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Grand Roundup

Grand Roundup: Week of Oct. 19

Grand Roundup: Week of Oct. 19

The five most-read stories this week on Scope were:

“Stop skipping dessert:” A Stanford neurosurgeon and cancer patient discusses facing terminal illness: Paul Kalanithi, MD, a chief resident in neurological surgery at Stanford, was diagnosed at age 36 with stage IV lung cancer. In this Q&A, he talks about his experiences and about the importance of end-of-life decisions.

Why “looking dumb” in medical school isn’t such a bad thing: In the latest installment of SMS Unplugged, first-year medical student Nathaniel Fleming describes how asking questions is an important part of early medical training.

“Every life is touched by suicide:” Stanford psychiatrist on the importance of prevention: Laura Roberts, MD, chair of Stanford’s Department of Psychiatry and Behavioral Sciences, had the opportunity as editor-in-chief of the journal Academic Psychiatry to focus attention on suicide prevention. She talks about the special issue and about suicide prevention in this Q&A.

Unbroken: A chronic fatigue patient’s long road to recovery: A video and Stanford Medicine magazine story talk about research being done at Stanford on chronic fatigue syndrome and tell the story of CFS patient “Erin.”

Screening could slash number of breast cancer cases: Research published this week in Cancer Epidemiology, Biomarkers & Prevention by Stanford researchers offers intriguing evidence that genetic screening at birth could help prevent breast cancer.

And still going strong – the most popular post from the past:

What are the consequences of sleep deprivation?: Brandon Peters, MD, an adjunct clinical faculty member at the Stanford Center for Sleep Sciences and Medicine, explains how lack of sleep can negatively affect a person’s well-being in this Huffington Post piece.

Health and Fitness, Nutrition

Eat well, be well and enjoy (a little) candy

Eat well, be well and enjoy (a little) candy

260823789_3eda4b0439_oAs Halloween treats fill cupboards, jack-’o-lanterns and workplace counters, I bet you’re hunting for a middle ground between candy glutton and candy curmudgeon. Anticipating this tricky balance, Stanford dieticians Rosalyne Tu, MS, RD and Raymond Palko, MS, RD, offered some healthy eating tips in this BeWell@Stanford feature:

What are some common pitfalls during the holidays that can contribute to weight gain?

RP: Often, the concept of “moderation” can undermine our good intentions. Moderate eating does not mean consuming two pieces of pumpkin pie instead of three. Rather, it means having a small slice of pie, one or two times over the course of a week.

RT: Sometimes we are too “good” about budgeting our calories and we skip meals or under-eat during the day to save up calories for large holiday meals. This strategy can backfire on us because our appetite hormones get very strong and we end up in less control of our appetites, causing us to overeat later. Our bodies were designed to treat starvation as our worst enemy; therefore, when we are hungry, we naturally crave highly caloric foods (high sugar and fat). For some people, giving in to these foods brings on feelings of guilt when the biological response was natural.

RP: Increased alcohol consumption is another road bump. At parties, alcohol can flow freely, and it is very calorically dense without any nutritional benefits.

RT: Liquid calories are often empty calories. Alcohol, specifically, can promote overeating because of its ability to break down willpower while causing blood sugars to drop — both of which could encourage overeating.

But it’s still possible to enjoy your favorite treats, the two dieticians said:

RT: Food is meant to be enjoyed! Give yourself permission to enjoy your favorite treat and practice eating mindfully. Eat your treat like it is a fine dining experience: slow down, savor every morsel, and minimize the distractions like the television and computer. Eating mindfully helps your body decide how much it is truly hungry for.

Previously: When it comes to weight loss, maintaining a diet is more important than diet type, Where is the love? A discussion of nutrition, health and repairing our relationship with food and How to avoid a candy-coated Halloween
Photo by Juushika Redgrave

Cancer, Patient Care, Stanford News, Videos

How a new Stanford program is helping transform cancer care

How a new Stanford program is helping transform cancer care

Earlier this week my colleague wrote about a new program where experienced nurses help newly diagnosed cancer patients navigate their medical care. The video above talks more about the program (“We want to take the fear away from our patients and their family,” explains oncologist Oliver Dorigo, MD, PhD) and how it fits into Stanford’s efforts to transform cancer care.

Previously: Pioneering cancer nurses guide patients through maze of care, Ironman of Stanford Women’s Cancer Center and Director of the Stanford Cancer Institute discusses advances in cancer care and research

Cancer, Events, Genetics, Imaging, Stanford News, Surgery, Women's Health

Don’t hide from breast cancer – facing it early is key

Don't hide from breast cancer - facing it early is key

cat_hiding-pgMy cat suffers from acute anxiety. Although she and I have lived together for more than 12 years, and the worst thing I’ve ever done to her was cut her nails, she’s terrified of me. (She’s also very smart – she runs from the sound of my car, but not my husband’s). During trips to vet, Bibs hides her eyes in the crook of my elbow.

It’s a strategy that’s only minimally effective. After all, what I can’t see, or don’t recognize, can still hurt me.

Take breast cancer. It terrifies most women. And if you don’t look for it, you won’t find it. But if you do look, and find it early, you might save your life and your breast, says Amanda Wheeler, MD, a Stanford breast surgeon. She joined other Stanford breast cancer experts at a recent public program sponsored by the Stanford Women’s Cancer Center called “The Latest Advancements in Screening and Treatment for Breast Cancer.”

“One of our biggest challenge is women are scared of breast cancer, but[we have to get] the word out that we have such great advances, we’ve just got to catch it early,” Wheeler said.

She pointed to a tiny dot on a screen. At that size, Wheeler said, breast cancer is almost 100 percent curable. She performs a small lumpectomy. If it’s a little bigger, she can still probably save the nipple.

And if the entire breast must be removed, surgeons like Rahim Nazerali, MD, come in. Nazarali explained the importance of choosing a reconstruction surgeon carefully: The doctor should be accredited by the American Society of Plastic Surgeons and have experience with microsurgery, preferably on the breast. There are different ways to remold a breast and doctors can use either a synthetic implant or a patient’s own tissue, from their abdomen, hips or thighs, Nazerali explained.

All of Wheeler and Nazerali’s artistry depends on expert imaging performed by specialists like Jafi Lipson, MD, whose message at the event was simple and encouraging.

Thanks to many new developments, mammography isn’t the only way to detect nascent breast cancers, Lipson said. Her team can employ 3-D mammography, or tomosynthesis, to reveal a layered look at a breast. And genetic screening, particularly for those with a history of breast cancer in the family, can provide the earliest warning signal of all, the breast cancer team said.

Women no longer need to hide their eyes from the risk, the experts emphasized. Women should take a peek – there’s help coping with what they may find.

Previously: Screening could slash number of breast cancer cases, The squeeze: Compression during mammography important for accurate breast cancer detection, Despite genetic advances, detection still key in breast cancer, NIH Director highlights Stanford research on breast cancer surgery choices, Breast cancer awareness: Beneath the pink packaging and Using 3-D technology to screen for breast cancer
Photo by Notigatos

Cancer, Events, In the News, Patient Care, Stanford News

A neurosurgeon’s journey from doctor to cancer patient

A neurosurgeon's journey from doctor to cancer patient

image.img.320.highEarlier this week, I had the chance to hear Stanford neurosurgeon Paul Kalanithi, MD, discuss living with advanced-stage lung cancer in a conversation with palliative care specialist Timothy Quill, MD. The idea for the night’s event, which was held on the Stanford medical school campus, was to provide a good example of how the doctor-patient relationship can help improve quality of life for the very sick. On stage before a packed audience, Kalanithi, prodded by Quill’s gentle but pointed questions, told the story of how serious illness changed his life. As I wrote in an online story posted yesterday:

“Are there things in particular that you worry about now?,” asked Quill… a professor of psychiatry and medical humanities at the University of Rochester School of Medicine and an expert in end-of-life decision making. “Not really,” [Kalanithi] said. “I am sad at not seeing my daughter grow up, at probably not being here long enough for her to have a memory of me. I try to worry about things that are actually changeable. I worry about getting my book finished. I’d like to have that done for my daughter to know me.”

What surprised Kalanithi most about his life after being diagnosed with lung cancer was just how hard it was dealing with those “existential” questions, he told Quill:

“Having to deal with questions like, ‘What am I going to do with my life?’ was exceedingly difficult. After realizing I wasn’t going to die in weeks or months, figuring out what I was going to do with that time was a struggle.”

Kalanithi has reorganized his priorities since his diagnosis in May 2013, setting new priorities for a much shorter lifespan than he once expected – planning for years instead of decades. He and his wife got their finances in order, they had their first child July 4. Kalanithi said he has found solace in his love of poetry, and through his writing. Kick-starting a writing career that he had planned to start in 20 years was one of those changes.

In January, he wrote an op-ed piece for the New York Times about his cross over from physician to patient titled: “How long have I got left?” He told the audience how surprised he was at the overwhelmingly positive response he received to the story. “My own thoughts on something very personal, really resonated with people. I still get an email every other day in response to the New York Times piece. It’s a great inspiration to me to remember why writing is important.” [Editor's note: Kalanithi's recent Q&A here on Scope has also drawn massive attention; it's already one of our most popular posts of the year.]

Kalanithi’s final message, particularly to those young physicians and medical students in the audience, was to listen to your patients. Take time to get to know them. Remember why it is that you went to medical school. When asked if he treats his own patients differently since his diagnosis, he was characteristically thoughtful. “I think I felt a depth that I didn’t before… But I had excellent role models. I was trained you don’t just go over what are the risks and benefits. You really try to convey as much as you can about what it’s going to feel like.” He told his favorite example of a pediatric oncologist who he observed talking to parents whose daughter had just been diagnosed with a brain tumor. The doctor’s advice: “You need to support each other. You have to prepare your patients as much as you can for that larger emotional experiential landscape. You have to get enough sleep.”

Previously: “Stop skipping dessert:” A Stanford neurosurgeon and cancer patient discusses facing terminal illness and No one wants to talk about dying but we all need to.
Photo by Norbert von der Groeben

Cancer, Genetics, Medicine and Society, Research, Stanford News, Women's Health

Screening could slash number of breast cancer cases

Screening could slash number of breast cancer cases

dna-163466_1280Should every newborn baby girl be genetically screened to prevent breast cancer? Obviously, that isn’t cost-effective — yet. But if it were, would it be worthwhile?

A previous study said no. But research published today in Cancer Epidemiology, Biomarkers & Prevention by Stanford researchers suggests otherwise.

Led by senior author Alice Whittemore, PhD, the team examined 86 gene variants known to increase the chances of breast cancer. They created a model that accounted for the prevalence of each variant and the associated risk of breast cancer. Each possible genome was then ranked by the likelihood of developing breast cancer within a woman’s lifetime.

“It was quite a computational feat,” Whittemore told me.

Working with Weiva Sieh, MD, PhD; Joseph Rothstein, PhD; and Valerie McGuire, PhD, the team found that women whose genomes ranked within the top 25 percent of risk include 50 percent of all future breast cancers. Those women would then have the opportunity to get regular mammograms, watch their diets and make childbearing and breast-feeding decisions with the awareness of their higher risk. Some women might even select, as Angelina Jolie did quite publicly, to have their breasts removed.

“The main takeaway message is we can be more optimistic than previously predicted about the value of genomic sequencing,” Whittemore said. “But we still have a way to go in preventing the disease.”

“Our ability to predict the probability of disease based on genetics is the starting point,” Sieh said. “If a girl knew, from birth, what her inborn risk was, she could then make more informed choices to alter her future risk by altering her lifestyle factors. We also need better screening methods and preventative interventions with fewer side effects.”

“We want to focus on those at the highest risk,” Whittemore said.

Previously: Despite genetic advances, detection still key in breast cancer, NIH Director highlights Stanford research on breast cancer surgery choices  and Breast cancer awareness: Beneath the pink packaging 
Photo by PublicDomainPictures

Biomed Bites, Genetics, Research, Stanford News, Videos

DNA architecture fascinates Stanford researcher – and dictates biological outcomes

DNA architecture fascinates Stanford researcher - and dictates biological outcomes

It’s time for the next edition of Biomed Bites, a weekly feature that highlights some of Stanford’s most innovative research and introduces Scope readers to groundbreaking researchers in a variety of disciplines. 

It’s a puzzle that would delight puzzle master Will Shortz: How do you pack 2 meters of DNA into a container (the nucleus) only .000005 meters wide? Precisely, and according to plan, it seems. Stanford biophysicist Will Greenleaf, PhD, studies the architecture of the genome, building on the knowledge that DNA’s shape effects how a gene is expressed.

In the video above, Greenleaf, now an assistant professor of genetics, explains: “The genes have to be unpacked to be expressed. The mechanics of that are really fascinating.”

Greenleaf is a physics guy, earning a PhD in applied physics at Stanford to build on his undergraduate Harvard physics degree. He has also studied computer science and chemistry, bringing all of this knowledge to bear on demystifying the structure of DNA, and its RNA offshoots. Greenleaf and his team also develop new instruments needed to measure, see and manipulate DNA structure.

This is important for many reasons, but most directly to treat chromatinopathies, or diseases caused by the improper folding or structure of DNA and its associated proteins.

Learn more about Stanford Medicine’s Biomedical Innovation Initiative and about other faculty leaders who are driving forward biomedical innovation here.

Previously: Caught in the act! Fast, cheap, high-resolution, easy way to tell which genes a cell is using, “Housekeeping” protein complex mutated in about 1/5 of all human cancers, say Stanford researchers and Mob science: Video game, EteRNA, lets amateurs advance RNA research

Cardiovascular Medicine, Chronic Disease, In the News, Research, Science, Stanford News

How best to treat dialysis patients with heart disease

How best to treat dialysis patients with heart disease

523392_4923732760_zKidney failure patients on dialysis often have other chronic diseases – heart disease topping the list. They’re prescribed an average of 12 pills a day by physicians, according to Stanford nephrologist Tara Chang, MD, and they spend three-to-four hours at a treatment center three times a week connected to an artificial kidney machine.

For Chang, this makes it all the more important that any medication she prescribes for a patient on dialysis is both essential and effective.

The problem is, particularly in the case of treating kidney patients with heart disease, evidence-based treatment guidelines just aren’t available. Kidney doctors are left making best guesses based on guidelines written for the general population.

“Our patients might be different from patients not on dialysis,” said Chang. “Dialysis patients have a lot of heart disease, yet rarely does a cardiology study enroll patients on dialysis, so we just don’t know.”

This was part of the motivation behind Chang’s most recent study examining the use of anti-platelet drugs such as clopidogrel, one of the most commonly prescribed drugs for kidney patients. The researchers looked at the use of anti-platelet medications such as clopidogrel as treatment following stenting procedures to unclog arteries in the heart in 8,458 dialysis patients between 2007 and 2010. The data suggests that longer-duration of drug use may be of benefit to patients on dialysis who get drug-eluding stents but not those who get bare metal stents. Chang told me:

We found that for those who got drug-eluting stents who took the drug for 12 months compared to those who had stopped the drug at some earlier time point, there was a non-statistically significant trend towards lower risks of death and heart attacks. So for this group, following the same guidelines as for the general population may be appropriate. However, we found no indication of benefit with longer duration of anti-platelet drug use for patients on dialysis who got bare metal stents.

About half of the 400,000 patients in the U.S. on dialysis also have coronary artery disease, as referenced in the study. The number of those getting stents inserted to unclog arteries also has increased 50 percent in the past decade, the study states. The results of the study, while not definitive as to exactly how long doctors should prescribe the drug, does stress the need for more clinical research on patients with kidney failure to provide guidance on treatment strategies for heart disease.

“Because our study was not a randomized trial,” said Chang, “we tried to be very measured in how we interpreted the results. What it does point to is the fact that we can’t assume that what works in non-dialysis patients works in dialysis patients. Hopefully our study will help convince researchers to include our dialysis patients in their studies.”

The paper was published this week in the Journal of the American Heart Association.

Previously: Keeping kidney failure patients out of the hospitalStudy shows higher rates of untreated kidney disease among older adults and Study shows daily dialysis may boost patients’ heart function, physical health.
Photo by newslighter

Ask Stanford Med, Health and Fitness

Director of Stanford Runner’s Injury Clinic discusses treating and preventing common injuries

Director of Stanford Runner's Injury Clinic discusses treating and preventing common injuries

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It may surprise you to learn that past studies show that runners have a 50 percent chance of sustaining an injury that disrupts their training, and those that compete in marathons have an incidence rate as high as 90 percent. But don’t hang up your sneakers just yet. Many common aches and pains that nag runners can easily be treated or avoided.

On Thursday, Michael Fredericson, MD, who is director of the Stanford Runner’s Injury Clinic and has been head team physician with the Stanford Sports Medicine Program since 1992, will talk about the latest running prevention and treatment methods during a Stanford Health Library lecture. (For those unable to attend the event in person, you can watch the live webcast starting at 7 PM Pacifiic time.) To kick off the conversation, I reached out to Fredericson to discuss some of the topics of his upcoming talk, including the harms of overstriding, the benefits of cross-training, and remedies for prevalent joint problems. He and Adam Tenforde, MD, a sports medicine fellow at Stanford, responded to my questions.

How can overstriding lead to injury?

The term “overstriding” refers to running with the foot striking the ground too far forward from normal stride length. This results in heel strike pattern that may increase stress in the hip and knee joints. Research has shown that forefoot strike patterns tend to reduce stress on the knees and hips, although this may lead to greater stress on the foot and ankle. We conduct a clinic called RunSafe, where we evaluate gait of runners using video and markers. More efficient stride frequency is 90 strides per leg per minute. When a runner overstrides, this may result in a lower stride rate and an inefficient gait. We evaluate for the causes of overstriding, including poor hip extensor strength (weak gluteal muscles), decreased flexibility and technique and encourage correction of these biomechanical contributors. Also, we may suggest shoes with reduced weight, such as ‘minimalist shoes’ as these tend to encourage a runner to run with a more mid-foot strike pattern. However, we caution any changes in shoe type or technique be introduced gradually to decrease risk of developing an injury from changes in gait pattern that stress the body in a new way.

Why is it important for runners to cross-train?

Cross-training refers to forms of aerobic exercise that do not involve running. Doing exercises that do not involve the repetitive ground-impact experienced during running help to rest tired muscles and decrease stress on bones, assisting in recovery while building aerobic capacity. There are no established forms of cross-training to prevent injuries, but performing exercises that do not involve impact loading through the legs, such as elliptical trainer, cycling or deep water running may be helpful.

Many runners select shoes that compensate for how their foot pronates. But recent research shows that pronating too much or too little may not actually increase a runner’s risk of injury. How important is pronation and foot type in preventing injuries?

We evaluate foot type and pronation during our RunSafe clinics. Pronation is a normal motion that helps to distribute forces while landing through the foot and ankle, reducing stresses through the lower extremities. If the foot abruptly stops moving from too much or too little pronation, the other joints and lower limbs may absorb these forces and can become injured. Foot type (having too high an arch or too flat a foot) may also result in higher forces in the legs and joints through associated biomechanics. Foot type and concerns of pronation need to be put into context of prior injury history, as recent research has suggested that foot type and pronation do not necessarily predict future injury risk.

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Autoimmune Disease, Chronic Disease, Immunology, Stanford News, Videos

Unbroken: A chronic fatigue patient’s long road to recovery

Unbroken: A chronic fatigue patient’s long road to recovery

“Fatigue is what we experience, but it is what a match is to an atomic bomb,” said Laura Hillenbrand, the author of Unbroken, about how it feels to live with chronic fatigue syndrome.

I recently finished a Stanford Medicine story and video (above) about another CFS patient, “Erin,” who asked that her real name not be used. After an acute illness in rural Mexico, Erin went from being an elite soccer player to one of the 17 million people worldwide who suffer from the condition.

Most people who acquire hit-and-run infections go back to their normal lives after a few days. But these patients don’t. They become virtual shut-ins, prisoners of a never-ending cycle of flu-like symptoms, many of them bedridden for years. CFS, also called myalgic encephalomyelitis or ME/CFS, has no known cause or cure, frustrating both patients and physicians.

What makes Erin’s CFS story somewhat rare is its happy ending. With the help of Stanford infectious disease expert José Montoya, MD, and cardiac electrophysiologist Karen Friday, MD, Erin is back to working fulltime and playing soccer.

“Dr. Montoya and doctors like him are heroes for taking up an unpopular disease and patients that most doctors shun,” said Lori Chapo-Kroger, a registered nurse and CEO of the patient charity, PANDORA Org. “He combines his medical expertise and a creative approach with a truly caring heart for suffering patients.”

Dr. Montoya is also collaborating with immunologist Mark Davis, PhD, on the Stanford Initiative on Infection-Associated Chronic Diseases, a research project using cutting-edge technologies to identify the biomarkers and root causes of ME/CFS. Working at the Human Immune Monitoring Center, team members are searching 600 blood samples for infectious microbes, inflammation-related molecules and genetic flaws. In addition, they’re conducting brain scans and physical exams to look for physical abnormalities among these patients.

Early results are promising — the team has discovered a number of measurable biological markers that indicate that ME/CFS patients may be suffering from out-of-control inflammation.

The team’s goal: To find out what is wrong with the immune systems of patients with infection-triggered diseases such ME/CFS and Lyme disease, then figure out how to help them get better.

Previously: Deciphering the puzzle of chronic fatigue syndrome

The HIMC is partially funded by Spectrum, Stanford’s NIH Clinical and Translational Science Award.

Stanford Medicine Resources: