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Clinical Trials, Emergency Medicine, Neuroscience, Research

Clinical trial shows progesterone doesn’t improve recovery from head trauma

Clinical trial shows progesterone doesn't improve recovery from head trauma

800px-thumbnailResearchers had high hopes that progesterone, that multipurpose endogenous steroid, could stave off some of the worst effects of head injuries. A quick injection soon after a blunt trauma and  — wa-zam — marked improvement on the widely used Glasgow Outcome Scale, which measures brain injuries on a scale from death to low disability. Or so they thought.

Instead, a nationwide clinical trial was called off after early analyses showed no benefit. The findings were published last week in The New England Journal of Medicine.

“These results are plainly disappointing,” said lead investigator David Wright, MD, an emergency medicine physician at Emory University, in an Emory release.

Stanford, in partnership with Santa Clara Valley Medical Center and the Regional Medical Center of San Jose, enrolled approximately 80 patients in the study between 2008 and 2013, said James Quinn, MD, a Stanford emergency medicine physician. Quinn said there were many benefits to the study even though the results didn’t suggest an improvement.

“The patients all got great care,” Quinn said.  The care teams worked to ensure the care was standardized and top notch for study participants, he said. In addition, there’s still a possibility that progesterone administered closer to the time of injury might help patients. To adhere with study protocols, the teams had to wait one hour after the patient arrived at the emergency room before providing the progesterone or placebo, Quinn said.

The study had a unique design, in part because emergency trauma patients can often not provide consent. Instead, the research team publicized the study before starting and gave participants the opportunity to opt out when they were able.

Quinn also made note of an observation made by he and his colleagues:  Although nationwide most injuries stemmed from vehicle crashes, the Stanford-led teams saw an abundance of bicycle accidents.

Previously: For prolonged seizures, a quick shot often does the trick, study finds, Stanford Medicine story on surviving brain injury wins health journalism award and Estradiol — but not Premarin — prevents neurodegeneration in women at heightened dementia risk
Photo by U.S. Navy

Emergency Medicine, Medical Education, Patient Care, SMS Unplugged

Role reversal: How I went from med student to ED patient in under two minutes

Role reversal: How I went from med student to ED patient in under two minutes

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.

emergency sign - smallAs part of the second-year clinical skills course, each member of my class is required to complete two 8-hour Emergency Department (ED) shifts. I had my first ED shift last week, and when I walked in, I introduced myself as a second-year medical student who needed to practice IV placements, EKGs, and any other procedures that happened to come my way. Three hours later, when I walked out of the ED, staff knew me not as a medical student, but as a recently discharged patient, grasping paperwork with my official diagnosis: “syncope and collapse.”

It was 30 minutes into my ED shift, while I was watching a pelvic exam (ironic, given my post a couple weeks ago), when I began to feel a little dizzy. I’ve fainted twice before – once in high school after getting my blood drawn, and once when watching a C-section at a clinic in India – so I recognized the signs: feeling a little hot, starting to see black dots, slightly swaying. I tried to fight off the sensation by breathing slowly, but I could tell it wasn’t working. At the earliest possible opportunity, I turned to the attending in the room, saying, “Is it okay if I leave? I’m feeling lightheaded.”

I barely waited to hear her response before I bolted out of the room and found the closest stool to sit on. Bad call. The stool had no back to it, and next thing I knew, I was on the ground. When I opened my eyes, there were at least five  nurses around me, one whom matter-of-factly said, “Honey, you just became a patient.” Another nurse quietly slipped my hospital badge off my jacket, returning two minutes later with a medical bracelet that she fastened around my wrist.

My memory of those early moments is a little shaky, but I do remember saying over and over again, “I’m so sorry, I’m so sorry.” I felt awful that I had come to the ED to learn from the patients, physicians, and staff – without being a burden – but had ended up being another patient for whom they had to provide care. The nurses and attendings immediately normalized the situation, telling me repeatedly that this is a common occurrence in the ED and that many of them had had this happen to them as well. Their assurances made me feel so much better.

The efficiency of the events that followed totally impressed me. The nurse helping me to the bed did the fastest history on me I’ve ever heard, all while hooking me up to a BP cuff and a pulse oximeter. Did I have allergies? (Nope.) Did I  have diabetes? (Nope.) When was the last time I ate? (That morning). Any other medical conditions that I’m being treated for? (Nope.) Any family history of cardiac conditions? (Nope.)

The attending who was with me when I initially felt lightheaded came in at that point and asked, “Has this happened to you before?” and when I told her about the C-section, joked, “ObGyn probably isn’t your favorite thing, huh?” She then laid out the plan for what would happen next: an EKG, a glucose stick, and a blood test, to check for cardiac abnormalities, low blood sugar, and anemia, respectively. Within 30 minutes, all three of these had been done, and I even got a bonus ultrasound thrown in by someone who was practicing recognizing cardiac pathology (not that I had any). Noticing my scrubs and med student badge, this person took the time to show me each ultrasound image, pointing out the various heart chambers, valves, and the location where my IVC entered my right atrium.

By 2 PM, my tests were all back, everything was normal, and I was able to laugh about the entire situation: Somehow, I had come into the ED hoping to practice blood draws and EKGs but came out having them done to me instead. Just another day in the life of a med student.

Hamsika Chandrasekar is a second-year student at Stanford’s medical school. She has an interest in medical education and pediatrics.

Photo by zoomar

 

Emergency Medicine, Global Health, Stanford News, Videos

Improving global emergency medicine to save lives

Improving global emergency medicine to save lives

In July 2013, Stanford physician S. V. Mahadevan, MD, and colleagues conducted a study at the largest children’s hospital in Karachi, Pakistan to understand the kinds of medical emergencies that doctors treated at the facility. “What we found was astonishing,” he says in this Stanford+Connect video. “By fourteen days 10 percent of [the 1266 children enrolled in the study] were dead.” Mahadevan saw more children die during the one week he spent in the Pakistan hospital than in his entire 22-year-career in the United States.

Despite such dire statistics, there is hope. Mahadevan, founder of Stanford Emergency Medicine International, explains in the video how important early interventions can be made in the chain of survival to save thousands of lives in low-resource countries. Watch the full lecture to learn more about his efforts to establish Nepal’s first ambulance service, India’s first paramedic training program and his ongoing work to improve emergency care in Cambodia.

Previously: Stanford undergrad uncovers importance of traditional midwives in India, Providing medical, educational and technological tools in Zimbabwe and Saving lives with low-cost, global health solutions

Addiction, Emergency Medicine, Health Policy, Research, Stanford News

Assessing the opioid overdose epidemic

Assessing the opioid overdose epidemic

Vicodin bottle Flickr Sharyn MorrowIn recent years, doctors and policy-makers have become aware of the dangers of prescription opioid medications like methadone, oxycodone and hydrocodone (which is sold as OxyContin or Vicodin). In a study published in this month’s JAMA Internal Medicine, Stanford medical student Michael Yokell and Stanford surgeon Nancy Wang, MD, took a new approach to quantifying those dangers.

Many previous studies of the toll of opioids looked at death certificate data and examined trends among deaths due to opioid overdoses, including street drugs like heroin and prescription painkillers. The new study looked at emergency department admissions and found that more than two thirds of ER visits due to overdoses were related to prescription opioids, while heroin overdoses accounted for 16 percent. Moreover, only about 2 percent of cases that made it to the ER died, but more than half the patients needed further hospitalization.

The study also found that those admitted to the emergency room because of opioid overdoses are more likely to have conditions such as chronic breathing problems, heart problems or mental health issues. Yokell explained that it’s important for doctors to be aware of the possibility of overdose and consider prescribing alternatives or discuss the risk of overdose with patients.

Beyond providing better access to emergency medical care and treatments for patients, an important next step to resolving the problem of opioid misuse is to establish or improve statewide prescription monitoring programs. For example, California has a prescription drug-monitoring database called CURES, but not all doctors actively use the program. “We can do a better job of making that database more widely used by physicians in the state.  We need more doctors to sign up and use it. It’s a valuable resource,” said Yokell.

Additionally, many people get access to prescription opioids via fraudulent prescriptions or from dealers that have illegally obtained the drugs – sometimes from breaking into and raiding pharmacies. “It’s important to keep in mind that good prescribing practices are one component of an effective strategy. There are many other ways for people to get their hands on [prescription opioids] and use them inappropriately.”

Although fixing things on the prescription side is important for managing the opioid overdose epidemic, Yokell notes that it’s not enough. Cases that make it to the ER are likely to survive, but Yokell noted that the fear of criminal charges often results in people avoiding medical care for overdoses caused by opioids and that getting this group better access to emergency services and treatment could improve outcomes. Paramedics and doctors have access to the drug naxolone, marketed as Narcan, which is safe and effective treatment for opioid overdose. But “people don’t call 911, so they are dying,” Yokell told me.

Previously: Stanford addiction expert: It’s often a “subtle journey” from prescription-drug use to abuse, Increasing access to an anti-overdose drug and A focus on addiction, the country’s leading cause of accidental death
Photo by Sharyn Morrow

Emergency Medicine, Events, Imaging, Medical Education, Stanford News

Ultrasound has its day – and evangelists galore

Ultrasound has its day -  and evangelists galore

ULTRAfestUltrasound isn’t just for babies anymore.

“We use it for everything from head to toe and skin and organs,” emergency medicine instructor Laleh Gharahbaghian, MD, recently told writer Sara Wykes for an Inside Stanford Medicine story. “It’s become an essential tool at  the bedside we apply to immediately rule out — or rule in — medical conditions.”

That’s why Gharahbaghian and her colleagues are hosting ULTRAfest, a full day of ultrasound instruction open to all medical students on Oct. 18. Last year, more than 300 students from across the western United States attended.

Ultrasound uses sound waves that are too high pitched for our ears to detect. The waves bounce off material in the body, providing a glimpse inside.

ULTRAfest2What’s so great about ‘Sound (as Gharahbaghian calls it on her Twitter page)? It’s relatively cheap — new scanners start at $90,000 — non-invasive and portable. Ultrasound has also moved beyond mere diagnostics. For example, Stanford radiologist Pejman Ghanouni, MD, PhD, uses ultrasound to treat uterine fibroids.

Although the technology isn’t new, researchers are finding new uses for ultrasound. As detailed in that Inside Stanford Medicine piece:

More recently, the use of ultrasound has crossed into another part of the anatomy long thought to be immune to its imaging prowess: the lungs. In the air-filled environment of the lungs, the sound waves that are the basis of ultrasound have nothing to ping against. However, in lungs where disease has produced fluids, ultrasound has proven more accurate than a chest X-ray and faster than CT scan to diagnose common lung conditions, including pulmonary edema, pneumonia and pleural effusions.

Other doctors and medical students, including U-fest volunteer William White aren’t shy about touting ultrasound’s benefits: “I just fell in love with the technology, picking up a probe and looking into the body in real time.”

Previously: New technology enabling men to make more confident decisions about prostate cancer treatment, Listening to the stethoscope’s vitals, Plane crash creates unexpected learning environment for medical students 
Photos by Teresa Roman-Micek

Emergency Medicine, Health Policy, In the News, Patient Care, Research, Stanford News

Exploring how the Affordable Care Act has affected number of young adults visiting the ER

Exploring how the Affordable Care Act has affected number of young adults visiting the ER

ER sign - 560

One of the earliest – and most popular – parts of the Affordable Care Act allowed young adults to stay on their parents insurance until their 26th birthday. This week, Stanford researchers led by Tina Hernandez-Boussard, PhD, published a paper in the journal Health Affairs that tracked emergency room visits in California, New York and Florida for two age groups: 19 to 25 year olds – the group affected by the new requirement –  and 26 to 31 year olds for comparison. The researchers examined ER visits for the two years prior to the ACA requirement (2009 and 2010) and one year after the requirement went into effect (2011). Their findings showed that in 2011, 19- to 25-year-olds had slightly fewer ER visits – 2.7 per 1,000 people -compared to the older group.

The researchers calculated that the drop in ER use means more than 60,000 fewer visits for 19- to 26-year-olds across the three states  in 2011. They also found that the  largest relative decreases in ER use were among women and blacks.

post on Washington Post‘s Wonkblog covered the study and discussed further findings:

The researchers had another finding that seems just as important. While the total number of ER visits among the under-26 group was down, about the same number of people still went to the ER. The distinction here is that young adults with chronic conditions, who have greater care needs, probably now had better access to non-ER care settings, so their number of visits to the ER decreased. But the finding also suggests that healthy young adults, who might have shunned health insurance before, still continued to see the ER as a place for seeking out routine care, according to the study. Further, insurance likely makes those ER visits cheaper, which could actually increase how much people use the ER, the researchers wrote.

Hernandez-Boussard and her colleagues concluded in their paper, “As EDs face capacity challenges, it is important to consider how to meet the broad underlying needs of young adults through other channels and ensure the needed availability of these alternative health services.”

Previously: Abraham Verghese on health-law battle: “We’ve worried so much about the process, not the patient”
Photo by Eric Staszczak/KOMU

Addiction, Emergency Medicine, Public Health, Research, Technology

Text messages after ER visit could reduce young adults' binge drinking by more than 50 percent

Text messages after ER visit could reduce young adults' binge drinking by more than 50 percent

Bar_texting_0701414Researchers have demonstrated that text message programs can, among other things, help diabetes patients better manage their condition, assist smokers in kicking their nicotine habit, and encourage expecting mothers to get flu shots.

Now new findings published in the Annals of Emergency Medicine show that text messages can also be an effective tool for reducing binge drinking among young adults whose hazardous alcohol use has resulted in an emergency room visit. During a 12-week study, 765 patients who were treated in the emergency room and screened positive for a history of hazardous drinking were divided into three groups. The first group received text messages prompting them to respond to drinking-related queries and received text messages in return offering feedback aimed at either strengthening their low-risk drinking plan or promoting reflection on their drinking plan or decision not to set a low-risk goal. Another group received only text queries about their drinking, and the remaining individuals received no text messages.

A story published today on PsychCentral reports on the researchers’ results:

The group receiving both text message queries and feedback decreased their self-reported binge drinking days by 51 percent and decreased the number of self-reported drinks per day by 31 percent.

The groups that received only text messages or no text messages increased the number of binge drinking days.

“Illicit drugs and opiates grab all the headlines, but alcohol remains the fourth leading cause of preventable death in the U.S.,” said [Brian Suffoletto, MD, assistant professor in the Department of Emergency Medicine at the University of Pittsburgh School of Medicine].

“If we can intervene in a meaningful way in the health and habits of people when they are young, we could make a real dent in that tragic statistic. Alcohol may bring them to the ER, but we can do our part to keep them from becoming repeat visitors,” [he added].

Previously: CDC explores potential of using smartphones to collect public health data, Could better alcohol screening during doctor visits reduce underage drinking?, Personality-based approach can reduce teen drinking and The costs of college binge drinking
Photo by Anders Adermark

Cancer, Emergency Medicine, Research, Science, Stanford News

Small molecule may protect against radiation exposure, say Stanford scientists

Small molecule may protect against radiation exposure, say Stanford scientists

P1060359No one wants to imagine a nuclear accident. But, as Fukushima and Chernobyl showed, they do happen. Unfortunately there’s no truly effective way to protect people who have been exposed to large amounts of radiation (more than 10 gray, for those of you wondering; for you overachievers out there, 1 gray is the absorption of 1 joule of radiation energy per kilogram of matter).

Many of these people will die from what’s known as radiation-induced gastrointestinal syndrome when the rapidly dividing cells in their intestinal lining begin to die. As a result, the intestine loses its ability to regulate fluid loss and prevent the entry of pathogens into the body, causing severe diarrhea, electrolyte imbalance and sepsis.

Stanford radiation oncologist Amato Giaccia, PhD, and his colleagues wondered whether a cellular pathway that controls how cells respond to stress could be involved in the intestine’s response to radiation. Their study was featured today on the cover of Science Translational Medicine. As I explain in our release:

The researchers were studying a molecular pathway involved in the response of cells to conditions of low oxygen called hypoxia. Hypoxic cells produce proteins known as hypoxia-inducible factors, which help the cells survive the stressful conditions. (The HIF proteins – HIF1 and HIF2 – are normally degraded quickly when oxygen levels are normal.)

Hypoxia often occurs in fast-growing solid tumors as cells find themselves far from oxygen-delivering blood vessels, but it can also occur during times of inflammation, or in tissues like the intestine that experience natural gradations in oxygen levels. HIF proteins help the intestine absorb needed nutrients while blocking the entry of pathogens and maintaining healthy fluid exchange.

Giaacia and lead study author Cullen Taniguchi, MD, PhD, a postdoctoral scholar, wondered if increasing the levels of HIF proteins in intestinal epithelial cells could help the them survive damaging amounts of radiation. To test their theory, they used a small molecule called DMOG to block the naturally occurring degradation of HIF proteins in laboratory mice exposed to radiation. They found that administering DMOG to the mice significantly increased their survival – even when the molecule was given 24 hours after initial exposure.

The study suggests it may one day be possible to prevent or reduce the incidence of  radiation-induced gastrointestinal syndrome in humans.  It also provides an intriguing hint that it may be possible to mitigate some of the gastrointestinal side effects experienced by patients undergoing radiation therapy for cancer.

Continue Reading »

Emergency Medicine, Stanford News, Videos

Stanford Life Flight celebrates 30 years

Stanford Life Flight celebrates 30 years

In May 1984, Stanford Life Flight’s first helicopter transport lifted a 70-year-old woman, critically injured in a car accident, over the Santa Cruz Mountains to Stanford Hospital. With that flight, Stanford became the first medical center in the Bay Area to have its own helicopter and air medical transport team. In its 30 year history, the air ambulance medical service has transported more than 15,000 patients going as far as 250 miles to California’s Northern and Central coasts, Central Valley and to Reno, Nev.

Priding themselves on their flight nurses’ extensive training and experience in caring for critically ill or injured patients, and on their accident-free flight track record, the men and women of Life Flight are an example of how combining compassionate care with advanced care capabilities saves lives. We celebrate their work in the hospital video above.

Previously: Teen benefited by Stanford surgeon’s passion for trauma care

Emergency Medicine, Health Costs, Health Disparities, Pediatrics, Research, Stanford News

ER visits for U.S. newborns show racial disparities

ER visits for U.S. newborns show racial disparities

Haiti Earthquake“Baby’s first trip to the ER” is probably one photo that no one ever wants to put in a baby book. But a surprising number of newborns – 320,000 each year – visit an emergency department within their first month of life. For reasons that are likely a complex mix of socioeconomic and biological factors, black newborns across the U.S. are more than twice as likely to make the trip.

Henry Lee, MD, an assistant professor of pediatrics at Stanford, broke down the stats of how often newborns end up in the emergency department and looked at race, age and insurance status. In collaboration with researchers at the University of California-San Francisco, Lee analyzed data from nationwide emergency room visits collected by the National Center for Health Statistics. The study appears in the May issue of the journal Pediatric Emergency Care.

The researchers found that 14.4 percent of black babies visited the emergency department, compared to 7.7 percent of Hispanic babies and 6.7 percent of white newborns. Some trips to the ER are unavoidable, such as when a baby has an infection or isn’t gaining weight. But it’s likely that some of these visits could have been prevented.

All babies must get a checkup within several days of being born. But if the delivering doctor failed to counsel the new parents about checkups – or if the doctor missed a common problem, such as jaundice – then the new family might end up in the ER instead of at a clinic. In addition to representing a lack of continuity of care for the newborns, these visits drive up health-care costs.

Additional studies may tease apart the factors that cause black newborns to end up in the emergency room more often than other groups, and to find ways to reduce spending on health care while providing better services.

“Improving the quality of care for this higher-risk group could also help to improve disparities and outcomes as well,” Lee said.

Patricia Waldron is a science writing intern in the medical school’s Office of Communication & Public Affairs.

Previously: Decreasing demand on emergency department resources with “ankle hotline” and Speed it up: Two programs help reduce length of stay for emergency-room visitors
Photo by Olav Saltbones / Norwegian Red Cross

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