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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.

Anesthesiology, 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

Ethics, Events, Medical Education, Medicine and Literature, Stanford News

During their first days at Stanford, medical students ponder the ethical challenges ahead

During their first days at Stanford, medical students ponder the ethical challenges ahead

students reading oath2 - 560

In an effort to help prepare this year’s crop of new medical students for the future challenges of keeping true to the spirit of the Hippocratic Oath – to first do no harm ‑ Stanford’s School of Medicine held a new discussion session during orientation.

In between learning about housing and schedules and all the necessary details of starting medical school, the 90 new students who started class on Monday joined with two deans of the school last week to discuss one of the most controversial topics in the world of medicine: euthanasia.

Included among the students’ summer reading assignment was the book Five Days at Memorial, a blow-by-blow account of the days medical staff and patients spent trapped in a New Orleans hospital after Hurricane Katrina struck. Left without electricity or sanitation, staff slept little and worked endlessly to care for the sick and dying patients not knowing if any of the patients – or anyone else trapped at the hospital — would survive. An online story explains why the book was assigned as summer reading:

Most [new students] had not yet faced the responsibilities they will encounter routinely as physicians. It was the ethical and emotional challenges ahead that [Lloyd Minor, MD, dean of the medical school, and Charles Prober, MD, senior associate dean of medical education] hoped to explore during the book discussion. “I think one of the key lessons from this book: If we’re going to make progress in medicine, we’re going to have to face realistically when we make errors,” Minor said. “Progress only occurs when we are able to frankly address those situations and acknowledge those errors.”

The book describes health-care workers treating patients in a way that could arguably violate tenets of the Stanford Affirmation. “You will be reciting this later today after you receive your white coats and stethoscopes,” Prober said. “Hopefully, the affirmation will have more meaning to you. It will help you to reflect more deeply on the words as you ponder it into the future.”

The book describes how medical staff and patients had to fend for themselves in the days following Hurricane Katrina. After the waters receded, and authorities entered the hospital, 41 bodies were found. Three health-care professionals, including one physician, were arrested for murder. A New Orleans grand jury ultimately refused to indict them on charges of involuntary euthanasia and murder, but exactly what happened during those five days, when temperatures soared, sleep was rare and proper sanitation was nonexistent, remains unclear.

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Big data, Cardiovascular Medicine, Chronic Disease, In the News, Research, Stanford News

Using “big data” to improve patient care: Researchers explore a-fib treatments

Using "big data" to improve patient care: Researchers explore a-fib treatments

Turakhia photoA Stanford cardiac electrophysiologist and colleagues have used a unique research method to learn more about atrial fibrillation. Mintu Turakhia, MD, and collaborators at Medtronic and Massachusetts General Hospital, extracted data out of decades of continuously recorded medical information from implanted medical devices – pacemakers and defibrillators — in 10,000 heart patients. Then they linked it to medical records, and analyzed it.

The researchers’ goal was to explore whether patients who experienced sudden attacks of a-fib, an irregular and rapid heart rate caused by spasms of the heart’s upper chambers, should be treated with long-term anticoagulants like those who had permanent a-fib or whether perhaps temporary drug therapy could be considered an option. They wanted to know if a patient’s risk of stroke changes as a-fib comes and goes.

The results, which were published recently in Circulation: Arrhythmia and Electrophysiology, found that patients were at an increased risk of stroke the first seven days after their hearts went into a-fib.

A-fib, which afflicts more than 3 million Americans, is known to increase a patient’s risk of stroke – but exactly when this risk occurs is controversial. Currently, physicians recommend long-term anticoagulation for patients, whether the a-fib occurs in sudden attacks or is continuous. This study indicates that transient use of anticoagulants could be an option for some patients and deserves further investigation. Future treatment plans might explore the idea of some kind of wearable device that shows when a patient goes in and out of a-fib, then taking medications just when needed rather than for a lifetime, said Turakhia.

Turakhia told me the study also provides an important example of how using “big data” research methods can ultimately lead to improved clinical care. In an email, he explained:

This is truly a big data approach where we took raw data from implanted pacemakers and implanted defibrillators and linked it to clinical data. The medical device data comes from home remote monitoring systems that patients have and goes to the cloud. We pulled the raw data off the cloud and linked it to VA (Veterans Affairs) electronic health records, VA claims, Medicare claims, and death records. This is truly a novel approach where we are assembling highly disparate data sources and linking them to gain insight into disease.

Previously: A little help from pharmacists helps a-fib patients adhere to prescriptions, Study highlights increased risk of death among patients with atrial fibrillation who take digoxin and What is big data?
Photo of Turakhia by Norbert von der Groeben

Medical Education, Medical Schools, Stanford News

Passing the boards: Reassessing “Step 1 madness”

Passing the boards: Reassessing "Step 1 madness"

medical booksCharles Prober, MD, senior associate dean of medical education at Stanford, has long been concerned about the misuse of Step 1. The national standardized test, which must be passed in order to get a medical license, is also often used inappropriately, according to Prober, as a screening tool by residency programs.

But his concern about the test — dubbed “Step 1 madness” by some med students and the first of three required for medical licensure — extends even further to what he and others believe are the unnecessary and sometimes detrimental effects on both the education of medical students and their stress levels.

In a commentary published this week in the journal Academic Medicine, Prober and his co-authors — which includes the president of the National Board of Medical Examiners, the non-profit that develops and manages the test — issue a “plea to reassess” its role in residency selection. They write:

There is an increasingly pervasive practice of using the score, especially the Step
1 component, to screen applicants for residency. This is despite the fact that the test was not designed to be a primary determinant of the likelihood of success in residency… [I]t is disconcerting that the test preoccupies so much of our students attention with attendant substantial costs (in time and money) and mental and emotional anguish.

Prober and his colleagues go on to explain how students sequester themselves for four to nine weeks on average studying full-time for the day-long multiple-choice examination, which is usually taken sometime following their second year of medical school. The stress to pass the test, which is designed to test  “important concepts of the sciences basic to the practice of medicine,” is particularly high because students know a poor score may keep them from qualifying for the first step to get into a residency program — the interview:

Despite its intended purpose, many residency program directors continue to use applicants’ USMLE Step 1 scores as a sole or primary filter for selecting candidates to interview… In general, the more competitive the residency discipline (e.g. orthopedic surgery, radiation oncology, dermatology, ophthalmology, and otolaryngology,) the higher the Step 1 score needed to pass through the filter.

The authors express the opinion that it is “ill advised” to use the test for a purpose for which it was not developed, that the test is not a good predictor of who will do well in residency and that it is being misused for “convenience” as a easy to apply mechanism to reduce large applicant pools. Their solution isn’t to get rid of the test, which is still a valuable tool, but to create additional measurement tools of equally important skills for selection by residency programs.

“A more rational approach to selecting among residency applicants would give greater attention to other important qualities, such as clinical reasoning, patient care, professionalism, and ability to function as a member of a health
care team,” they conclude.

Previously: Using the flipped classroom model to bring medical education into the 21st-century and Student transitions in medicine: putting blinders on
Photo by jcalyst

Cardiovascular Medicine, Medical Apps, Public Health, Research, Stanford News

Stanford’s MyHeart Counts app reaches overseas to Hong Kong and the UK

Stanford's MyHeart Counts app reaches overseas to Hong Kong and the UK

MyHeart Counts on phoneIn an effort to continue signing up new participants for their heart research study at groundbreaking speeds, researchers at Stanford launched their iPhone app MyHeart Counts overseas in Hong Kong and the United Kingdom today. The goal is to reach out far and wide — quickly.

To date, about 41,000 users have signed up for the free app launched in March, which allows users to learn about their own heart health while also participating in a large-scale heart study. That’s an unprecedented number of people in such a short amount of time, researchers say, adding that it’s only the beginning. From our press release on today’s launch overseas:

“The idea is to move into one country at a time until we go global,” said Euan Ashley MD, a professor of cardiovascular medicine at Stanford and co-investigator for the MyHeart Counts study. “We hope to add more countries every few months.

“We are ready to take the study as far as it will go. We would like to build a new Framingham heart study for the ages,” Ashley said, referring to the long-term cardiovascular study that has followed three generations of participants in Framingham, Massachusetts. “We would like millions of participants.”

MyHeart Counts is the first of the initial handful of apps designed using ResearchKit, Apple’s open-source software platform for creating medical-research apps, to expand overseas. Along with its reach into Hong Kong and the U.K., the app is also being upgraded today, providing more information to users about their own heart health and breaking heart health news. The press release gives a brief overview of what the app does:

The free app offers users a simple way to participate in the study, complete tasks and answer surveys from their iPhones. Once every three months, participants are asked to monitor one week’s worth of physical activity, complete a 6-minute walk fitness test if they are able, and enter their risk-factor information. The app now also delivers a comprehensive summary of each user’s heart health and areas for improvement.

Previously: Lights, camera action: Stanford cardiologist discusses MyHeart Counts on ABC’s NightlineBuild 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

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