered when they left Africa,” said Dmitri Petrov, PhD, an evolutionary biologist at Stanford’s School of Humanities and Sciences, in a recent Stanford news release.

In the study, the researchers gathered a large dataset of several thousand proteins that interact with viruses in modern humans. They then identified 152 Neanderthal DNA snippets present in the genes that make these proteins. Most of the 152 genes create proteins that interact with a specific type of viruses, RNA viruses, which have RNA encased in a protein shell.

The team identified 11 RNA viruses with a high number of Neanderthal-inherited genes, including HIV, influenza A and hepatitis C. These viruses likely played a key role in shaping human genome evolution, they said.

Overall, their findings suggest that the genomes of humans and other species contain signatures of ancient epidemics.

“It’s similar to paleontology,” said David Enard, PhD, a former postdoctoral fellow in Petrov’s lab. “You can find hints of dinosaurs in different ways. Sometimes you’ll discover actual bones, but sometimes you find only footprints in fossilized mud. Our method is similarly indirect: Because we know which genes interact with which viruses, we can infer the types of viruses responsible for ancient disease outbreaks.”

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

Looking beyond opioids: Stanford pain psychologist briefs Congress

Photo by K-State Research and Extension

Reducing opioid use has become a national priority, but where does that leave the millions of Americans who suffer from underdiagnosed or undertreated chronic pain?

Do alternative treatments strategies like cognitive behavioral, physical and pharmacologic therapies alleviate chronic pain? And how should these alternatives be implemented for different populations with different needs?

These questions will be explored at an upcoming congressional briefing in Washington, D.C. on Oct. 2, which is organized by the Patient-Centered Outcomes Research Institute. Beth Darnall, PhD, a clinical professor of anesthesiology, perioperative and pain medicine at Stanford, is one of the speakers.

Congress is considering legislation — The Opioid Crisis Response Act of 2018 — that would affect the federal funding allocated to address the opioid crisis, including funding for non-opioid pain treatments. So it is critical that Congress understand evidence-based research on implementing safer chronic pain treatments in real-world clinical settings, Darnall told me.

Darnall was invited to speak about her EMPOWER study, a clinical trial in which participants partner with their clinicians to slowly reduce their opioid dose over a year. Patients are randomized to receive pain self-management classes, cognitive behavioral classes for chronic pain, or tapering only.

“The goal is not zero opioids. We’re aiming to help patients reduce to lower, safer doses without increasing their pain,” said Darnall. “We are testing whether the two types of classes help.”

Darnall argues that the best pain care is comprehensive and personalized to each patient’s needs. Although she recognizes that staving the flow of prescription opioids is important and can save lives, she says opioids can be part of a comprehensive care plan that works for some patients.

Darnall explained:

“Much of the overprescribing of opioids was born from a lack of opioid data, lack of clinician education about how best to treat pain and lack of accessible alternatives. Limiting opioids alone will not solve these three underlying problems. We need to better train physicians, psychologists, physical therapists, nurses and all healthcare clinicians on how to treat pain, so patients have access to evidence-based pain care.”

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

Bill for later school start times is defeated, but Stanford sleep specialist isn’t

 

Photo by Santiago Gomez

The medical evidence is clear — teens are suffering physical and mental health problems due to chronic sleep deprivation. That’s why the American Academy of Pediatrics and many other health organizations recommend starting classes at all middle and high schools at 8:30 am or later.

“We’ve known for decades that teenagers are not getting enough sleep,” says Rafael Pelayo, MD, a clinical professor in psychiatry and behavioral sciences with the Stanford Center for Sleep Sciences and Medicine. “Senate Bill 328 came out of presenting the strong evidence-based, peer-reviewed data to elected officials. Even the people opposed to the bill accept the science.”

So if everyone agrees that our teens need more sleep, why didn’t the bill pass? The main objection of teachers, school boards and ultimately Governor Jerry Brown centers on giving the local community control of individual school decisions.

“We’ve stepped into this ongoing battle between state control and local control of schools,” Pelayo says. “But I don’t consider this a political issue. This is a public health issue. Hundreds of schools have already changed and they see the same result — kids are healthier and perform better. This is a matter of honoring kid’s biology. It doesn’t work to just say they should go to bed earlier.”

Pelayo’s push for later school start times is also inspired by his professional experiences. “My career as a sleep doctor began through my knowledge of adolescent sleep. During medical school, my research found a link between suicidal thinking and sleep problems in teenagers. I’ve been learning about poor sleep and mental health issues in teens since the 1980s.”

Despite this recent setback, Pelayo plans to keep volunteering. For years, he’s been giving talks about sleep at many local high schools and middle schools. “Teenagers are interested in sleep apnea, their dreams and all aspects of sleep. I’ve given a bunch of talks on sleep for years,” Pelayo says.

He’s also recently become a director of a national organization called Start School Later. Overall, he hopes to promote more education, research and funding for this issue.

“About 300 school districts have already mandated a later school start time,” Pelayo says, adding that San Diego schools are planning to implement later start times by 2020. “If California had passed SB 328, it would have accelerated this process. Instead, we’ll have to do it piecemeal. And that’s too bad, since kids need sleep now.”

But, Pelayo says, “This issue is not going away, it is actually gaining momentum.”

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

Tai chi may help prevent older adults from falling, a study finds

Photo by Craig Nagy

As our parents age, we worry about them falling. Falls in older adults can lead to emergency department visits, hospital admissions and even death. At best, falls cause anxiety for patients and their loved ones.

Studies show that regular exercise can reduce the risk of falling, but it is unclear which kind of exercise is most effective for older adults. Now, a new multi-institutional clinical trial has assessed the effectiveness of two proven exercise interventions — tai chi and a multimodal exercise program — which were compared to a control intervention of stretching.

Tai chi is an ancient Chinese practice involving a series of movements performed in a slow, focused manner. Traditionally, people practicing tai chi flow between as many as 100 different postures. However, the study investigated a simplified form focused on eight core movements that were selected to improve balance for older adults.

The researchers also evaluated a more conventional, multimodal exercise program that incorporated aerobic, strength, balance and flexibility exercises.

The 670 participants were 70 years and older with a high risk of falling, based on impaired mobility or a history of falling in the previous year. They performed a 60-minute exercise session twice weekly for 24 weeks, which was randomly assigned as either tai chi balance training, multimodal exercise or stretching.

These interventions were primarily evaluated by the incidence of falls, which were self-reported monthly and then confirmed using follow-up appointments and medical records.

The study found tai chi balance training to be more effective than the conventional exercise approaches for reducing falls, as recently reported in JAMA Internal Medicine. During the 6 months, 152 falls occurred among 85 participants in the tai chi group, 218 falls among 112 participants in the multimodal exercise group and 363 falls among 127 participants in the stretching group.

TC Cowles, a nurse and program manager at Stanford Health Care’s Supportive Care Program, said he wasn’t surprised that tai chi reduced falls. These new findings agree with previous smaller studies, including a meta-analysis study. However, he was very excited to have it confirmed with so many participants.

“This is the largest study I’ve seen focused on tai chi as a fall prevention. It’s encouraging to see that it reduces falls by 58 percent compared to the stretching exercises and 31 percent compared to a multimodal exercise intervention,” Cowles said.

Cowles manages similar tai chi classes on Tuesdays through the Neuroscience Supportive Care Program and on Thursdays through the Cancer Supportive Care Program. These classes are very popular — almost 900 people have attended the tai chi classes in the last year, he said. Many of the participants are in their mid-60s or 70s.

“I like the practice because it is modifiable. You can start in a chair with arms to decrease the risk of falling during some of the movements. And if you strengthen, you can advance to a standing position,” said Cowles.

According to Cowles, however, attending consistently is key. “Patients that come regularly report that they feel less wobbly and can walk better on their own,” he said. “They also build core strength, so they can hold themselves upright for longer periods of time. And they build confidence, so they’re more apt to participate in other programs and activities.”

Stanford Supportive Care Programs also offer weekly classes on qigong, meditation and yoga, which can increase stability too. And all the classes are free and open to the community.

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

Space, the new surgical frontier? A Q&A

Photo by WikiImages

Many medical treatments — in their current form — would be unfeasible on deep space missions, such as a journey to Mars.

How will we diagnose and treat the ailments of future space travelers? And what medical issues will they likely encounter? I posed these questions to Sandip Panesar, MD, a postdoctoral research fellow at Stanford who wrote a recent article about surgery in space in the British Journal of Surgery.

What inspired you to research surgery in space?

“From a young age, I’ve always been interested in space travel. I also have a background in surgery, trauma and emergency medicine. So it just clicked one day when I was reading about SpaceX. I realized they may actually send people to Mars, so we need to consider the medical implications of that. Specifically, how would you perform surgery?

The need for surgical care in space in the near future will likely revolve around emergency situations — such as crushes, impacts, falls and burns — since the possibility of trauma occurring during exploratory missions can never be ruled out. In cases of severe trauma, significant internal bleeding may necessitate invasive surgical procedures.”

What adverse conditions do space travelers face?

“People are exposed to a few key physical conditions in space — solar particle radiation, temperature extremes and a lack of gravity. Solar particle radiation is a lot different than the particles people are exposed to on Earth. It has a higher chance of causing DNA damage, leading to an increased risk of high-grade cancers prone to metastasize. However, a lack of gravity causes a whole host of even more critical changes in the human body.”

How does this extraterrestrial environment impact human physiology?

“One of the biggest changes is the redistribution of bodily fluids. On Earth, gravity and walking upright pulls most of our fluids down to our legs. In space, these fluids distribute evenly throughout the body. This affects heart rate and blood pressure, increases intracranial pressure and causes face swelling. And it decreases leg size, a phenomenon called ‘chicken legs.’

An absence of gravity also causes the bones and muscles to atrophy.

In addition, the makeup of white blood cells changes in space. Plus, the body produces more stress hormones, called glucocorticoids, which further weaken the immune system. This may negatively affect wound healing, which is critical to surgical recovery.

Microbes are also known to be more pathological in space, making the risk of a serious infection after surgery even higher.”

How can surgery be adapted for space?

“One idea is to include a trauma pod, an enclosed medical suite, in the space station or vessel — a concept that originated in military medicine.

We’ve also proposed minimally-invasive keyhole surgery, but it has limited use in trauma situations and a pretty large learning curve. So open surgery is likely but challenging in space. For instance, the bowel is free-floating within the abdominal cavity,  so it can float out when you open the stomach if there’s no gravity. This carries a risk of infection, contamination and perforation. One potential solution is to use a hermetically sealed enclosure — placing a clear plastic box over the wound and working essentially in a glove box with a pressure differential.”

Could surgical robots or other equipment help?

“Mars is 48 million miles away and the radio signal delay is 20 minutes, so using robots controlled by surgeons on Earth isn’t feasible. Instead, researchers are developing robots that can perform surgery by themselves or with really minimal human assistance. There have already been trials of robots that can suture together pig bowels with minimal assistance.

Finally, the size and weight of the payload is a huge barrier and surgical specialties all use different tools. A feasible solution is to bring a 3D printer that can print bandages, casts, surgical tools and even maybe pharmaceuticals. Also, you could diagnosis with an ultrasound scanner and a compact CT scanner like the ones used in ambulances in the UK.”

Would you want to be an on-board surgeon?

“Not just yet. I still have a lot of things I want to do on Earth.”

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

Stanford psychiatrist focuses on mental health needs of Muslims

Photo, of Rania Awaad giving a recent talk, by Anum Ahmad

Prior to studying medicine, Stanford psychiatrist Rania Awaad, MD, studied Islamic law. As a local religious leader, she said that many people in her community are actually surprised to learn that she’s also a physician.

However, this dual training is at the heart of Awaad’s research and clinical work, which focuses on the mental health needs of Muslims. I recently spoke with her to learn more.

What are the mental health challenges faced by Muslims?

“In our recent sociopolitical climate, there’s been quite a bit of negative focus on Muslims and other groups. And we have the highest level of hate crimes against Muslims ever in American history — about six times higher than post 9/11.

In the Bay Area, we have a consortium of mental health and general medical providers who are trying to figure out how Islamophobia — the fear of the Islam religion or Muslims — affects the general health of Muslims. So far, we’ve seen a lot of anxiety, depression and post-traumatic stress disorder.

There’s already quite a bit of PTSD within the community, because many Muslims that immigrate to America come from areas of conflict. Current policies can trigger immigrants’ underlying PTSD, anxiety and depression, as I recently described in the American Journal of Psychiatry.”

Are there barriers to mental health care for your patients?

“There’s a lot of paranoia about medical providers documenting their issues in an electronic medical record. They’re afraid this medical information will be combined with a Muslim registry. Initially we told patients not to worry, because unconstitutional things like that don’t happen here. But then the travel ban helped substantiated their fears.

There are also barriers directly tied to faith beliefs — concepts like the evil eye or spirits. If someone is having psychosis, for example, people may say he is possessed and should be taken to his religious leader instead of a mental health professional.”

What can you do to overcome these challenges?

“Mental health professionals can approach a patient’s faith leader for a religious consultation. I help train chaplains and imams and I’m also teaching doctors to engage with faith leaders. For many people, their faith is a source of strength and support. So leaving that out completely means that you’re not really providing adequate, holistic care.

There are a limited number of mental health professionals proficient in understanding the Muslim faith and culture. Through the Khalil Center, I’m working with other dual-trained practitioners to develop a manual, book and training seminar on Islamic psychology from a practical clinical perspective. We’re trying to provide guidance for practitioners without Islamic training to work with this unique minority group.”

How did you end up specializing in the mental health needs of Muslims?

“I thought I was going to be an ob/gyn. But during medical school, I married my husband who is an imam and a director of a nonprofit. At one point he told me what our community really needs is someone who can work in mental health, based on what he saw as a community leader. He inspired me to become a psychiatrist.

I also feel my dual training was meant to be. In high school I embarked on a lifelong journey of formal Islamic studies training. I’m currently a professor of Islamic Law at Zaytuna College, a Muslim liberal arts college in Berkeley. My dual training kickstarted the Stanford Muslim Mental Health Lab and Wellness Program that I founded and direct, and it has allowed me to lay the groundwork to train others.”

What are some other things you’re working on?

“The SMMH Lab is part of a consortium that is studying the effectiveness of integrating faith concepts with therapy for different faith communities — Muslim, Jewish and Christian groups. We’re using evidence-based, objective metrics like the depression inventory scale.

I also oversee the Bay Area Muslim Mental Health Professionals group, which has led to many other initiatives like a Bay Area Muslim mental health community advisory board and a crisis response team.”

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