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Cardiovascular Medicine, Events, Research, Stanford News

At Stanford Cardiovascular Institute’s annual retreat, a glimpse into the future of cardiovascular medicine

At Stanford Cardiovascular Institute’s annual retreat, a glimpse into the future of cardiovascular medicine

doctor listening to heartWhat will the future of cardiovascular medicine look like?

A group of scientists, engineers, educators, surgeons, physicians and students explored this question at the Stanford Cardiovascular Institute’s annual retreat earlier this month. More than 100 attendees crowded into Stanford’s Li Ka Shing Center for Learning and Knowledge to learn about the research and advances that will transform cardiovascular care.

“For this year’s retreat we’ve  asked selected members to dig deep into the past and project the future of their specialties,” institute director Joseph Wu, MD, PhD, told the audience.

Talks presented during the day – on topics including sports medicine, stem cells, women’s health and biodesign – reflected the breadth of the institute’s scholarship and the diversity of its members.

Stem cell scientist Hiromitsu Nakuchi, MD, PhD, spoke about recent advances in stem cell biology and regenerative medicine. Only a few years ago, stem cell-based regenerative medicine was widely perceived as the province of science fiction. No more, Nakuchi said. His lab has been working on a new technique to transform human skin cells into induced pluripotent stem cells, or iPS cells, which can then be used to develop organs. The ultimate goal of this research: To create genetically matched human organs in large animals.

Researchers like geneticist Michael Snyder, PhD, envision a day when an “omics” profile will be sequenced before birth, and Snyder took to the stage to discuss the potential of personalized medicine. “I’m a believer in the future,” he said. “Genomics will move medicine from diagnose-and-treat to predict-and-prevent.” After sequencing his own genome and thousands of other biomarkers to create an integrated personal omics profile, Snyder learned that he was at risk for Type 2 diabetes. This knowledge allowed him to transform his diet and ramp up his physical activity, and it provided him a first hand glimpse of the diagnostic power of genomics. Genomic sequencing has the potential to change the way physicians care for patients, Snyder told the audience, resulting in more effective, patient-tailored therapies and a greater focus on disease prevention.

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Big data, Cancer, Cardiovascular Medicine, Fertility, Men's Health, Research, Stanford News

Male infertility can be warning of hypertension, Stanford study finds

Male infertility can be warning of hypertension, Stanford study finds

sperm graffitiA study of more than 9,000 men with fertility problems links poor semen quality to a higher chance of having hypertension and other health conditions. The findings suggest that more-comprehensive examinations of men undergoing treatment for infertility would be a smart idea.

About a quarter of the adults in the United States (and in the entire world) have hypertension, or high blood pressure. Although it’s the most important preventable risk factor for premature death worldwide, hypertension often goes undiagnosed.

In a study published today in Fertility and Sterility, Stanford urologist Mike Eisenberg, MD, PhD, and his colleagues analyzed the medical records of 9,387 men, mostly between 30 and 50 years old, who had provided semen samples in the course of being evaluated at Stanford to determine the cause of their infertility. The researchers found a substantial link between poor semen quality and specific diseases of the circulatory system, notably hypertension, vascular disease and heart disease.

“To the best of my knowledge, there’s never been a study showing this association before,” Eisenberg told me when I interviewed him for a press release about the findings. “There are a lot of men who have hypertension, so understanding that correlation is of huge interest to us.”

In the past few years, Eisenberg has used similar big data techniques to discover links between male infertility and cancer and heightened overall mortality, as well as between childlessness and death rates in married heterosexual men.

Eisenberg sums it all up and proposes a way forward in the release:

Infertility is a warning: Problems with reproduction may mean problems with overall health … That visit to a fertility clinic represents a big opportunity to improve their treatment for other conditions, which we now suspect could actually help resolve the infertility they came in for in the first place.

Previously: Poor semen quality linked to heightened mortality rate in men, Men with kids are at lower risk of dying from cardiovascular disease than their childless counterparts and Low sperm count can mean increased cancer risk
Photo by Grace Hebert

Cardiovascular Medicine, Chronic Disease, Health Costs, Research, Stanford News

Home health-care treatments for lymphedema patients cut costs and improve care

Home health-care treatments for lymphedema patients cut costs and improve care

Lymphedema, an incurable chronic illness that involves severe swelling of the limbs, is frequently ignored, often misdiagnosed and under treated. Now a study by a Stanford researcher, who has for years worked to change this, illustrates how the use of home health-care treatment can help. The research appears today in PLOS ONE.

In a story I wrote on the study, Stanley Rockson, MD, a leading expert on lymph disorders, explains that one of the major challenges to improving care for lymphedema patients is that home care is poorly reimbursed by third-party payers. Rockson and colleagues set out to examine the cost effects of the use of one of these home-care therapeutics called a compression device to reduce swelling.

This is clearly a compelling argument for increased coverage of compression devices and similar home-care devices to reduce costs

By examining the health-care claims from a national private health insurer from 2007 to 2013, researchers found that patients who used these compression devices reduced annual health-care costs from $62,190 to $50,000. As Rockson explains in a press release, “Total health-care costs for these patients are very high, but can be profoundly reduced with treatment intervention, in this case a compression device. This is clearly a compelling argument for increased coverage of similar home-care devices to reduce costs.”

Rockson, who both researches lymphedema and treats patients with the disorder, has worked over the years to educate both the public and health-care professionals about this “hidden” disease. As a reporter who covers his research, he has also helped educate me – and in my piece I describe both the cause of the disease and available treatments:

Lymphedema is most commonly caused by the removal of or damage to lymph nodes as a part of cancer treatment. It results from a blockage in the lymphatic system, which is part of the immune system. The blockage prevents lymph fluid from draining well, and the fluid buildup leads to swelling, which can be painful and debilitating. These symptoms can be controlled with various treatments, including treatments done at home and outpatient physical therapy. Home treatments for lymphedema include manual lymphatic massage, multilayer bandaging techniques and application of various compressive garments to reduce tissue fluid.

I’ve written several other stories about Rockson’s work on lymphedema over the years. One such piece, published in 2009, helps bring a greater understanding to the disease by describing how it impacted one patient. Hearing firsthand from a patient about what it’s actually like to live with lymphedema day-in and day-out makes the ongoing search for better treatments and possible cures all the more pressing:

Julie Karbo fights a battle every day to keep her lymphedema under control. Every night she hooks her arm up to a portable pump to help drain away fluids. Every day she wears compression sleeves to keep the swelling down. She limits the number of groceries she carries into the house to make sure she doesn’t put undue strain on the affected arm, and keeps a close watch for any possible infection-causing scratches or spider bites.

“A bee sting or a spider bite can lead to a very serious infection,” says Karbo, 49, a high-tech public relations executive and single mother of two in the Bay Area, who—unlike many lymphedema patients—never had cancer. “It’s something that greatly impacts the way you live your life.”

Previously: New blood test could bring lymphedema detection (and treatment) into the 21st century and New Stanford registry to track lymphedema in breast cancer patients

Big data, Cardiovascular Medicine, Chronic Disease, Research, Science, Stanford News, Videos

Big data approach identifies new stent drug that could help prevent heart attacks

Big data approach identifies new stent drug that could help prevent heart attacks

Ziad Ali, MD, PhD, was a cardiovascular fellow at Stanford with a rather unique skill when a 6-year study published today online in The Journal of Clinical Investigation first began.

The multi-talented physician-scientist – who is now associate director of translational medicine at Columbia University Medical Center – had figured out a way to put tiny little stents into mice with clogged arteries as a PhD student.

The skill would become key as he and colleagues set out to find a better pharmaceutical for the drug-eluting stents that are used in combination with angioplasty to treat coronary artery disease. In order to prevent stent disease, the often serious medical problem caused by stents themselves, chemotherapy drugs were added to bare metal stents. But these drug-eluting stents have their own problems: The drugs work like “hitting a pin with a sledgehemmer,” as Ali describes it, often damaging the lining of the arteries which can lead to heart attacks. As a result, patients are required to take blood thinners for up to a year after the procedure to prevent clots.

“A lot of our patient population is on the elderly side with bad hips or diabetes,” Ali told me. “Once you get a drug-coated stent, you can’t have surgery for a year. And if you stop the blood thinners for any reason, you’re at risk of a stent clotting off. And that actually causes a heart attack. Stent thrombosis has a high mortality rate.”

By using a “big data” computational approach, learning about the genetic pathways involved in coronary artery disease, then testing the new theories on mice models in the lab, researchers were able to pinpoint a potential new treatment for patients: Crizotinib, a pharmaceutical approved by the FDA for treatment in certain cases of lung cancer.

“This could have major clinical impact,” Euan Ashley, MD, PhD, senior author of the study, who discusses the work alongside Ali in the video above, said.

Previously: Euan Ashley discusses harnessing big data to drive innovation for a healthier world, New computing center at Stanford supports big data, Trial results promising for new anti-clotting drug and A call to use the “tsunami of biomedical data” to preserve life and enhance health
Photo in featured entry box by Mark Tuschman

Bioengineering, Cardiovascular Medicine, Clinical Trials, Research, Science, Stanford News

Using "nanobullets" for good – not evil

Using "nanobullets" for good - not evil

14858598815_b572bddbf9_zMy husband, a big science fiction fan, perked up the other day when I told him I was writing a medical science story about nanotechnology. Apparently, nanotechnology – the study and application of extremely small things – has long been big in the world of science fiction. There, authors have used it to create lots of cool-sounding phantasmagorical stuff like the “nanoprobes” used by the Borg in the movie Star Trek: The Next Generation to assimilate individuals into their collective.

I’m not sure how the fictional nanoprobe was supposedly built, but in my real-life story on the modern day use of nanotechnology to design better methods for heart disease treatment, I do describe the creation of “nanobullets” by Stanford researchers. And it’s pretty cool.

Jayakumar Rajadas, PhD and his colleagues detailed their work in a scientific paper published this month in the journal Biomaterials. Their idea was to create a new and improved delivery system for the delicate peptide apelin into the heart as a treatment for hypertrophic heart disease, which I discuss in the piece:

In a treatment model similar to giving insulin to diabetes patients, physicians have attempted to treat these heart conditions with doses of apelin. The therapeutic agent is delivered intravenously through to the cardiovascular tissue, but due to its short half-life — the drug is quickly eliminated from the blood plasma — the success of this treatment has been limited.

Rajadas considered the possibility for improving the delivery system of the peptide using nanotechnoloy because it has been used for the past 10 years to stabilize therapeutic agents in the body and target them to specific tissues, he said. In this case, the idea was to protect the quickly degrading apelin peptides with large, stable molecules to help transport them to their target organ – the heart:

The research team developed a novel technique to increase the stability of the fragile apelin peptides by protecting them with a lipid cover that Rajadas calls the ‘Trojan Horse’ method of delivery. The liposome ‘nanocarriers’ encapsulates the apelin and sneaks it through the blood to the heart tissue.

The resulting apelin “nanobullets,” as the researchers refer to them, were then delivered through the blood system to the cardiovascular tissue of mice with induced hypertrophic heart conditions. The theory was that the apelin would not be released until it was near the heart tissue.

Researchers then tried it out, shooting the nanobullets into the hearts of mice with hypertrophic heart disease. They delivered two shots over a 14-day period. Results showed that symptoms dramatically improved in the mice that received the shots with the apelin nanobullets when compared to mice shot with saline treatments or even treatments of apelin not protected with the liposome covering.

“Apelin in this form could eventually be used as treatment for humans delivered as a shot rather than intravenously as in the past,” Rajadas told me. “The idea is that regular monthly or bimonthly shots could lesson symptoms.”

Previously: Stanford team develops nanotech-based microchip to diagnose Type 1 diabetes
Photo by NMK Photography

Cardiovascular Medicine, Medicine X, Patient Care, Surgery

Operation Heart: Engaging patients in caring for patients

Operation Heart: Engaging patients in caring for patients

Stanford’s Medicine X is a catalyst for new ideas about the future of medicine and health care. This new series, called The Engaged Patient, provides a forum for some of the patients who have participated in or are affiliated with the program. Our inaugural post comes from Sarah E. Kucharski.

mended heartRivulets of deep brown iodine trickled across the patient’s body as nurses swabbed with sponges and unfurled blue surgical drapes. I contemplated his bare feet. I wondered if they were cold. I wondered if he wore no socks so that the nurses might palpitate for his dorsalis pedis and posterior tibial pulses. And I thought about how many times the patient on the operating table had been me.

When given the opportunity to observe surgery, I had accepted eagerly. One hardly could have called it an exercise in learning self-care techniques — no matter how empowered I am as a patient, even I draw a line at doing by own arterial bypass. Rather I wanted to see how the other half lived. For once I entered the operating room wearing scrubs and surgical mask instead of an open-backed gown and an IV line pushing Versed through my veins.

My conscious presence meant I represented not just myself but my fellow patients who clamored for meaningful engagement. There is much talk about being able to view health care and the medical establishment from another perspective, but few truly have an opportunity to do so. It has been pointed out that doctors attend school to learn how to be doctors, yet patients do not attend school to learn how to be patients. More importantly there is no school to teach doctors how to be patients and, save for those patients whose condition manifests early enough to motivate medical school, no method of teaching patients how to be doctors. Collaborations to re-imagine health care for our joint benefit will be ineffective unless we expand medical education to regularly include the patient, which will facilitate empathy and improved health literacy through shared experiences.

As surgery preparations continued, the operating room nurses appeared apprehensive they were going to share an experience with me. I had signed on with a go big or go home philosophy — the aortic root and mitral valve replacement would be my first surgery. Each nurse’s eyes widened for two tell-tale seconds when I told them my novice status, and their voices caught as they tried to mitigate surprise, “Ooh.” Their apprehension meant I had something to prove. There would be no circumstance under which I would faint.

And with the loud whine of the sternum saw, we were underway.

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Behavioral Science, Cardiovascular Medicine, Medicine and Society, Research, Stanford News

The lonely are more likely to die. But why?

The lonely are more likely to die. But why?

11317715623_e27537b3f3_zLoneliness isn’t healthy — most everyone knows that. But why exactly does isolation lead to disease, or even death? Stanford researcher Sylvia Kreibig, PhD, set out to answer that question by digging through data from the Heart and Soul Study, an inquiry that followed more than 1,000 coronary heart disease patients for about 10 years, starting in 2000.

Turns out that socially isolated patients are 61 percent more likely to die in any given year than other patients, Kreibig and her team found. Yet you don’t need many friends to stave off the ill effects of solitude. Those with at least one to three regular contacts fared no better than the most-social butterfly. Even tossing in factors that affect mortality such as age and weight didn’t affect general conclusion: friendless folks die sooner. But why?

Kreibig’s team, which included Stanford psychologist James Gross, PhD, delved deeper to figure it out.

It isn’t depression. Depression is independently related to mortality, but it couldn’t explain the link between solitude and risk of death. Instead, Kreibig and colleagues found a strong link between several behavior factors such as smoking, omega-3 concentration (a representative of diet quality), and medication adherence and isolation.

“If you are more integrated, you have people around that look after you and care for you, making sure you’re eating healthy foods, not smoking and taking medications as directed,” Kreibig told me. “You yourself as a patient actually have a lot of control over factors that affect your health… Just by integrating some salmon into your diet, you have a better chance of survival.”

The team classified 1,019 patients into four categories of social integration (low, medium, medium-high and high), based on whether or not they had a partner, strength of linkages with family and friends and membership in religious congregations and community groups. Patients in the low category were more likely to smoke, eat unhealthy foods and skip their medications, the study found.

She cautioned that the study, which appears in this month’s issue of Psychosomatic Medicine, demonstrated correlation, not causation. In addition, the patients were primary male and, as they suffered from heart disease, could be affected differently than healthy, or younger, patients.

Next, Kreibig said she plans to examine the emotions related to social isolation and their effect on health.

Previously: The importance of human connection as part of the patient experience, How social media and online communities can improve clinical care for elderly patients and How loneliness can impact the immune system
Photo by Alex Krasavtsev 

Cardiovascular Medicine, Mental Health, Research

The link between mental-health conditions and cardiovascular disease

The link between mental-health conditions and cardiovascular disease

14496537236_932d9a9acd_zA growing body of research has shown the connection between our emotional well-being and physical health. Among the latest findings: Schizophrenia, bipolar disorders and major depressive and anxiety disorders can greatly increase a person’s risk of heart disease and stroke.

In a study presented at this year’s Canadian Cardiovascular Congress in Vancouver, Canada, researchers examined connections between mental-health conditions, use of psychiatric medication, and heart health using data from the Canadian Community Health Survey. Medical News Today reports:

They found that patients who had a mental illness at any point in their life were twice as likely to have had a stroke or experienced heart disease than the general population, while patients who had not experienced heart disease or stroke had a higher long-term risk of cardiovascular disease.

Furthermore, patients who used psychiatric medications for their mental illness were twice as likely to have heart disease and three times as likely to have had a stroke than those who did not use such medications.

“This population is at high risk,” says [Katie Goldie, PhD, lead author of the study and a postdoctoral fellow at the Centre for Addiction and Mental Health in Toronto], “and it’s even greater for people with multiple mental health issues.”

Goldie and colleague said that there are three main factors that contribute to mental-health patients’ increase cardiovascular risk. They are: lifestyle behaviors, such as tobacco and alcohol use, poor diet and physical inactivity; psychiatric medications, which can induce weight gain and inhibit the body from breaking down fats; and inadequate access to health care.

The findings are significant in light of statistics (.pdf) from the National Alliance of Mental Health showing that 1 in 4 adults in the United States experience a mental health disorder in annually and that serious mental illness costs the nation $193.2 billion in lost earnings per year.

Previously: Examining how mental stress on the heart affects men and women differently, Study shows link between traffic noise, heart attack and Study offers insights into how depression may harm the heart
Photo by Holly Lay

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

How best to treat dialysis patients with heart disease

How best to treat dialysis patients with heart disease

523392_4923732760_zKidney failure patients on dialysis often have other chronic diseases – heart disease topping the list. They’re prescribed an average of 12 pills a day by physicians, according to Stanford nephrologist Tara Chang, MD, and they spend three-to-four hours at a treatment center three times a week connected to an artificial kidney machine.

For Chang, this makes it all the more important that any medication she prescribes for a patient on dialysis is both essential and effective.

The problem is, particularly in the case of treating kidney patients with heart disease, evidence-based treatment guidelines just aren’t available. Kidney doctors are left making best guesses based on guidelines written for the general population.

“Our patients might be different from patients not on dialysis,” said Chang. “Dialysis patients have a lot of heart disease, yet rarely does a cardiology study enroll patients on dialysis, so we just don’t know.”

This was part of the motivation behind Chang’s most recent study examining the use of anti-platelet drugs such as clopidogrel, one of the most commonly prescribed drugs for kidney patients. The researchers looked at the use of anti-platelet medications such as clopidogrel as treatment following stenting procedures to unclog arteries in the heart in 8,458 dialysis patients between 2007 and 2010. The data suggests that longer-duration of drug use may be of benefit to patients on dialysis who get drug-eluding stents but not those who get bare metal stents. Chang told me:

We found that for those who got drug-eluting stents who took the drug for 12 months compared to those who had stopped the drug at some earlier time point, there was a non-statistically significant trend towards lower risks of death and heart attacks. So for this group, following the same guidelines as for the general population may be appropriate. However, we found no indication of benefit with longer duration of anti-platelet drug use for patients on dialysis who got bare metal stents.

About half of the 400,000 patients in the U.S. on dialysis also have coronary artery disease, as referenced in the study. The number of those getting stents inserted to unclog arteries also has increased 50 percent in the past decade, the study states. The results of the study, while not definitive as to exactly how long doctors should prescribe the drug, does stress the need for more clinical research on patients with kidney failure to provide guidance on treatment strategies for heart disease.

“Because our study was not a randomized trial,” said Chang, “we tried to be very measured in how we interpreted the results. What it does point to is the fact that we can’t assume that what works in non-dialysis patients works in dialysis patients. Hopefully our study will help convince researchers to include our dialysis patients in their studies.”

The paper was published this week in the Journal of the American Heart Association.

Previously: Keeping kidney failure patients out of the hospitalStudy shows higher rates of untreated kidney disease among older adults and Study shows daily dialysis may boost patients’ heart function, physical health.
Photo by newslighter

Cardiovascular Medicine, Men's Health, Mental Health, Research, Women's Health

Examining how mental stress on the heart affects men and women differently

Examining how mental stress on the heart affects men and women differently

stress_womanPast research has shown that stress, anger and depression can increase a person’s risk for stroke and heart attacks. Now new findings published in the Journal of the American College of Cardiology show that cardiovascular and psychological reactions to mental stress vary based on gender.

In the study (subscription required), participants with heart disease completed three mentally stressful tasks. Researchers monitored changes in their heart using echocardiography, measured blood pressure and heart rate, and took blood samples during the test and rest periods. According to a journal release:

Researchers from the Duke Heart Center found that while men had more changes in blood pressure and heart rate in response to the mental stress, more women experienced myocardial ischemia, decreased blood flow to the heart. Women also experienced increased platelet aggregation, which is the start of the formation of blood clots, more than men. The women compared with men also expressed a greater increase in negative emotions and a greater decrease in positive emotions during the mental stress tests.

“The relationship between mental stress and cardiovascular disease is well known,” said the study lead author Zainab Samad, M.D., M.H.S., assistant professor of medicine at Duke University Medical Center, Durham, North Carolina. “This study revealed that mental stress affects the cardiovascular health of men and women differently. We need to recognize this difference when evaluating and treating patients for cardiovascular disease.”

Previously: Study shows link between traffic noise, heart attack, Ask Stanford Med: Cardiologist Jennifer Tremmel responds to questions on women’s heart health and Study offers insights into how depression may harm the heart
Photo by anna gutermuth

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