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.

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Space, the new surgical frontier? A Q&A

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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.

Brain’s serotonin system includes multiple, sometimes conflicting, pathways

Photo by Pablo García Saldaña

Although the serotonin system — which helps regulate mood and social behavior, appetite and digestion, sleep, memory and motor skills — is critical to so many functions in the human body, its underlying organization and properties are not well understood. Past studies have even reported divergent results.

New research may help clear up this confusion, as recently reported in Cell. Stanford biologist Liqun Luo, PhD, discovered the serotonin system is actually composed of multiple parallel subsystems that function differently, at times in opposing ways.

“The field’s understanding of the serotonin system was like the story of the blind men touching the elephant,” Luo said in a recent Stanford news release. “Scientists were discovering distinct functions of serotonin in the brain and attributing them to a monolithic serotonin system, which at least partly accounts for the controversy about what serotonin actually does. This study allows us to see different parts of the elephant at the same time.”

Luo’s team studied the dorsal raphe, a region of the brainstem containing a high concentration of serotonin-producing neurons, in mice. They injected this region’s nerve fibers with a modified virus engineered to exhibit bright green fluorescence — allowing them to image and trace how the dorsal raphe’s neurons are connected to other regions in the brain. They observed two distinct groups of neurons in the dorsal raphe.

Using behavioral tests, they then determined that these two neuron groups sometimes responded differently to stimuli. For instance, in response to a mild punishment, neurons from the two groups showed opposite responses.

The researchers also found these neurons released the chemical glutamate in addition to serotonin, raising the question of whether they should even be called serotonin neurons.

These research findings have the potential for wide-ranging clinical applications, including the development of better drugs to treat depression and anxiety. Currently, the most commonly prescribed type of antidepressant are selective serotonin reuptake inhibitors (SSRIs), which target the serotonin system. However, some people can’t tolerate the side effects from SSRI antidepressants. A better understanding of the serotonin system may help.

“If we can target the relevant pathways of the serotonin system individually, then we may be able to eliminate the unwanted side effects and treat only the disorder,” said study first author Jing Ren, PhD, a postdoctoral fellow in Luo’s lab.

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

Airline crew don’t have significantly elevated risk of thyroid cancer, new study finds

Photo by pxhere

Commercial airline crew typically spend 1,000 hours per year working at cruising altitudes — above the atmosphere that protects them from cosmic ionizing radiation. In fact, aircrew receive the largest annual radiation dose of all U.S. workers.

Studies have shown that pilots and flight attendants have higher rates of certain cancers than the general population, including breast cancer and melanoma. But less was understood about the link between air travel and thyroid cancer, which is known to be associated with childhood radiation exposure.

Stanford researchers addressed this question with a meta-analysis of published data on thyroid cancer rates in airline crew, as recently reported in Cancers of the Head and Neck. They analyzed eight studies with a total of almost 250,000 crew members from 11 countries. They found no evidence of increased thyroid cancer risk in airline crew.

“None of the eight studies showed a statistically significant increase in risk of thyroid cancer,” wrote first author George Liu, MD, a Stanford medical student, in a recent blog post. “Aggregating the results, using a statistical method called random-effects model, also did not change our conclusion.”

The key phrase in Liu’s statement may be “statistically significant.”

On the surface, the new Stanford results seem to contradict recent findings from the Harvard Flight Attendant Study that stated, “Compared to … [controls] with a similar socioeconomic status, flight attendants had a higher prevalence of every cancer we examined.” And the study included thyroid cancer.

However, the higher prevalence of cancers observed by the Harvard study was statistically significant for only three of the cancers examined: breast cancer, melanoma and non-melanoma skin cancer, Liu argued. In fact, both studies found very similar results for thyroid cancer. In the blog, Liu called for the paper’s authors and media to correct their statements to avoid “undue alarm.”

Based on their own study, the Stanford authors also called for further research that better captures variables such as gender, age and primary and secondary smoking data for airline crew, as well as larger studies with longer follow-up periods.

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

Busting myths about milk

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Milk used to be simple. Your local dairy, say Berkeley Farms, delivered it to your doorstep.

But now we are faced with an unfathomable array: nonfat, low-fat or whole milk? Almond, soy, rice, hemp or oat milk? From goats or cows? With or without lactase? Raw or pasteurized? Plain or flavored? There’s even an ongoing controversy over which of these drinks can be called milk.

To sort through the confusion, I spoke with Stanford nutrition scientist Christopher Gardner, PhD. He is working to clear up some of the biggest misconceptions we have about milk.

Most of us grew up believing that milk is important for children to build strong bones and for the elderly to prevent osteoporosis. But milk, a good source of calcium, isn’t necessarily the most critical factor for bone health, Gardner said.

“There are countries like Japan and India where the population is predominantly lactose intolerant, where milk intake is low and hip fracture rates are also low. But many of those cultures do more weight-bearing activities than Americans,” he said. “It’s better to be physically active than drink milk as a way to strengthen your bones.”

Studies have shown that drinking milk can improve your bone density, but whether it helps prevent bone fractures is debatable, he added.

But don’t young kids need milk? According to Gardner, it depends on what kind of milk. Breast milk is incredibly important, but cow’s milk isn’t, he said.

“This myth goes way back to before the food pyramid when the National Dairy Council offered to provide nutrition material to schools for free. And in all those materials, they said that you need multiple servings of dairy every day for a healthy diet,” Gardner said. “That was never agreed on. A lot of people are lactose intolerant, and you don’t need it.”

Milk can be healthier than other options like soda. He recommended checking the nutrition panel to make sure the milk isn’t just as sugary as soda though, particularly with plant-based milks. “The popular vanilla and chocolate versions of the plant-based milks are often loaded with added sugar. Even the plain is typically sweetened, but you can get unsweetened. The lactose in milk isn’t so bad so there is no need to water it down, just avoid milks with added sugars.”

The nutrition label also allows you to compare the amount of fats, protein, carbs and vitamins in each type of milk. “For example, the plant-based milks generally don’t have saturated fat like cow’s milk so they don’t raise LDL-cholesterol as much as dairy milk, but they do have about the same amount of calcium,” he said. “And soy milk has the same amount of protein as dairy milk, but almond milk has much less protein.”

Another common misunderstanding is that 2 percent milk means that two percent of the calories are from fat — it’s really 2 percent of the weight (which is mostly water) and 35 percent of the calories, he said. “Whole milk has close to 50 percent of its calories as fat, and 1 percent milk has about 20 percent.”

However, your milk’s fat content may not affect your weight. The old belief was that drinking whole fat milk will make you fat and skim milk will help you lose weight. But this was refuted by Harvard’s Nurses’ Health Study that followed the diets of over 100,000 nurses for over 30 years, including how their diets changed.

“The Harvard study found that switching back and forth from whole fat to 2 percent to 1 percent was not associated with changes in weight,” explained Gardner.

But does drinking more milk help? Some small, short-term studies showed that people lost weight if they drank more milk. According to Gardner, this raises the always present nutrition research challenge: Was it drinking more milk or was it consuming less of something else that caused the weight loss?

And what about raw milk? Raw milk proponents argue that pasteurization kills off important healthy bacteria along with the bad listeria bacteria, but Gardner says that it’s difficult to prove any health benefits from these bacteria. Some raw milk producers also claim that it is easier to digest. However, Gardner’s study found that lactose intolerant participants had the same symptoms with raw and pasteurized milk.

And what does Gardner himself drink? He said he gave up cow’s milk for ethical reasons.

“Now, I drink unsweetened soy milk,” he admitted. ‘In our household, my wife doesn’t digest dairy milk very well, so we don’t even have it around. My four boys all drink unsweetened soy milk.”

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

Deep brain stimulation might benefit those with severe alcoholism, preliminary studies show

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Alcoholics struggling to stay sober are faced with countless triggers that can lead to relapse — driving past a bar, getting together with former drinking buddies or even just feeling down. 

And this is a big problem. Alcoholism is a growing epidemic responsible for at least a quarter trillion dollars in US health care costs per year, as well as inestimable anguish. Current medical therapies suffer from high rates of noncompliance and variable effectiveness.

In the future, severe alcoholics with multiple failed attempts at intensive medical therapies and in-patient rehabilitation may have a different treatment option for their addiction — deep brain stimulation (DBS) — as recently reported in a review article by Stanford researchers in Neurosurgical Focus.

Currently, deep brain stimulation therapy for alcohol use disorders is not approved by the U.S. Food and Drug Administration, but it is widely used to treat Parkinson’s disease and obsessive-compulsive disorder.

“DBS is a minimally-invasive brain surgery,” explained senior author Casey Halpern, MD, an assistant professor of neurosurgery at Stanford. “For Parkinson’s, we place deep brain stimulators to restore normal function of the region in the brain known to be dysfunctional. Patients improve immediately when a small dose of current is delivered to this area. We anticipate a similar treatment will be possible for alcoholism. At the moment, we’re performing animal studies to optimize this potential therapy and to learn its underlying mechanism of action.”

For alcohol use disorders,  researchers are targeting the nucleus accumbens, which plays a central role in the brain’s reward circuitry. They previously found that brain stimulation of this region could reduce impulsive behavior.

“The nucleus accumbens is triggered when patients anticipate a reward or prior to completing a rewarding behavior. It’s been shown to be perturbed in both addictive disorders and OCD,” said Allen Ho, MD, a Stanford neurosurgery resident working with Halpern. “By targeting this brain structure with stimulation, we hope to modulate the reward circuit in the brain to help patients resist the temptation to indulge in a binge and other addictive behaviors.”

The review article outlines extensive animal studies and pilot human subject studies have shown promising reductions in alcohol consumption and, in some cases, long-term abstinence.

According to Ho, this success is in part due to the fact that DBS doesn’t rely on patient compliance with therapy sessions, in-patient rehab, medications and abstinence. “Once the patient makes a decision to undergo treatment and the stimulator is implanted and turned on, they don’t have to make a conscious decision to pursue treatment — it is ‘on’ all the time,” said Ho.

Brain surgery may sound scary, but Ho explained that DBS is one of the safest and least invasive operations that they do as neurosurgeons. He believes alcoholics will consider the treatment since the addiction can devastate their lives, he said.

The Stanford team also hopes to apply deep brain stimulation to other addictions. “Should DBS prove effective for alcoholism, we anticipate a similar therapy could be very helpful for all addictions and even obesity,” said Halpern.

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