Published by
Stanford Medicine

Cardiovascular Medicine, Patient Care, Stanford News, Technology, Videos

“Liberated from LVAD support”: One patient’s story

“Liberated from LVAD support”: One patient’s story

One of the first things I noticed about Donna Jackson — 68 years old when I met her in 2011 — was her decisive nature. She had a schedule filled with activity, and regardless of how many people (many of her children, grandchildren, great-grandchildren, in-laws and friends live very near at hand) came to visit in her modest home in Central California, she was a certain force of calm. She was also someone who did not like restrictions on what she could do.

Back then, she was just a few months out from surgery at Stanford Hospital to implant a mechanical pump, a left ventricular assist device or LVAD, on her heart. She knew it had saved her life, but she chafed at the battery, back-up battery and controller she had to wear at all times. Before the surgery, she had been a regular at a water aerobics class, and she loved to swim with her grandchildren. Even in those early months, Jackson was leaning on her Stanford doctors to find a way to get her back in the water. She asked her cardiologist, Dipanjan Banerjee, MD, to consider allowing her to swim in a wetsuit.

Banerjee did her one better. It had become apparent to him that she could be one of that small percentage of LVAD recipients whose heart recovers after the rest that the LVAD gives it and who no longer need the device. (He had been waiting, he said, to find a patient “who can be liberated from LVAD support.”) By Spring 2013, a little less than three years after her LVAD implantation, Banerjee and Jackson’s surgeon, Richard Ha, MD, put Jackson in an even smaller percentage. She became the first person to have her LVAD deactivated by catheter in the most minimally invasive approach yet.

The challenge set by Jackson for her Stanford team — and its groundbreaking procedural response — appears today in the August issue of the Annals of Thoracic Surgery. The lead author of the paper is Sanford Zeigler, MD, a cardiothoracic surgery resident.  Ha, surgical director of the hospital’s Mechanical Circulatory Support Program is the paper’s senior author, and Banerjee, medical director of Mechanical Circulatory Support Program, is a co-author. As they explain in the paper, Jackson, nearing 71,  was a high surgical risk for complete removal of the implant — that would have required them to crack open her ribs again — a procedure that’s followed typically by a long and sometimes painful recovery.  So, her doctors instead threaded a slim plastic tube through a small incision to her femoral artery in the groin and up to her aorta, allowed them to plug the flow of blood to the LVAD. Then, they cut, cleaned and capped the wiring powering the LVAD so it no longer emerged from an opening in her abdomen. (The LVAD remains inside Jackson’s chest.)

The new catheter-based deactivation of the LVAD has value beyond Jackson’s way of life, as the paper explains. She inspired the team to begin research on how to predict which LVAD patients might be like her and reach a point where they no longer need the LVAD. “If we can find out which patients are going to recover sooner, we can be more aggressive with them so they can be liberated from the LVAD,” said Banerjee, “and many of these patients will not want or be able to tolerate a complete removal of the LVAD.”

Continue Reading »

Global Health, Infectious Disease, Stanford News

Stanford global health chief launches campaign to help contain Ebola outbreak in Liberia

Stanford global health chief launches campaign to help contain Ebola outbreak in Liberia

A Medical Officer at Lacor hospital in Gulu, 360 kilometers (224 miles) north of the Ugandan capital, Kampala examines a child suspected of being infected with the Ebola virus Tuesday, Oct.17, 2000. Only days after it was announced that an outbreak of Ebola, the world's most feared virus, had struck in northern Uganda the death toll rose to 35 and according to health officials 38 other people have been affected by the virus. (AP Photo/Sayyid Azim)Michele Barry, MD, director of Stanford’s Center for Innovation in Global Health, has launched a fundraising campaign to help combat the Ebola outbreak in Liberia, which has claimed the life of a colleague who mentored residents in the Yale/Stanford Johnson & Johnson Scholars Program.

Samuel Brisbane, MD, was the first Liberian doctor to die in the outbreak, which the World Health Organization says is responsible for 670 deaths in West Africa. Brisbane was an internist who treated patients at the John F. Kennedy Memorial Hospital in the capital city of Monrovia, the country’s largest hospital. A second medical officer has become ill at the hospital, one of the sites for the scholars’ program, Barry told me.

Through the program, Brisbane mentored physicians from Stanford and other institutions who volunteer for six-week stints in resource-limited countries. He quarantined himself after showing signs of illness but died on July 26 after being transferred to a treatment center, Barry said.

Like HIV, the Ebola virus is spread through direct contact with blood or body fluids from an infected individual. Barry said Liberia is in desperate need of personal protective equipment for health care workers, such as masks, gowns and gloves, as well as trained personnel who can do contact tracing and isolation of infected individuals. The Ebola virus has a 21-day incubation period, during which time an infected individual can transmit the virus.

Barry joined an informal fundraising campaign with her colleagues on Tuesday to help Liberian health-care workers contain the spread of the disease, raising $11,000 in 48 hours. Today, she broadened the appeal in an e-mail sent to all Stanford medical school faculty.

Barry has had experience fighting Ebola in Uganda, where she said outbreaks have been limited by isolating patients in outdoor, tented hospitals and where physicians and nurses have had access to good protective gear. In the past, she said the disease typically has had “hot spots” that last a month and then subside.

But the latest epidemic, which has affected patients in Guinea, Sierra Leone and Nigeria, as well as Liberia, has followed a somewhat different path.

“I think we are doing a better job of taking care of patients and keeping them alive longer, so they become more viremic — meaning the virus has spread through their bloodstream — and more infectious,” she said. “And with globalization, there is more traffic across borders so spillover to other countries occurs.”

She said she does not see the disease as a major threat to the United States, where effective infection control methods are widespread.

“I think we need to be vigilant, but I don’t think there needs to be any true concern that this is going to spread to the United States,” she said. “There’s always a risk of a patient coming in unknown to the hospital, but we practice good universal precautions because we have the equipment and we’ve been trained to treat HIV.”

Donations to the health-care project can be made online here.

Photo, from 2000 outbreak in Uganda, by ASSOCIATED PRESS

Media, Podcasts, Surgery

CNN’s Sanjay Gupta, MD: journalist, surgeon, advocate

CNN's Sanjay Gupta, MD: journalist, surgeon, advocate

Gupta - smallWhen the history about medical marijuana’s path to legitimacy is written, CNN’s chief medical reporter Sanjay Gupta, MD, may be more than a footnote. Gupta famously authored a 2009 TIME magazine column decrying efforts to legalize marijuana for medicinal purposes. In a 180-degree turnabout in August 2013, he issued an apology and said he was wrong. He wrote that he didn’t look hard enough at the “remarkable research” indicating that for some illnesses marijuana provided a relief. He told me in this 1:2:1 podcast that while he’s cautious about the impact of marijuana on some brain and psychiatric disorders, he feels that the evidence is clear for certain diseases like epilepsy, neuropathic pain and muscle spasms brought on by MS that cannabis has the power to heal.

I wanted to talk to Gupta for this special issue of Stanford Medicine on surgery not only because of his controversial yea-and-nay positions about weed as medicine but because he’s also a neurosurgeon who still spends time with patients in and out of the OR  between covering health crises around the globe. And in recognition of his clinical and advocacy skills, he was also personally asked by President Obama to consider taking the position of U.S. Surgeon General. (He turned down the offer as the timing just wasn’t right for him.)

And what about this new campaign to Just Say Hello that he launched on Oprah.com? He tells me that if we were a friendlier society – neighbor greeting neighbor -  perhaps we could heal some of the loneliness out there and become a more civilized society.

I asked Gupta, since he travels internationally, whether there’s one universal truth that he finds all human beings seek. “Most everyone wants to do good by their bodies, understand health and how they can improve the health of their family members. I think that the desire for good health and desire for improved function is a universal thing,” he told me. And in his storytelling, what impact does he want to make with the viewer?  What does he want the audience to understand about the world as seen through his eyes?  He said:

If I can explain to them that as the bombs came raining down the same family that was driving their kids to school the day before, grocery shopping after that, stopping at a bank to withdraw some money, that they are now fleeing with whatever few possessions they could garner and run for the border… that they are a lot like families in your own neighborhood… That’s really important to me as a reporter.

Previously: Stanford Medicine magazine opens up the world of surgery and The vanishing U.S. surgeon general: A conversation with AP reporter Mike Stobbe
Illustration by Tina Berning

Ethics, Events, Health Policy, Stanford News, Transplants

At Stanford Health Policy Forum, panelists dig into the issue of organ donation

At Stanford Health Policy Forum, panelists dig into the issue of organ donation

Sally Satel, MD, was a practicing psychiatrist with a long history of scholarly research and policy-making in health care when a diagnosis of kidney failure popped her across the line that separates doctors from patients. Without a transplant or dialysis, the 16 percent of function left in her kidneys wouldn’t last long, and she became one of the 60,000 people in the U.S. waiting for a deceased donor kidney. That was in 2004.

One decade later, there are more than 100,000 people on that list. Last year, according to the National Kidney Foundation, just over 14,000 people received donated kidneys, a number that has remained flat since 2007. About 18 people die every day waiting on the list; another 12 are taken off the list daily because they have become too sick to survive transplant surgery. Satel was lucky – an acquaintance volunteered after others had bowed out – and Satel did receive a life-saving kidney transplant.

We need a transparent, safe and ethical system of exchange

From that unexpected experience, Satel wrote a book, ‘When Altruism Isn’t Enough: The Case for Compensating Kidney Donors,” to highlight the shortage. She also became a vocal advocate for changes in the organ donation system that could improve those increasingly dire numbers. This week, she joined a couple of thousand health professionals and interested others at the 2014 World Transplant Congress in San Francisco and also came here to participate in a Stanford Health Policy Forum on organ donation. She spoke alongside David Magnus, PhD, director of the Stanford Center for Biomedical Ethics, and Tom Mone, former president of the Association of Organ Procurement Organizations.

The forum was hosted by the office of Lloyd Minor, MD, dean of the medical school. “Our Health Policy Forums were created to serve as a platform for experts from Stanford and across the globe to discuss important and sometimes controversial medical topics,” he said in a post-event interview. “Our hope is that fostering dialogue on issues of critical importance to our clinicians and patients will take us one step closer to developing solutions.”

At the forum, moderator/Stanford professor Keith Humphreys, PhD, began the conversation by asking Satel what it was like being on the waiting list. “It was extremely difficult,” she answered. “You’re really put in a position of facing years of dialysis (and the wait for a deceased donor kidney) can be five years. In Los Angeles, it’s almost 10 years. The average person doesn’t survive that long.” Asking friends and family isn’t easy either, she said: “You are asking someone to give you a body part.”

Satel has proposed a system of rewards – “not, a check, but some sort of in-kind incentive like a contribution to a charity or a 401k,” she said. “We need a transparent, safe and ethical system of exchange.”

The ethics of such a compensation system is what worries Magnus, who told the audience:

Every time we’ve drawn a line — ‘Here’s what we think is acceptable’ — [it’s] almost always been erased and moved somewhere else… Because of the incessant drumbeat of need, there’s a tendency to move and move the line, and maybe those moves are okay and appropriate, but it makes the slippery slope very, very, very steep. We have had only two absolutes: the rule that prohibits taking organs while people are still alive and the prohibition of payment. Both of these principles are now under attack.

Continue Reading »

Genetics, Research, Stanford News

A molecular “flag” marks key genes

A molecular "flag" marks key genes

metronome - smallPoint to an important gene in a cell, any cell, from most any creature, and it’s likely to have a particular elongated molecular flag stuck onto the proteins wrapped around its DNA.

This isn’t just a pretty flag, plopped in for decoration. It’s thought to regulate how often this gene is transcribed, according to Anne Brunet, PhD, associate professor of genetics here. She’s the senior author of a study appearing in the July 31 issue of Cell.

Little is known about the importance of transcriptional consistency — how regularly a gene is transcribed, Brunet said. “I think the notion of transcriptional consistency is new, and it’s very important,” she commented in a release. “This is completely uncharted territory.”

It surely matters if a polymerase — that molecular workhorse that kicks off the protein-making process — spurts out dozens of copies, then chills for a bit, picking up only when it is good and ready.

This flag, abbreviated as H3K4me3, physically standardizes the transcription process, ensuring the polymerase pops off copies as if governed by a metronome — tic, tic, tic, tic, tic, tic…

The genes that are important enough to merit this transcriptional timekeeper — about 1,000 per cell, although it’s a different 1000 in each type of cell — can provide clues to the cell’s function, Brunet said. Her team plugged all the data into an online database, which other researchers can use to find the key genes in the cells of their choice.

The opportunities are endless and Brunet, for one, is psyched. Her lab focuses on the biology of aging, but this molecular flag holds all kinds of research promise.

And, as Brunet is keen to point out, it wouldn’t be possible without the megadata-crunching that’s possible at top research universities like Stanford. Other researchers had spotted this stretched-out H3K4me3, but no one had taken the time, or the computing power, to determine its extent and function, Brunet said.

“This is the new era of using available data to make really new hypotheses and new discoveries,” Brunet said.

Becky Bach is a former park ranger who now spends her time writing, exploring, or practicing yoga. She’s currently a science writing intern in the medical school’s Office of Communication & Public Affairs.

Photo by Niki Odolphie

Autism, Neuroscience, Pediatrics, Research, Stanford News

Finding of reduced brain flexibility adds to Stanford research on how the autistic brain is organized

Finding of reduced brain flexibility adds to Stanford research on how the autistic brain is organized

A Stanford brain-imaging study has just shown that the brains of children with autism are less able to switch from rest to taking on a new task than the brains of typically developing children.

According to the study, which appears this week in the scientific journal Cerebral Cortex, instead of changing to accommodate a job, connectivity in key brain networks of autistic children looks similar to connectivity in the resting brain. The degree of inflexibility was linked to the intensity of children’s autism symptoms: those with less flexibility had more severe restrictive and repetitive behaviors, one of the hallmarks of the developmental disorder.

From our press release on the research:

“We wanted to test the idea that a flexible brain is necessary for flexible behaviors,” said Lucina Uddin, PhD, a lead author of the study. “What we found was that across a set of brain connections known to be important for switching between different tasks, children with autism showed reduced ‘brain flexibility’ compared with typically developing peers.” Uddin, who is now an assistant professor of psychology at the University of Miami, was a postdoctoral scholar at Stanford when the research was conducted.

“The fact that we can tie this neurophysiological brain-state inflexibility to behavioral inflexibility is an important finding because it gives us clues about what kinds of processes go awry in autism,” said Vinod Menon, PhD, the Rachel L. and Walter F. Nichols, MD, professor of psychiatry and behavioral sciences at Stanford and the senior author of the study.

The study is the first to examine unusual patterns of connectivity in the brains of children with autism while they are performing tasks; Menon’s team has previously published research on connectivity between different regions of the autistic brain at rest. Some regions of the autistic brain are over-connected to each other, that work has shown, and the degree of over-connection is linked to children’s social deficits, perhaps in part because it interferes with their ability to derive pleasure from human voices. Menon’s lab has also explored how differences in the organization of the autistic brain may contribute to better math performance in some people with autism.

“We’re making progress in identifying a brain basis of autism, and we’re starting to get traction in pinpointing systems and signaling mechanisms that are not functioning properly,” Menon told me. “This is giving us a better handle both in thinking about treatment and in looking at change or plasticity in the brain.”

Previously: Greater hyperconnectivity in the autistic brain contributes to greater social deficits, Unusual brain organization found in autistic kids who best peers at math and Stanford study reveals why human voices are less rewarding for kids with autism

Medicine and Literature, Patient Care, Stanford News, Surgery

Surgery: Up close and personal

Surgery: Up close and personal

gholami - smallTens of millions of patients undergo surgery every year in the United States, yet very few have the opportunity to be on the other side and observe a surgical procedure in action.

I had that rare privilege recently in the course of writing a story for Stanford Medicine magazine about surgery and how far the field has come in recent decades. The operating room, I discovered, is a world unto itself. It’s governed by a strict set of rules to help safeguard patients, but within those strictures, there is an elaborate kind of dance and much artistry in the way clinicians work together and finesse the tools to help heal their patients.

Sepideh Gholami, MD, a six-year surgery resident at Stanford who is featured in the story, said it was in part this sense of artistry – the movement, rhythm and pacing – that attracted her to the profession. And like many surgeons, she found it gratifying to be able to use her hands to fix a problem to quickly restore a patient’s well-being. She describes one of her early experiences, assisting in a procedure to remove a life-threatening tumor from a young man’s colon.

“I remember going to the family afterward, saying that we were able to get it all out, and seeing the glow in their faces,” she told me. She said it was reminiscent of the experience of her own mother, who had a tumor extracted from her breast: “This is how it happened for my mom, who is now disease-free,” she said.

In the story, Gholami talks about her rather unusual path from an early childhood in revolutionary Iran to becoming a surgeon in the United States, as well as the changes in the profession that have opened the way  to young women like her. The story also explores the remarkable innovations in technology that have made the patient experience today far less invasive and less painful. Those innovations, as well as new workplace rules that limit trainees’ hours, have dramatically changed the way young surgeons like Gholami are being trained to become the independent, skilled practitioners of the future.

Previously: Stanford Medicine magazine opens up the world of surgery
Photo of Gholami by Max Aguilera-Hellweg

Cancer, Health Costs, In the News, Stanford News, Videos

TV spot features a more humane approach to late-stage cancer care

Is it possible to cut the costs of late-stage cancer care by 30 percent and provide a much better experience for patients?

That’s the question that recently brought an Al Jazzera America TV news crew out to the VA Palo Alto Health Care System, to interview patients enrolled in a new Stanford-designed pilot study on cancer care. You can watch their 9-minute video on this topic here.

The guiding principle behind this cancer-care program is this: Make sure that patients are fully informed about survival odds and treatment side effects well before they’re on the brink of death, when emotions overwhelm the decision-making skills of patients, their families and clinicians.

“Eighty percent of all cancer patients express a desire to die at home, yet only 10 percent do,” says Manali Patel, MD, the VA hospital oncologist running this study. “These end-of-life conversations, which typically take two hours in the beginning and require many follow-on conversations, are too hard, time-consuming and draining for a busy oncologist to do well.”

For these life-and-death discussions, patients are assigned personal care coaches who help them understand the big picture — treatment side effects, survival odds and pain-relief options. They also have access to a 24-hour symptom-management hotline and an option for in-home chemotherapy.

Architects of this new cancer care model, working with Arnold Milstein, MD, at Stanford’s Clinical Excellence Research Center, estimate that this program will lead to fewer unwanted treatments and expensive emergency room visits, saving the overall heath-care system money, while at the same time improving patient quality of life.

Previously: Communicating with terminally ill patients: A physician’s perspective, Identifying disparities in palliative care among cancer and non-cancer patients, Uncommon hero: A young oncologist fights for more humane cancer care, The money crunch: Stanford Medicine magazine’s new special report and New Stanford center to address inefficient health care

SMS Unplugged

How to get a student-friendly room for under $100

How to get a student-friendly room for under $100

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

Natalia in her roomTo all the incoming med students wanting ideas on how to set up their rooms with the staggering debt of higher education, here’s what I suggest:

  • $13.38 for 32 sq feet of “Thrifty White Hardboard Panel Board,” but we can call it your new best friend. Home Depot
  • $10 for screwdriver and screws. Home Depot
  • $10.79 for dry erase markers, eraser, and spray. Office Depot
  • $4.99 for a 3 pack of scented candles in glass holders. Ikea
  • $2.98 for 300 pack of matches. Home Depot
  • $8.99 for a plastic storage box that fits under most beds – reserve that for the pile of discarded clothes, papers, and notes that you don’t have time to clean up until after finals. Ikea
  • $14.99 for a basic night stand. Let’s be real, you’re going to study late into the night on your bed and fall asleep. Set yourself up with a nightstand so you don’t have to drool on the laptop you were using. Ikea
  • $6.99 for a table lamp to go on your night stand. Ikea
  • $9.99 for curtains – color so it feels like home. Ikea
  • $7.96 for curtain rod set. Ikea
  • $4.99 for the Swedish meatballs. Ikea

Total: $91.06 with room for tax

You’re welcome.

Natalia Birgisson will soon start her second year at Stanford’s medical school. She is half Icelandic, half Venezuelan and grew up moving internationally before coming to Stanford for college. She is interested in neurosurgery, global health, and ethics. Natalia loves running and baking; when she’s lucky the two activities even out.

Photo courtesy of Natalia Birgisson

Research, Science, Stanford News

They said “Yes”: The attitude that defines Stanford Bio-X

They said "Yes": The attitude that defines Stanford Bio-X

bio-X peopleI write a lot about interdisciplinary research (it’s my job), but it was just recently that I heard the best description of what it is that makes interdisciplinary collaborations possible. It came from Carla Shatz, PhD, who directs Stanford Bio-X — an interdisciplinary institute founded in 1998 that brings together faculty from the schools of medicine, humanities & sciences and engineering. She told me:

You have to be able to walk into someone’s lab and say, “You know, I have this problem in my lab. Would you like to have a cup of coffee and talk about it?” And then that person needs to say, “Yes.”

We were talking about a recent report by the National Research Council of the National Academies. They had put together a workshop and then published a report giving advice and best practices for supporting interdisciplinary research. The report used Bio-X as a success story for the type of innovation that can come out of programs that cross disciplines.

Nowhere in the report is there a subhead reading, “Faculty have to say yes,” but a lot of the other advice is straight out of the Bio-X playbook. The institute needs to be located at the cross section of several schools or departments (check). The institute needs a building that brings people together (check). The institute needs to support students (check). The institute needs to be a financial value add rather than taxing participating departments (check).

This isn’t specifically called out in the report, but Shatz added that a good interdisciplinary institute also needs good food. She pointed out that people come from all over campus to eat at Nexus, located in the middle of the Clark Center that houses Bio-X and serves as a focus for its activities. It turns out scientists are just like the rest of us: offer good food and they will come. And then they will chat, and the next thing you know they’ll be collaborating.

I wrote a Q&A with Shatz based on our conversation. From now on, when I hear the phrase “She said yes” I’ll think of her, and her great description of the attitude that underlies collaboration.

Previously: Bio-X Kids Science Day inspires young scientists, Dinners spark neuroscience conversation, collaboration, Stanford’s Clark Center, home to Bio-X, turns 10 and Pioneers in science
Photo from Bio-X

Stanford Medicine Resources: