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Aging, Medical Apps, Stanford News, Technology

Stanford Letter Project, which helps users have end-of-life discussions, now available for mobile devices

Stanford Letter Project, which helps users have end-of-life discussions, now available for mobile devices

Stanford_LetterFor many of us, the topic of how we want to spend our final days rarely comes up in discussions with our family members or doctors. And a big reason why is that we think of reflecting on how we want to die as highly emotional and unpleasant.

But there are some compelling reasons to take the time to clarify what matters to you most in your waning days of life: It can reduce stress on your loved ones and help your physician provide a better quality of care.

Earlier this year, VJ Periyakoil, MD, director of palliative care education and training at Stanford, launched the Stanford Letter Project, a campaign to empower all adults to take the initiative to talk to their doctor about what matters most to them at life’s end.

Recently, Periyakoil released mobile app versions of the Stanford Letter Project for both the iPhone and Android. The apps, which offer templates comprised of simple questions aimed at getting the end-of-life conversation rolling, are free and can be downloaded from the iTunes and Google Play stores. Templates are available in Spanish, English, Italian, Taglog, Russian and Hindi.

As Periyakoil explained in a recent 1:2:1 podcast, “2.6 million Americans die every year, and very few of them get to talk to their doctor about their end of life wishes.” She urges every adult to tell their doctors about how they want to spend their last days; she suggests engaging in end-of-life discussions each time you reach a milestone in your life such as getting married, having a baby or being diagnosed with a chronic illness.

Previously: How would you like to die? Tell your doctor in a letter, Stanford doctor on a mission to empower patients to talk about end-of-life issues, Medicare to pay for end-of-life conversations with patients and “Everybody dies – just discuss it and agree on what you want

Research, Science, Stanford News

How Bio-X is fueling the #NextGreatDiscovery

How Bio-X is fueling the #NextGreatDiscovery


The videos, images and stories of #NextGreatDiscovery share two things in common: 1) They reveal the lives and motivations of amazing scientists carrying out basic research, and 2) All the scientists are affiliated with Stanford’s pioneering interdisciplinary institute Bio-X.

Almost 15 years ago, Stanford Bio-X was founded to support biomedical research with an interdisciplinary blend of X, which is to say all the fields across the street from Stanford University School of Medicine – engineering, chemistry, physics, biology, math and statistics as well as the professional schools of business, law and education. Bio-X later came to be housed in the Clark Center, located with crosswalks linking those schools and departments.

Two of the scientists featured in #NextGreatDiscovery recently won Nobel prizes in chemistry, and both discuss the importance of Stanford’s collaborative spirit in their research.

From Michael Levitt, PhD:

The university has the medical school and other departments very close to each other. This means that you can mix together all the sciences whether it is engineering and medicine, mathematics and medicine, statistics and medicine. All of these things are really close together so people are able to interact, groups are able to mix. I think it really is a remarkable environment.

From W.E. Moerner, PhD:

One aspect of research today is that our science has become more and more multidisciplinary. Exciting science occurs at the boundaries between conventional disciplines. Here at Stanford we have a spectacular environment for multidisciplinary work. That’s because in a very close proximity we have all of the humanities and sciences departments, the medical school departments and the engineering departments all close together, essentially across the street from one another right here close to my office.

In the series, scientists discuss the importance of funding for the basic sciences, as federal sources become more scarce. Both Levitt and Moerner have received Seed funding through Bio-X, which support new collaborations between scientists bridging disciplines. These grants are critical for promoting interdisciplinary research through funding at a time when federal resources for early stage collaborations are hard to come by, even for scientists whose research receives a nod from Stockholm.

Previously: #NextGreatDiscovery: Exploring the important work of basic scientists, The value of exploring jellyfish eyes: Scientist-penned book supports “curiosity-driven” research, Basic research underlies effort to thwart “greatest threat to face humanity”For third year in row, a Stanford faculty member wins the Nobel Prize in Chemistry and Stanford’s Michael Levitt wins 2013 Nobel Prize in Chemistry
Photo by Peter van Agtmael/Magnum Photos

Chronic Disease, Palliative Care, Parenting, Pediatrics

Missing out on “normal”: Advice from an expert on how to help kids with serious illnesses

Missing out on "normal": Advice from an expert on how to help kids with serious illnesses

Erica Medina and mom Jan 2012 #2When I first met Erica Medina in 2012, she was already practiced at living in two worlds. Then 17, she loved the ordinary teenage realm of high school classes, basketball and volleyball games, and trips to the mall with her friends. But since her diagnosis with juvenile idiopathic arthritis at age 11, she had also spent a lot of time in the medical world, where she and her doctors struggled to manage the pain caused by a disease that has no cure.

The story I wrote about Erica explained how the two worlds sometimes collided:

Back pain made it taxing to sit through school lectures, go on field trips or walk through the mall with friends. It wasn’t just the pain that bothered her: “When I was younger I hated taking my meds,” Erica said, adding that it felt like “giving up” to take pain medicine.

Stephanie [Erica’s mom] was glad Erica’s doctors tackled this issue head-on. “They convinced her that treating pain has nothing to do with weakness,” she said.

Although juvenile idiopathic arthritis is fairly rare, Erica’s longing for normalcy is not. Children and teenagers with all kinds of chronic and serious conditions have the same desire, says pediatric psychologist Barbara Sourkes, PhD, who directs the palliative care program at Lucile Packard Children’s Hospital Stanford.

A big part of Sourkes’ role is to help children, teenagers and their families navigate the divide between living with a difficult diagnosis and simply being a kid. She’s summarized her insights about this in a thoughtful piece on the blog for Digging Deep, a publication designed to help kids facing health challenges. Young people like Erica “commute” between the normal and medical worlds, “an extraordinary challenge,” Sourkes says. From her piece, here is some of her advice for families and others on how to help:

Be aware and sensitive to the importance of feeling “normal” – as normal as possible – for all children and adolescents living with illness. While we typically focus more on adolescents’ desire to “fit in,” even very young children are sensitive to being “different.” Help them focus on and remember what aspects of their lives – and of themselves – are still the same despite the illness.

“Missing out on things” comes in two categories: (1) missing a specific, often special event or activity (e.g. a celebration, a trip) and (2) missing out on life in general (day-to-day daily life, in all its routine).

Adults tend to focus more on the first category, in part because these are events that stand out from the backdrop of daily life. Allow the child to express disappointment / anger / sadness at the prospect of missing the event – do not try to minimize these feelings. After the event, it is very important to let children know that people asked about them and that their presence was missed. It makes the “missing out on things” a little more shared and less one-sided. When realistically possible, promise the child that they will participate in a similar event at a future time.

The second category of “missing out on life in general” is more ongoing and subtle, and probably has more impact on adolescents than on young children. It is also harder to address, since it encompasses all the frustration and sadness of the impact of the illness. Most important is simply to listen to what the children say, without trying to distract them or “problem solve” or cheer them up. These are times that they may just want to be heard and to have their hardship acknowledged.

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Addiction, Behavioral Science, Genetics, Neuroscience, Research, Stanford News

Found: a novel assembly line in brain whose product may prevent alcoholism

Found: a novel assembly line in brain whose product may prevent alcoholism

alcohol silhouette

High-functioning binge drinkers can seem charming and stylish. The ultimate case in point: Nick and Nora of the famed Thirties/Forties “Thin Man” film series (you can skip the ad after the first few seconds).

But alcoholism’s terrific toll is better sighted on city streets than in celluloid skyscraper scenarios. At least half of all homeless people suffer from dependence on one or another addictive drug. (My Stanford Medicine article “The Neuroscience of Need” explores the physiology of addiction.) Alcohol, the most commonly abused of them all (not counting nicotine), has proved to be a particularly hard one to shake.

Alcoholism is an immense national and international health problem,” I wrote the other day in a news release explaining an exciting step toward a possible cure:

More than 200 million people globally, including 18 million Americans, suffer from it. Binge drinking [roughly four drinks in a single session for a man, five for a woman] substantially increases the likelihood of developing alcoholism. As many as one in four American adults report having engaged in binge drinking in the past month.

While there are a few approved drugs that induce great discomfort when a person uses them drinks alcohol, reduce its pleasant effects, or alleviate some of its unpleasant ones, there’s as of yet no “magic bullet” medication that eliminates the powerful cravings driving the addictive behavior to begin with.

But a study, just published in Science, by Stanford neuroscientist Jun Ding, PhD, and his associates, may be holding the ticket to such a medication. In the study, Ding’s team identified a previously unknown biochemical assembly line, in a network of nerve cells strongly tied to addiction, that produces a substance whose effect appears to prevent pleasurable activity from becoming addictive. The substance, known as GABA, acts as a brake on downstream nerve-cell transmission.

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Neuroscience, Pediatrics, Research

Tutoring changes the brain in kids with math learning disabilities

Tutoring changes the brain in kids with math learning disabilities

One-on-one tutoringA new Stanford study, publishing today in Nature Communications, sheds light on how to help children with math learning disabilities. One-on-one cognitive tutoring improves math performance and also normalizes problems in several parts of the brains of these children, the research found.

The findings are important because math learning disabilities often fall off educators’ and parents’ radar. (Everyone has heard of dyslexia, but its numerical equivalent, dyscalculia? Not so much.) Yet math learning disabilities can hamper a child’s ability to gain basic life skills such as managing time and money, and can prevent children from growing up to pursue math- and science-related careers.

The new study is similar to another recent experiment that demonstrated alleviation of math anxiety with tutoring. Both studies are the work of the Stanford MathBrain Project, led by Vinod Menon, PhD.

In the new research, 30 children in third grade received eight weeks of one-on-one tutoring in basic arithmetic skills; half of the kids had math learning disabilities and half did not. The instructors adjusted the sessions’ pace and emphasis individually for each child, helping students past bottlenecks in their learning without making them feel like they might be falling behind their peers. All of the children got MRI brain scans before and after tutoring.

Before tutoring began, the kids with math learning disabilities had abnormal function in a network of brain areas involved in solving numerical problems, including the parietal, prefrontal and ventral temporal-occipital areas. Kids without math learning disabilities did not show these problems. After tutoring, the differences between the two groups’ brain scans disappeared. The children’s math performance also improved, in sync with the brain changes.

These findings suggest that tutoring actually fixes the brain issues at the root of math learning disabilities, rather than providing children with a work-around that circumvents the real problem.

“We demonstrate that, in parallel with performance normalization, 1:1 tutoring elicits extensive functional brain changes in children with math learning disabilities, normalizing their brain activity to the level of neurotypical peers,” the researchers wrote in their paper.

The scientists want to conduct follow-up studies to find out how long the effects of tutoring last. Their new discoveries also lay a framework for studying how to intervene in other forms of learning disabilities.

Previously: Stanford team shows that one-on-one tutoring relieves math anxiety in children, Stanford team uses brain scans to forecast development of kids’ math skills and New research tracks “math anxiety” in the brain
Photo by U.S. Department of Education

Health and Fitness, Public Health, Research

Study shows taking short walks may offset negative health impact of prolonged sitting

Study shows taking short walks may offset negative health impact of prolonged sitting

3046594832_cc702e6266_zWhile most of us know that sitting for prolonged periods of time can be detrimental to our health, sometimes, despite our best intentions, we’re locked into our seats by other circumstances. Perhaps you’re on a long flight with lots of turbulence and, even though our activity tracker is buzzing us to stand up, the fasten seatbelt sign forces you to ignore the alerts. Or maybe you’re at a daylong workshop or training and the opportunities to stretch your legs are few and far between. But recent research suggests that you may be able to counteract such periods of prolonged sitting with a short walk.

In the small study published in Experimental Physiology, researchers at the University of Missouri and University of Texas at Arlington compared the vascular function of a group of healthy men at the beginning of the project, after sitting for six hours and again once they completed a short walk. Results confirmed that when you sit for the majority of an eight-hour work day, blood flow to your legs is significantly reduced. The findings also showed “that just 10 minutes of walking after sitting for an extended time reversed the detrimental consequences,” lead author Jaume Padilla, PhD, said in a release.

In addition to keeping your vascular system in good working order, walking can boost your creative inspiration. A past Stanford study showed a person’s creative output increased by an average of 60 percent when he or she was walking.

Previously: Does TV watching, or prolonged sitting, contribute to child obesity rates?, More evidence that prolonged inactivity may shorten life span, increase risk of chronic disease, Study shows frequent breaks from sitting may improve heart health, weight loss and How sedentary behavior affects your health
Photo by Laura Billings

Cardiovascular Medicine, Research, Stanford News, Stem Cells

Tension helps heart cells develop normally, Stanford study shows

Tension helps heart cells develop normally, Stanford study shows

heart_newsTension might not be fun for us, but it looks like it’s critical for our hearts. So much so that without a little tension heart cells in the lab fail to develop normally.

This is a finding that took a mechanical engineer looking at a biological problem to solve. For many years now scientists have been able to mature stem cells into beating clumps of cells in the lab. But although those cells could beat, they didn’t do it very well. They don’t produce much force, can’t maintain a steady rhythm and would be a failure at pumping actual blood.

Beth Pruitt, PhD, a Stanford mechanical engineer, realized that in our bodies heart cells are under considerable tension, and thought that might be critical to how the cells develop.

She and postdoctoral scholar Alexandre Ribeiro started investigating how heart cells matured in different shapes and under different amounts of tension. They found a combination that produces normal looking cells with strong contractions.
The work could be useful for scientists hoping to replace animal heart cells as the gold standard for identifying heart-related side effects of drugs. Those cells are quite different from our own and often fail to detect side effects that could damage hearts in people taking the drug.

In my story about the work, I quote Ribeiro saying, “We hope this can be a drop-in replacement for animal cells, and potentially instead of having to do individual recordings from each cell we could use video analysis.”

Previously: A new era for stem cells in cardiac medicine? A simple, effective way to generate patient-specific heart muscle cells and “Clinical trial in a dish” may make common medicines safer, say Stanford scientists
Photo by Alexandre Ribeiro

Research, Stanford News, Women's Health

Measuring how military service affects women’s longevity and overall health

Measuring how military service affects women's longevity and overall health

16044566446_77b89745de_zDespite the large numbers of women who serve in the military, there is a dearth of information about their postmenopausal health risks and how military service might impact their longevity. Now comes a study of more than 3,700 female veterans, led by a Stanford-affiliated psychologist, which is the first to examine the postmenopausal health of women veterans who participated in the Women’s Health Initiative (WHI) and who, given their ages, likely served in World War II or the Korean War.

The study, which appears online in the journal Women’s Health Issues, shows these women have higher all-cause mortality rates than non-veterans, even though their risks for heart disease, cancer, diabetes and hip fractures were found to be the same.

“The findings underscore the salience of previous military service as a critical factor in understanding women’s postmenopausal health and mortality risk, and the value of comparing women veterans to appropriately selected groups of non-veteran women, rather than benchmarking their health against that of the general public. It also reminds us of the importance of including women veterans in research,” said Julie Weitlauf, PhD, the study’s lead author and a clinical associate professor (affiliated) of psychiatry and behavioral sciences at the School of Medicine.

The Women’s Health Initiative is one of the most comprehensive research initiatives undertaken on the post-menopausal health of women, involving more than 160,000 women, including nearly 4,000 veterans.

Women can only serve in the military if they are deemed to be in good health, and military service stresses physical activity and many other elements of a healthy lifestyle, thus contributing to the concept of a “healthy soldier effect,” Weitlauf said. That explains why research typically shows that veterans, including women, have better health and lower mortality risk than non-veterans from the general public, she said. While the women in the study, most of whom who were likely military nurses, were probably very fit and healthy during their time of service, this effect may not be sustained throughout their lifetimes.

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Medical Education, Medicine and Society, Stanford Medicine Unplugged

Learning how to learn medicine

Learning how to learn medicine

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.

A few weekends ago, I saw a patient with bloated shins at our school’s free clinic, and I marked in my notes that she exhibited “peripheral edema,” an esoteric phrase that means little to those outside of the medical community. That experience only highlighted the tendency in medicine to inflate common bodily functions into opaque medical jargon. Its use can be frustrating for patients who are trying to understand their illness — and at times even for the uninformed medical student who is trying to learn about his patient.

As medical students, we feel as if we’re training to become glorified breathing-and-walking medical dictionaries

It doesn’t help that the list of jargon is endless. Itchiness becomes pruritus. Listening to the body’s internal noises condenses into auscultation. When you urinate, you’re really micturating, and if you have trouble doing so, you also have dysuria. Having a rash turns into having erythema. An abnormally large liver translates to hepatomegaly. An unhealthy level of cholesterol is labeled as hyperlipidemia. Chest pain is referred to as angina. Even the simple act of sweating is termed hidrosis. For vast majority of the first two years of medical school, we spend our time learning this vast and complex language that seems to have a word or phrase for every single bodily event — health and unhealthy, normal and abnormal.

But that is what medical training and much of medicine are — making observations of the human body and noting them with memorized jargon. And once we have acknowledged all the relevant observations, we connect the dots to form a story. If we’re astute and lucky enough, that story will end with the name of the disease along with its possible treatments and cures.

One would think that in order to provide adequate treatment to our patients, our education would possess more depth into the mechanisms behind drugs and diseases. But we only graze their physiological and molecular basis. It isn’t a reflection on our lack of curiosity. Rather, unfortunately, medicine is still limited by our dearth of knowledge. Despite the trillions of dollars poured into research, our advances in human genomics, and the fancy gadgetry, the human body remains a stubborn black box. Most of the time, all we can do is look at the inputs and outputs. Take aspirin, for example. Cardiologists recommend patients with a history of cardiovascular disease to take a baby aspirin every day to reduce their chances of a heart attack. But how this drug — first discovered by the ancient Egyptians — leads to decreased risk of death still remains a mystery.

These days, patients can sequence their entire genomes at a speed and price that was unimaginable a decade ago. They can scan their entire bodies to produce images with unprecedented detail. But in a unexpected twist, in order to confirm a diagnosis, physicians may still resort to the primitive practice of taking a gross piece of tissue from the patient and viewing it under a compound microscope, a contraption invented nearly half a century ago. Our expensive technology has been only able to expand our ability to observe and has done little peel back the veil covering the underlying mechanisms of human diseases.

But that is not to say that we should lose faith in medicine and underestimate the importance of labeling our observations. For the patient, putting a name on an abnormality, even if there may no treatment available, can be comforting and give hope for recovery. For the caretaker, being able to identify an important physical finding can point to a set of suspect diseases. For my patient, leg swelling strongly suggested that he might be suffering from congestive heart failure.

As medical students, we must feel as if we’re training to become glorified breathing-and-walking medical dictionaries. Make no mistake — we are. We’re learning to make observations, note them down, and make sense of them down the road. And we shouldn’t underestimate the power of this process. It is at the core of the scientific process, and it’ll be how we ultimately serve our patients.

Steven Zhang is a second-year medical student at Stanford. When he’s not cramming for his next exam, you can find him on a run around campus or exploring a new hiking trail.

Photo in featured entry box by Patrick

Health Policy, NIH, Research, Science Policy, Stanford News

NIH tries to reduce the gray in the grant pool

NIH tries to reduce the gray in the grant pool

This 45-second animation vividly illustrates the funding crisis that young scientists face as they work to launch their research careers: For the last three decades, large NIH grants have increasingly been awarded to older investigators.

“The average age of first-time, R01-funded investigators who have PhDs remains 42, even after seven years of policies at NIH to increase the numbers of new and early-stage investigators,” said Robin Barr, director of the NIH’s Division of Extramural Activities, in a recent editorial on the NIH website.

But there is hope on the horizon, as the NIH rolls out a series of funding mechanisms that aim to give new investigators a leg up. I recently wrote about one such program, the KL2 mentored career development award, and an inspirational Stanford physician-researcher, Rita Hamad, MD, MPH, who is taking full advantage of it.

Hamad is interested in studying the cause-and-effect relationships between poverty and health. The KL2 program helps Hamad’s research through salary support, mentoring, pilot grants and tuition subsidies. In just two years, she has produced actionable data that can be used by policymakers and by health-care providers to improve the overall health of populations, including a study exploring the impact of the earned-income tax credit on child health in the United States. It will be published this fall in the American Journal of Epidemiology.

Previously:NIH funding mechanism “totally broken,” says Stanford researcher, NIH director on scaring young scientists with budget cuts: “If they go away, they won’t come back” and Sequestration hits the NIH – fewer new grants, smaller budgets
Animation by the NIH

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