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Cancer, Chronic Disease, Dermatology, Stanford News, Surgery, Transplants

Rebuilding Cassie’s smile: A lung transplant patient’s struggle with skin cancer

lung patientWhen I first met Cassie Stockton, she was seated in an exam chair in Stanford’s dermatology clinic, getting cosmetic skin treatments. Lovely and young, just 21 years old, it seemed a bit silly. How could she possibly need injectable lip fillers or laser skin treatments?

I knew Stockton had a lung transplant at 15 and that the immunosuppressant drugs she was required to take to keep her body from rejecting the donated lungs had made her susceptible to skin cancer. But it wasn’t until I researched her story in depth that I truly understood how she ended up needing regular cosmetic treatments here.

As I explain in my recently published Stanford Medicine article, her story began at birth:

Born premature, [Cassie] was intubated the first two weeks of life, then sent home with her mother and an oxygen tank. She remained on oxygen 24 hours a day for the first two years of her life. Eventually, she was diagnosed with bronchopulmonary dysplasia, a chronic lung disorder …

Sixteen years later, the donated gift of new lungs saved her life – but it left scars, both emotional and physical:

The day Stockton woke up out of the anesthesia six years ago after a 13-hour surgery at the Transplant Center at Lucile Packard Children’s Hospital Stanford, she breathed in oxygen with newly transplanted lungs, and breathed out sobs. Tears streamed down her face. “At first, I thought she was in pain,” says her mother, Jennifer Scott, who stood by her side. But that wasn’t it. Stockton was overwhelmingly sad because she now knew her new lungs were the gift of a child. It was Dec. 6, 2009, just before Christmas. The death of someone else’s child had given her a whole new life.

And now:

Every four months, she and her fiancé make the four-hour drive from their home in Bakersfield, California, past the oil rigs and cattle farms to Stanford’s Redwood City-based dermatology clinic for her skin cancer screening. It’s been two years of treatments: freezings, laserings, a total of eight outpatient skin surgeries — the most significant resulting in the removal of the left half of her lower lip. The dermatologic surgeon removes the skin cancers, and then gets to work to repair the damage. “It’s heart-breaking to have to remove the lip of a 21-year-old woman,” says Tyler Hollmig, MD, clinical assistant professor of dermatology and director of the Stanford Laser and Aesthetic Dermatology Clinic, who leads Stockton’s treatment and keeps her looking like the young woman she is, restoring her skin, rebuilding her lip, making sure she keeps her smile.

Stockton doesn’t complain about any of the struggles she’s had post transplant. She knows she got a second chance at life. And, she tells me, it’s her job to take care of the lungs given to her by that child who died.

Previously: This summer’s Stanford Medicine magazine shows some skin
Photo by Max Aguilera-Hellweg

Cardiovascular Medicine, Chronic Disease, In the News, Research, Stanford News, Transplants

Are donor hearts getting wasted?

Are donor hearts getting wasted?

heart choiceI wrote a press release recently on a study that showed a high percentage of donated hearts were not being used, raising concerns that some were getting wasted when they could be used to save lives. This made me curious about the process of just how a donor heart, which ideally has about a two-hour window before it gets transplanted to a patient with heart failure, gets matched.

The result is a Stanford Medicine magazine story titled “Heart Choices” that describes this process, the tough decisions that family members make when a loved one donates a heart, and the excruciating waiting that patients in need of a new heart go through.

Most importantly the article asks the question: Should more “high-risk” donor hearts be used? An estimated 20,000 people across the country are waiting for new hearts, and only a few thousand transplants happen on average per year. My story explains the dilemma:

The general assumption is that there simply are not enough donor hearts available to meet a growing demand. But new research is questioning that assumption. Some researchers and surgeons claim that thousands of donor hearts that could be used are turned away each year. The hearts are considered marginal because they come from older, sicker or riskier donors, but many argue they are safe for transplant, and could be saving lives.

“As patients wait longer, they often get sicker, and we often lose patients,” says Stanford cardiologist Kiran Khush, MD, whose research reports that 65 percent of available heart donations are discarded because of stringent acceptance criteria. Yet the criteria have not been critically evaluated, she says. “Increasing the supply of donor hearts is, of course, a great concern of mine.”

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Cardiovascular Medicine, Chronic Disease, Imaging, Research, Stanford News, Technology

DNA damage seen after CT scanning, study shows

DNA damage seen after CT scanning, study shows

16288548276_e155ec8843_zUsing new laboratory techniques, Stanford scientists have been able to get a closer look at what happens inside the cells of patients undergoing medical imaging techniques. In a study published today, their research clearly shows that there is cellular damage in heart patients after CT scanning.

The researchers explained to me in interviews for a press release on the study that this doesn’t link CT scans to cancer. But as Patricia Nguyen, MD, lead author said in the release, it is further indication for caution:

“Whether or not this (cellular damage) causes cancer or any negative effect to the patient is still not clear, but these results should encourage physicians toward adhering to dose reduction strategies.”

Due to an explosion in the use CT scans for heart patients over the past decade, public health concerns have been raised over whether there might be a causal link with cancer. But until now, little has been known about exactly what happens at a cellular level when patients undergo CT scanning, a type of medical imaging which exposes them to low-dose radiation. This study took advantage of new laboratory techniques that made it possible to look inside cells of patients after they underwent CT scanning. As Nguyen explained in my release:

“Because we don’t know much about the effects of low-dose radiation — all we know is about high doses from atomic bomb blast survivors — we just assume it’s directly proportional to the dose. We wanted to see what really happens at the cellular level.”

Researchers examined the blood of 67 patients undergoing cardiac CT angiography using such techniques as whole-genome sequencing and flow cytometery to measure biomarkers of DNA damage. The results:

… showed an increase in DNA damage and cell death, as well as increased expression of genes involved in cell repair and death, the study said. Although most cells damaged by the scan were repaired, a small percentage of the cells died, the study said.

“These findings raise the possibility that radiation exposure from cardiac CT angiography may cause DNA damage that can lead to mutations if damaged cells are not repaired or eliminated properly,” the study said.

Photo by frankieleon

Public Health, Research, Stanford News

Study sheds light on physicians testifying in court that smoking didn’t cause cancer

addict-84430_1280 (1)A small group of board-certified physicians helped defend the tobacco industry in more than 50 cases by providing expert testimony that years of heavy smoking did not cause the head and neck cancers of the individual plaintiffs despite overwhelming scientific evidence to the contrary.

This is the finding of a study led by Robert Jackler, MD, professor and chair of otolaryngology-head and neck surgery at Stanford. From a press release I wrote on the research, which was published today in the journal Laryngoscope:

 “I was shocked by the degree to which these physicians were willing to testify, in my opinion in an unscientific way, to deny a dying plaintiff — suffering the aftermath of a lifetime of smoking — of a fair trial,” said Jackler, referring to the physicians cited in the study as a “pool of experts willing to say over and over again that smoking didn’t cause cancer.”

In previous research, Jackler has written about the tobacco industry’s influence on public health through advertising, marketing, manipulation, and promotion. But most of his research up to this point has focused on the past. In this study Jackler turned to the present day. He read through thousands of publicly available expert-witness depositions and trial testimony from Florida courtrooms from 2009 to 2014 and took a hard look at the accuracy of the testimony. In his study, he states that testimony was remarkably similar from case to case and was “faithful to the tactical narrative that there are many, many causes of head and neck cancer — and that factors other than smoking must have caused the plaintiff’s disease.” But as I wrote in our release:

An obvious fallacy of this argument lies in the fact that literally billions of nonsmoking people are exposed regularly to gasoline fumes, use cleaning solvents, eat salted fish or live in urban environments. Were these causative factors for head and neck cancer, with even a minute fraction of the potency of tobacco, the rate of head and neck cancer among nonsmokers would be much greater than what has been observed.

The study, which includes a review of the scientific literature, said this testimony is just inaccurate:

“The tobacco industry identifies the best experts that money can buy, trains them in their well-honed narrative to manufacture doubt in the minds of the jury and makes use of them over and over in case after case,” the study said. Given the ethical traditions of medicine, it seems likely that these physicians believe their well-compensated testimony on behalf of tobacco companies occurs in the shadows, out of view of their families, friends and professional colleagues, Jackler said.

Previously: What’s being done about the way tobacco companies market and manufacture productsHey doc, got a light? Research highlights Big Tobacco’s long history with the medical community and Throat doctors manipulated by Big Tobacco
Photo by PublicDomainPictures

Chronic Disease, In the News, Pain, Research, Science, Stanford News

Scientific discovery could lead to treatments for chronic pancreatitis

Scientific discovery could lead to treatments for chronic pancreatitis

Pancreatitis is one of the most common gastrointestinal hospital admissions-related illness. Patients with the acute form of the disease show up at hospitals doubled over with severe abdominal pain, a swollen belly that’s tender to the touch, nausea, and vomiting.

For some patients the disease flares up then disappears. For others, it develops into an ongoing, chronic form of the disease with no known cure. Not only is it extremely painful, it also causes malnutrition and carries with it a high risk of leading to pancreatic cancer. Treatment options are pretty much limited to prescription pain killers.

This has great implication in a disease that has no active therapy with no known agents that can alter its natural devastating course

It’s known that chronic pancreatitis is marked by the uncontrolled growth of scar tissue in the pancreas known as fibrosis, which slowly destroys the organ’s ability to function. Since the pancreas is in charge of excreting enzymes to digest food, patients begin to suffer malnutrition. It’s also known that excessive alcohol consumption is the leading cause of pancreatitis but just what is happening at a molecular level to cause the fibrosis is less clear.

Now, Stanford researcher and gastroenterologist Aida Habtezion, MD, and colleagues here and at Cedars-Sinai Medical Center have published research that sheds light on what exactly is happening and could lead to treatments for the severe disease. In a story I wrote on the study, Habtezion discusses their discovery of a new molecular pathway that when blocked by an experimental pharmacological drug can slow the progression of pancreatitis in animal models and in human cells.

As Habtezion told me, her lab’s research into just how the immune cells of the pancreas behave when inflamed with pancreatitis unveiled the new pathway:

“For the first time we can show that macrophages interact with pancreatic stellate cells via a particular immune pathway, and by targeting this pathway we show a decrease in chronic pancreatitis/fibrosis progression,” she said. “This has great implication in a disease that has no active therapy with no known agents that can alter its natural devastating course.”

The hope is that researchers will now be able to develop a form of the experimental pharmacological agent used in the study to block the molecular pathway that can be given to humans. Blocking the pathway will block the scar tissue growth, and hopefully either slow the progression of the disease or reverse it altogether.

Cardiovascular Medicine, Medical Apps, Precision health, Research, Stanford News, Technology

MyHeart Counts shows that smartphones are catching on as new research tool

MyHeart Counts shows that smartphones are catching on as new research tool

using iPhone - 560

In the three months since Stanford researcher and cardiologist Michael McConnell, MD, told ABC’s Nightline that the new MyHeart Counts iPhone app would give scientists “a whole new way to do research,” the number of users has continued to steadily climb.

“Traditionally reaching many people to participate in research studies is quite challenging,” McConnell told business correspondent Rebecca Jarvis in March. “The ability to reach people through their phone is one major advance.”

The number of iPhone owners who have downloaded the app and consented to participate in a large-scale study of the human heart has now reached 40,000. In an effort to keep updated on how the app is progressing as a new research method, I reached out to McConnell, the lead investigator of the study, with a few questions. The MyHeart Counts study continues to break ground as a new method for reaching large numbers of research participants in a short amount of time, McConnell told me. Comparing it to traditional research trials, he said:

There have been larger research studies, particularly national efforts to study their populations, but we believe enrolling this many participants in such a short time frame is unprecedented.

The app, which was launched in early March, collects data about users’ physical activity using the smartphone’s built-in motion sensors. Participants also answer surveys concerning their cardiac-risk factors. In return, they get coaching tips and feedback on their chances of developing heart disease.

McConnell says that the next phase of the project, which will use behavior-modification methods to encourage healthy behaviors, is about to be launched. App users will be given more personalized feedback about their individual behaviors and risk, based on the American Heart Association’s Life’s Simple 7 guidance. Future tips will include messages on everything from how to manage blood pressure, eat better, lose weight and control blood sugar. Part of the study is to determine whether these type of “pings” used through apps are actually successful at changing human behavior, McConnell told me:

Healthy behaviors are critical to preventing heart disease and stroke, so the MyHeart Counts app will study which motivational tools are most helpful. This will follow the second activity and fitness assessment… The initial approach will be empowering participants with more personalized feedback about their individual behaviors and risk.

To sign up for the MyHeart Counts study, visit the iTunes store.

Previously: Lights, camera, action — Stanford cardiologist discusses MyHeart counts on ABC’s Nightline, Build it (an easy way to join research studies) and the volunteers will comeMyHeart Counts app debuts with a splash and Stanford launches iPhone app to study heart health
Photo by Japanexperterna (CC BY-SA)

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

Medical students explore the wide, wide world of research at annual Stanford symposium

Medical students explore the wide, wide world of research at annual Stanford symposium

Research SymposiumTraining medical students in research skills has long been a focus at Stanford. To get an inside glimpse of how this works, read my story on the Stanford Medical Student Research Symposium, an annual event where students present poster boards of their research for judging by faculty.

The depth and breadth of individual research accomplished by medical students who, at the same time are juggling classroom and clinical education, is impressive. The faculty representative at the event explained the educational process to me:

“Stanford tries really hard to open doors in the area of scientific research and give students a little nudge to go through,” said Laurence Baker, PhD, director of the Scholarly Concentration program, a required program of study for medical students that promotes in-depth learning and scholarship. Each of Stanford’s medical students are required to complete at least one quarter’s worth of research, but most do more, he said.

“We train the kind of doctors who become leaders,” Baker said. “Whether that involves publishing, clinical work, research or patenting — education in scientific research is a key element of training.”

My story also provides a taste of the conversation between one of the students who used the Veterans Administration database to conduct his research of opioid drug use and a judge of the event, who plays the dual role of evaluator and teacher. She provides both constructive criticism and encouragement to the budding physician-scientist:

In a dress shirt and tie, Raymond Deng, a third-year medical student, stood next to a poster describing his research on opioid use among veterans. “I’m interested in addiction medicine,” he said. “Prescription drug abuse is huge.” He was discussing his findings with Sonoo Thadaney, director of the Program in Bedside Medicine… Thadaney, the symposium judge, listened intently to his description, nodding her head in encouragement. “Why did you pick this study?” she said, clipboard in hand. “Personal reasons,” Deng said, adding that someone in his life has a heroin addiction, and that an epidemic in prescription drug abuse has been shown to have contributed to an increase in heroin use. She nodded again. “The great thing with data like this is that the data itself can bring up questions that we didn’t think of,” she said. “If the Googles and the Yahoos of the world can use data like this for research, so can we. Great work. Go crazy with it.”

Previously: Contemporary health issues focus of Stanford med students research presentation, As part of annual tradition, budding physician-scientists display their work and New class of physician-scientists showcase research.
Photo by Norbert von der Groeben

otolaryngology, Research, Science, Stanford News, Stem Cells

Molecular sleuthing uncovers new clue toward deafness cure

Molecular sleuthing uncovers new clue toward deafness cure

In another step along the path toward finding cures for deafness, Stanford scientists report they have discovered a subset of cells in the mammalian utricle, the inner ear structure that controls balance, that can regenerate into hair cells when damaged.

The study was published today in Nature Communications, and senior author Alan Cheng, MD, explained the significance of the findings to me this way:

We rely on our inner ear sensory organs to hear and sense motion. Such functions require specialized hair cells to detect the vibrations of sound or motion. Once lost, hair cells needed for hearing do not regenerate and thus hearing loss is permanent, while those to sense motion can regenerate to a limited degree. Until now, the origin of these regenerated hair cells and the mechanisms that limit this process of regeneration in the utricle have not been clear. Here, we found two distinct populations of such hair cell progenitors in the neonatal mouse utricle, where they can regenerate lost hair cells. Unlike the utricle from older mice, the degree of regeneration and also cell division at this age are a lot more robust.

The study also provides an improved understanding of the molecular pathway that leads to this transformation, knowledge that could maybe one day be used to help researchers figure out how to artificially encourage hair cell renewal in humans.

Previously: Understanding hearing loss at the molecular level, New version of popular antibiotic eliminates side effect of deafness and Stanford chair of otolarnygology discusses future regenerative therapies for hearing loss

Cardiovascular Medicine, Research, Stanford News, Technology

Stanford launches iPhone app to study heart health

Stanford launches iPhone app to study heart health

Dr. Alan Yeung,  MD., Chief (Clinical) Division of Cardiovascular Medicine Interventional Cardiology,and Dr Michael McConnell, MD.,  with a new health app for iPhone on Thursday, February 26, 2015. ( Norbert von der Groeben/ Stanford School of Medicine )

A new, first-of-its-kind iPhone app, designed by Stanford Medicine heart experts as a fun way for users to learn about their own heart health while at the same helping to advance the field of cardiovascular medicine, was launched today.

The app, called MyHeart Counts, takes advantage of the iPhone’s built-in motion sensors to collect data on physical activity and other cardiac risk factors for a research study. It’s now available for free in the App Store. As I describe in our press release:

The free app uses the new ResearchKit framework announced today by Apple to present users with a simple way to participate in the study, complete tasks and answer surveys from their iPhone. The app will deliver a comprehensive assessment of each user’s heart health and provide information on how to improve it. It will also be used to study various methods — designed to be both easy and fun — for using smartphones and other wearable devices to enhance heart-healthy habits.

“MyHeart Counts aims to be the largest study of measured physical activity and cardiovascular health to date,” [said Stanford cardiologist Michael McConnell, MD, lead investigator for the study]. “We want people to join in this research effort to give fundamental new insights into how activity helps your heart, across all ages, genders, cultures and countries.”

Users start by providing some basic health information – age, weight, blood pressure – all kept confidential, and are then asked to record a week of activity. The app in return provides the user with a number representing their “heart age.” For example, if you’re 40 years old, and your heart age is reported as 20 years, that’s good news. If those numbers are reversed, there might be something to worry about.

The ultimate goal of the study, McConnell and his collaborator Alan Yeung, MD, told me, is to provide scientific evidence as to the effectiveness of the myriad methods of behavioral motivation techniques marketed through wearable devices to improve health. The idea is to use hard data to find out what really works:

Recently, there has been an explosion in the marketing of wearable devices to record and report information about behaviors, such as physical activity or sleep patterns, to improve health, but there is limited scientific evidence available to show whether they are effective, McConnell said.

As a physician who regularly sees patients in the clinic, McConnell knows first hand how hard it can be to change a patient’s behavior. Physical activity has been shown to be far more effective in improving health than medication, but getting patients to be more active isn’t easy.

“Preventive medicine hasn’t worked by having doctors make to-do lists for their patient, then seeing them six months later and hoping they did everything on the list,” McConnell told me. “The future needs a much more ongoing engagement with people’s health. We need to understand how to reach out to modify behavior long before we end up having to see someone for a heart attack or stroke.”

Previously: Lack of exercise shown to have largest impact on heart disease risk for women over the age of 30
Photo, of Alan Yeung (left) and Michael McConnell, by Norbert von der Groeben

LGBT, Medical Education, Medical Schools, Research, Stanford News

Stanford study shows many LGBT med students stay in the closet

Stanford study shows many LGBT med students stay in the closet

doctor by rainbow flagFears of discrimination from faculty, peers and patients continue to pressure many in the lesbian, gay, bisexual and transgender community to stay “in the closet” while in medical school, according to a Stanford study published today in Academic Medicine.

Some medical students worry that “coming out” could affect their grades; others are influenced by homophobic or sexist remarks overheard from peers and faculty to keep their sexual or gender identity hidden, according to the results of an online survey sent by the study’s authors to medical students throughout the U.S. and Canada. One respondent recounted an appointment during a surgery rotation with a transgender patient who was “treated like a freak by the residents and attendings behind closed doors, joking at his expense.”

The study, authored by members of the Stanford Lesbian, Gay, Bisexual & Transgender Medical Education Research Group, was accompanied by a commentary that maintains the medical community is less accepting of sexual and gender minorities than the business or law communities. From a press release I wrote on the study:

“There is still this huge percentage of medical students who are afraid of discrimination in medical school and how it could affect the rest of their careers,” said Mitchell Lunn, MD, a co-author of both papers and co-founder of Stanford’s LGBT research group. “We are supposed to be a field that is accepting of people and one that takes care of people regardless of differences, and yet we can’t even do that for people who are part of our own community.”

The study found that a third of sexual minority medical students choose to remain “in the closet” during medical school, 40 percent of medical students who identify as “not heterosexual” are afraid of discrimination in medical school, and two-thirds of gender minority medical students (those identifying as something other than male or female) conceal their gender identity during medical school.

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