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Aging, Pain, Palliative Care, Research, Stanford News

How would you like to die? Tell your doctor in a letter

How would you like to die? Tell your doctor in a letter

writing a letterAsking patients how they would like to die is not a question that comes easy to most doctors. Not surprisingly, most of us – doctors and patients alike – prefer to avoid the topic completely. That’s not good, says VJ Periyakoil, MD, director of palliative care education and training at Stanford.

As I wrote in an Inside Stanford Medicine article on Periyakoil’s new study on end-of-life conversations:

End-of-life conversations help clarify for doctors what matters most to patients in their waning days of life… “What are their hopes, wants, needs and fears? Do they want to die at the hospital on a machine? Do they want to die at home? We can’t know unless we have a conversation,” she said.

Her study, published today in PLOS One, surveyed more than 1,000 medical residents and found that most balk at talking with seriously ill patients about what’s important to them in their final days, especially if the patient’s ethnicity is different than their own. Of those surveyed, 99.99 percent reported barriers, with 86 percent rating them as very challenging.

The upshot for Periyakoil, as she explains in a New York Times column published today, is that if we want to have a say in how we die, we should start that conversation ourselves.

To get these conversations started far and wide, she has launched the Stanford Letter Project – a campaign to empower all adults to take the initiative to talk to their doctor about what matters most to them at life’s end. The project’s website hosts templates for a letter about this to your doctor to get the conversation rolling. The templates are in Mandarin, Spanish and Tagalog as well as English – and Periyakoil says translations in additional languages will be available soon.

Previously: In honor of National Healthcare Decisions Day: A reminder for patients to address end-of-life issues, Study: Doctors would choose less aggressive end-of-life care for themselvesAsking the hardest questions: Talking with doctors while terminally ill, On a mission to transform end-of-life care and The importance of patient/doctor end-of-life discussions
Photo by Gioia De Antoniis

Aging, Medicine and Society, Videos

In honor of National Healthcare Decisions Day: A reminder for patients to address end-of-life issues

In honor of National Healthcare Decisions Day: A reminder for patients to address end-of-life issues

When San Jose, Calif. residents Shirley and Eddie Jones wanted to discuss their end-of-life wishes, they encountered resistance from an unexpected source. As detailed in the video above, their beloved children refused to participate in the conversation.

As with the Jones, the people who love you the most may not be willing to help you because they care too much – and your doctors may be largely silent as they’re uncomfortable broaching this sensitive topic for fear of offending you. So, when it comes to end-of-life planning, you’re largely on your own. And it’s important that you take the first step and break this wall of silence.

Even as you’re reading this, you may be thinking that the topic of end-of-life decision making is not relevant to you right now – that it’s too early. Or it may be that you’re uncomfortable thinking about death. You may even be waiting for your doctor to broach this subject with you and lead the way. After all, as long as you do what the doctor tells you to do, you can get pretty good results with your health care. But, this ‘wait-for-your-doctor’ strategy isn’t going to serve you well when it comes to end-of-life decision making and planning.

Don’t believe me? Then just take a moment to review the evidence (link to .pdf): Eighty percent of people say that it’s important to have end-of-life wishes in writing, but only 23 percent say they have have done so. Eighty percent wish to have end-of-life conversations with their doctor but only 7 percent get to do this. Research also shows that most doctors have neither the training nor the time to skillfully conduct end-of-life conversations with their patients.

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Aging, Immunology, Infectious Disease, Research, Stanford News

Frenemies: Chronic cytomegalovirus infection boosts flu vaccination efficacy (IF you’re young)

Frenemies: Chronic cytomegalovirus infection boosts flu vaccination efficacy (IF you're young)

cheapo boost“The enemy of my enemy is my friend.” This phrase, or at least the thinking it embodies, is at least 2,400 years old. So, there must be something to it, right?

Of course, it’s arguably a vast oversimplification. The more nuanced and much newer term “frenemy,” dating back merely to the early 1950s, is more apt in the case of infection by the microbe known as cytomegalovirus (CMV, for short). If the name is unfamiliar, brace yourself: You’ve probably already been introduced. It’s ubiquitous.

“Between 50 percent and 80 percent of adults in the United States have had a CMV infection by age 40,” states a page on the National Institutes of Health’s website. (Worldwide, the proportion of people infection exceeds 90 percent.) Once CMV is in a person’s body, it stays there for life,” the page soberly adds.

For the most part in healthy people, CMV pretty much sits there inside of cells (particularly in the salivary glands), pretty much biding its time and getting slapped down by the immune system if it tries to act up.

On the other hand, the virus can cause serious trouble if you’re immune-compromised: say, getting a bunch of immune-suppressing drugs pending or after a transplantation operation, or carrying another virus, the infamous immune-deficiency-causing HIV (which as far as we know is nothing but an enemy, plain and simple.)

But in a new study published in Science Translational Medicine, Stanford immunology expert Mark Davis, PhD, and his colleagues show that carriers of CMV mount a more robust immune response to seasonal influenza vaccinations, increasing the chances that the annual vaccine will be more effective in those people.

That’s the good news. The not-so-great news is that this only holds for young people (20-30 years old), not the older ones (age 60 and up) who could really use a boost: The older you get, it’s well known, the less effective the standard seasonal flu vaccine is in helping you fight off an influenza infection.

Experimenting with mice, Davis and his associates went a step farther. They actually infected the animals with influenza itself. Sure enough, young mice who were carrying CMV fought off the bug better than the non-infected mice did.

That’s the good news. The not-so-great news is that the old mice didn’t.

And although the study didn’t say so, one wonders whether in young people whose immune systems are going strong, that extra rocket fuel CMV seems to provide may have a dark side, for example a tendency to autoimmunity. Women’s immune systems tend to be more robust than those of men (very possibly due to the effects of testosterone, as Davis and his crew found a little over a year ago. And they have several times the rate of many autoimmune diseases that men do.

Previously: In human defenses against disease, environment beats heredity, study of twins shows, Why do flu shots work in some but not others? Stanford researchers are trying to find out, In men, a high testosterone count can mean a low immune response and Mice to men: Immunological research vaults into the 21st century
Photo by Joe Lillibridge

Aging, Global Health, Medical Education, Patient Care, SMS Unplugged

After the rain: Experiencing illness as a medical student and granddaughter

After the rain: Experiencing illness as a medical student and granddaughter

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

rainy groundIn India, when the first heavy droplets of rain meet dry earth it releases a particular kind of smell: a dampness arising from sizzling soil that in Bengal we call shnoda gondho. It is raining on the second day we go to visit my grandfather in the hospital.

He has been readmitted to the hospital, after spending a week recovering at home from a hospitalization for rib fractures and bleeding into his lungs. The irony of his hospitalization is not lost on his family: that a renowned doctor, one of the first cancer surgeons in the city of Kolkata and one who spearheaded oncological care in this region, is now gowned and sitting in a hospital bed. This happens frequently, of course, for doctors are not immune to being patients, even if we would like to think so. The problem is that we are little prepared for the unstructured, unscripted nature of experiencing illness rather than treating it.

Certainly for my grandfather, a man who even recently traveled to multiple hospitals each day to supervise surgeries and see patients in clinic, being confined to bed for respiratory treatments and being unable to walk without support feels equivalent to being bound up, tied down, and chained to the hospital. This is the way illness imprisons. For his family, used to seeking his wise medical advice on various things from pesky coughs to unremitting cancers, we are unprepared to now help make decisions for him.

We never stop being medical students, and later we never stop being doctors, whether in relationships with family members, friends, acquaintances, or strangers in emergency situations

Perhaps this reflection is too personal for a forum created for sharing medical school experiences. But I suppose my realization is that medical school is not a place but rather a privilege we hold. We never stop being medical students, and later we never stop being doctors, whether in relationships with family members, friends, acquaintances while traveling, or strangers in emergency situations.

But, as I spend these three weeks with my grandfather and my family in Kolkata, I find that it is important to play both roles: that of medical student, the one who can help translate the staccato of medical jargon into fluid lines, and that of loved one, the one who listens not via an earpiece through the taut drum of a stethoscope but through bare ears and naked eyes, the one who listens for and is moved by the cries of pain, or suffering, or confusion, or desperation, of the ones they love.

In many ways the loved one is the harder role to play, for it is the role with no lines. No chest x-rays to evaluate in the morning. No medications to re-dose for a rising creatinine. No growing charts of oxygen saturation, or heart rate, or urine output. As someone who has recently grown used to doing these things on the medicine wards of Stanford Hospital, I now acculturate to a more improvisational kind of care. Placing a soothing hand on an aching back. Sitting at someone’s bedside while he nods in and out of sleep. Holding down an arm so that it doesn’t tremble like the string on a harp. In Indian hospitals, the family must often arrange to bring the medications that the doctors have prescribed and may often visit the hospital multiple times a day to bring food. We mix rice with soft, curried vegetables or boiled eggs and offer them to our loved ones, hoping to find through these labors some connection, some solace.

As family members we grasp for metaphors. In India, these metaphors of illness are often built around ideas of hot or cold, of water or wind. Perhaps that is why I find it so poignant that it rained today, the dense, gray clouds releasing their water just as the water from the pleural effusion in my dadu’s lungs was drained.

I hope that one day soon, when this rain had cleared, my grandfather will write his own words as he has planned to do. And then he can tell you his story, not I.

Amrapali Maitra is a fifth-year MD/PhD student working towards a PhD in Anthropology. She is interested in the illness experience, the cultural and social basis of health, and practices of care.   Amrapali grew up in New Zealand and Texas, and she studied history and literature as an undergraduate at Harvard. She is a 2013 Paul and Daisy Soros Fellow.  

Photo by Jason Devaun

Aging, Chronic Disease, Events, Health Policy, Neuroscience, Public Health, Women's Health

Alzheimer’s forum with Rep. Jackie Speier spurs conversation, activism

Alzheimer's forum with Rep. Jackie Speier spurs conversation, activism

10776927963_3dd8d244da_zWhat happens when you bring together a woman with Alzheimer’s, a congresswoman, a policy expert and two doctors? No, this isn’t a joke – but an intro to an informative and wide-ranging discussion on Alzheimer’s disease and its effects on women.

“I was pretty ignorant until fairly recently,” said Rep. Jackie Speier (D-CA), who organized the forum Alzheimer’s: A women’s health issue held in San Mateo, Calif. yesterday. She also penned an opinion piece published recently in the San Francisco Chronicle. “I had no idea that two out of three people diagnosed with Alzheimer’s are women.”

Although it’s the fifth leading cause of death in California, Alzheimer’s receives much less federal money than many other major diseases, she said.

To spur conversation and provide information, Speier invited Cynthia Ortiz Guzman, a former nurse who suffers from Alzheimer’s; Ruth Gay, director of public policy and advocacy for the Alzheimer’s Association; Elizabeth Landsverk, MD, medical director of ElderConsult, and Stanford’s Michael Greicius, MD, MPH, an associate professor of neurology and neurology and medical director of the Stanford Center for Memory Disorders. Greicius has done research on women’s risk of the disease.

Nearly all of the 150-plus people who attended the forum had a loved one who suffered from Alzheimer’s. “We still have a good life, but there is so much that needs to be done,” Guzman told them.

Greicius and Landsverk fielded questions about how to diagnose and treat Alzheimer’s as well as promising directions of research.

At Stanford, Greicius said a person with memory impairment would meet with a neurologist, take a several hour neuropsychological exam, have bloods tests and a brain scan, and meet with social workers and nurses. He emphasized that this is far above the level of care available in more community medical centers. Sometimes physicians are able to find biomarkers that signal Alzheimer’s presence more than a decade before symptoms appear he said.

Greicius urged attendees to find out if they’re eligible for a neurological research trial at Stanford and to consider donating their brains and the brains of their loved ones to use for research. He also thanked Speier for focusing attention on Alzheimer’s.

“We’ve got to get the attention of policymakers to address this issue,” Speier said, adding that she might try to secure federal funds as part of the defense budget.

Gay, who recently traveled to Washington, D.C. to advocate for the disease, agreed. “We know that today we need a game changer – we need people to step forward and speak out about this disease,” she said.

Previously: Science Friday explores women’s heightened risk for Alzheimer’s, The state of Alzheimer’s research: A conversation with Stanford neurologist Michael Greicius and The toll of Alzheimer’s on caretakers 
Photo by Marjan Lazarevski

Aging, Genetics, Research, Science, Stanford News

“Are we there yet?” Exploring the promise, and the hype, of longevity research

"Are we there yet?" Exploring the promise, and the hype, of longevity research

Brunet photoThe days are getting longer, and it’s no longer dark outside when I drop my teenager at school for her early-bird class. I appreciate the light, of course, and there’s something soothing about the rhythmic change of seasons.

If only we could extend our lifespan in a similar gentle, reliable manner.

The idea of living longer, and healthier, is the theme of my story for the new issue of Stanford Medicine magazine. It’s my favorite kind of article – a dash of juicy science history, a panoply of dedicated scientists and a brand-new animal model (and my newest crush) that may open all kinds of research doors. Best of all, there’s a sense of real progress in the field. From my article:

“Ways of prolonging human life span are now within the realm of possibility,” says professor of genetics and newbie fish keeper Anne Brunet, PhD. Brunet, who is an associate director of Stanford’s Paul F. Glenn Center for the Biology of Aging, focuses her research on genes that control the aging process in animals such as the minnowlike African killifish I’d watched fiercely guarding his territory.

The killifish is especially important to researchers like Brunet because it has an extremely variable, albeit short, life span. One strain from eastern Zimbabwe completes its entire life cycle — birth, maturity, reproduction and death — within about three to four months. Another strain can live up to nine months.

It’s also a vertebrate, meaning it belongs to the same branch of the evolutionary tree as humans. This gives it a backbone up over more squishy models of aging like fruit flies or roundworms — translucent, 1-millimeter-long earth dwellers you could probably find in your compost pile if you felt like digging.

I hope you’ll read the rest of my piece to learn more.

Previously: My funny Valentine – or, how a tiny fish will change the world of aging research, Stanford Medicine magazine reports on time’s intersection with health and Living loooooooonger: A conversation on longevity
Photo of Anne Brunet by Gregg Segal

Aging, Applied Biotechnology, Biomed Bites, Research, Science, Videos

Are your cells stressed out? One Stanford researcher is helping them relax

Are your cells stressed out? One Stanford researcher is helping them relax

Welcome to Biomed Bites, a weekly feature that introduces readers to some of Stanford’s most innovative researchers. 

In her family, Daria Mochly-Rosen, PhD, is the odd woman out: One parent and four of her siblings are architects.

But as the George D. Smith Professor in Translational Medicine at Stanford, Mochly-Rosen brings her family’s focus on space and design to her work as a biomedical researcher. “I’m looking at the cell as a physical space as a room or a building where things need to touch each other in certain ways,” Mochly-Rosen says in the video above.

She applies this lens of the world to address several basic research questions, including learning about how cells deal with stress. For a cell, stress isn’t a bad day at work or a rough commute home. Instead, its prolonged exposure to chemicals or physical forces that build up and impair cellular function.

In healthy cells, there are “lots of little machines” that reduce the stress, Mochly-Rosen said. In her lab, researchers work to enhance the efficacy of these built-in destressors and to capitalize on the cell’s existing machinery. She says:

We are really interested in finding ways to boost them up and to increase their activity so we can deal better with stresses that are associated with disease or even with simple aging.

And what we do there is we try to find small molecules — in other words, drugs — that will boost the system.

For example, Mochly-Rosen and her team have discovered a molecule that helps with the negative effects of alcohol and alcohol-related cancers.

Learn more about Stanford Medicine’s Biomedical Innovation Initiative and about other faculty leaders who are driving biomedical innovation here.

Previously: Why drug development is time consuming and expensive (hint: it’s hard), New painkiller could tackle pain, without risk of addiction and Stanford researchers show how hijacking an enzyme could help reduce cancer risk

Aging, Chronic Disease, In the News, Media, Neuroscience, Women's Health

Science Friday explores women’s heightened risk for Alzheimer’s

Science Friday explores women's heightened risk for Alzheimer's

More than two-thirds of the Americans living with Alzheimer’s are women — some like the character Alice in the movie “Still Alice,” who suffers from an early onset form of the disease.

Science Friday tackled that topic Friday, with guests Michael Greicius, MD, MPH, associate professor of neurology and director of the Stanford Center for Memory Disorders, and Roberta Diaz Brinton, PhD, professor of pharmacology at the University of Southern California. The two quickly disputed the belief that more women get Alzheimer’s disease because they live longer.

“The way women age puts them at risk,” Brinton said. As they transition through menopause, some women develop cognitive symptoms such as insomnia, depression and short-term memory loss, leaving them at greater risk for Alzheimer’s, she explained.

Women who have a form of a gene called APOE-e4 are particularly at risk, although it doesn’t seem to affect men, Greicius said. The gene interacts with estrogen.

Scientists are continuing to decipher the link between estrogen and Alzheimer’s and the possibility of hormone therapies, as well as the connection — if any — between pregnancy and Alzheimer’s risk, the scientists told listeners.

The 18-minute segment is available here.

Previously: Blocking a receptor on brain’s immune cells counters Alzheimer’s in mice, The state of Alzheimer’s research: A conversation with Stanford neurologist Michael Greicius, Having a copy of ApoE4 gene variant doubles Alzheimer’s risk for women but not for men and The toll of Alzheimer’s on caretakers

Aging, Cancer, Emergency Medicine, Medical Education, Pregnancy, Stanford News

Stanford Medicine magazine reports on time’s intersection with health

Stanford Medicine magazine reports on time's intersection with health

Why is it that giant tortoises typically live for 100 years but humans in the United States are lucky to make it past 80? And why does the life of an African killifish zip past in a matter of months?

I’ve often mused about the variability of life spans and I figure pretty much everyone else has too. But while editing the new issue of Stanford Medicine magazine’s special report on time and health, “Life time: The long and short of it,” I learned that serious scientists believe the limits are not set in stone.

“Ways of prolonging human life span are now within the realm of possibility,” says professor of genetics Anne Brunet, PhD, in “The Time of Your Life,” an article on the science of life spans. My first thought was, wow! Then I wondered if some day humans could live like the “immortal jellyfish,” which reverts back to its polyp state, matures and reverts again, ad infinitum. Now that would be interesting.

Also covered in the issue:

  • “Hacking the Biological Clock”: An article on attempts to co-opt the body’s timekeepers to treat cancer, ease jetlag and reverse learning disabilities.
  • “Time Lines”: A Q&A with bestselling author and physician Abraham Verghese, MD, on the timeless rituals of medicine. (The digital edition includes audio of an interview with Verghese.)
  • “Tick Tock”: A blow-by-blow account of the air-ambulance rescue of an injured toddler.
  • “Before I Go”: An essay about the nature of time from a young neurosurgeon who is now living with an advanced form of lung cancer. (The neurosurgeon, Paul Kalanithi, MD, is featured in the video above, and our digital edition also includes audio of an interview with him.)

The issue also includes a story about the danger-fraught birth of an unusual set of triplets and an excerpt from the new biography of Nobel Prize-winning Stanford biochemist Paul Berg, PhD, describing the sticky situation he found himself in graduate school.

Previously Stanford Medicine magazine traverses the immune system, Stanford Medicine magazine opens up the world of surgery and Mysteries of the heart: Stanford Medicine magazine answers cardiovascular questions.

Aging, Genetics, In the News, Mental Health, Neuroscience, Research, Women's Health

Are women at greater risk for Alzheimer’s? Stanford expert to discuss on today’s Science Friday

Are women at greater risk for Alzheimer’s? Stanford expert to discuss on today's Science Friday

2187905205_158290644d_zConfession: I named my parents’ cat (who died recently) Watson after listening to Ira Flatow interview James Watson, PhD, while driving cross country with my dad in 2000. Both before and after the all-critical cat-name-inspiring program, Science Friday has been a part of my Friday as often as I can squeeze it in.

So I was happy to hear that today’s program (which airs locally from 11 a.m. to 1 p.m. on KQED) will feature Stanford’s Michael Greicius, MD, MPH. He’ll be talking about Alzheimer’s disease and why the disease affects men and women differently.

Greicius, medical director of the Stanford Center for Memory Disorders, has worked with the gene variant known as ApoE4 – the largest single genetic risk factor for Alzheimer’s, particularly for women. Last spring, he published a study showing that healthy ApoE4-positive women were twice as likely to contract the disease as their ApoE4-negative counterparts.

Greicius is expected to be on in the second hour, from 12 to 1 p.m. Pacific time.

Previously: Blocking a receptor on brain’s immune cells counters Alzheimer’s in mice, Examining the potential of creating new synapses in old or damaged brains, The state of Alzheimer’s research: A conversation with Stanford neurologist Michael Greicius and Having a copy of ApoE4 gene variant doubles Alzheimer’s risk for women but not for men
Photo by *Ann Gordon

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