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Health Costs, Health Policy, Patient Care, Stanford News

A call for medical malpractice reform

Golden Lady Justice, Bruges, BelgiumA new report in the Journal of the American Medical Association offers a look at the current decline in medical malpractice suits and makes some predictions about their future. The authors include two Stanford faculty, Michelle Mello, JD, PhD, and David Studdert, LLB, ScD, who both have joint appointments at the School of Medicine and the School of Law.

Using national databases, the researchers found that the paid claims against doctors decreased between 2002 and 2013. Rates decreased by an average of 6.3 percent for medical doctors (MDs) and 5.3 percent for doctors of osteopathy (DOs). The amount of an average paid claim peaked in 2007 at $218,400, but had gone down a bit as of 2013. A post on the Stanford Law School’s blog explains why this may be a good time for policy-makers to consider reforms in the medical liability system:

“After years of turbulence, the medical liability environment has calmed,” said Mello. “Although many aspects of the malpractice system are dysfunctional, causing angst for physicians, the cost of malpractice claims and insurance have been stable for the last few years and the number of claims has been declining.”

She added, “Usually, attention is only focused on reform during ‘malpractice crises,’ but highly charged political environments are not conducive to cool-headed policy decisions. This current period of calm is a good time to be thinking about reforms that could improve our medical liability system.”

In their piece, the authors describe seven different novel approaches to medical malpractice reform, including one that encourages medical institutions and providers to communicate with complaining patients and find resolutions that might include payouts to patients before they file suit.

The paper also includes some predictions about the trends that will be important for medical liability policy in the coming decade. The authors assert that traditional tort reforms “will never deliver,” but the previously mentioned communication-and-resolution programs are likely to expand, as will “safe harbor” laws that protect clinicians and their institutions if they can show they are following a prescribed course of clinical treatment. Other trends include the increasing consolidation of health care within hospitals and large health systems. These large entities are likely to use their growing size to influence the liability system.

More ominously, authors note that liability insurance crises have happened in regular cycles since the system was expanded in the 1960s, and warn that another is imminent. They conclude their report by saying:

Action now to reduce the amplitude of the next medical liability cycle is both prudent and feasible. Further testing of nontraditional reforms, followed by wider implementation of those that work, holds the most promise. Prospects for permanent improvement in the medical liability climate depend on it.

Photo by Emmanuel Hybrechts

Research, Science

Nature tracks 100 most-cited scientific papers

Nature tracks 100 most-cited scientific papers

Bound journals on shelves Flickr Taber Andrew BainAfter a researcher painstakingly collects the data, analyzes it, sweats over the manuscript that describes the findings, and finds a journal to publish it, a study that likely took years to conduct finally appears in public. Other researchers will read it and maybe get ideas for further research, and eventually cite the original article when publishing new findings.

The number of citations a paper receives is a way  – though imperfect – of keeping track of its influence in any given scientific field. And so, Nature recently compiled a list of the most-cited papers of all those cataloged in Thomas Reuters’ Web of Science since 1900. The journal ran some nifty graphs related to the list, including a yearly breakdown of the number of citations for each paper.

The top paper, by biochemist Oliver Lowry, MD, PhD, garnered more than 300,000 citations since its publication in 1951. The last one on the list had just a little more than 12,000 citations. Many famous discoveries such as Watson and Crick’s description of DNA’s double helix aren’t on the list, probably because those revolutionary findings quickly become well-known enough and authors didn’t consider citing the work necessary.

The story includes a mention of the work of a Stanford faculty member:

Number 41 on the list is a description of how to apply statistics to phylogenies. In 1984, evolutionary biologist Joe Felsenstein of the University of Washington in Seattle adapted a statistical tool known as the bootstrap to infer the accuracy of different parts of an evolutionary tree. The bootstrap involves resampling data from a set many times over, then using the variation in the resulting estimates to determine the confidence for individual branches. Although the paper was slow to amass citations, it rapidly grew in popularity in the 1990s and 2000s as molecular biologists recognized the need to attach such intervals to their predictions.

Felsenstein says that the concept of the bootstrap, devised in 1979 by Bradley Efron, a statistician at Stanford University in California, was much more fundamental than his work. But applying the method to a biological problem means it is cited by a much larger pool of researchers. His high citation count is also a consequence of how busy he was at the time, he says: he crammed everything into one paper rather than publishing multiple papers on the topic, which might have diluted the number of citations each one received. “I was unable to go off and write four more papers on the same thing,” he says. “I was too swamped to do that, not too principled.”

The article concludes with a description of some of the highlights in the fields of biological techniques, bioinformatics, phylogenetics, statistics, density fuctional theory and crystallography. It’s a nice look at some seminal findings that you won’t likely find in textbooks.

Previously: The benefits and costs for scientists of communicating with the public, Scientists preferentially cite successful studies, new research shows and A new era in scientific discourse? PubMed gets comments
Photo by Taber Andrew Bain

Clinical Trials, Health Policy, NIH, Women's Health

A look at NIH’s new rules for gender balance in biomedical studies

A look at NIH’s new rules for gender balance in biomedical studies

In May, Francis Collins, MD, PhD, director of the National Institutes of Health, co-authored a Comment piece in Nature, outlining new requirements for biomedical researchers that made balancing the sex of animals and cell lines in studies much more important than they have been in the past. The first changes were set to be implemented this month. But, as Scientific American reported earlier this week,  the NIH isn’t likely to implement the changes as quickly as previously thought:

Funding rules, however, have yet to change, with only one week left in the month. Instead, the agency is gathering comments from researchers about which research areas need sex balance the most and the challenges scientists face in including male and female subjects in their studies. Officials have set aside $10.1 million in grants for scientists who want to add animals of the opposite sex to their existing experiments. The NIH is also making videos and online tutorials to teach scientists who are new to studying both sexes how to design such studies. Meanwhile, [Janine A. Clayton, director of the NIH’s Office of Research on Women’s Health] “can’t say” when new funding rules will take effect. “Details about the policy and implementation plans will roll out during the next year,” she says.

Scientists rely heavily on male animals, rarely using females, and the changes would require some drastic changes for researchers seeking funds from NIH. More from Scientific American:

Once in place and codified, the requirement would be a major shift for the nation’s biomedical labs, many of which study mostly or exclusively male animals. One estimate found that pharmacology studies include five times as many male animals as female ones, while neuroscience studies are skewed 5.5:1 male-to-female.

Scientists assumed biology findings that held in males would apply just as well to females, but a growing body of research has discovered this is not always true. Female and male mice’s bodies make different amounts of many proteins, for example. Men and women have differing risks for many health conditions that are not obviously sex-based, including anxiety, depression, hypertension and strokes. Yet those diseases are still predominantly studied in male animals. Scientists who study sex differences think the mismatch might be the reason women suffer more side effects than men do from drugs approved by the U.S. Food and Drug Administration. Pharmaceuticals that researchers test mainly on male animals may work better for men than for women.

When the NIH does begin to implement these changes, the first steps will be training staff and grantees on what these changes mean for experimental design. And it should be noted that this isn’t the first time that NIH has encouraged sex balance. In 2013, its Office of Research on Women’s Health started a program of supplemental grants for currently funded researchers to add enough animals for gender-balanced study results.

Previously: Why it’s critical to study the impact of gender differences on diseases and treatments, Large federal analysis: Hormone therapy shouldn’t be used for chronic-disease prevention and A call to advance research on women’s health issues
Photo by Mycroyance

Cancer, In the News, Nutrition, Patient Care, Surgery

“Prehab” routines before cancer surgery help patients bounce back faster

Surgery_flickr_thinkpanamaIf you’ve ever had surgery, especially an orthopedic one, you’ve probably had rehabilitation therapy. In recent years, orthopedic surgery plans have begun to include a period of “prehabilitation” exercise to help prepare patients for their procedure. Now, researchers have demonstrated that a pre-surgery work-out routine combined with some dietary changes may be able to help cancer patients regain their baseline strength levels sooner. A story on NPR’s Shots blog described the recent study:

Researchers from McGill University in Montreal studied 77 patients scheduled for colorectal cancer surgery. A kinesiologist gave the patients aerobic exercises and strength training to do at home. A registered dietitian gave them nutritional counseling and prescribed a whey supplement to make up any protein deficits, and a psychologist provided anxiety-reducing relaxation exercises.

Half of the patients were told to start the program before surgery – an average of about 25 days before – and to continue afterward for eight weeks. The other group was told to start right after surgery.

Not surprisingly, the group assigned to prehabilitation did better on a presurgery test that measured how far they could walk in 6 minutes. And it paid off.

Two months after surgery, the prehabilitation group walked an average of 23.7 meters farther than when they started the study. Rehab-only patients walked an average of 21.8 meters less than when they started. (A change of 20 meters is considered clinically significant.) And a greater proportion of the prehabilitation group was back to baseline exercise capacity by then.

Because of the methology the researchers used, it’s not clear how the diet or the exercise prescribed in the pre-surgery regimen affected the outcome. Previous studies that looked at exercise-only regimens did not show post-surgery improvements. A larger study with a more varied pool of patients is likely needed for definitive answers.

Previously: Wellness after cancer: Stanford opens clinic to address survivors’ needs and A call for rehab services for cancer survivors
Photo by thinkpanama

Addiction, Emergency Medicine, Health Policy, Research, Stanford News

Assessing the opioid overdose epidemic

Assessing the opioid overdose epidemic

Vicodin bottle Flickr Sharyn MorrowIn recent years, doctors and policy-makers have become aware of the dangers of prescription opioid medications like methadone, oxycodone and hydrocodone (which is sold as OxyContin or Vicodin). In a study published in this month’s JAMA Internal Medicine, Stanford medical student Michael Yokell and Stanford surgeon Nancy Wang, MD, took a new approach to quantifying those dangers.

Many previous studies of the toll of opioids looked at death certificate data and examined trends among deaths due to opioid overdoses, including street drugs like heroin and prescription painkillers. The new study looked at emergency department admissions and found that more than two thirds of ER visits due to overdoses were related to prescription opioids, while heroin overdoses accounted for 16 percent. Moreover, only about 2 percent of cases that made it to the ER died, but more than half the patients needed further hospitalization.

The study also found that those admitted to the emergency room because of opioid overdoses are more likely to have conditions such as chronic breathing problems, heart problems or mental health issues. Yokell explained that it’s important for doctors to be aware of the possibility of overdose and consider prescribing alternatives or discuss the risk of overdose with patients.

Beyond providing better access to emergency medical care and treatments for patients, an important next step to resolving the problem of opioid misuse is to establish or improve statewide prescription monitoring programs. For example, California has a prescription drug-monitoring database called CURES, but not all doctors actively use the program. “We can do a better job of making that database more widely used by physicians in the state.  We need more doctors to sign up and use it. It’s a valuable resource,” said Yokell.

Additionally, many people get access to prescription opioids via fraudulent prescriptions or from dealers that have illegally obtained the drugs – sometimes from breaking into and raiding pharmacies. “It’s important to keep in mind that good prescribing practices are one component of an effective strategy. There are many other ways for people to get their hands on [prescription opioids] and use them inappropriately.”

Although fixing things on the prescription side is important for managing the opioid overdose epidemic, Yokell notes that it’s not enough. Cases that make it to the ER are likely to survive, but Yokell noted that the fear of criminal charges often results in people avoiding medical care for overdoses caused by opioids and that getting this group better access to emergency services and treatment could improve outcomes. Paramedics and doctors have access to the drug naxolone, marketed as Narcan, which is safe and effective treatment for opioid overdose. But “people don’t call 911, so they are dying,” Yokell told me.

Previously: Stanford addiction expert: It’s often a “subtle journey” from prescription-drug use to abuse, Increasing access to an anti-overdose drug and A focus on addiction, the country’s leading cause of accidental death
Photo by Sharyn Morrow

Applied Biotechnology, Health and Fitness, Stanford News

Fits like a glove: Stanford researchers develop medical applications for the Cooling Glove

Fits like a glove: Stanford researchers develop medical applications for the Cooling Glove

Weightlifting1-CoreControlTwo years ago we wrote about the Cooling Glove, a device developed by Stanford biologists Craig Heller, PhD, and Dennis Grahn that helps athletes cool off and recover from active play more easily. At the time, the Cooling Glove was being used by a few sports teams, especially Stanford football, but others included the San Francisco 49ers and Manchester United. This past July, the glove was used by the Germans in the FIFA World Cup soccer competition, where they handily beat the heavily favored Brazilian team on their home turf.

The device fits over an athlete’s hand and is connected to a cooler and a vacuum source. Grahn and Heller’s major insight was that the non-hairy skin of the palms, soles, and face are our major sites of heat dissipation. These areas have special blood vessels that can receive a large volume of blood and act as radiators, and the cooled blood from these surfaces flows back to the body’s core.

When asked about other applications for the glove, Heller rattles off half a dozen that his lab is looking into in quick succession. One includes building a prototype for military working dogs. If they’re in an extremely hot climate, they pant more, which compromises their ability to sniff and find the dangerous compounds they are searching for. A canine cooling device that keeps their body temperature cool can help their sniffers work more efficiently.

The team is also working on several medical applications. One variant aims to maintain patient’s temperature during surgery. In this application, booties can be used leaving the arms free for IV lines and other instrumentation. The researchers are also looking at how the Cooling Glove can help menopausal women manage their hot flashes. Heller will soon begin enrolling volunteers for this trial. Another application involves using the glove in its heating mode to stave off migraine headaches before they become full-blown.

The U.S. Department of Energy is interested in how personal heating and cooling devices could be used as an alternative to heating and cooling whole buildings or rooms. The glove or bootie technology could mean a broader dead band on thermostats – the temperature range within which neither the cooling or heating system needs to be turned on – thus saving lots of energy.

Despite the recent success at the World Cup, Heller says the Cooling Glove has not been as popular with athletes as it could be. He notes that Avacore, the company marketing the glove commercially, is relatively small and doesn’t have a large enough budget to develop a more streamlined and user-friendly version or market it widely. He says that the device’s novelty also slows down acceptance:

If you have a concept that doesn’t fit existing ideas, breaking into a market is difficult. We had to overcome skepticism that we were selling snake oil. We overcome that with research, but getting basic research translated and disseminated for the user community is not easy.

One finding of the research is that use of the glove in a conditioning program produces impressive results – beyond what is produced by performance enhancing substances, such as steroids. In a study involving students, some freshmen women – not varsity athletes – were did more than 800 pushups in less than 45 minutes. Some professional athletes tripled their capacities in particular routines such as dips or pullups in 5-6 weeks.

Heller is optimistic about the Cooling Glove’s future in sports. “I expect it will be adopted eventually. If, for no other reason, safety – in sports and many other endeavors such as emergency response.”

Heller is a founder of Avacore, but no longer affiliated with the company.

Previous: Researchers explain how “cooling glove” can improve exercise recovery and performance
Photo courtesy of Avacore

Global Health, In the News, Infectious Disease, Microbiology, Public Health

Exploiting insect microbiomes to curb malaria and dengue

Original Title: Aa_FC2_23a.jpgEvery year, more than 200 million people are affected by malaria and 50 to 100 million new dengue infections occur. Now, a group of scientists from Johns Hopkins University may have found a novel way of curbing both diseases: by “vaccinating” mosquitos against the parasite that causes malaria and the virus that causes dengue. The researchers are using the bacteria Chromobacterium, which prevents the pathogens from effectively invading and colonizing mosquito guts.

As Science magazine reported last week:

Like humans and most other animals, mosquitoes are stuffed with microbes that live on and inside of them—their microbiome. When studying the microbes that make mosquitoes their home, researchers came across one called Chromobacterium sp. (Csp_P). They already knew that Csp_P’s close relatives were capable of producing powerful antibiotics, and they wondered if Csp_P might share the same talent.

In another experiment, done with mosquitoes that weren’t pretreated with antibiotics, Csp_P-fed mosquitoes were given blood containing the dengue virus and Plasmodium falciparum, a single-celled parasite that causes the most deadly type of malaria. Although a large number of the mosquitoes died within a few days of being infected by the Chromobacteriumthe malaria and dengue pathogens were far less successful at infecting the mosquitoes that did survive, the team reports today in PLOS Pathogens. That’s good news: If the mosquito isn’t infected by the disease-causing germs, it is less likely to be able to transmit the pathogens to humans.

The bacteria also inhibited growth of Plasmodium and dengue in lab cultures, indicating that Csp_P is producing compounds that are toxic to both pests. One possible application of these toxins is to develop treatment drugs for people already infected with malaria or dengue. Real-world applications of this research are many years in the future, but it hints at a whole new way of dealing with otherwise intractable diseases.

Previously: Close encounters: How we’re rubbing up against pathogen-packing pestsClosing the net on malaria and Fighting fire with fire? Using bacteria to inhibit the spread of dengue
Photo by Sanofi Pasteur

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

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