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Patient Care, Pregnancy, Stanford News, Women's Health

New obstetric hemorrhage tool kit released today

New obstetric hemorrhage tool kit released today

pregnantbelly-3A few years ago, when my niece was born, my sister had a severe postpartum hemorrhage. I remember getting off the phone with my mom, who had just delivered the simultaneous news of the baby’s birth and my sister’s serious condition, and feeling terrified. My sister was being taken into surgery to try to stop the bleeding. What if she died? In the U.S., deaths from postpartum hemorrhage are rare, but they do happen.

The first thing that gave me a sense of reassurance, strangely, was a search of the medical database PubMed. After I got off the phone, I sat at my laptop looking at a multicolored flow chart that summarized how to stop an obstetric hemorrhage. All of the steps taken by my sister’s medical team were listed. Although she was hundreds of miles away, I felt comforted by the knowledge that her doctors were following well-established, evidence-based guidelines for what to do.

It wasn’t until a few minutes later that I realized the flow chart was developed by doctors I know. It was part of the Obstetric Hemorrhage Toolkit, a set of guidelines published by the California Maternal Quality Care Collaborative (CMQCC). I had first heard of the toolkit from a Stanford obstetric anesthesiologist who helped put it together, but had never imagined it might save someone in my family.

The toolkit was developed because maternal hemorrhages are rare, risky, and extremely time-sensitive. The kit gives medical teams the information they need to rehearse for, recognize and treat these hemorrhages immediately, without wasting minutes that could save the patient’s life.

Today, the CMQCC is releasing a new version of the toolkit. The update strengthens several areas of the kit, providing clearer parameters for use of certain medications and blood products and more information about how to support patients and families after a maternal hemorrhage, for instance.

And the flow chart I found calming is still there, on page 21 of this .pdf file. I’m so happy to see it again because, for me, it symbolizes the doctors, patients and families who will benefit from the kit in the future.

As for my family’s story, my mom called back later on the evening of my niece’s birth to tell me that the bleeding had stopped and my sister was recovering. Her introduction to motherhood was rougher than most, but today my sister and her daughter are fine: My favorite moment of a recent family gathering was seeing my chubby-cheeked niece racing toward me yelling “Aunnnnntie Errrrin!” with my beloved sister in hot pursuit behind her.

Previously: In poorest countries, increase in midwives could save mothers and their babies, Cardiac arrest in pregnancy: New consensus statement addresses CPR for expectant moms and Program focuses on treatment of placental disorders
Photo by bies

Events, Pediatrics, Public Health, Research, Stanford News

Countdown to Childx: Q&A with pediatric health expert Alan Guttmacher

Countdown to Childx: Q&A with pediatric health expert Alan Guttmacher

jumpforjoyIt’s just a few weeks until the inaugural Childx conference, a TED-style meeting at Stanford that will highlight innovations in health problems of pregnancy, infancy and childhood. (Conference registration for the April 2-3 event is still open, with details available on the conference website.) Childx is attracting nationally and internationally prominent speakers: keynotes will be given by Alan Guttmacher, MD, head of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and by Rajiv Shah, MD, former head of USAID.

I spoke recently with Guttmacher about the upcoming conference. Because I spend most of my time working with scientists who focus their attention on specific research niches within obstetric and pediatric medicine, I was interested in getting his take on the “big picture” of these fields. An edited version of our conversation is below.

What are you planning to say in your keynote address at the Childx conference?

Children’s lives are about more than just health. While biomedical research is crucial to improving kids’ lives, we should put it in the larger context of kids’ lives and do not just research that has an impact on health, but also on children’s overall well-being.

Within the health sphere, I’ll talk about several areas where we need more research. We need to study how to do a better job of preventing prematurity, both to gain a better understanding of biological and environmental causes of preterm birth, and also of how to do a better job of employing the knowledge we already have.

Another topic I’ll address is vaccination: How do we both pursue the science of vaccination to figure out how to make more vaccines more effective, and also, how do we work with parents so they make decisions about kids’ lives that are in the best interests of the kids and are evidence based, rather than based on, say, something they recently read on the web?

I’ll also discuss the developmental origins of health and disease. Pediatricians have always been very invested in anticipatory guidance, telling families about the kinds of things to do to prevent future disease for their children. But this goes farther; this is the idea that health factors, not only in childhood but even in utero, have lifelong impact on health. For instance, what happens in pregnancy potentially has large impact on whether someone develops hypertension in their 60s or 70s. We’re beginning to do science that will tell us the connections between early factors and later health, that will actually influence health along the entire age span. It’s an area of very important research.

And I’ll address intellectual and developmental disabilities. We need research to figure out how to more effectively prevent intellectual and developmental disabilities, research to understand how to allow kids who have these disabilities to function more effectively in society, and also research to figure out how to have society function better in the lives of kids with intellectual and developmental disabilities.

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Pediatrics, Pregnancy, Stanford News, Surgery

A difficult decision that saved three young lives

A difficult decision that saved three young lives

Estrada-Triplets_013I first met Lily Estrada and her identical triplets almost a year ago. The three babies, who were nearly ready to go home from Lucile Packard Children’s Hospital Stanford, looked pretty ordinary. In fact, that’s why I love the photo at the right, which was taken at the time. Baby Pedro, in blue, was gazing at his mom; Ayden, in orange, was wiggling; and William, in grey, was sucking contentedly on his pacifier.

But they had survived an extraordinarily complicated and rare prenatal disorder. The single placenta that connected all three boys to their mother during pregnancy developed a vascular problem called twin-to-twin transfusion syndrome. Blood flowing through the placenta was not being shared equally between the fetuses, straining their hearts and putting all of them at risk of dying before birth.

When Estrada was diagnosed in late 2013, she and her husband, Guillermo Luevanos, faced a difficult decision. A surgery on the placenta might help save the babies, but it was by no means a sure bet. And, at the time, no one at Stanford performed the procedure, although a new partnership between our maternal-fetal medicine experts and their counterparts at Texas Children’s Hospital, in Houston, provided an opportunity for Estrada to be treated there. In the Stanford Medicine magazine story I wrote about the case, Estrada described how her family felt:

“We were saddened and sort of confused,” Estrada says, recalling the first reactions that she and her husband had to the news. “It was: We could wait and see what happened, but the likelihood was that we were going to have no baby, or we could terminate one and see what happened with the other two, or take the risk, go to Houston, have the surgery and hope it worked for all three. But they didn’t guarantee anything.”

One piece of background that helped inform the couple’s decision was the fact that when the surgery worked, research had shown it helped moms stay pregnant about four weeks longer, allowing their babies more time to develop before birth. (Because the uterus gets so crowded, twins and other multiples are almost always born early, but a less premature delivery makes a huge difference for the babies’ health.) Sealing the connecting blood vessels also seemed to protect surviving fetuses in the event that one died. “We’re separating, or attempting to separate, their fates,” [Estrada’s obstetrician] Yair Blumenfeld, MD, says.

After a lot of counseling and discussion with the Stanford team, “we decided to go for it and do surgery,” Estrada says.

Once they had made the choice, they had no second thoughts. “My husband was a little bit stronger,” Estrada recalls. “He just wanted me to go for it, and see what happened.”

triplets-medresThe surgery, performed at Texas Children’s by Michael Belfort, MD, PhD, was a success. And, as my story describes, the collaboration between the two institutions is going well, too. Stanford researcher Christopher Contag, PhD, and colleagues are studying how to make better and safer surgical tools for future maternal-fetal surgeries, while surgeons here have advanced their capabilities and now offer the surgery for twin-to-twin transfusion here in Palo Alto.

Meanwhile, William, Ayden and Pedro are doing well. My favorite moment in preparing the story was when I got to see our new photo of them, above. As their mom told me, “They’re really happy babies.”

Previously: NIH puts focus on the placenta, the “fascinating” and “least understood” organStanford Medicine magazine reports on time’s intersection with healthPlacenta: the video game and Program focuses on the treatment of placental disorders
Photo of triplets as infants by Norbert von der Groeben; photo of triplets as toddlers by Gregg Segal

otolaryngology, Patient Care, Pediatrics, Research

A serendipitous save that changed treatment of the most common tumor of infancy

A serendipitous save that changed treatment of the most common tumor of infancy

IsabellaManley1stgrade-cropAt research institutions like Stanford, we often talk about the value of evidence-based medical care, the kind based on careful scientific comparisons of which treatments work best.

But sometimes, even the best-studied treatments fail. That’s what happened in 2008, when a baby named Isabella Manley was brought by her parents from their Sacramento, Calif., home to Lucile Packard Children’s Hospital Stanford because of a tumor in her trachea that threatened to block her breathing. Her case illustrates that serendipity sometimes plays a key role in medical success.

Isabella had a hemangioma, the most common tumor of infancy. Most hemangiomas, which consist of extra blood vessels, create harmless red marks on a baby’s skin that fade with time. Isabella’s was much more serious. Although her doctors tried all the hemangioma treatments then reported in the medical literature, including high-powered steroid drugs and two types of surgery, her breathing problems persisted. Pediatric otolaryngologist Kay Chang, MD, who oversaw her care at Stanford, ordered an MRI to find out why. A story I wrote about her case explains what happened next:

“We found, to our horror, that this hemangioma was massive, surrounding her entire windpipe and also her heart,” Chang said.

“It was becoming tangled into every structure in her neck and crawling down into her chest,” said Mai Thy Truong, MD, a pediatric otolaryngologist now with the hospital’s vascular malformations clinic.

… The tumor was too extensive for surgery and was still growing. Truong and Chang feared that it would soon block Isabella’s airway. They were not sure they could save her.

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Genetics, Pediatrics, Podcasts, Research, Stem Cells

Countdown to Childx: Stanford expert highlights future of stem cell and gene therapies

Countdown to Childx: Stanford expert highlights future of stem cell and gene therapies

RoncaroloNext month’s inaugural Childx conference will bring a diverse group of experts to Stanford to discuss big challenges in infant, child and maternal health. Today, in a new 1:2:1 podcast interview, stem cell and gene therapy expert Maria Grazia Roncarolo, MD, provides an interesting preview of a once-controversial area of research that will be featured at the conference.

Roncarolo talks about the history and future of stem cell and gene therapy treatments, which have recovered from tragic setbacks such as the 1999 death of 18-year-old Jesse Gelsinger in an early gene therapy trial. The early problems forced researchers to reevaluate what they were doing, with the result that the entire field has reemerged stronger, she explains:

I would say that there were major problems, that we underestimated the complexity that it takes to manipulate the genome, and to introduce a healthy gene to fix a genetic disease. However, from these mistakes and from these tragedies, we learned a lot. We were really forced as doctors, and more importantly, as scientists, to go back to the bench and develop better technologies and to understand more of what was required. … [Today] we use better vectors — which are the carriers to introduce the healthy gene — we know much more about what we have to do to prepare the patient to receive the gene therapy, and we also learned that we need to do a very careful monitoring of the patients to really understand where the gene lands in the genome.

At the Childx conference, Roncarolo will moderate a panel on “Definitive Stem Cell and Gene Therapy for Child Health,” hosting such guests as GlaxoSmithKline’s senior vice president of rare diseases, Martin Andrews, and Nadia Rosenthal, PhD, founding director of the Australian Regenerative Medicine Institute.

Information about registration for Childx, being held here April 2–3, is available on the conference website.

Previously: Stanford hosts inaugural Childx conference this spring and Stanford researchers receive $40 million from state stem cell agency
Photo by Norbert von der Groeben

In the News, Infectious Disease, Nutrition, Pediatrics

Raw milk still a health hazard, says Stanford doctor

Raw milk still a health hazard, says Stanford doctor

MoooooooIn spite of looser regulations around the sale of unpasteurized milk, it’s still unsafe to drink. That’s the message from Stanford pediatric infectious disease expert Yvonne Maldonado, MD, who is quoted in a new story on Today.com about the relaxation of raw-milk regulations in West Virginia and Maine.

In the United States, each state writes its own rules for in-state sales of raw milk, and they vary — a lot. Until last week, West Virginia required all dairy products sold in the state to be pasteurized, or heated briefly to kill germs. The state’s new laws allow for “cow shares,” in which individuals can pay to share ownership of a cow in exchange for some of the cow’s unpasteurized milk. Maine, meanwhile, is considering relaxing its license regulations on farmers who sell milk directly to consumers. (Other states take different approaches, ranging from entirely banning raw milk sales to allowing it in retail stores.)

Raw-milk aficionados claim that unpasteurized dairy products are safe and have health benefits.

Not so fast, says Maldonado, who was the lead author of the American Academy of Pediatrics’ 2013 policy statement discouraging the consumption of raw milk. In the Today.com story, she explains:

“People want to be more responsible for their sustainable environment and what they are putting into their bodies but they conflate the two issues because natural doesn’t always equal healthy,” says [Maldonado].

… “Our recommendations are evidence-based and there is no scientific evidence that drinking raw milk is better than drinking pasteurized milk and milk products,” says Maldonado, an infectious disease expert and pediatrician at Lucile Packard Children’s Hospital. “But we do see a very large number of diseases and illnesses from raw milk and raw milk products and the infections can be just horrible,” causing diarrhea, fever, cramps, nausea and vomiting, and some may even become systemic.

Previously: Stanford pediatrician and others urge people to shun raw milk products and Stanford study spoils hopes that raw milk can aid those who are lactose-intolerant
Photo by Steven Zolneczko

Addiction, FDA, Health Policy, Pediatrics, Public Health

Raising the age for tobacco access would benefit health, says new Institute of Medicine report

Raising the age for tobacco access would benefit health, says new Institute of Medicine report

cigarette packToday, the Institute of Medicine released a new report evaluating the public health effects of reducing teenagers’ access to cigarettes and other tobacco products. Right now, in most places in the United States, you must be 18 years old to buy cigarettes and other tobacco products. But a few states and cities have higher minimums, and in 2013, the IOM convened a committee, at the request of the U.S. Food and Drug Administration, to examine the potential effects of a higher minimum legal age for tobacco access across the country.

The committee, which was led by Richard Bonnie of the University of Virginia and included Stanford adolescent medicine expert Bonnie Halpern-Felsher, PhD, reviewed the existing scientific literature on tobacco use in teens. They also devised mathematical models to predict what would happen if the federal minimum legal age were 19, 21 or 25.

The report brief (.pdf) says, in part:

Based on its review of the literature, the committee concludes that overall, increasing the MLA [minimum legal age] for tobacco products will likely prevent or delay  initiation of tobacco use by adolescents and young adults. The age group most impacted will be those age 15 to 17 years. The committee also concludes that the impact of raising the MLA to 21 will likely be substantially higher than raising it to 19. However, the added effect of raising the MLA from 21  to 25 will likely be considerably less.

The parts of the brain most responsible for decision making, impulse control, sensation seeking, and susceptibility to peer pressure  continue to develop and change through young adulthood, and adolescent brains are uniquely vulnerable to the effects of nicotine. In  addition, the majority of underage users rely on social sources—like family and friends—to get tobacco. Raising the MLA to 19 will therefore not have much of an effect on reducing the social sources of those in high school. Raising the MLA to 21 will mean that those who can legally obtain tobacco are less likely to be in the same social networks as high school students.

Although it can take time to fully realize the benefits of reduced smoking, since heart disease, lung cancer and other diseases linked to smoking take decades to develop, the payoff would ultimately be significant, the report adds:

…if the MLA were raised now to 21 nationwide, there would be approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung  cancer, and 4.2 million fewer years of life lost for those born between 2000 and 2019.

Previously: How e-cigarettes are sparking a new wave of tobacco marketing, To protect teens’ health, marijuana should not be legalized, says American Academy of Pediatrics and UN’s top health official: Anti-tobacco efforts can lead to better health “in every corner of the world”
Photo by Thomas Lieser

Chronic Disease, Obesity, Research, Stanford News

Faulty fat cells may help explain how Type 2 diabetes begins

Faulty fat cells may help explain how Type 2 diabetes begins

heavywaterWhy do some obese people develop Type 2 diabetes while others don’t? New evidence suggests the answer may lie just beneath the skin. A study published this month in the Journal of Lipid Research found metabolic anomalies in the subcutaneous fat of a group of people at risk for diabetes. Basically, fat cells under their skin weren’t very good at storing fat.

That’s a problem because fat that doesn’t get stored in these cells must go somewhere, and it often ends up in other organs, such as the liver, muscle, pancreas and heart. In those locations, there is evidence that too much fat causes “lipotoxicity,” in part by interfering with the messages of the sugar-handling hormone insulin.

The new research, a collaboration between Stanford’s Tracey McLaughlin, MD, and her colleagues here and at UC Berkeley and the National Institutes of Health, used a state-of-the-art technique developed by Berkeley’s Marc Hellerstein, MD, PhD, to monitor fat synthesis and storage in the subcutaneous fat cells of 15 people. All of the subjects were overweight or obese. Half were insulin resistant: Although their blood-sugar levels were normal, their bodies responded poorly to their own insulin, a state that precedes full-blown Type 2 diabetes. (Many scientists think that understanding insulin resistance could lead to preventive strategies for Type 2 diabetes.) The other subjects had normal insulin sensitivity.

Each day for four weeks, the subjects drank a few sips of heavy water, a non-radioactive substance labeled with “heavy” hydrogen atoms that have an extra neutron. After four weeks, the scientists took small samples of the subjects’ subcutaneous belly fat and measured how much heavy hydrogen had been incorporated into the cells’ stored fat molecules and their DNA.

The insulin-resistant subjects had less heavy hydrogen in their fat molecules than the insulin-sensitive subjects, suggesting that their subcutaneous fat cells made and stored less fat during the study. The amount of heavy hydrogen in the DNA of the two groups’ fat cells was the same. This means that the insulin-resistant people were making new subcutaneous fat cells at the same rate as the insulin-sensitive people. The bodies of the insulin-resistant people could generate new fat cells under the skin, but the cells didn’t work quite right.

“This is an important extension of limited static and nonhuman data supporting the hypothesis that dysfunctional fat storage in subcutaneous adipose tissue contributes to obesity-associated insulin resistance,” the scientists wrote, adding that future identification of the molecules that cause this problem may help researchers develop drugs that could treat insulin resistance and prevent Type 2 diabetes.

Previously: The role of nutrition in diabetes prevention and management, Preventing pre-diabetes from turning into diabetes and The importance of regular exercise in delaying and treating diabetes
Photo by Kim P

Big data, Events, Pediatrics, Pregnancy, Research, Stanford News

Stanford hosts inaugural Childx conference this spring

Stanford hosts inaugural Childx conference this spring

Chandler's 15 Month CheckupRegistration is now open for the first ever Childx conference, a TED-style conference focused on inspiring innovation in pediatric and maternal health. The conference will bring thought leaders from several disciplines to the Stanford campus April 2 and 3 for two days of conversation about how to harness many branches of medicine to solve the health problems of pregnancy, infancy and childhood.

“Pediatric medicine faces unique challenges,” said systems biology researcher Dennis Wall, PhD, who leads the conference’s scientific advisory board. “Most children are quite healthy, which can make it difficult to attract adequate research attention to severe pediatric diseases that affect relatively few children. At the same time, every child’s health status is influenced by a complex array of factors, which cause decades-long ripple effects as today’s children mature into tomorrow’s adults.”

The conference, developed and sponsored by Stanford’s Child Health Research Institute, has five themes:

  • Definitive stem cell and gene therapy for child health
  • The arc of fetal, developmental/cognitive, and adult health
  • Accelerating child and maternal health innovation
  • Precision medicine for rare and historically untreatable childhood disease
  • The health ecosystem and the impact of social, economic, political, environmental, and cultural issues on children’s health and well-being

Featured guests include Martin Andrews, who leads Glaxo Smith Kline‘s rare diseases team; Nadia Rosenthal, PhD, founding director of the Australian Regenerative Medicine Institute; Harvard’s Matthew Gillman, MD, an expert on early-life prevention of chronic disease; Sheena Josselyn, PhD, a neuroscientist at the University of Toronto and the Hospital for Sick Children who studies molecular processes behind learning and memory; and Donald Schwarz, MD, the director of the Robert Wood Johnson Foundation, as well as a large cast of Stanford stars from several areas of pediatric medicine.

“Pediatric medicine needs to turn its focus more to creating advanced, technology-enabled solutions that will increase our ability to detect, monitor and treat child health,” Wall said. “No pediatric conference to-date has combined these key themes of precision healthcare with the most pressing challenges and opportunities in child and maternal health. The inaugural Childx will be the first conference to do so.”

The conference will welcome maternal and child health researchers, clinicians, investors, industry experts and interested community members. Early bird registration is open through February 28.

Addiction, Health Policy, In the News, Pediatrics

To protect teens’ health, marijuana should not be legalized, says American Academy of Pediatrics

To protect teens' health, marijuana should not be legalized, says American Academy of Pediatrics

teen smoking Today, the country’s most prominent group of pediatricians issued a policy statement that opposes marijuana legalization and advocates for policies to help minimize the drug’s harmful effects on children and adolescents. The new statement, from the American Academy of Pediatrics, was written in response to recent research on adolescent brain development and the biology of addiction, as well as a changing national climate on marijuana laws.

I spoke with Stanford’s Seth Ammerman, MD, an adolescent medicine specialist and the lead author of the new statement and accompanying technical report. Ammerman studies substance-use issues in youth and also has extensive experience working with at-risk young people, in part through his role as medical director of the Adolescent Health Van run by Lucile Packard Children’s Hospital Stanford.

“The national trend is definitely toward more medical marijuana, and also toward legalization for adults,” he said. “This trend can definitely affect kids, so it was really important for the Academy to have a voice, to be working on a national conversation about this.”

During our conversation, Ammerman explained some of the latest research that has motivated the AAP’s stance against marijuana legalization:

In the past decade, we’ve learned that brain development doesn’t finish until one’s early to mid-20s, and substance use can alter the developing brain. There are a few ways we know this: One, there’s clear evidence that the younger you start using drugs regularly, the more likely you are to become addicted. This is true for alcohol, tobacco, and marijuana, among others. For those who put off substance use until their late teens or early 20s, addiction rates are significantly lower.

We also know that the developing brain is very vulnerable to substance use. One in 10 adolescents who use marijuana become addicted. That means that 90 percent won’t — which is the good news — but the problem is we can’t predict which 10 percent will develop addiction.

We also have a lot of research about the adverse effects of marijuana use. Heavy users fare worse in many ways: their cognitive levels fall, they are less likely to finish high school or attend college, and they tend to suffer more from depression. Most users are not heavy users, but again, we can’t predict who will fall into this category.

The AAP is also in favor of decriminalizing marijuana, replacing current criminal penalties with lesser criminal or civil penalties and drug treatment. This is an especially important step to reduce the long-term damage to educational and job opportunities that currently comes with marijuana arrests, Ammerman said, adding: “There is a significant problem of racial inequity associated with marijuana arrests: minorities are way over-arrested and their lives are messed up because of marijuana arrests. It’s a very important step to say we need to help kids, not punish them.”

Previously: Medical marijuana not safe for kids, Packard Children’s doc says, Pediatrics group calls for stricter limits on tobacco advertising and To reduce use, educate teens on the risks of marijuana and prescription drugs

Photo by mexico rosel

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