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Research, Science, Sleep, Stanford News

Flashing light at night could help beat jet lag, Stanford study says

Flashing light at night could help beat jet lag, Stanford study says

plane in sunsetThe body will eventually adjust to jet lag, it’s just that it takes time — about an hour a day to be precise. And anyone who has suffered the unpleasant side effects of jet lag – brain fog, body achiness, an overwhelming need for endless pots coffee — might have an interest in speeding the process up.

A new Stanford study suggests that exposing travelers to short bursts of flashing lights the night before a trip while asleep could help speed up the process significantly. In a press release I wrote on the study, which was published today in the Journal of Clinical Investigation, researchers explained how this works at a biological level:

The transfer of light through the eyes to the brain does more than provide sight; it also changes the biological clock. A person’s brain can be tricked into adjusting more quickly to disturbances in sleep cycles by increasing how long he or she is exposed to light prior to traveling to a new time zone.

Light therapy is designed to speed up the brain’s adjustment to time changes. By conducting light therapy at night, the brain’s biological clock gets tricked into adjusting to an awake cycle even when asleep. It’s a kind of “biological hacking” that fools the brain into thinking the day is longer while you get to sleep.

 To determine whether continuous or flashing lights would provide the fastest method of sleep cycle adjustment, researchers had 39 study participants sleep in a lab, exposing some to continuous light for an hour, and others to flashing light for an hour. They found that the flashing light —which most could sleep through just fine— elicited about a two-hour delay in the onset of sleepiness, while those exposed to continuous light, the delay was only 36 minutes.

Jamie Zeitzer, PhD, the senior author of the study, described how flashing-light therapy could be used to adapt to traveling from California to the East Coast: “If you are flying to New York tomorrow, tonight you use the light therapy. If you normally wake up at 8 a.m., you set the flashing light to go off at 5 a.m. When you get to New York, your biological system is already in the process of shifting to East Coast time.”

“This could be a new way of adjusting much more quickly to time changes than other methods in use today,” he told me.

Previously: Cheating jet lag: Stanford researchers develop methods to treat sleep disturbances, Why sleeping in on the weekends may not be beneficial to your health, How sleep acts as a cleaning system for the brain, Study shows altered circadian rhythms in the brains of depressed people, Jet-lag drug is a no go and Jet-lagged hamsters flunk IQ test
Photo by Eric Prado

Health Disparities, History, In the News, LGBT, Medicine and Society

Film honors transgender pioneers

Film honors transgender pioneers

pride-828056_1920I knew little about the film “The Danish Girl” last weekend when, diverted from a sold-out showing of the Oscar favorite the “Revenant,” my husband and I disappointedly walked down Pacific Avenue in Santa Cruz to another theater to see the film about a transgender woman instead.

It proved to be a fortuitous diversion. “The Danish Girl” is artistically gorgeous and well acted, as today’s Academy Award nominations point out. The film received nominations for Eddie Redmayne as best actor in his role as a transgender artist, best supporting actress for Alicia Vikander, his wife who stands by him as he confesses that he believes he was born in the wrong gender and begins to dress as a woman they call Lili — and nods for costume design and production design as well.

But the film struck a more personal chord, halfway through its viewing, when I sucked in a short gasp realizing that, in addition to being a love story with a socially relevant message, the film was recounting a piece of medical history. And suddenly, the film took on a frightening edge.

I knew from my research for a story I wrote for Stanford Medicine magazine in 2012 titled “Transition point: The unmet needs of transgender people,” something of the challenges facing transgender people today as they navigate the medical world trying to get the care they need. The story describes the paucity of evidence-based medicine for transgender health care and the lack of training for physicians on how to provide care. As I wrote in the story:

The problem is that in the United States, most physicians don’t exactly know what treatment for the transgender patient entails. For an untrained professional, it’s a challenge to provide care to a patient with a penis who wants a vagina, or to a patient who has been tortured emotionally by being told she’s a boy when she knows she’s a girl. General practitioners — the majority of doctors who treat patients in the United States — are equally unprepared to care for those transgender patients after they have begun to take hormones and have undergone genital-reconstruction surgery. The lack of medical education on the topic, a near-total absence of research on transgender health issues and the resulting paucity of evidence-based treatment guidelines leave many at a loss.

The film, as I suddenly realized sitting in the darkened theater, must have been inspired by those transgender pioneers in 1920s Europe who chose to undergo the first experimental sex reassignment surgeries. Of course, as with any surgery, there had to be those first patients. I’d just never thought about it before.

In fact, I later learned, the film was inspired by the real life Lili Elbe, a Danish transgender woman born in 1882, who was one of those first patients. The film honors the memory of these brave transgender pioneers, and, perhaps, will prod others to consider the continued inadequacies of medical care today, and what can be done to improve them.

Previously: Stanford study shows many LGBT med students stay in the closet, Study shows funding for LGBT health research lacking, offers solutions and Gay, lesbian, bisexual and transgendered health issues not being taught in medical school
Photo by nancydowd

Education, In the News, Medical Schools, Research, Stanford News

Medical schools get an “F” at grading graduates, study suggests

Medical schools get an "F" at grading graduates, study suggests

witteles word cloud imagePerformance evaluations, an important piece of the medical residency application packet, are often incomprehensible, sometimes useless and, at worse, misleading and unfair, according to a recent Stanford study published in Academic Medicine.

The study, which examined performance evaluations — commonly referred to as the “Dean’s letter” — from 131 medical schools across the nation, found that about half don’t follow recommended guidelines set by the Association of American Medical Colleges in 2002.

“This has real consequences as it leaves residency programs in the dark about how well an applicant performed,” says Ronald Witteles, MD, senior author of the study and director of the internal medical residency program at Stanford. “Some of the examples are actually rather humorous, such as one school having 33 percent of its students in the ‘top quartile’ and only 8 percent in the ‘bottom quartile.’ ”

AAMC guidelines recommend that medical schools include “easily interpretable comparative data on core clerkship performance and overall academic performance,” the study states.

To quantify whether the 117 medical schools in the study achieved this goal, researchers examined the grading and ranking systems used, if any. Among the results, they found that 14 of the schools didn’t use any ranking systems at all. Among the 83 medical schools that did assign key words to rank students, there was “tremendous variability” in the terms used — a total of 72 — making it extremely difficult to compare students across institutions.

Adding to the confusion, those 83 medical schools used 27 different words and phrases to describe the “top tier” students such as: exemplary, superior, distinguished, outstanding, exceptional, most outstanding, recommended highly, recommended with distinction, extraordinary and enthusiastically recommended. The meanings of the words varied from institution to institution, Witteles says, and were often difficult to interpret.

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Education, Health Costs, In the News, Patient Care, Research, Stanford News, Technology

Medical errors caused by doctors not examining their patients

Medical errors caused by doctors not examining their patients

800px-Child_examined_by_doctorStories of shocking medical errors that occur because doctors miss something during a physical exam — or forget to examine a patient at all — are common. Every physician knows them, says Stanford physician Abraham Verghese.

A missed breast mass in a patient that presents with chest pain. A missed gunshot wound in a patient wheeled into the emergency room. A missed pregnancy in a patient with a large belly.

But little has been done to quantify this type of medical error. In a first step toward creating data-based measurements of medical errors due to inadequacies in the physical exam, a study published recently in the American Journal of Medicine reports on a collection of 208 such occurrences, and their consequences.

I think of it as my worst nightmare, that a patient will slip through my grasp with a diagnosable or treatable condition.

Researchers collected the incidents from responses to surveys sent to 5,000 physicians asking for first-hand stories of such medical errors. The cause of the oversights in the 208 responses was most often a failure to perform the physical examination at all — in 63 percent of the cases, the study states. Other times, errors were caused by misinterpretating or overlooking physical signs.

“I think of it as my worst nightmare, that a patient will slip through my grasp with a diagnosable or treatable condition,” says Verghese, who is known as a champion of bedside medicine. “I call it the ‘low hanging fruit,'” he says, referring to the simple yet essential process of conducting the physical exam — and its low cost.

The consequences of these mostly preventable mistakes varied from missed or delayed diagnoses in 65 percent of the patients, to incorrect diagnosis in 27 percent or unnecessary treatment in 18 percent, the study says.

“We are talking about missing things that are very common, a mass, or a sore or a heart murmur or something in the lungs, that leads you down the wrong path,” says John Ioannidis, MD, senior author of the study. “This is something that happens everyday, and it’s something that could be corrected to a good extent.”

A well-known report conducted by the Institute of Medicine titled, “To Err is Human,” found that medical errors cause nearly 100,000 deaths per year, according to the study. The extent to which physical examination errors contribute to this figure remains uncertain and, as a result, little has been done to prevent them, it says.

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Palliative Care, Patient Care, Research, Science, Stanford News

Desire for quality end-of-life care crosses ethnic groups

Desire for quality end-of-life care crosses ethnic groups

VJ in officeEthnic minorities want quality end-of-life care, including in-depth conversations with their physicians about how to achieve this, but they often face barriers to getting the care they desire. That’s according to a study published today in the Journal of Palliative Care.

In a press release I wrote about the study, lead author VJ Periyakoil, MD, a Stanford expert in end-of-life care, explained why she decided it was important to conduct a study with the goal of reaching out to traditionally hard-to-reach ethnic groups within the communities where they live:

There is so much generalization and stereotyping by physicians about how ethnic minorities want everything done, irrespective of how effective these treatments might be at the end of life. I decided that we needed to go into their communities and ask them what they want.

Periyakoil and her colleagues conducted a series of in-person interviews at a scattering of community-based senior centers around the San Francisco Bay Area accompanied by interpreters. The populations are particularly hard to reach because of a number of issues, including language barriers, immigration status, and poverty levels, Periyakoil said. In addition to English, interviews were conducted in Spanish and five Asian languages — Burmese, Hindi, Mandarin, Tagalog and Vietnamese. As I described in the release:

The researchers… found that all participants valued high-quality end-of-life care. A majority, 61 percent, said there were barriers to receiving high-quality care for members of their ethnic group.

The 191 participants who reported barriers to getting quality end-of-life care were asked to describe the biggest barriers, which were, in order of how often they were cited: finances and health insurance; physician behavior; communication problems with doctors; family beliefs; health system barriers; and cultural/religious barriers.

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Behavioral Science, Palliative Care, Stanford News

Stanford physician highlights the “never-ending battle” of PTSD

Stanford physician highlights the "never-ending battle" of PTSD

VJ Periyakoil, MD, a palliative care physician at Stanford, first met Mr. M, a 78-year-old veteran with heart failure, in the remaining few weeks of his life – when he was wheelchair bound and tethered to an oxygen cylinder. She asked him about his condition, his pain levels, and his military service, but he would share little at first. He vehemently denied having PTSD, with his wife simply saying, “He doesn’t like to talk about war.”

Mr. M’s medical records showed he had chest pain and trouble sleeping, but he just shrugged and refused any pain medicine. Over his next few weeks in the hospital, as Periyakoil grew to know her patient better and he grew to trust her more, the veteran began talking with Periyakoil about his war wounds, and he revealed a heart-wrenching tale.

Periyakoil writes about Mr. M in a perspective piece published today in the New England Journal of Medicine, telling readers:

Even if the war they fought is long over, many veterans are perpetual prisoners of an ongoing inner war that rages silently in their heads. Men and women on active duty may be forced to commit actions that directly conflict with their ethical and moral beliefs. Their stoicism and “battlemind” may serve them well as long as their psychological defenses are intact. At the end of life, however, their previous coping strategies may crumble, especially if they’re taking mind-altering medications to relieve pain. Many may even prefer to bear severe pain and avoid pain medications, which make them fuzzy-headed and can unleash war-related nightmares and flashbacks.

What unfolds in the piece is a the tale of a brave solider, still on active combat duty battling the mental wounds of war daily the best he knows how: “The nights were pretty bad for him. He was hyper alert but exhausted, and he often prowled the hospital hallways on his electric scooter all night long,” she writes.

On one of those nights, while Periyakoil was treating the weeping ulcers on his ankles, Mr. M told her about the pivotal event from the war, the one that haunted him at night, keeping him from closing his eyes to sleep:

Finally, Mr. M looked straight into my eyes and said softly, “The girl was pregnant. I noticed it after… you know … as I was cleaning my knife. Whenever I close my eyes, I see her face, that split second when she understood what was about to happen. I cannot get it out of my head.”

The story continues:

After several minutes of companionable silence, he asked, “VJ, am I going to hell for killing two innocents?” Without waiting for a response, he continued, “Well, I’m going to find out soon enough.”

As a nationally recognized leader in geriatrics and palliative care, Periyakoil, is both a researcher and a clinician. But this piece is a reminder of just how important her work with patients is. She said she’s telling the story of Mr. M in honor of both Veteran’s Day and the memory of the many veterans with similar stories who she has treated over the years.

Previously: Examining the scientific evidence behind experimental treatments for PTSDThe promise of yoga-based treatments to help veterans with PTSDHow a Stanford physician became a leading advocate for palliative care and Are veterans with PTSD at higher risk for medical illnesses?

Cardiovascular Medicine, Chronic Disease, Dermatology, Research, Stanford News

Limb compression device reduces skin infections caused by lymphedema

Limb compression device reduces skin infections caused by lymphedema

Key among the nasty problems caused by lymphedema, a common cardiovascular disease that causes limb and trunk swelling, is the risk of skin infection. Lymphedema causes the skin to thicken and become inelastic, which open the doors for infection to enter more easily; according to Stanford’s Stanley Rockson, MD, about 25 percent of lymphedema patients experience recurring infections that can result in hospitalization.

Thus the results of a recent study published in JAMA Dermatology offers some exciting news, says Rockson, a world renowned expert in lymphedema.

The fact that we saw dramatic reductions in the incidence in rate of infections… is very noteworthy

In the study, an advanced model of a pneumatic compression device used to treat lymphedema was found to reduce skin infections from the disease by nearly 80 percent. Rates of cellulitis, the medical term for such skin infections, were lowered from 21 percent to 4.5 percent in the people with lymphedema due to cancer and from 28.8 percent to 7.3 percent in individuals whose lymphedema was not due to cancer.

Pneumatic compression devices, which have been in use for decades, are inflatable garments that when applied to the swollen area of the skin inflate and deflate in cycles to help drain lymph fluid build up. Most of these devices simply apply an increasing degree of pressure from the garment, but the model used in this study goes a step further. As Rockson, a co-author on the study, explains in a podcast accompanying the journal article:

This device works not just by adding pressure… It actually intends to simulate the intervention used by physical therapists when they do manual lymphatic massage. It places very low pressure stress on the skin increasing the filling of the lymphatic capillaries and thereby stimulating intrinsic contractility.

The idea is that the distribution of the pressure can be relegated and the treatment more targeted, he says.

“The fact that we saw dramatic reductions in both the incidence in rate of infections as well as the decreases in cost-related to care, ER visits, hospitalizations, intravenous antibiotics, is very noteworthy,” Rockson concludes.

The research was conducted at the University of Minnesota School of Public Health in collaboration with Vanderbilt University School of Nursing.

Previously: Home health care treatments for lymphedema patients cut costs and improve care; New Stanford registry to track lymphedema in breast cancer patients.

Patient Care, Research, Stanford News

Study on training program for anesthesiologists shows challenges of changing doctor behavior

Study on training program for anesthesiologists shows challenges of changing doctor behavior

Simulation RAWith the problem of opioid addiction reaching epidemic proportions, anesthesiologists are pushing for greater use of non-narcotic methods of pain control, according to Edward Mariano, MD, an associate professor of anesthesiology, perioperative and pain medicine at Stanford.

One of those methods is ultrasound-guided nerve blocks, which involves using ultrasound to guide a small catheter next to a nerve to deliver pain relieving anesthesia directly to the site of the injury. The method is particularly effective in procedures like the 700,000 knee replacements that are done yearly, and its use has become somewhat commonplace over the past 10 years since it routinely began to be taught to anesthesiology residents, Mariano recently told me. But any anesthesiologist who entered practice prior to 10 years ago probably hasn’t received adequate training in the technique.

“I had to learn on my own,” said Mariano, which is what most established anesthesiologists end up doing if they use the procedure at all. Mariano set out to research whether teaching this method of pain control to anesthesiologists in a continuing medical education (CME) course using simulation training with mannequins might increase both the doctors’ ability to do the procedure and the use of the procedure when the physicians returned to their practice. Current CME courses are available to teach this procedure, but they don’t use simulation training with mannequins.

For the study, Mariano and colleagues recruited 32 anesthesiologists who had been in practice for 10 years or more to participate in the trial. During an eight-hour course, the physicians were taught how to use the procedure receiving both hands on training on mannequins and lectures by faculty.

What they found was that 12 of the participants used the method at least once after training – “however, there were no differences in the monthly average number of procedures or complications after the course when compared to baseline.”

In Mariano’s words: “Within eight hours we could take any anesthesiologist and train them to be proficient in very advanced ultrasound despite the technique being tough to learn. But sadly, even though we can train them in a day, they generally don’t change their practice when they go home.”

The researchers acknowledge that this was a small study, and the study sample was perhaps too small to draw firm conclusions. But they also point out that plenty of past research has shown just how difficult it can be to change physicians’ behavior in general.

“It’s very difficult to have an ongoing practice and to do something brand new,” Mariano told me. “Not only is there the pressure and time demands of taking care of patients, there is also a natural hesitancy to try new things.”

The results of the study appear in the print edition of the Journal of Ultrasound in Medicine this week.

Photo, of co-investigator T. Kyle Harrison, MD, working in simulation lab, by Edward Mariano

Cardiovascular Medicine, Chronic Disease, Science, Stanford News, Stem Cells

Patching broken hearts: Stanford researchers regrow lost cells

Patching broken hearts: Stanford researchers regrow lost cells

Design 1_2Most heart attack survivors face a long and progressive course of heart failure due to damage done to the heart muscle. Now, in a study published in the journal Nature, researchers are reporting a method of delivering a missing protein to the lining of the damaged heart that regenerates heart muscle cells — cardiomyocytes — killed off during a heart attack.

The study, which was conducted in animal models, offers hope for future treatments in humans, according to the senior author of the study. “This finding opens the door to a completely revolutionary treatment,” Pilar Ruiz-Lozano, PhD, told me. “There is currently no effective [way] to reverse the scarring in the heart after heart attacks.”

The delivery system that researchers used in this study is a biodesigned tissue-like patch that gets stitched directly onto the damaged portion of the heart. The protein Fstl1 is mixed into the ingredients of the patch, and the patch, made of an acellular collagen, eventually gets absorbed into the heart leaving the protein behind. Our press release explains how the patch came to be:

The researchers discovered that a particular protein, Fstl1, plays a key role in regenerating cardiomyocytes. The protein is normally found in the epicardium — the outermost layer of cells surrounding the heart — but it disappears from there after a heart attack. They next asked what would happen if they were to add Fstl1 back to the heart. To do this, they sutured a collagen patch that mimicked the epicardium to the damaged muscle. When the patch was loaded with Fstl1, it caused new cardiomyocytes to regenerate in the damaged tissue.

In reading over the study, I was particularly interested in what an engineered tissue-like patch applied to a living heart looked like – and how exactly the patch got made. I called one of the study’s first authors and went to see him in his lab.

Vahid Serpooshan, PhD, a postdoctoral scholar in cardiology at Stanford, told me he can make a patch in about 20 minutes. It’s a bit like making Jell-O, he said; collagen and other ingredients get mixed together then poured into a mold. Serpooshan uses molds of various sizes depending on what kind of a heart the patch will be surgically stitched onto.

“The damaged heart tissue has no mechanical integrity,” Serpooshan said. “Adding the patch is like fixing a tire… Once the patch is stitched onto the heart tissue, the cardiac cells start migrating to the patch. They just love the patch area…”

Previously: Stanford physician provides insight on use of aspirin to help keep heart attacks and cancer away, Collagen patch speeds healing after heart attacks in mice and Big data approach identifies new stent drug that could help prevent heart attacks
Image, of a patch stitched to the right side of the heart, by Vahid Serpooshan

Chronic Disease, Neuroscience, Pain, Research, Stanford News

Study: Effects of chronic pain on relationships can lead to emotional distress

Study: Effects of chronic pain on relationships can lead to emotional distress

sad womanIt’s not surprising that people living with chronic pain often have high levels of emotional distress. The question that Stanford researcher Drew Sturgeon, MD, a postdoctoral pain psychology fellow in the Stanford Pain Management Center, recently aimed to determine was why. Is a patient’s depression or anger caused by his or her inability to do physical things or is it perhaps because pain can limit social relationships?

“What I hear from patients is that it’s not just that it hurts, but that the pain takes you away from things that matter to you – the things that are meaningful to you,” Sturgeon recently said.

To explore this further, Sturgeon and colleagues analyzed data from 675 patients who came into the Stanford pain clinic and filled out data sets for the national open source Collaborative Health Outcomes Information Registry, referred to as CHOIR. CHOIR is a registry that originated at the Stanford pain center to help improve the collection and reporting of data on pain.

The researchers examined both physical functioning and social satisfaction reported by chronic pain patients, since both have been shown to play a role in causing anger and depression. Their results — published online recently in the journal Pain — show that the effects of chronic pain on a patient’s social relationships can be a key trigger of depression and anger, even more so than the limits that pain can place on physical activity.

“My suspicion was that there was going to be a stronger frustration when [the pain] affects social relations,” Sturgeon told me. “Relationships are one of the strongest predictors of mood. If you’re an avid bicyclist and can no longer cycle, that’s frustrating. But if cycling is the primary source of your social relationships, that’s even more frustrating.”

“The conversation when you have a patient with chronic pain who is very depressed tends to [focus on] how we treat the pain,” he continued. “Perhaps considering how the pain is affecting the people around the patient is also important… This is something that as a field we haven’t been paying very good attention to.”

Previously: National survey reveals extent of Americans living with pain, Chronic pain: getting your head around it and Advances in pain research and treatment
Photo by rochelle hartman

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