Posted tagged ‘public health’

Physicians urged to talk to their patients about guns

October 20, 2017

Physicians often discuss sensitive issues such as sexual behavior and substance use with their patients. Although everyone may squirm a bit, these conversations help doctors identify health risks so they can properly counsel their patients.

Now, there is a growing movement to add guns to the exam room discussion. Many professional organizations, including the American College of Physicians, recognize that gun-related injuries and deaths are a major public health problem, not just a criminal violence issue. So they advocate that physicians speak with their patients about firearms and intervene when patients are at risk for injuring themselves or others due to firearm access.

Editors from the Annals of Internal Medicine recently wrote, “Regardless of whether one believes guns hurt people or that people hurt people with guns, we have a public health crisis and health care professionals have an obligation to do what we can to combat it.” They later added in the editorial, “Physicians and other health professionals at the frontline of patient care can help prevent firearm-related harm one patient at a time.”

Although horrifying, mass shootings account for only 1 to 2 percent of deaths from firearm violence; other incidents involving guns cause about 95 such deaths per day. Such statistics inspired Garen Wintemute, MD, a professor of emergency medicine and director of the Violence Prevention Research Program at the University of California, Davis, to research firearm violence.

In a recent article in Annals of Medicine, Wintemute explained that people who commit firearm violence — whether against others or themselves — have well-recognized risk factors that often bring them into contact with physicians. These risk factors include alcohol and substance abuse, a history of violence, suicide attempt(s), poorly controlled severe mental illness and serious life stressors, he wrote.

However, not all physicians are comfortable discussing firearms with their patients, even if they think it is appropriate. For instance, they may feel they don’t know enough about firearms. Wintemute urges doctors to educate themselves and hospitals to develop continuing education programs on the benefits and risks associated with owning and using firearms. He also urges physicians to make a public commitment to ask their patients about firearms.

There are online resources to help physicians get the conversation started. For example, the Massachusetts Medical Society has online materials and a CME course that covers practical tips on how to talk to patients about gun safety. Wintemute is also happy to provide resources and to follow-up with physicians who make the online pledge — just click the box giving him permission to contact you.

An opinion piece in the Washington Post provides some additional guidance. In the article, Stanford resident Nathanial P Morris, MD, gave practical advise to physicians that identify a patient who owns a gun and wants to self-harm or harm others. “We can pursue a range of options, from handing out gun locks to requesting family or friends temporarily hold onto firearms to asking that local police perform a welfare check at the patient’s home,” he said in the piece. “In extreme cases, if patients pose an imminent risk to themselves or others because of mental illness, we can place them on a legal hold to evaluate them in the hospital for up to 72 hours.” The goal of these actions, he wrote, is to limit patients’ access to guns to protect them from transitory suicidal or homicidal impulses. Morris added:

“ We’re not out to get anyone’s guns. We don’t wake up hoping to infringe on patients’ personal lives. But, to keep patients and communities healthy, clinicians need to be able to ask about firearms.”

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

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

April 19, 2017

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

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

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

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

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

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

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

Nonetheless, Pelayo believes the effort is important:

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

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

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

Clinical guidance on genetic testing: A Q&A

April 18, 2017

 

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

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

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

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

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

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

What was the committee’s mission?

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

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

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

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

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

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

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

What you need to know about e-cigarettes

February 7, 2017

 

Photo by 1503849

Photo by 1503849

E-cigarettes are extremely popular with millions of middle and high school students across the United States. Kids love the flavors — like strawberry, bubble gum, chocolate cake and cotton candy — and blowing vapor into rings. And, they are inundated with ads that tout e-cigarettes as cool, harmless alternatives to cigarettes.

But, not surprisingly, e-cigarettes aren’t really safe. A recent University of California news story outlines ten important facts about e-cigarettes, including how they can harm your health.

One of the biggest health concerns is that e-cigarettes contain nicotine, which is addictive and can lead to the use of traditional cigarettes. “A lot of kids who take up [nicotine-free] vaping are at low risk for smoking, but once they start using e-cigarettes, they are three to four times more likely to start using cigarettes,” said Stanton Glantz, PhD, a tobacco researcher at the University of California, San Francisco, in the article.

In addition, e-cigarettes can contain other harmful ingredients, including:

  • Ultrafine particles that can trigger inflammatory problems and lead to heart and lung disease
  • Toxic flavorings that are linked to serious lung disease
  • Volatile organic compounds
  • Heavy metals, such as nickel, tin and lead

Stanford’s Bonnie Halpern-Felsher, PhD, a developmental psychologist who has studied tobacco use, also commented in the piece:

“Youth are definitely using e-cigarettes because they think they are cool… Adolescents and young adults don’t know a lot about e-cigarettes. They think it’s just water or water vapor. They don’t understand it’s an aerosol. They don’t understand that e-cigarettes can have nicotine. They don’t understand that flavorants themselves can be harmful.”

Furthermore, when e-cigarette users exhale the mainstream vapor containing these toxins, they can cause secondhand health effects.

The article discusses other hazards as well, including the possibility of battery explosion, and the products’ mixed record on helping smokers quit. It concluded with a call for more research to better understand the long-term health effects of e-cigarettes.

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

Saliva tests may help identify marijuana-impaired drivers

November 22, 2016
Photo by ashton

Photo by ashton

As of the recent election, seven states and the District of Columbia have now legalized marijuana for recreational use and 19 other states have legalized medical marijuana. And this legalization has raised concerns about driving under the influence of marijuana.

A number of research groups are now focusing on ways to identify drivers impaired by marijuana. As recently reported by KQED, the Center of Medicinal Cannabis Research at the University of California, San Diego, are working to “gather data about dosages, time and what it takes to impair driving ability — and then create a viable roadside sobriety test for cannabis.” And a group of Stanford engineers have created a test called a ‘potalyzer.’

The Stanford effort was led by Shan Wang, PhD, a Stanford professor of materials science and engineering and of electrical engineering. He and his colleagues developed a mobile device that detects the amount of tetrahydrocannabinol (THC) molecules in saliva. (THC is the main psychoactive agent in marijuana.)

The test would allow police officers to collect a saliva sample from the driver’s mouth with a cotton swab, analyze it with the new device, and then read the results on a smartphone or laptop in as little as three minutes.

The technology combines magnetic nanotechnology with a competitive immunoassay. During the test, saliva is mixed with antibodies that bind to both THC molecules and magnetic nanoparticles. The mixture is placed on a disposable test chip, inserted into the handheld device and the THC-antibody-nanoparticles are detected by magnetic biosensors. The biosensor signal is then displayed on a Bluetooth-enabled device.

Wang’s group focused on developing a THC saliva test because it is less invasive and may correlate better with impairment than THC urine or blood tests. Also key is the need for a very sensitive test. A Stanford news release explains:

“Wang’s device can detect concentrations of THC in the range of 0 to 50 nanograms per milliliter of saliva. While there’s no consensus on how much THC in a driver’s system is too much, previous studies have suggested a cutoff between 2 and 25 ng/ml, well within the capability of Wang’s device.”

There is still a lot to do before police can deploy this ‘potalyzer’ device, including making it more user-friendly, getting it approved by regulators and investigating whether there is a better biomarker to detect marijuana impairment than THC. In addition, the test may not work well for THC edibles, the researchers wrote in a recent paper published in Analytical Chemistry.

On the upside, the Stanford technology could also be used to test for morphine, heroin, cocaine or other drugs — and for multiple drugs at the same time.

More research is needed, but there is now a new funding source in California: Proposition 64 allots millions of dollars per year to research marijuana and develop ways to identify impaired drivers.

This is an expanded version of my Scope blog story, courtesy of Stanford School of Medicine.

Quitting smoking: Best drug differs for men and women

July 22, 2016

It’s tough to quit smoking. I’ve seen friends and family members struggle with nicotine withdrawal symptoms: cravings for tobacco, anxiety, anger, irritation, increased hunger and even trouble thinking.

One out of six adults in the United States currently smoke and about half of them are trying to quit, but the success rate remains low. What’s the best way to stop smoking? A new study may help point the way — for women.

The study found that a medication frequently used to help smokers quit is more effective for women than men. Philip Smith, PhD, assistant medical professor at the City College of New York, led the multi-institutional study: a network meta-analysis of 28 randomized clinical trials involving a total of 14,389 smokers (51 percent female).

The researchers did a head-to-head comparison between the three common types of medications used for smoking cessation: the nicotine patch, varenicline (sold as Chantix and Champix) and sustained-release bupropion (sold as Wellburtin or Zyban). The quit rate of the participants was based on biochemical verification of their abstinence after six months.

The authors reported in their new paper in Nicotine & Tobacco Research:

“Women treated with varenicline were 41 percent more likely to achieve 6-month abstinence compared to women treated with TN [transdermal nicotine patch], and were 38 percent more likely to achieve 6-month abstinence than women treated with bupropion. For men, the benefit of varenicline over TN and bupropion were smaller and were not statistically significant.”

“Before our study, research had shown that among the choices for medications for smokers who wanted to quit, varenicline was the clear winner when it came to promoting quitting,” said Smith in a recent news release. “Our study shows this is clearly the case for women. The story seems less clear among men, who showed less of a difference when taking any of the three medications.”

The research findings identify varenicline as a particularly potent first option treatment for women. However, the good news for all smokers is that all three medicines significantly improved quit rates for both men and women, when compared with placebo.

If you’re trying to quit smoking, a combination of counseling and medication has been shown to be an effective way to treat tobacco dependence — speak with your doctor or contact a smoking cessation program.

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

Stanford expert calls for more targeted anti-obesity policies

October 28, 2015
U. S. Department of Agriculture's helps educate shoppers about the value of food labeling in December 1975. Photo courtesy National Archives and Records Administration.

U. S. Department of Agriculture helps educate shoppers about the value of food labeling in 1975. Photo courtesy National Archives and Records Administration.

Reality TV shows like “The Biggest Loser” are popular in part because the audience can relate to the participants — more than two-thirds of adults and about one-third of children and adolescents are obese or overweight in the US. The Surgeon General and the Centers for Disease Control and Prevent have declared obesity to be a national epidemic and a major contributor to leading causes of death, including heart disease, stroke, diabetes and some types of cancer.

Although our country is committed to finding solutions to the increase in obesity, public policies have fallen short, according to Deborah Rhode, JD, a Stanford law professor and legal ethics scholar. In a recent journal article, she wrote:

Many policy responses have proven controversial, and those most often recommended have frequently faced an uphill battle at the federal, state, and local level. At the same time that obesity rates have been rising sharply, many jurisdictions have resisted, or rolled back, strategies such as soda taxes or regulation of advertising directed at children.

In the journal article, Rhode evaluates anti-obesity policies, including calorie disclosure requirements, taxes or bans on sugar-sweetened beverages, food stamp modifications, zoning regulations, children’s marketing restrictions, physical activities initiatives, food policies and education. She suggests that a more targeted approach is needed to combat obesity. For instance, Rhode recommends creative zoning regulations that restrict the location of fast-food restaurants near schools while encouraging healthy food retailers in underserved neighborhoods.

In a Stanford news release, Rhode noted that the first lady Michelle Obama’s “Let’s Move!” campaign against childhood obesity applies to politics as well as physical activity. Rhode summarized, “Although we need more evaluation of policy strategies, we know enough about what works to chart a course of reform. We should act now on what we know.”

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


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