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Cancer, Patient Care, Stanford News

Pioneering cancer nurses guide patients through maze of care

Pioneering cancer nurses guide patients through maze of care

cancer-birminghamLearning you have cancer is a life-changing diagnosis. Even after the initial shock wears off, the gauntlet of medical care necessary to manage the disease can be overwhelming and confusing. At the Stanford Cancer Center, a new program that partners experienced nurses with newly diagnosed cancer patients aims to help the patients navigate the convoluted path their medical care can take.

A recent story in the Stanford Medicine Newsletter profiled Laura Birmingham, RN, (on the left, with cancer patient Sharron Brockman) and Vitale Battaglini, RN, who founded the new program. Birmingham coordinates care for patients with gynecological cancers and Battaglini works with head and neck cancer patients. They are the first people at the Stanford Cancer Center that patients meet and they stay in touch via phone calls, text messages and emails in between patient visits. The staff explained the benefits of a one-on-one program:

“Someone newly diagnosed doesn’t know what to expect, and things that seem basic to us are new to them. Our job is to be their first and main point of contact,” Battaglini said. “It’s a reversal of the traditional nurse’s role: We are the patient’s nurse, not the doctor’s nurse. And what the patient needs depends on that particular patient.”

“Cancer care has become so complex because it involves so many subspecialties,” said Julie Kuznetsov, director of the Cancer Patient Experience, who oversees the new program. “The field continues to evolve with new technologies and specialized expertise. While that means more options and better outcomes, for patients it has become more difficult to put the pieces together to coordinate their care.”

In Birmingham’s words, “Our role is to act as an agent of change in terms of the patient experience.” There are about 18 patients in the program, but that number is expected to grow quickly.

Previously: Stanford researchers examine disparities in use of quality cancer centers and Director of the Stanford Cancer Institute discusses advances in cancer care and research
Photo by Norbert von der Groeben

Applied Biotechnology, Research, Stanford News, Technology

Tiny size, big impact: Ultrasound powers miniature medical implant

Tiny size, big impact: Ultrasound powers miniature medical implant

14395-chip_newsFor years, scientists have been trying to create implantable electronic devices, but challenges related to powering such technologies has limited their success. Enter a prototype developed by Stanford engineer Amin Arbabian, PhD, and colleagues that uses ultrasound waves to operate the device and send commands.

As explained in a Stanford Report story, researchers designed the “smart chip” to use piezoelectricity, or electricity generated by pressure, as a source of power and selected ultrasound because it has been extensively, and safely, used in medical settings:

[The researchers’] approach involves beaming ultrasound at a tiny device inside the body designed to do three things: convert the incoming sound waves into electricity; process and execute medical commands; and report the completed activity via a tiny built-in radio antenna.

“We think this will enable researchers to develop a new generation of tiny implants designed for a wide array of medical applications,” said Amin Arbabian, an assistant professor of electrical engineering at Stanford.

Every time a piezoelectric structure is compressed and decompressed a small electrical charge is created. The Stanford team created pressure by aiming ultrasound waves at a tiny piece of piezoelectric material mounted on the device.

“The implant is like an electrical spring that compresses and decompresses a million times a second, providing electrical charge to the chip,” said Marcus Weber, who worked on the team with fellow graduate students Jayant Charthad and Ting Chia Chang.

The prototype is about the size of a ballpoint pen head, but the team ultimately wants to make it one-tenth that size. Arbabian and his colleagues are now working with other Stanford collaborators to shrink the device even further, specifically to develop networks of small implantable electrodes for studying brains of laboratory animals.

Previously: Miniature wireless device aids pain studies, Stanford researchers demonstrate feasibility of ultra-small, wirelessly powered cardiac device and Stanford-developed retinal prosthesis uses near-infrared light to transmit images
Photo by Arbabian Lab/Stanford School of Engineering

Aging, Health and Fitness, History, Neuroscience

Walking and aging: A historical perspective

Walk on by_flickrThe evidence that exercise helps stave off mental decline in elderly people has been mounting for several years now, but an article by Wayne Curtis in The Atlantic today puts this research in perspective by looking back a century at Edward Payson Weston’s walk from San Francisco to New York in 1909, when Weston was 70.

Curtis notes that the field of gerontology, the study of aging, had been around for less than a decade at that point. Most scientists thought brain cells were not capable of regenerating – something we know today that they’re most definitely capable of – and doctors were of the mind that too-vigorous exercise could harm mental acuity. Popular reaction to Weston’s trek is documented through newspaper accounts of the day:

A column in the Dallas Morning News admitted that many considered Weston’s walk from ocean to ocean “foolishness” and “an idle waste of time.” But, the writer asked, was it “preferred to the needless senility into which far too many men begin to drift at the period of three score years and 10?”

Curtis eventually moves into recent decades and details some of the recent research into how moderate to vigorous walking can actually improve mental acuity in several populations, including Alzheimer’s patients:

The results [of one long-term study], published in the journal Neurology, were sweeping and conclusive: Those who walked the most cut in half their risk of developing memory problems. The optimal exercise for cognitive health benefits, the 
researchers concluded, was to walk six to nine miles each week. That’s a mile to a mile and a half a day, without walking on Sundays if you’re inclined to follow Weston’s example of resting on the Sabbath. (This study concluded that walking an additional mile didn’t help all that much.)

I have to admit I’m glad I live in this century and not in Weston’s time. I don’t think I have the fortitude he showed in bucking popular opinion – or, to be honest, in walking.

Previously: Even old brains can stay healthy, says Stanford neurologistExercise and your brain: Stanford research highlighted on NIH Director’s blog and The state of Alzheimer’s research: A conversation with Stanford neurologist Michael Greicius
Photo by  Stefano Corso

Aging, Health Policy, In the News, Neuroscience, Patient Care

The toll of Alzheimer’s on caretakers

The toll of Alzheimer’s on caretakers

Loving Hands Vannesa Pike-Russell FlickrMy last grandparent, my paternal grandmother, passed away earlier this year. She lived into her 90s and, like both my maternal grandmother and grandfather, she suffered mild to moderate dementia in the final years of her life. My mother cared for each of them as one by one their health declined. She had ample support from our extended family, but she was the one who had to bathe them and help them go to the bathroom or remind repeatedly them that so-and-so relative had died many years ago. My parents’ experience taking care of elderly family members who no longer had their full mental faculties lasted two to three years in each case, unlike people who care for family members with Alzheimer’s disease – a task that can last a decade or more.

Last week, Tiffany Stanley wrote a feature in the National Review about her experience caring for her ailing aunt, Jackie, who was diagnosed with early onset Alzheimer’s. Stanley’s father had been caring for his sister when his congestive heart failure made him too ill to continue, so his 29-year-old daughter stepped in. She was unprepared for the realities of caring for an Alzheimer’s patient, and she chronicles her experiences with touching anecdotes about her family’s experiences, as well as a detailed look at Alzheimer’s care in the U.S. She also details the impact the disease has on caregivers:

Alzheimer’s places a heavy toll on family caregivers. Their own health suffers. Dementia caregivers report higher rates of depression and stress than the general population. Some studies show they have an increased risk for heart disease and stroke as well as higher mortality rates. Their own use of medical services, including emergency-room visits and doctors’ appointments, goes up, and their yearly health care costs increase by nearly $5,000, according to research from the University of Pittsburgh and the National Alliance for Caregiving. “Caring for a person with dementia is particularly challenging, causing more severe negative health effects than other types of caregiving,” reads an article in the American Journal of Nursing.

Stanley also writes about the tension between funding a cure – to keep people from spiraling late stage dementia – and caring for those who are already sliding down that route:

Lost too often in the discussion about a cure has been a much more basic, more immediate, and in many ways more important question: How can we better care for those who suffer from the disease? Dementia comes with staggering economic consequences, but it’s not the drugs or medical interventions that have the biggest price tag; it’s the care that dementia patients need. Last year, a landmark Rand study identified dementia as the most expensive American ailment. The study estimated that dementia care purchased in the marketplace—including nursing-home stays and Medicare expenditures—cost $109 billion in 2010, more than was spent on heart disease or cancer. “It’s so costly because of the intensity of care that a demented person requires,” Michael Hurd, who led the study, told me. Society spends up to $56,000 for each dementia case annually, and the price of dementia care nationwide increases to $215 billion per year when the value of informal care from relatives and volunteers is included.

The story is equal parts frustrating and heart-wrenching, but I came away much better informed about what a diagnosis entails, not just for the patients, but the families connected to them.

Previously: No one wants to talk about dying, but we all need to, Mindfulness training may ease depression and improve sleep for both caregivers and patients, Can Alzheimer’s damage to the brain be repaired?The state of Alzheimer’s research: A conversation with Stanford neurologist Michael Greicius and Exploring the psychological trauma facing some caregivers
Photo by Henry Rabinowitz

Imaging, Research, Science, Stanford News, Videos

Breaking the light barrier in medical microscopy: More on today’s Nobel-winning work

Breaking the light barrier in medical microscopy: More on today's Nobel-winning work

Earlier today, Stanford University’s W.E. Moerner, PhD, was one of three scientists to be awarded the Nobel Prize in Chemistry for work in super-resolution microscopy. Before this technology, the only way to look at structures inside cells was with electron microscopy. But that requires researchers to kill the tissue in order to prepare it for the microscope. Essentially, the objects being examined were frozen in place; scientists could make out cellular structures but couldn’t watch them in action.

Microscopes that use refracted light, or optical microscopes, can be used to observe living cells, but for decades, they were limited from going below 220 nanometers, a hard limit imposed by the wavelength of light. Eric Betzig, PhD, of Howard Hughes Medical Institute, and Stefan W. Hell, PhD, of the Max Planck Institute for Biophysical Chemistry in Germany shared the prize with Moerner for work that helped break that barrier. Now, researchers can peek inside cells as they are going about their business and observe real-time changes as they happen.

This morning, Moerner spoke to Stanford’s news office via Skype from Brazil about his work and how other researchers, including Lucy Shapiro, PhD, and Matt Scott, PhD, of Stanford’s School of Medicine are applying the new methods to medical research (see above video). Shapiro, a 10-year collaborator of Moerner’s, is examining structures inside bacteria and Scott is looking at subcellular signalling structures. (Shapiro provides comment on her work in a Stanford press release.)

“Because of this revolutionary work, scientists can now visualize the pathways of individual molecules inside living cells,” Francis Collins, MD, PhD, director of the National Institutes of Health, which funds some of Moerner’s work, said in a statement. “Researchers can see how molecules create synapses between nerve cells in the brain, and they can track proteins involved in Parkinson’s, Alzheimer’s and Huntington’s diseases.”

Below is a clip of Moerner describing what those studying Huntington’s disease have learned using the prize-winning microscopy technology.

Previously: For third year in row, a Stanford faculty member wins the Nobel Prize in Chemistry
Videos courtesy of Stanford University Communications

Cancer, Infectious Disease, Pediatrics, Research, Stanford News

Summer’s child: Stanford researchers use season of birth to estimate cancer risk

Summer’s child: Stanford researchers use season of birth to estimate cancer risk

Four_seasons

One of the hardest parts of unraveling childhood cancers is understanding what causes them. In recent years, evidence has been mounting that cancer and many other chronic diseases begin early in life – and perhaps even in utero. To untangle some of these early causes of cancer in children and young adults, Stanford epidemiologist and family physician Casey Crump, MD, PhD, is partnering with researchers at Lund University in Sweden, a working relationship was set up by Marilyn Winkleby, PhD, MPH, professor emeritus of medicine here. The team is using Sweden’s national registries for birth certificates and medical records to track how factors during gestation and soon after birth – called perinatal factors – affect cancer risks.

Because Sweden has a national health care system, it’s relatively easy to track the course of illness in individuals. By comparison, the U.S.’s health care system is fragmented across dozens of health care providers and insurers, so getting medical records for a single person that might span decades is a much more difficult prospect.

Crump’s team is focusing on cancers that are common in childhood and early adulthood: brain tumors, leukemia and lymphoma among them. Two papers published earlier this year examine how the time of year a child is born affects cancer risk. The most recent, published ahead of print in April in the International Journal of Cancer, examined whether the season of birth was linked to the risk of developing either Hodgkin’s lymphoma or non-Hodgkin’s lymphoma later in life. Crump explained:

Lymphomas are among the most common cancers in childhood but the causes are still largely unknown. It’s been hypothesized that infectious exposures, such as Epstein Barr virus and others may play an important role, but it’s still unclear what the critical age window of susceptibility might be. We had an opportunity to use season of birth from birth records as a proxy for infectious exposures in the first few months of life, and see the relationship between that and subsequent risk of Hodgkin’s and non-Hodgkin’s lymphoma – following these people from birth through childhood and on into young adulthood.

The researchers found that children born in spring or summer had a higher risk of developing non-Hodgkin’s lymphoma later in life compared to kids born in winter. The team didn’t find any similar seasonal pattern for risk of Hodgkin’s lymphoma. The results lend additional support to the “delayed exposure hypothesis.” Children born in spring or summer may not be exposed to critical pathogens during a critical early period of immune system development, leaving them vulnerable later in life. Children born in the fall or winter, by comparison, do get that important exposure at just the right time. Crump was quick to note that season of birth provides only a rough estimate of these exposures, since the team didn’t have accurate measures of exposures to Epstein Barr or other viruses, but he also added that these results “shed additional light on possible pathways of risk that may contribute to the development of non-Hodgkin’s lymphoma.”

A similar study published in January in the International Journal of Epidemiology found that children born in spring and summer had a higher chance of developing melanoma later in childhood or early adulthood. The team hypothesized that spring and summer babies are exposed to more UV radiation in warm summer months in the first few months of life – an exposure that fall and winter babies are less likely to have.

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Clinical Trials, Ethics, Genetics, NIH, Pediatrics

The promise and peril of genome sequencing newborns

NICUEven though doctors and researchers have made great strides in caring for patients in the past few decades, there are still many illnesses that are difficult to diagnose, let alone treat. Among the most heartbreaking cases are those newborns who come down with mysterious illnesses that defy medical expertise. But in recent years, doctors have turned to genetic sequencing in some of these cases to identify the culprit causes of the illnesses.

Last year, the National Institutes of Health funded four pilot projects looking into the efficacy and ethics of genetic screening for otherwise inexplicable illnesses in newborns. The first of the trials will begin next week at Children’s Mercy Hospital in Kansas City, Missouri, as reported in a recent story from Nature. The trial at Children’s Mercy Hospital will focus on rapid genome sequencing with a 24-hour turn-around. Genetic sequencing normally takes weeks, but some of these infants don’t survive that long. Doctors have used similar rapid genome sequencing to diagnose an infant with cardiac defects at Lucile Packard Children’s Hospital Stanford.

Earlier this year, I had the opportunity to report on a rare genetic mutation that leads young infants to develop inflammatory bowel disease. I spoke with some parents of children with the mutation, which was identified by sequencing the children’s exome – just the protein-producing part of the genome – as part of a new project (separate from the NIH trials) at the University of Toronto in Canada. As I explain in the piece, getting a bone marrow transplant early enough can help alleviate symptoms and save the child’s life.

The parents were uniformly grateful for the sequencing technology that made it possible to understand what was causing their baby’s illness, even in cases where the child didn’t survive long after diagnosis. One mother mentioned that realizing some of the best doctors in the country didn’t know what was ailing her daughter made the experience even more frightening. After months of worried confusion about their young children’s deteriorating health, for these parents to have an answer was a relief.

But because the technique is so new, several ethical details still need clarification – which the NIH study hopes to answer. From the Nature news story:

Misha Angrist, a genomic-policy expert at Duke University in Durham, North Carolina, says that although the 24-hour genome process is impressive, it is not clear whether genomic sequencing of newborns will soon become standard practice. Many questions remain about who will pay for sequencing, who should have access to the data and how far clinicians should go in extracting genome information that is unrelated to the disease at hand. Then there is the question of how informative the process is. “I think it’s really important that we do these experiments so that we start to see what that yield is,” Angrist says.

All four teams will include an ethicist who will be responsible for dealing with questions like the ones Angrist raises. The other three trials at Boston Children’s Hospital, the University of North Carolina in Chapel Hill, and at the University of California, San Francisco are still awaiting approval from the Federal Drug Adminstration.

Previously: Stanford patient on having her genome sequenced: “This is the right thing to do for our family” When ten days = a lifetime: Rapid whole-genome sequencing helps critically ill newborn Assessing the challenges and opportunities when bringing whole-genome sequencing to the bedside Whole genome sequencing: The known knowns and the unknown unknowns
Photo by kqedquest

Research, Science

The benefits and costs for scientists of communicating with the public

The benefits and costs for scientists of communicating with the public

twitter_bird_sketch_Shawn_CampbellToday’s researchers are under immense pressure to produce scientific results in the form of peer-reviewed journal articles—and do it on tighter and tighter budgets. And although there’s a myth that scientists don’t like talking to the media or interacting with non-scientists, many researchers consider it part of their jobs to explain their research to the general public, either through interviews with reporters or social media.

But does this “science-splaining” take valuable time away from research that results in journal articles? A new study highlighted by science writer Matt Shipman at his blog Communication Breakdown suggests that, in fact, it might help by boosting the number of times a paper is cited by other researchers. The findings were published in the most recent issue of Journalism and Mass Communication Quarterly. Shipman writes:

This is only the latest article to link news coverage of research to scientific impact (I’ve written about related research here and here), but the new paper does a few things I haven’t seen before. First, it looks at a number of public communications approaches (including working with reporters, blogging and talking to nonscientists) and whether social media mentions affect their impact. Second, the researchers used Jorge Hirsch’s h-index as their metric for measuring scientific impact in the context of public outreach efforts.

Study results showed that that researchers who talked to reporters were more likely to have a higher h-index, though science bloggers and those that talked to nonscientists did not see a similar boost. Being mentioned on Twitter appears to act as an amplifier of that effect for both scientists who talked to reporters and for scientists who talked to nonscientists, but not for science bloggers.

So although science outreach might seem like a distraction from producing research results, it could turn out to be one more brick that builds a researcher’s legacy.

Previously: Scientists preferentially cite successful studies, new research shows, John Ioannidis discusses the popularity of his paper examining the reliability of scientific research, Listening to elephants, communicating science, and inspiring the next generation of researchers, Hawkeye Pierce (i.e. Alan Alda) teaches scientists how to better communicate about their work, and Chris Mooney: Use science to identify effective science communicators
Image by Shawn Campbell

Cancer, Global Health, Health Policy, Infectious Disease, Public Health

Treating an infection to prevent a cancer: H. pylori and stomach cancer

Treating an infection to prevent a cancer: H. pylori and stomach cancer

Hpylori-pic-thumb-460x385-2092

The number of newly diagnosed stomach cancer cases in the United States is less than a tenth of the number of prostate cancer cases or breast cancer cases, which may be part of the reason it doesn’t get the same attention as breast and prostate cancer. But the mortality rate is much higher for stomach (or gastric) cancer. Nearly 11,000 Americans will likely die from gastric cancer this year, with only 28 percent of cases surviving five years or more. For comparison, the five-year survival rate for prostate cancer is nearly 99 percent and for breast cancer, it’s more than 89 percent.

On a global scale, an estimated 700,000 people will die from gastric cancer this year, as Stanford infectious disease specialist Julie Parsonnet, MD, and her co-authors note in a Viewpoint piece in the most recent issue of the Journal of the American Medical Association. The authors also point out that worldwide, about 77 percent of gastric cancer cases are linked to chronic infections of Helicobacter pylori, a helix-shaped bacteria that was identified in the early 1980s and found to be linked to gastric ulcers a few years later, as well as to gastritis, an inflammation of the stomach lining that is a precursor to stomach cancer.

Researchers are still trying to understand exactly how H. pylori causes cancer or even how it colonizes the gastrointestinal track – they believe it’s picked up via food or water. Until recently, there was a dearth of randomized clinical trials that looked at the effectiveness of screening and treatment for H. pylori as a method for preventing stomach cancer.

Ignoring gastric cancer in the hope that it will soon disappear is not a tenable health policy

In the opinion piece, the authors describe the recommendations of a working group that met in December 2013 at the behest of the International Agency for Research on Cancer. Taking the burden of the disease and the availability of treatment options in consideration, the group considered gastric cancer “a logical target for intervention,” according to the authors of the JAMA piece. They go on to write:

Screening and treatment for H pylori is generally acceptable and affordable. An inexpensive serological test can determine who may be infected, with a sensitivity and specificity that could be sufficient for population-based prevention programs. Low-cost treatment regimens using 2 or 3 generic antibiotics plus a proton pump inhibitor for 7 to 14 days can eradicate the infection in more than 80% of cases, depending on the antibiotic resistance patterns of H pylori within the population. Economic modeling studies indicate that H pylori screening and treatment strategies are cost-effective under a large range of assumptions about effectiveness and costs. However, the models are limited by reliance on observational data rather than randomized trial results, by a lack of information on possible adverse effects of treatment, and by limited data from lower-income countries.

Researchers still have many gaps in their understanding of the best methods to prevent stomach cancer, but several trials may answer some of those questions in the coming decade.

Stomach cancer is not the only cancer known to be linked with an infection. Doctors routinely test whether women who come in for a PAP smear are infected with the human papilloma virus (HPV), which is linked to cervical cancer. Chronic hepatitis B and C infections are known to be linked to liver cancer. In time, screening for H. pylori to prevent stomach cancer may become routine. Until then, Parsonnet and her coauthors say in their conclusion, “Ignoring gastric cancer in the hope that it will soon disappear is not a tenable health policy.”

Previously: Researchers identify potential drug target in ulcer bug that infects half the world’s population, Good-bye cancer, good-bye stomach: A survivor shares her tale and Image of the Week: Helicobacter pylori colonizing the stomach
Photo by Shuman Tan and Lydia-Marie Joubert

In the News, Public Health

Healthy gut bacteria help chicken producers avoid antibiotics

Healthy gut bacteria help chicken producers avoid antibiotics

chicks for productionIf you watch TV, you’ve probably seen actress Jamie Lee Curtis selling Activa, Dannon’s probiotic yogurt – or perhaps you’ve  taken probiotic supplements to help you recover after a nasty intestinal infection. Probiotics are microorganisms that are thought to help improve the bacterial balance in our guts. It’s not clear whether they are effective in humans, but they do appear to work in chickens.

Recently, the third-largest chicken producer in the nation, Perdue Farms, announced that it had eliminated almost all antibiotics from its farm operations – a move that has been in the works at the company for a dozen years. As NPR’s The Salt blog recently reported, the company has turned, instead, to probiotics to help keep the chickens healthy:

“As we took antibiotics out of the feed, we put some other things in, such as probiotics,” says Bruce Stewart-Brown, an executive at Perdue Farms. “We’ve increased the amount of probiotics by five times over the past five years. It’s a significant part of our program.”

Since the 1970s, farmers have given low doses of antibiotics to livestock animals to help them grow faster and bigger, a practice called “sub-therapeutic” use. And for almost as long, the practice has been viewed with suspicion by many concerned that it may encourage antibiotic resistance. Approximately 15-17 million pounds of antibiotics are given to livestock in the U.S. every year, according to Stuart Levy, MD, of Tufts University, director of the Alliance for the Prudent Use of Antibiotics.

In December, the FDA asked antibiotic producers to label their drugs so that they did not promote “sub-therapeutic” doses to fatten animals and earlier this month, the White House issued a report on combatting antibiotic resistance. One of the criticisms of the plan was that it didn’t make strong recommendations for reducing sub-therapeutic use of antibiotics in livestock animals.

Probiotics are a more expensive intervention than sub-therapeutic antibiotics, but offer an alternative – at least in chickens, as The Salt reports:

Stewart-Brown says that he was initially skeptical about probiotics. “Eight years ago, I would have said that they’re not working in poultry. They’re not very useful. Today, I’m saying that they are useful. Expensive, but useful. “Chickens that got probiotics stayed healthier and grew faster than birds that didn’t.

Perdue’s experiment with probiotics is probably the largest of its kind among commercial producers. How they fare may be a bell weather of what’s to come for other agricultural livestock producers and provide them with a route away from antibiotic overuse.

Previously: Interactive online map helps researchers track spread of antibiotic-resistant bacteria and Some unlikely sources for antibiotics
Photo by Loaf

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