Behind the scenes with a co-director of The Pride Study

In our “Behind the Scenes” series, Stanford Medicine physicians, nurses, researchers and staff members share a glimpse of their daily lives.

For Stanford obstetrician/gynecologist Juno Obedin-Maliver, MD, MPH, there is no typical day. Part of what she loves about her job is that every day is different.

Obedin-Maliver practices the full spectrum of gynecology, including outpatient, inpatient, operative and emergency services. She also co-directs The PRIDE Study, which is a national prospective, longitudinal cohort of sexual and/or gender minority people — including but not limited to lesbian, gay, bisexual, transgender and queer people.

I was excited to speak with her about how she fits all of this into her day — both before and during the COVID-19 pandemic.

Pre-COVID morning routine

I get up between 5 a.m. and 6:15 a.m. I usually make some tea and have breakfast before getting my three-year-old son up, dressed and fed. Then, either my partner or I take him to school. Next, I head down to Stanford from San Francisco where I live.

Organizing the workweek

I see patients about 30% of the time, and the rest of the time I do research. Days that I don’t see patients are a mix of research writing and meetings — with overnight calls or surgery kind of sprinkled in here and there.

Part of my research team is at Stanford, part at the University of California San Francisco and part at our office in the Oakland City Center. So, I have meetings with folks all over the Bay, and also all over the country, because we have collaborators and stakeholders across the United States.

The PRIDE Study

The main focus of  The PRIDE Study is understanding the relationship between being a sexual and/or gender minority person and a person’s health. And we think about health broadly: physical health, mental health, social health and wellbeing. We want to understand in more detail the well-documented health disparities among sexual and gender minority people, but also their health resiliency. We’ve enrolled about 18,000 people in the study.

I’m also working to build an LGBTQ+ program at Stanford, which will include clinical care, research and education.

Juno Obedin-Maliver, MD, MPH, and Mitchell Lunn, MD, co-direct The PRIDE Study, a national prospective, longitudinal cohort of sexual and/or gender minority people.
Most productive time of the day

My most productive time is in the morning at home. I usually triage my email — deleting spam, putting actionable items on my to-do list and putting anything that requires significant time on my calendar. And if I get up at 5 am, I can get an hour of uninterrupted writing in before my son wakes up, which is awesome.

Evening ritual

I get home between 6 p.m. and 7:30 p.m., then I just hang out with my son and my partner. We give him dinner and a bath, read him books and get him to sleep. And then we have our own dinner. Sometimes we just hang out until bedtime. And sometimes, unfortunately, we get back on the computer to work.

In the evening, I like to meditate, if only for 10 minutes. I remember what I’m grateful for. And I generally read a novel before I go to bed. Right now, I’m reading a book called The Hakawati by Rabih Alameddine. It’s pretty great. I try to get to sleep by 10 or 10:30 p.m.

My day during the pandemic

I still see patients one day a week, and it’s a mix of in-person and video visits in the clinic. I also work some shifts on labor and delivery.

In terms of research, my team is still rocking and rolling, despite the challenges of COVID-19 and systemic violence around the country. I’m very luck to work with an inspiring team dedicated to equity and justice.

Professionally, it’s been a productive time, and we’ve published a number of papers. We’ve also launched a survey about the impact of COVID-19 for LGBTQ+ people, and a related survey about respiratory symptoms, and have had a few thousand responses already. The pandemic seems to be exacerbating systems of inequality, and that’s certainly true for LGBTQ+ — and even more so for LGBTQ+ people of color and those who are economically disadvantaged. As we enter Pride Month, we are also about to launch our fourth annual questionnaire on June 8, and celebrate having over 18,000 participants.

Having a 3-year-old at home and splitting his care throughout the day with my partner has been a big challenge though. Our kiddo misses his friends and school, as we all do. In many ways, we’re closer than ever, and have had a lot of opportunities to do crafts and bake — and we’re growing food on our porch (tomatoes, lettuce, peppers, chard and strawberries!).

On the other hand, trying to still fit in a full work day is a struggle; it means working before he is up and long after he goes to sleep, and unfortunately more screen time for him than ever before. That being said, we’re so lucky to be healthy, have access to food and have jobs that allow us to work at least some of the time from home while still being of service.

Photos by Steve Fisch

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

Physicians re-evaluate use of lead aprons during X-rays

When you get routine X-rays of your teeth at the dentist’s office or a chest X-ray to determine if you have pneumonia, you expect the technologist to drape your pelvis in a heavy radioprotective apron. But that may not happen the next time you get X-rays.

There is growing evidence that shielding reproductive organs has negligible benefit; and because a protective cover can move out of place, using it can result in an increased radiation dose to the patient or impaired quality of diagnostic images.

Shielding testes and ovaries during X-ray imaging has been standard practice since the 1950s due to a fear of hereditary risks — namely, that the radiation would mutate germ cells and these mutations would be passed on to future generations. This concern was prompted by the genetic effects observed in studies of irradiated fruit flies. However, such hereditary effects have not been observed in humans.

“We now understand that the radiosensitivity of ovaries and testes is extremely low. In fact, they are some of the lower radiation-sensitive organs — much lower than the colon, stomach, bone marrow and breast tissue,” said  Donald Frush, MD, a professor of pediatric radiology at Lucile Packard Children’s Hospital Stanford.

In addition, he explained, technology improvements have dramatically reduced the radiation dose that a patient receives during standard X-ray films, computerized tomography scans and other radiographic procedures. For example, a review paper finds that the radiation dose to ovaries and testes dropped by 96% from 1959 to 2012 for equivalent X-ray exams of the pelvis without shielding.

But even if the radioprotective shielding may have minimal — or no — benefit, why not use it just to be safe?

The main problem is that so-called lead aprons — which aren’t made of lead anymore — are difficult to position accurately, Frush said. Even following shielding guidelines, the position of the ovaries is so variable that they may not be completely covered.  Also,  the protective shield can obscure the target anatomy. This forces doctors to live with poor-quality diagnostic information or to repeat the X-ray scan, thus increasing the radiation dose given to the patient, he said.

Positioning radioprotective aprons is particularly troublesome for small children.

“Kids kick their legs up and the shield moves while the technologists are stepping out of the room to take the exposure and can’t see them. So the X-rays have to be retaken, which means additional dose to the kids,” Frush said.

Another issue derives from something called automatic exposure control, a technology that optimizes image quality by adjusting the X-ray machine’s radiation output based on what is in the imaging field. Overall, automatic exposure control greatly improves the quality of the X-ray images and enables a lower dose to be used.  

However, if positioning errors cause the radioprotective apron to enter the imaging field, the radiographic system increases the magnitude and length of its output, in order to penetrate the shield.

“Automatic exposure control is a great tool, but it needs to be used appropriately. It’s not recommended for small children, particularly in combination with radioprotective shielding,”  said Frush.

With these concerns in mind, many technologists, medical physicists and radiologists are now recommending to discontinue the routine practice of shielding reproductive organs during X-ray imaging. However, they support giving technologists discretion to provide shielding in certain circumstances, such as on parental request. This position is supported by several groups, including the American Association of Physicists in MedicineNational Council on Radiation Protection and Measurements and American College of Radiology.

These new guidelines are also supported by the Image Gently Alliance, a coalition of heath care organizations dedicated to promoting safe pediatric imaging, which is chaired by Frush. And they are being adopted by Stanford hospitals.

“Lucile Packard Children’s revised policy on gonadal shielding has been formalized by the department,” he said. “There is still some work to do with education, including training providers and medical students to have a dialogue with patients and caregivers. But so far, pushback by patients has been much less than expected.”

Looking beyond the issue of shielding, Frush advised parents to be open to lifesaving medical imaging for their children, while also advocating for its best use. He said:

“Ask the doctor who is referring the test: Is it the right study? Is it the right thing to do now, or can it wait? Ask the imaging facility:  Are you taking into account the age and size of my child to keep the radiation dose reasonable?”

Photo by Shutterstock / pang-oasis

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

Physicists curate list of COVID-19 projects to join

As we continue to deal with the global COVID-19 pandemic, biomedical researchers are racing to understand the virus that causes the disease, to evaluate its spread, and to develop tests, treatments and vaccines.

Physicists are volunteering to assist in these efforts, using their skills in data analytics, machine learning, simulation, software, computing, hardware development and project management. And an organization called Science Responds is helping to match them with projects that need their support.

As Savannah Thais, a postdoctoral researcher in high-energy physics and a co-founder of Science Responds, reported at the April meeting of the American Physical Society, physicists are assisting with a variety of types of projects, divided into the following categories:

Epidemiology

Epidemiology is the branch of medical science that studies public health problems and events in order to understand what causes them, how they are distributed among populations and possible ways to control them. Epidemiologists investigate diverse problems including pollution, foodborne illnesses, natural disasters and infectious diseases such as COVID-19.

Science Responds is connecting physicists with epidemiological projects that are working to model how the virus that causes COVID-19 might spread. Physicists hope to help address a major problem that the experts making these models face: incorporating data from a multitude of dissimilar sources.

Thais says physicists have the background and experience needed to provide epidemiologists this kind of support.

“We don’t think physicists should be building their own epidemiological models from scratch, because they don’t have the domain expertise of an epidemiologist or biologist about infectious diseases,” she says. But “physicists can be most effective by providing their computing and statistics skills to interdisciplinary research.”

One epidemiology project Science Responds encourages volunteers to join is HealthMap, which displays data about COVID-19 cases across the globe over time via an openly accessible website and mobile app. HealthMap integrates and filters data from diverse, publicly available sources—including online news aggregators and reports from governments and agencies such as the World Health Organization—and then creates intuitive visualizations of the state of the outbreak by location.

Other modeling projects use analyses of the genomic features of previously studied viruses to help estimate unreported COVID-19 cases; integrate health and hospital resource data to inform localized risk predictions; and incorporate information from previous animal and human outbreaks to improve model accuracy.

Diagnosis

An important part of dealing with an epidemic is determining who has the disease, but shortages of testing supplies have made diagnosis a challenge. Science Responds promotes projects that are trying to address this gap in different ways.

Some projects use artificial intelligence to process visual or audio data. The project CAD4COVID, for example, builds off an existing technology that has been highly successful in diagnosing tuberculosis through the analysis of chest X-rays. The project COVID Voice Detector, on the other hand, is collecting audio recordings to develop an AI that can recognize signs of COVID-19 infection in a patient’s voice.

Other projects are building tools to predict who is likely to experience the most severe effects of COVID-19. These machine-learning-based efforts identify indicators such as markers that appear in blood tests or specific features from lung biopsies to predict the likelihood of long-term hospitalization or death.

Treatments and cures

The race to develop COVID-19 vaccines and treatments begins with understanding the physical structure of the virus. On this front, Science Responds collaborators are providing key support for an effort called Folding@Home, which uses computer simulations to map out the proteins the SARS-CoV-2 virus uses to reproduce and suppress a patient’s immune system. Physicists are helping to develop the protein-folding simulations, but they are also playing a pivotal role in looking for help from anyone with a computer that Folding@Home can use remotely to run folding simulations.

In addition, physicists are helping process the massive amount of data related to the SARS-CoV-2 genome. They’re hoping to identify molecules that are important to the growth and spread of the virus and to understand its mutations.

Science Responds collaborators are also aiding efforts to use machine learning to identify drugs that could be repurposed to treat COVID-19. For example, they are using natural-language-processing algorithms to comb through a massive database of scholarly articles, called CORD-19, for relevant ideas. Other projects are using deep-learning-based models with existing data to predict how commercially available drugs will interact with the virus.

Supporting hospitals and healthcare systems

Science Responds participants are volunteering on projects to support frontline workers who are providing medical care to COVID-19 patients. These efforts include developing models to help predict hospital overload and to allow for the sharing of resources such as mechanical ventilators and personal protective equipment.

One example is the CHIME project, which gathers information on hospital resources and predicts when the needs of patients will exceed an institution’s capacity. CHIME has already been deployed in several hospitals, including the University of Pennsylvania Health System.

Another project in this area is COVID Care Map, which is using open-source data to map existing supplies of hospital beds, ventilators and other resources needed to care for COVID-19 patients such as available staff.

Other projects highlighted by Science Responds are aimed at improving telehealth. Enhanced at-home care could reduce the spread of COVID-19 by eliminating unnecessary hospital visits and improving access to care for rural areas.

Researchers are helping to develop AI-based chatbots that can be used to assess possible infections, educate patients and call on human providers when necessary. Other projects are working to combine in-home sensors and cameras with AI-assisted technologies to remotely monitor the health of vulnerable populations.

Socio-economic response

Finally, Science Responds volunteers are also working to address what they call “second-order effects,” not directly related to healthcare.

Some projects deal with infodemiology, research into what we can learn from user-contributed, health-related content on the internet. Researchers are analyzing millions of real-time tweets related to COVID-19 to answer questions like: How are people reacting to the outbreak? How is Twitter being used to pass on vital information? How is Twitter being abused to spread false information, panic and hate?

Physicists with data-analysis and data-engineering expertise can volunteer for projects aimed at bringing attention to at-risk populations. Thais leads a project that is developing a COVID-19 Vulnerability Index, an AI-based predictive model used to identify communities at high risk of socio-economic and health impacts associated with the spread of COVID-19.

The index looks at a wide range of measures, such as whether community members have access to home Wi-Fi, whether they are affected by non-COVID health issues such as diabetes, and whether healthcare resources are available to them.

Are you a physicist looking to volunteer? Thais recommends checking out the Science Responds website, which lists projects organized by their required skills, highlights available data sources, computing resources and funding opportunities, and provides instructions for getting connected.

Illustration by Sandbox Studio, Chicago with Ana Kova

This is a reposting of my news feature, courtesy of Symmetry magazine.

 

Nerve interface provides intuitive and precise control of prosthetic hand

Current state-of-the-art designs for a multifunctional prosthetic hand are restricted in functionality by the signals used to control it. A promising source for prosthetic motor control is the peripheral nerves that run from the spinal column down the arm, since they still function after an upper limb amputation. But building a direct interface to the peripheral nervous system is challenging, because these nerves and their electrical signals are incredibly small. Current interface techniques are hindered by signal amplitude and stability issues, so they provide amputees with only a limited number of independent movements. 

Now, researchers from the University of Michigan have developed a novel regenerative peripheral nerve interface (RPNI) that relies on tiny muscle grafts to amplify the peripheral nerve signals, which are then translated into motor control signals for the prosthesis using standard machine learning algorithms. The research team has demonstrated real-time, intuitive, finger-level control of a robotic hand for amputees, as reported in a recent issue of Science Translational Medicine.

“We take a small graft from one of the patient’s quadricep muscles, or from the amputated limb if they are doing the amputation right then, and wrap just the right amount of muscle around the nerve. The nerve then regrows into the muscle to form new neuromuscular junctions,” says Cindy Chestek, an associate professor of biomedical engineering at the University of Michigan and a senior author on the study. “This creates multiple innervated muscle fibers that are controlled by the small nerve and that all fire at the same time to create a much larger electrical signal—10 or 100 times bigger than you would record from inside or around a nerve. And we do this for several of the nerves in the arm.”

This surgical technique was initially developed by co-researcher Paul Cederna, a plastic surgeon at the University of Michigan, to treat phantom limb pain caused by neuromas. A neuroma is a painful growth of nerve cells that forms at the site of the amputation injury. Over 200 patients have undergone the surgery to treat neuroma pain.

“The impetus for these surgeries was to give nerve fibers a target, or a muscle, to latch on to so neuromas didn’t develop,” says Gregory Clark, an associate professor in biomedical engineering from the University of Utah who was not involved in the study. “Paul Cederna was insightful enough to realize these reinnervated mini-muscles also provided a wonderful opportunity to serve as signal sources for dexterous, intuitive control. That means there’s a ready population that could benefit from this approach.”

The Michigan team validated their technique with studies involving four participants with upper extremity amputations who had previously undergone RPNI surgery to treat neuroma pain. Each participant had a total of 3 to 9 muscle grafts implanted on nerves. Initially, the researchers measured the signals from these RPNIs using fine-wire, nickel-alloy electrodes, which were inserted through the skin into the grafts using ultrasound guidance. They measured high-amplitude electromyography signals, representing the electrical activity of the mini-muscles, when the participants imagined they were moving the fingers of their phantom hand. The ultrasound images showed the participants’ thoughts caused the associated specific mini-muscles to contract. These proof-of-concept measurements, however, were limited by the discomfort and movement of the percutaneous electrodes that pierced the skin.

Next, the team surgically implanted permanent electrodes into the RPNIs of two of the participants. They used a type of electrode commonly used for battery-powered diaphragm pacing systems, which electrically stimulate the diaphragm muscles and nerves of patients with chronic respiratory insufficiency to help regulate their breathing. These implanted electrodes allowed the researchers to measure even larger electrical signals—week after week from the same participant—by just plugging into the connector. After taking 5 to 15 minutes of calibration data, the electrical signals were translated into movement intent using machine learning algorithms and then passed on to a prosthetic hand. Both subjects were able to intuitively complete tasks like stacking physical blocks without any training—it worked on the first try just by thinking about it, says Chestek. Another key result is that the algorithm kept working even 300 days later.

“The ability to use the determined relationship between electrical activity and intended movement for a very long period of time has important practical consequences for the user of a prosthesis, because the last thing they want is to rely on a hand that is not reliable,” Clark says.

Although this clinical trial is ongoing, the Michigan team is now investigating how to replace the connector and computer card with an implantable device that communicates wirelessly, so patients can walk around in the real world. The researchers are also working to incorporate sensory feedback through the regenerative peripheral nerve interface. Their ultimate goal is for patients to feel like their prosthetic hand is alive, taking over the space in the brain where their natural hand used to be.

“People are excited because this is a novel approach that will provide high quality, intuitive, and very specific signals that can be used in a very straightforward, natural way to provide high degrees of dexterous control that are also very stable and last a long time,” Clark says.

Read the article in Science Translational Medicine.

Illustration of multiple regenerative peripheral nerve interfaces (RPNIs) created for each available nerve of an amputee. Fine-wire electrodes were embedded into his RPNI muscles during the readout session. Credit: Philip Vu/University of Michigan; Science Translational Medicine doi: 10.1126/scitranslmed.aay2857

This is a reposting of my news brief, courtesy of Materials Research Society.

Why do viruses like the coronavirus sometimes steal our sense of smell?

When you catch a severe cold, your nose stuffs up, you can’t smell anything and food tastes funny. Fortunately, most people regain their sense of smell once the cold runs its course. But for others, the complete (anosmia) or partial (hyposmia) loss of the sense of smell is permanent.

I spoke with Zara Patel, MD, a Stanford associate professor of otolaryngology, head and neck surgery, and director of endoscopic skull base surgery, to learn more about her research on olfactory disorders. In particular, we discussed her recent study on the possible association between post-viral olfactory loss and other cranial neuropathies, which are disorders that impair your nerves and ultimately your ability to feel or move. She also described how her work pertains to the COVID-19 pandemic.  

How does a virus impair someone’s sense of smell?

A variety of viruses can attack the cranial nerves related to smell or the mucosal tissue that surrounds those nerves. Cranial nerves control things in our head and neck — such as the nerves that allow us to speak by using our vocal cords, control our facial motion, hear and smell.

For example, COVID-19 is just one type of disease caused by a coronavirus. There are many other types of coronaviruses that cause colds and upper respiratory illnesses, as well as rhinoviruses and influenza viruses. Any of these viruses are known to cause inflammation, either directly around the nerve in the nasal lining or within the nerve itself. When the nerve is either surrounded by inflammatory molecules or has a lot of inflammation within the nerve cell body, it cannot function correctly — and that is what causes the loss or dysfunction of smell. And it can happen to anyone: young and old, healthy and sick.

How did your study investigate olfactory loss?

In my practice, I see patients who have smell dysfunction. But I’m also a sinus and skull base surgeon, so I have a whole host of other patients with sinus problems and skull-based tumors who don’t have an olfactory loss. So we did a case-control study to compare the incidence of cranial neuropathies — conditions in which nerves in the brain or brain stem are damaged — in two patient groups. Ninety-one patients had post-viral olfactory loss and 100 were controls; and they were matched as closely as possible for age and gender.

We also looked at family history of neurologic diseases — such as Alzheimer’s disease, Parkinson’s disease and stroke.

What did you find?

Patients with post-viral olfactory loss had six-times higher odds of having other cranial neuropathies than the control group — with an incidence rate of other cranial nerve deficits of 11% and 2%, respectively. Family history of neurologic diseases was associated with more than two-fold greater odds of having a cranial nerve deficit. Although we had a small sample size, the striking difference between the groups implies that it is worthwhile to research this with a larger population.

Our findings suggest that patients experiencing these pathologies may have inherent vulnerabilities to neural damage or decreased ability of nerve recovery — something beyond known risk factors like age, body mass index, co-morbidities and the duration of the loss before intervention. For example, there may be a genetic predisposition, but that is just an untested theory at this point.

How does this work pertain to COVID-19?

Smell loss can be one of the earliest signs of a COVID-19 infection. It can sometimes be the only sign. Or it can present after other symptoms. Although it may not affect every patient with COVID-19, loss of smell and taste is definitely associated with the disease. In some countries, including France, they’ve used this as a triage mechanism. People need to know that these symptoms can be related to the COVID-19 disease process so they aren’t going about their lives like normal and spreading the virus.

The pandemic also might impact how we treat patients with olfactory dysfunction in general. When someone has a viral-induced inflammation of the nerve, we sometimes treat it with steroids to decrease the inflammation. But treating COVID-19 patients with steroids might be a bad idea because of its effect on the inflammatory processes going on in their heart and lungs.

What advice do you have for people who have an impaired sense of smell?  

First, if you lose your sense of smell and it isn’t coming back after all the other symptoms have gone away, seek care as soon as possible. If you wait too long, there is much less that we can do to help you. Interventions, including olfactory training and medications, are more effective when you are treated early.

Second, if you lose your sense of smell or taste during this pandemic and you don’t have any other symptoms, contact your doctor. The doctor can decide whether you need to be tested for COVID-19 or whether you need to self-isolate to avoid being a vector of the virus in your family or community.

Image by carles

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

Defend or delay? Grad students must decide whether to present their thesis virtually

Graduate students who are trying to finish their degrees amid the COVID-19 pandemic are finding, after years of research and months of preparation, that the big day of defending their thesis has to be delayed or done remotely.

Faced with a new order to shelter at her off-campus home, Anjali Bisaria, a graduate student in chemical and systems biology at Stanford, decided to forge ahead. She works in the lab of Tobias Meyer, PhD,  where they study how human cells move and divide to build, maintain and repair tissues and organs.

On the scheduled date and time, Bisaria logged into a Zoom session and defended her research to a virtual audience of advisors, classmates, friends and family members. She then virtually met with just her faculty examinees. After being declared a doctor, she celebrated with her lab via yet another Zoom session.

“I know it was the right thing to do to keep the community safe,” she said in a Stanford news story. “But it was a little bit sad because this is likely my last quarter on campus. So to not be able to interact with my classmates and not be able to enjoy that honeymoon phase of grad school felt unceremonious.”

Soon, microbiology and immunology graduate student Kali Pruss will face the same decision. Her in-person PhD oral is currently scheduled for May 22 at Munzer Auditorium on Stanford campus.

“I haven’t yet decided whether I’ll proceed with my defense via Zoom or delay my defense to later in the summer, in hopes that I would be able to have an in-person defense,” Pruss told me. “I was planning on staying through the summer, taking a writing quarter anyway. Thankfully, this gives me some flexibility in terms of timing.”

As a member of the lab run by Justin Sonnenburg, PhD, Pruss studies how Clostridium difficile — a bacteria that commonly causes diarrhea and colitis — adapts to the inflammation that it generates, she said.

Pruss is currently writing a paper on her research, but the pandemic is impacting that too. She told me that she’s doing more data analysis and relying less on experiments than she normally would — and she’s a bit worried about how this approach will be received.

“I’m concerned with how this is going to affect the review process, and whether I’ll be able to successfully address reviewer comments asking for additional experiments for my papers,” she said.

She added, “Ultimately, though, I feel incredibly privileged and grateful to be able to continue working remotely towards my dissertation. The question of how my research is being impacted, and whether to postpone my defense, has been a minor concern in the scope of what is currently happening at Stanford and around the world.”

Given the extension of the Bay Area’s shelter-at-home order to last through at least May 3, Pruss’s hopes of defending in-person on May 22 may not be realized. So, her extended family — from Wisconsin, Indiana and Illinois — canceled their travel arrangements. They hope to come in late summer if she delays her defense and sheltering orders have been lifted.  

Regardless of how she defends her thesis, she plans to celebrate her upcoming educational milestone.

“This is the one time we, as PhD students, get to celebrate our time in grad school as an accomplishment,” she said.

After graduation, Pruss plans to join Jeffrey Gordon’s lab at Washington University School of Medicine in St. Louis as a postdoc. Ultimately, she plans to run her own academic lab.

Photo by Anjali Bisaria

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

Twitter journal clubs: Sharing knowledge from a social distance

When I was an academic researcher, I attended many journal clubs — convening with my group in a conference room to discuss the methods and findings of a selected paper. These meetings are common in academic and medical education, allowing students to develop their presentation skills and helping everyone keep up with the flood of scientific literature.

In the era of social media, such in-person journal clubs are being replaced by Twitter journal clubs — now more than ever — and it’s led me to wonder, are 280 characters really enough?

I spoke with Roxana Daneshjou, MD, PhD, a dermatology resident at Stanford, to find out. She co-authored a recent editorial in JAMA that describes the advantages of using Twitter compared to the traditional format.

How do Twitter journal clubs work?

The journal club picks a paper to discuss, often using crowdsourcing to select something people are interested in. Everyone logs into Twitter at a specific time and has an online conversation with people from around the globe. Someone may facilitate and use pre-selected questions, but there’s also time for open discussion. You can string many tweets together, so you can basically write as much as you want.

Most journal clubs meet once a month for an hour, but the nice thing about Twitter is that the conversation is saved. So, if someone wants to comment the next day, the participants will see those responses whenever they log into Twitter. That’s important because participants are from different time zones. Having the conversation publicly recorded could be an issue for some people, but I think scientists and clinicians aren’t shy about asking questions and critiquing papers, even publicly.

Why did you start the first dermatology Twitter journal club?

I lurked in other journal clubs and participated in a dermatopathology one that was really interesting. But I wanted to have the same experience with medical dermatology, discussing disease management and new clinical discoveries.

I think Twitter journal clubs are particularly useful for small specialties like dermatology. They allow dermatologists to share knowledge across institutions. They also help promote the field of dermatology to a wider, cross-specialty audience, demonstrating the role that dermatologists can play for their patients. These interactions among specialists are easier with Twitter, compared to traditional journal clubs, because anyone can comment or ask a question about the topic, using the free Twitter website or app without advanced coordination.

Who participates?

We have over 1,700 people following our dermatology journal club, but we typically only have about 15 to 20 people actively participating in a meeting — with more people lurking. Our participants are a diverse group of residents, medical students, faculty and community physicians from across the country.

However, we’ve gotten a much larger group when we’ve done joint meetings with other specialties. For example, we did a joint journal club with nephrology — one of the largest Twitter journal clubs —  to discuss the role of dermatologists in helping manage immunosuppressed kidney transplant patients who are at higher risk of skin cancer. These cross-specialty Twitter interactions are great, because I’ve become friends with residents and faculty at other institutions and now feel comfortable sending them private messages if I have a question. For example, I met dermatologist Adewole Adamson, MD, MPP, through the journal club, and he provided me with a high level of mentorship to co-write the JAMA editorial.

How has the pandemic affected Twitter journal clubs?

Multiple Twitter journal clubs have discussed issues related to COVID-19 and their particular specialty. Our most recent dermatology journal club discussed how dermatologists were transitioning to virtual visits to help with social distancing and how resident training was continuing in dermatology with COVID-19. On April 6, infectious disease’s Twitter journal club will be discussing a paper entitled, “A Trial of Lopinavir-Ritonavir in Adults with Severe COVID-19.”

With social distancing, in-person journal clubs will be more difficult to have. Twitter is the perfect medium for having multiple conversations at once with many people. This is a really difficult time for many, and I hope Twitter journal clubs can help physicians and trainees continue to engage in academic conversations.

Image by Mohamed Mahmoud Hassan

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

Identifying and addressing gender bias in healthcare: A Q&A

International Women’s Day offered a reminder t0 “celebrate women’s achievement, raise awareness against bias and take action for equality.” Stanford-trained surgeon Arghavan Salles, MD, PhD, is up for the challenge.

As a scholar in residence with Stanford Medicine’s educational programs, Salles researches gender equity, implicit bias, inclusion and physician well-being. Beyond Stanford, she is an activist against sexual harassment in medicine, and she’s written on these topics from a personal perspective for the popular press, including Scientific Americanand TIMEmagazine.

I recently spoke with her to learn more.

What inspired your research focus?

As an engineering undergraduate, I never really thought about gender or diversity issues.

Then during the first year of my PhD at Stanford, I learned about stereotype threat. The basic idea is that facing a negative stereotype about part of your identity can affect your performance during tests. For example, randomized controlled studies show that if minority students are asked for their race or ethnicity at the beginning of a test of intellectual ability, like the GRE (Graduate Record Examination), this question can impair their performance. A lot of decisions are based on these kinds of test scores, and this really changed how I think about merit.

At the time, I was also in the middle of my residency to become a surgeon. I started thinking about whether stereotype threat affects women who are training to be surgeons, so that’s what I studied for my dissertation.

I have continued to think about these types of issues, studying things like: Who gets the opportunity to speak at conferences? Does gender affect how supervisors write performance evaluations for residents and medical students?  And how extensive is gender bias in health care?

How does gender bias impact women surgeons?

We all have biases. Growing up in the U.S., we generally expect men to be decisive and in control and women to be warm and nurturing. So when women physicians make decisions quickly and take charge in order to provide the best care to their patients, they’re going against expectations.

I hear the same struggles from women all over. For women surgeons in particular, for example, the operating room staff often don’t hear when they ask for instruments. The staff may not have all the devices and equipment in the room because their requests aren’t taken as seriously as those of men. And they are often labeled as being demanding or difficult if they act like their male colleagues, which has significant consequences on opportunities like promotions.

Related to gender bias, women surgeons also deal all the time with microaggressions from patients and health care professionals. For instance, patients report to the nursing staff they haven’t seen a surgeon yet, when their female surgeon saw them that morning. Or they say, ‘Oh, a woman surgeon. I’ve never heard of that.’ So you have to strategically decide what to confront.

How can we address these issues?

It’s really important to have allies to give emotional support and advice, but also to speak up when these things are happening. For example, an ally can speak up if a committee member brings up something irrelevant during a promotion review.  

In the bigger scheme, we need to change how we hire people, to make it more difficult to act on our biases. We should use a blinded review so we don’t know the gender or race of the applicant. We should have applicants do relevant work sample tests to select the most qualified candidate. And we should use standardized interview questions. Changing how we hire and promote people would make a big difference.

We also need to create a culture of inclusion, in addition to hiring more women, underrepresented minorities and transgender and nonbinary gender people to bring new ideas. Diversity without inclusion is essentially exclusion. We’ve talked about gender today, but a lot of the same challenges are faced by other underrepresented groups.

Why do you write about these topics from a very personal viewpoint?

In some ways, I’m a naive person. I don’t have the same degree of professional self-preservation that some people have. There may be unintended negative consequences, but I’m just honest to a fault.

The piece about anger came out of seeing time and time again women being misunderstood — having their anger attributed to some personality flaw rather than a reasonable consequence of what they were experiencing. I figured if I wrote about it, I could raise awareness and maybe a few people would react differently next time they saw a woman express anger.

I wrote the fertility piece because I wanted to share my experience to educate people, so fewer people would end up involuntarily childless. In general, I just feel that it’s important to share my experiences to help others not make the same mistakes that I have.

Photo courtesy of Arghavan Salles

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

Improving cancer prognoses: A radio show

“Looking in the patients’ eyes and having a conversation” has motivated Stanford oncologist Ash Alizadeh, MD, PhD, to improve the way we diagnose, talk about and treat cancer.

Patients go home nervous and the care team is nervous, he pointed out, because you’re fighting a battle together to save a life and the things you’re doing are toxic and expensive.

“It’s really sobering to look at how blunt our tools are for getting a sense for whether you’re making progress as you’re going through the course of your therapy,” said Alizadeh in a recent episode of the Sirius radio show The Future of Everything hosted by Russ Altman, MD, PhD.

A key area of his work aims to more accurately predict a patient’s prognosis. He developed a computer algorithm (the focus of a recent Stanford Medicine magazine article) that searches data for information likely to affect the patient’s long-term outcome — generating a unique personalized estimate of risk, called the continuous individualized risk index (CIRI). The goal is to use CIRI to guide personalized therapy selection.

In the episode, he explained that their integrated approach better forecasts a patient’s prognosis by analyzing the complete medical path of the patient, whereas oncologists typically give more weight to the most recent data.

The researchers validated their predictive model using data gathered over time from patients with three types of cancers: diffuse large B-cell lymphoma (DLBCL), chronic lymphocytic leukemia or early-stage breast cancer.

In the study, they also measured the amount of circulating tumor DNA (ctDNA) in the blood of 132 DLBCL patients, before and during their treatment. Circulating tumor DNA is DNA that was shed from dying tumor cells and released into the bloodstream.

For this small group of DLBCL patients, standard methods to forecast how well a patient will do had a predictive index of 0.6, where a perfectly accurate test would score 1 and a random test like a coin toss would score 0.5. Alizadeh’s CIRI score was 0.8 for the same patients — not perfect but markedly better than the current “crystal ball exercise,” he said in a news release.

In the radio show, he also discussed how this predictive model complements his work to develop new technologies for cancer diagnosis and treatment.

For example, he explained measuring ctDNA levels with a non-invasive liquid biopsy may help detect early-stage cancer, guide treatment selection and monitor treatment response. And if liquid biopsies detect cancers at an early stage, this may allow oncologists to leverage their patients’ immune system to attack their cancer, he said.

“So instead of directly attacking the tumor cells with drugs that kill the cancer cells, you now have drugs that engage the immune system to say, ‘Hey, wake up,’” he said. That means the same drug could work for many cancers.

Alizadeh is developing these new techniques to personalize cancer diagnosis and treatment in hopes of improving the outcomes for his patients, he said.

 Photo by Pikrepo

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

Behind the scenes with a Stanford pediatric surgeon

In a new series, “Behind the Scenes,” we’re inviting Stanford Medicine physicians, nurses, researchers and staff to share a glimpse of their day.

As a science writer, I talk to a lot of health care providers about their work. But I’ve often wondered what it is really like to be a surgeon. So I was excited to speak with pediatric surgeon Stephanie Chao, MD, about her day.

Chao is a pediatric general surgeon, an assistant professor of surgery and the trauma medical director for Stanford Children’s Health. In addition to performing surgeries on children of all ages, she has a range of research interests, including how to reduce gun-related deaths in children and the hospital cost associated with pediatric firearm injuries.

Morning routine
On days that I operate, I get up between 5:50 and 6 a.m., depending on whether I hit the snooze button. I typically don’t eat breakfast. I don’t drink coffee because I don’t want to get a tremor. I’m out the door by 6:30 a.m. and at the hospital by 7 a.m. I usually go by the bedside of the first patient I’m going to operate on to say hi. The patient is in the operating room by 7:30 a.m. and my cases start.

On non-surgical days, it’s more chaotic. I have a 3-year-old and 1-year-old. So every day there’s a jigsaw puzzle as to whether my husband or I stay to get the kids ready for preschool, and who comes home early.

Part of Stephanie Chao’s day involves checking on patients, including this newborn.

In the operating room
The operating room is the place where I have the privilege of helping children feel better. It’s a very calming place, like a temple. When I walk through the operating room doors, the rest of the world becomes quiet. Even if it is a high-intensity case when the patient is very sick, I know there is a team of nurses, scrub techs and anesthesiologists used to working together in a well-orchestrated fashion. So even when the unexpected arises, we can focus on the patient with full confidence that we’ll find a solution.

There are occasions when babies are so sick that we need silence in the operating room. Everyone becomes hyper-attuned to all the beeps on the monitors. When patients are not as critically sick, I often play a Pandora station that I created called “Happy.” I started it with Pharrell Williams’ “Happy” and then Pandora pulled in other upbeat songs, including a bunch of Taylor Swift songs, so everyone thinks I’m a big Taylor Swift fan.

The OR staff call me by my first name. I believe that if everyone is relaxed and feels like they have an equal say in the procedure, we work better as a well-oiled machine for the benefit of the patient.

“The OR staff call me by my first name,” Stephanie Chao said.

Favorite task
Some of the most rewarding times of my day are when I sit down with patients and their families to hear their concerns, to reassure them and to help them understand what to expect — and hopefully to make a scary situation a little less so. As a parent, I realize just how hard it is to entrust one’s child completely in the hands of another. I also like to see patients in the hospital as they’re recovering.

Favorite time
The best part of the day is when I come home. When I open the door into the house, my kids recognize that sound and I hear their little footsteps as they run towards the door, shrieking with joy.

Evening ritual
When my husband and I get home, on nights I am not on call, I cook dinner in the middle of the chaos of hearing about the kids’ day. Hopefully, we “sit down” to eat by 6:20 or 6:30 p.m., and I mean that term loosely. It’s a circus, but eventually everyone is somewhat fed.

And then we do bath time and bedtime. There’s a daily negotiation with my three-year-old on how many books we read before bed. On school nights, she’s allowed three books but she tries to negotiate for 10.

Eventually, we get both kids down for the night. Then my husband and I clean up the mess of the day and try to have a coherent conversation with each other. But by then both of us are exhausted. I try to log on again to finish some work, read or review papers. I usually go to sleep around 11 p.m.

Managing it all
When I can carve out time to do relaxing things for myself, like go to the gym, that is great. But it’s rare and I remind myself that I am blessed with a job that I love and a wonderfully active family.

The result sometimes feels like chaos, but I don’t want to wish my life away waiting for my kids to get older and for life to get easier. Trying to live in the moment, and embracing it, is how I find balance.

Photos by Rachel Baker

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