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Cancer, Global Health, Pediatrics, Stanford News

The “little angel” who helps young Latin American children with cancer

The “little angel” who helps young Latin American children with cancer

ZambranoEduardo Zambrano’s spare office in Stanford Hospital displays some of the essentials of his pathology practice: a large microscope which dominates his desktop and a cabinet overflowing with colorful, hand-painted wooden boxes, each one representing a Latin American child with cancer.

Over the last 12 years, Zambrano, MD, has received as many as 1,000 tumor samples from pediatric oncologists in Venezuela and other Latin American countries who treat desperately poor young patients with various forms of cancer. Each sample is carried on a glass side or embedded in wax, then carefully wrapped in tissue paper and lovingly packaged in a wooden box painted by a patient’s mother or local artisan as a gesture of gratitude. The boxes are covered in suns, stars, flowers and other images of life and hope.

“To me, behind each one of these boxes is a child with cancer, and to know we’ve been able to help them is very special to me,” said Zambrano, chief of pathology at Lucile Packard Children’s Hospital Stanford. An expert in pediatric solid tumors, he volunteers his service on behalf of these youngsters.

A professor of pediatrics and of pathology who came to Stanford a year ago, he said he receives one or two of these boxes a week. He examines the samples under the microscopic and then issues a diagnosis, some involving rare cancers. Clinicians ship the samples to him because in these low-resourced countries, they don’t have the means to accurately diagnose the problem.

“Very frequently the diagnosis (from the home country) is either incomplete because they don’t have the resources to perform confirmatory tests or it’s wrong because they don’t have expertise in pediatric tumors,” he said. “It’s frequent that I have to give them a significantly different diagnosis than what they sent.”

Among the most common tumors he sees are pediatric sarcomas, which can originate in various parts of the body; neuroblastomas; lymphomas; and brain tumors.

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Global Health, HIV/AIDS, Infectious Disease

Growing resistance to vital HIV drug raises concern

Growing resistance to vital HIV drug raises concern

tablets-193666_1280HIV resistance to the antiviral tenofovir, one of the mainstays of HIV treatment and prevention, is increasingly common following therapy, particularly in low and middle-income countries, according to a new, multi-national study.

“Public health organizations and global funders have been very effective at expanding antiretroviral drug therapy to increasing proportions of patients in need,” said Robert Shafer, MD, professor of medicine and co-author of the work. “This study highlights the need for efforts to ensure that the regimens used to treat HIV retain their effectiveness for as long as possible.”

Researchers studied 1,926 patients in 36 countries who developed virological failure after taking a first-line regimen containing tenofovir. In this group, tenofovir-resistant strains were found in 60 percent of the patients in sub-Saharan Africa, compared with fewer than 30 percent in Europe and North America. Patients most at risk for tenofovir resistance were those who started therapy late in the progression of the disease or who received tenofovir in combination with drugs less commonly used in upper-income countries.

About two-thirds of the patients with tenofovir-resistant strains also had become resistant to the other two drugs in their regimens, suggesting their treatment had become largely ineffective.

Resistance may develop when patients don’t take their medication regularly, although it may also occur in adherent patients on some of the regimens used in the developing world. People carrying resistant strains can pass them along to others, so that HIV resistance could become even more widespread, the researchers note.

“Tenofovir is a critical part of our armamentarium against HIV, so it is extremely concerning to see such a high level of resistance to this drug,” said lead author Ravi Gupta, MD, at University College London. “It is a very potent drug with few side effects, and there aren’t any good alternatives that can be deployed using a public health approach. Tenofovir is used not only to treat HIV but also to prevent it in high-risk groups, so we urgently need to do more to combat the problem of emerging resistance.”

The researchers say the results reinforce the need for increased drug resistance surveillance in both untreated and treated HIV-positive individuals. They are now working to better understand how these resistant viruses develop and spread.

The study, which involved dozens of researchers and institutions, appears today in the journal Lancet Infectious Diseases. It was co-authored by scientists at the London School of Hygiene and Tropical Medicine and funded by the Wellcome Trust.

Previously: Spread of drug-resistant HIV in Africa and Asia is limited, Stanford research finds, HIV study in Kenyan women: Diversity in a single immune-cell type flags likelihood of getting infected and Study: Chimps teach people a thing or two about HIV resistance
Image by bigblockbobber

Global Health, Pediatrics, Stanford News

Clean water for Dhaka, one pump at a time

Clean water for Dhaka, one pump at a time

Dhaka water 2

More than two years ago, Amy Pickering, PhD, and her Stanford colleagues were just starting to field-test a radical new approach to clean up the contaminated water supply in Dhaka, Bangladesh, and improve the health of the city’s slum dwellers.

Since then, the team has made major progress in the project, which uses a simple, low-cost chlorination system to eliminate dangerous microbes in the city’s drinking water, Pickering said in a recent talk at the Stanford Global Health Research Convening on campus.

Dhaka has notoriously unsafe water supplies, with testing showing that as much of 80 percent of the city’s water is contaminated with E. coli, a major cause of diarrhea, Pickering said. The source: human waste, which is sucked into the city’s water system by cracked, leaky PVC pipes.

“There’s open sewage everywhere,” Pickering told me for a 2013 story in Stanford Medicine magazine. “There’s not a well-functioning sewer system to remove feces from the communities. The kids are playing in it, and it’s very unsafe.”

Her team, which includes a group of Stanford undergraduates, created a simple device, attached to communal water pumps, which infuses a small amount of chlorine into the water to kill viruses and bacteria and most disease-causing pathogens. It’s the first automated chlorine disinfection system in use in a low-income area.

In 2014, the group tested the device over a 10-month period in more than 150 households and found it reduced E. coli contamination by 70 percent, Pickering told more than 100 faculty, students and staff at the recent conference. The event was sponsored by the Stanford Center for Innovation in Global Health.

The researchers are now midway through a much larger trial, funded by the World Bank, to test the health impacts of the purification system in more than 1100 Bangladeshi children under age 5. The researchers are looking at whether the system reduces the incidence of diarrhea, a common cause of childhood death, and improves weight gain among the children, who often suffer from stunted growth because of waterborne illness, said Pickering, now a research scientist at the Stanford Woods Institute for the Environment.

The researchers also have made progress in finding a way to support and sustain use of the purification system. Pickering said the group offered the pumps to local landlords, who could use them to attract potential renters. Some 60 landlords agreed to pay $3 to $5 a month for the pumps, almost enough to cover the cost of the system, she said.

“This was really encouraging to us,” Pickering said. “We weren’t expecting people to be willing to pay this much.”

She also has found some potential commercial partners, including MSR Global Health, a pioneering outdoor company, interested in helping further reduce costs and refining the technology as a prelude to commercially marketing the pumps, she said.

Pickering said she now hopes to expand the project to sub-Saharan Africa, and spread her dream of bringing clean water and good health to low-income residents across the globe.

Previously: Stanford pump project makes clean water no longer a pipe dream, The right tool for the job: Creating a waterborne disease reporting system for Nepal and How cutting the walking time to a water source can reduce childhood mortality in sub-Saharan Africa
Photo courtesy of Amy Pickering

Research, Stanford News

Pedicure soothes lab mice with serious skin disease

Pedicure soothes lab mice with serious skin disease

Apodemus_sylvaticus_bosmuisLaboratory mice commonly suffer from a skin problem called ulcerative dermatitis – itchy lesions that spur the animals to repeatedly scratch themselves with their hind claws, to the point where they practically shred themselves to pieces.

It’s been a longstanding issue for veterinarians who have tried various topical ointments, with limited success, said Stanford’s Sean Adams, DVM, PhD, who has been studying the problem. The result is that many valuable animals have to be euthanized as a humane gesture to save them from untreatable pain and suffering.

This is a simple, cheap, effective means of treating ulcerative dermatitis, which represents the single most preventable reason for euthanasia.

Adams and his colleagues came up with a simple solution. They adapted a plastic tube, with cutouts for the animals’ feet, in which they could briefly immobilize the animals while they trimmed their sharp claws.

More than 93 percent of animals who were given pedicures were cured of their skin problems, he and Stanford colleagues report in a new study. Only 25.4 percent of mice given a topical anti-inflammatory were cured of the disease.

“This is a simple, cheap, effective means of treating ulcerative dermatitis, which represents the single most preventable reason for euthanasia,” said Adams, a third-year resident in laboratory animal medicine and first author of the study. “I think it’s a very surprising finding how simple this technique is.”

The technique is easy to administer, with Stanford vets able to clip the animals’ nails in a few minutes or less. It’s far less labor-intensive than administering daily topical ointments, he said.

It is not only a humane approach but is cost-saving for laboratories, especially those that use unusual strains, such as transgenic mice.

“I think we’ll start seeing more people in other labs pick up this technique because it’s very easy to do,” Adams said. “There is definitely interest in finding good techniques for the problem because this is an issue for every institution that employs mice.”

The study appears in today’s issue of PLOS One.

Previously: Research prize for helping make mice comfy – and improving science, Animal study hints at potential treatment for skin-picking disorder and My funny Valentine — or, how a tiny fish will change the world of aging research
Photo by Rasbak

Global Health, Health Policy, Pregnancy, Stanford News, Women's Health

C-section rates up to 19 percent help save women and their newborns, global study finds

C-section rates up to 19 percent help save women and their newborns, global study finds

321699721_9002c5cebd_zCesarean sections are the most commonly performed operations around the world. But just how effective are these procedures, which have their own risks and complications, in saving the lives of women and their newborns?

To help answer that question, researchers at Stanford and Harvard’s Ariadne Labs examined C-section delivery rates in 2012 for 194 countries – all the member states of the World Health Organization. In that year, an estimated 22.9 million C-sections were performed in these countries.

The researchers found that maternal and child deaths declined when the C-section rate was up to 19 percent. When the number of C-sections was higher than that, there was no reduction in these mortality rates, the researchers report today in the online issue of the Journal of the American Medical Association.

Those numbers are higher than current WHO guidelines, which recommend that national C-section rates be no greater than 10 to 15 percent of deliveries. Worldwide, the number of C-sections varies widely from region to region, from .6 percent (South Sudan) to 56.6 percent (Brazil). In the United States, the C-section rate is roughly 30 percent.

Stanford surgeon Tom Weiser, MD, MPH, co-lead author, said the study “certainly presents a compelling argument for improved surgical capacity,” particularly in poor countries where there is limited capacity for surgical care. In parts of the developing world, women routinely die of obstructed labor and other pregnancy-related complications because there is no surgical infrastructure and personnel to provide advanced care, including C-section deliveries, he said.

Weiser and his co-authors argue for improving access to these potentially life-saving procedures, which could have many spillover effects, including improved facility infrastructure such as clean water and electricity – both needed for a functioning operating room – as well as improvements in healthcare systems as a whole.

“All the things you need to do to build up surgical capacity, like personnel training, improving supply chains, providing clean water and sterile environments, all contribute to general strengthening of health-care systems,” said Weiser, an assistant professor of surgery. “If you were to build a strong and robust surgical capacity, you’d have a health-care system more resilient and more resistant to catastrophic events, including Ebola or other infectious outbreaks.”

He noted, however, that new surgical services have to be provided within a safe environment to avoid potentially fatal complications, such as infection and bleeding.

“We cannot just advocate for increased access, as services have to be safe and they have to adhere to basic standards of surgical care,” he said.

Previously: Stanford microbiome research offers new clues to the mystery of preterm birth, From womb to world: Stanford Medicine magazine explores new work on having a baby and Study shows women prefer less-intense pain at the cost of a prolonged labor
Photo by Bonbon

Events, Global Health, Health Policy, Public Health, Stanford News

Using innovation to improve health in the developing world

Using innovation to improve health in the developing world

Ramano RaoHow can Silicon Valley-style know-how help improve health and lift up the lives of the poor in the developing world? That question was the focus of a panel discussion among four distinguished speakers last week at a Stanford conference on global development and poverty.

Panelist Ramana Rao, MD, described one technologically-based solution he helped develop with colleagues in Hyderabad, India:  a 911-type emergency care system which now serves some 750 million people across the South Asian country.

Though the system, users can call a single number – 108 – to summon an ambulance and team of skilled providers who can provide treatment en route to the nearest hospital.  The system, a public-private partnership known as GVK EMRI (Emergency Management and Research Institute), uses advanced call center technology, in which trained operators typically respond to calls within the first ring and relay them immediately to paramedics and emergency medical technicians on ambulances in the field, Rao told an audience of more than 200 people at the Stanford Graduate School of Business.

The system uses Google maps to help quickly locate patients. And the designers have introduced a mobile device app, which can be easily downloaded to call the service and which can be used to track the location of a caller during the first hour, the critical “golden hour” for treating trauma patients, he said.

Panel moderator Paul Yock, MD, PhD, noted the system is far more effective than the fragmented, 911 emergency system in the United States. “It’s a marvelous example of technology leap-frogging what we do here in this country,” said Yock, founder and director of Stanford Biodesign.

The Indian system was made possible in part by the soaring popularity of cell phones in India, used by 950 million people, including the poor.

“The mobile phone has been the most transformational technological advance in the developing world in the last 15 years,” noted panelist Rajiv Shah, MD, administrator of the U.S. Agency for International Development.

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Mental Health, Public Health, Public Safety, Sleep, Stanford News

From A to ZZZZs: The trouble with teen sleep

From A to ZZZZs: The trouble with teen sleep

go_to_bed_fullWhen I recently began working on a story on teen sleep for Stanford Medicine magazine, I was afraid I might not find teens who were troubled by sleep issues and willing to talk about them. I need not have worried: Virtually every teen I encountered had a story to tell about consistently having late nights stressing out over tests or papers or texting friends and cruising the web. It also wasn’t unusual for teens to say that they kept their cell phones on at night in case they got a message from a friend who needed to talk.

Some were tortured by the lack of sleep, often nodding off in class, but said they felt compelled to stay up in order to compete academically in these high-pressure local communities that worship at the altar of academic achievement.

“I’ve heard horror stories of being sleep-deprived,” one 17-year-old told me. “You’re not able to focus on homework, you feel moody and are not able to pay attention in class.”

Another teen reinforced what the National Sleep Foundation found in a recent poll – that 87 percent of American teens are chronically sleep-deprived. “You could probably talk to any teen when they reach their breaking point,” she told me. “You’ve pushed yourself so much and not slept enough and you just lose it.”

In my research, I learned that these students pay a heavy price, potentially compromising their physical and mental health. Study after study in the medical literature sounded the alarm over what can go wrong when teens suffer chronic sleep deprivation: drowsy driving incidents, poor academic performance, anxiety, depression, suicidal thoughts and even suicide attempts.

“I think high school is the real danger spot in terms of sleep deprivation,” Stanford’s William Dement, MD, PhD, the famed sleep researcher, told me. “It’s a huge problem.”

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Ebola, Events, Global Health

From bedside to patient: an Ebola survivor’s remarkable journey

From bedside to patient: an Ebola survivor's remarkable journey

Crozier in Sierra LeoneWhen Ian Crozier, MD, volunteered to treat Ebola patients in West Africa last year, he couldn’t possibly have imagined that he would become a case report in the New England Journal of Medicine and a living example of the serious, long-term consequences of Ebola infection.

Crozier described to a Stanford audience last week his extraordinary journey of survival from Ebola infection after suffering a shutdown of his vital organs and several hemorrhagic strokes.

“If I you had told me on day one that I would develop multisystem organ failure and asked me to predict my chances of survival, I would have said my chances were zero,” he told a School of Medicine audience of more than 100 people. “They [the Emory caregivers] really changed the game… I really think they were walking on the moon, but in a different kind of space suit.”

Crozier, who was a World Health Organization volunteer physician in Sierra Leone, was evacuated to Emory University Hospital in Atlanta, where he spent 6 weeks undergoing intensive treatment. As he began to recover from the infection, he had to relearn some basic functions, such as walking and talking.

Two months after he was discharged from the hospital, he was beset by serious eye problems and was found to be harboring billions of viral particles in his left eye. The infection also left him with some hearing loss and ringing in the ears, sleep issues and some neurologic complications, including seizures and short-term memory loss.

But none of this was apparent during his talk, in which he delivered a detailed, rapid-fire discussion of his remarkable medical journey.

“It must be odd to hear me talking about my own case… in what may seem a detached manner,” he told the audience. “This was not theoretical. I’m standing here, and I’m alive, and yet I’ve described some of the worst disease we’ve seen with Ebola.”

Colin Bucks, MD, a Stanford emergency physician who was a volunteer in Liberia during the Ebola crisis, says Crozier’s experience has given him a new perspective on how best to treat infected patients. Previously it was not standard practice to put patients on ventilators or dialysis machines, as Crozier was, as these were considered impractical and ineffective.

“It made me endorse the aggressive treatments that were previously considered futile,” Bucks told me during Crozier’s visit to Stanford. “So I consider his case pivotal in the way we view this disease.”

Crozier’s visit was sponsored by the Stanford Center for Innovation in Global Health, Stanford Immunology and the Stanford Medical Scientist Training Program.

Previously: Ebola: It’s not overBack home from Liberia, Stanford physician continues to help in fight against EbolaStanford physician shares his story of treating Ebola patients in Liberia and Experience from the trenches in the
Photo, of Ian Crozier with children in Sierra Leone, courtesy of WHO

Emergency Medicine, Global Health, Health Policy, Stanford News, Videos

A look at “India’s medical miracle,” the largest ambulance service in the world

A look at "India's medical miracle," the largest ambulance service in the world

A patient in shock arrives via ambulance at Gandhi Hospital in Hyderabad, India with a gaping wound in his right hand, blood spattered on his blue jeans and T-shirt. Emergency medical technicians wheel him into a dark room in the government-run hospital, where clinicians move quickly to irrigate the wound and pump fluids into the man, who appears to be in his 20s.

With luck, the patient might survive. Ten years ago, he would not have had a chance.

Thanks to some passionate philanthropists, businessmen and medical experts, India today has what we have long taken for granted in the United States: a modern, emergency 911-type system and a cadre of trained emergency responders who have helped save an estimated 1.4 million lives. Begun in 2005, it is now the largest ambulance service in the world and serves more than 750 million people in cities and villages across the Indian sub-continent.

I saw the system in action first-hand in August when I traveled to India, together with about 10 other faculty and staff from Stanford’s School of Medicine, including Dean Lloyd Minor, MD, to celebrate its 10th anniversary amid much color and fanfare. I was there to write a story about the new system for Stanford Medicine magazine.

Begun in August 2005 in the south Indian metropolis of Hyderabad, the service, known as GVK EMRI (Emergency Management and Research Institute), is operated as a public-private partnership, providing its services free of charge, mostly to the very poor. It is a remarkable achievement, given the diversity of India, with its 29 states and more than 120 major languages, and the bureaucracy and corruption that can sometimes impede progress in this vast country of 1.2 billion souls.

“It’s hard to fathom what this system has done in 10 years,” S.V. Mahadevan, MD, interim chair of Stanford’s Department of Emergency Medicine, told me while stationed in one of EMRI’s ambulances. “It could be regarded as one of the most important advances in global medicine in the world today.”

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Global Health, Health Costs, Health Policy, Stanford News

Pharmaceutical adventures in India

Pharmaceutical adventures in India

medication in IndiaIn the course of a recent trip to India, I developed some minor health problems and found myself doing what many locals do: consulting with a pharmacist. India’s cities are peppered with these modest little storefronts, some the size of a large closet, which sit along the street, the pharmacists stationed on a stool behind a counter awaiting customers.

The pharmacies are stocked floor-to-ceiling with a plethora of remedies for whatever ails the human body and spirit. My husband and I sought treatment for an affliction common both to travelers and local Indians, caused by contamination in food and water: diarrhea. Despite our best food precautions, we managed to contract a case of the runs after eating at a very elegant restaurant in Jaipur in the northern province of Rajasthan. When a dose of Lomotil did not prove entirely effective, we decided to turn to a pharmacist for advice, as my experience traveling abroad is that local practitioners often know best how to treat common local problems.

The pharmacist asked us several questions in perfect English: Did we have a fever? Any vomiting? Any stomach cramps? No to the first two, yes to the last. He radiated a sense of confidence. He then produced two sets of pills in silver and green packages. We were advised to take these twice a day. He also gave us an electrolyte replacement solution, to be mixed with purified water and consumed twice daily as well. The pills had names I did not recognize, so I largely took them on faith, explicitly following his directions. The total cost for both of us: the equivalent of $2.50.

“You actually behaved in many ways like a many locals would – like a person who doesn’t have easy access to a health-care provider,” Nomita Divi, program manager of the Stanford India Health Policy Initiative, told me recently when I related my experiences.

Divi took a group of Stanford students – one med student, one masters and two undergraduates – to India for 8 weeks this summer to study this very phenomenon: the role of pharmacists in healthcare delivery in India, where a dire shortage of physicians, particularly primary care physicians, severely limits access to care. These pharmacists often serve as first-line providers, she said. Some have formal training, but many do not and operate on the basis of experience, as the students observed this summer, she said.

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