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History, Research, Surgery

Ancient surgical technique still used to rebuild noses today

Ancient surgical technique still used to rebuild noses today

When facial surgeon Sam Most, MD, first contacted me about doing a story on one of his favorite procedures called the “forehead flap,” which he uses for major nose reconstructions, he sent along photos of what a patient looks like prior to surgery.

The photos make it clear real fast how unfortunate it is to lose your nose. The nose is the focal point of the face. It’s what people notice first. The numbers of people losing their noses due to skin cancer is on the rise, and many, are left wearing uncomfortable, unflattering prostheses for years.

Enter surgeons like Most, part artist, part scientist — a sculptor of noses. According to Most, it’s the most difficult facial plastic surgery procedure. And key among the many necessary tools needed to succeed is the “forehead flap” — a procedure that originated with cobblers in ancient India. My article tells the story of this fascinating surgery, which was first introduced into Western medicine in 1794:

Most is quick to recount the historical significance of the forehead flap, Most is quick to recount the historical significance of the forehead flap technique, which originated in India probably before the birth of Christ but wasn’t widely known to Western medicine until 1794 with the publication of a letter to the editor in Gentlemen’s Magazine of London. The letter provided the first account in English literature of the procedure.

At the time, India was a colony of the British. A sultan, angry at the occupation, offered bounties for the amputated ears, noses and hands of British sympathizers. The letter describes the nasal reconstruction of an Indian bullock driver who, having been imprisoned by the sultan, had his nose and one of his hands cut off for delivering supplies to British troops. It goes into detail how the driver’s nose was rebuilt 12 months later, after he joined the Bombay Army of the East India Company.

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History, Research, Science, Stanford News, Stem Cells

The making of a scientist — Stanford’s Irv Weissman under the Big Sky

The making of a scientist — Stanford's Irv Weissman under the Big Sky

Some people just seem larger than life. That’s certainly the case with stem cell scientist Irving Weissman, MD. His presence fills a room whether he’s speaking to a crowd or conversing one-on-one with a fellow researcher. Some of that presence comes from his academic stature. After all, he’s director of Stanford’s Institute for Stem Cell Biology and Regenerative Medicine and the Ludwig Center for Cancer Stem Cell Research and Medicine. But it’s immediately apparent that Weissman also has a natural ease and composure that’s hard to beat.

Recently, I had the opportunity to shadow Weissman during one of his regular visits to my home state of Montana. Like me, Weissman grew up in Montana and even cut his scientific teeth here at the McLaughlin Research Institute for Biomedical Sciences in Great Falls. My profile of his career is published today in our medical school newspaper, Inside Stanford Medicine.

From the article:

In school, Weissman was a good, but not exceptional, student. He struggled with memorization, and didn’t particularly enjoy reading. His mother was a classically trained pianist, and Weissman played the piccolo and flute.

When he was about 15 years old, a friend of his mentioned a man named Ernst Eichwald, MD, who had been recruited in 1953 from the University of Utah to work as a pathologist at Montana Deaconess Hospital in Great Falls. Eichwald had made the move on the condition that he be allowed to spend part of his time as a one-man research program, studying the biology of skin transplantation in laboratory mice.

“Instead of working at the scrapyard for my father’s hardware store, I went to see Ernst, because my friend said it was fun to be around mice and rats,” Weissman said. “But the difficulty was that he was very hard of hearing, and he spoke in a thick German accent. So I couldn’t understand anything that he was saying, and I was pretty sure he couldn’t understand what I was saying. Finally, in a moment of desperation, I said, ‘I’ll work for nothing!’ Suddenly he understood and could talk to me. So I started to work with him in the summer as mouse caretaker, autopsy assistant and lab researcher.”

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Health Disparities, History, In the News, LGBT, Medicine and Society

Film honors transgender pioneers

Film honors transgender pioneers

pride-828056_1920I knew little about the film “The Danish Girl” last weekend when, diverted from a sold-out showing of the Oscar favorite the “Revenant,” my husband and I disappointedly walked down Pacific Avenue in Santa Cruz to another theater to see the film about a transgender woman instead.

It proved to be a fortuitous diversion. “The Danish Girl” is artistically gorgeous and well acted, as today’s Academy Award nominations point out. The film received nominations for Eddie Redmayne as best actor in his role as a transgender artist, best supporting actress for Alicia Vikander, his wife who stands by him as he confesses that he believes he was born in the wrong gender and begins to dress as a woman they call Lili — and nods for costume design and production design as well.

But the film struck a more personal chord, halfway through its viewing, when I sucked in a short gasp realizing that, in addition to being a love story with a socially relevant message, the film was recounting a piece of medical history. And suddenly, the film took on a frightening edge.

I knew from my research for a story I wrote for Stanford Medicine magazine in 2012 titled “Transition point: The unmet needs of transgender people,” something of the challenges facing transgender people today as they navigate the medical world trying to get the care they need. The story describes the paucity of evidence-based medicine for transgender health care and the lack of training for physicians on how to provide care. As I wrote in the story:

The problem is that in the United States, most physicians don’t exactly know what treatment for the transgender patient entails. For an untrained professional, it’s a challenge to provide care to a patient with a penis who wants a vagina, or to a patient who has been tortured emotionally by being told she’s a boy when she knows she’s a girl. General practitioners — the majority of doctors who treat patients in the United States — are equally unprepared to care for those transgender patients after they have begun to take hormones and have undergone genital-reconstruction surgery. The lack of medical education on the topic, a near-total absence of research on transgender health issues and the resulting paucity of evidence-based treatment guidelines leave many at a loss.

The film, as I suddenly realized sitting in the darkened theater, must have been inspired by those transgender pioneers in 1920s Europe who chose to undergo the first experimental sex reassignment surgeries. Of course, as with any surgery, there had to be those first patients. I’d just never thought about it before.

In fact, I later learned, the film was inspired by the real life Lili Elbe, a Danish transgender woman born in 1882, who was one of those first patients. The film honors the memory of these brave transgender pioneers, and, perhaps, will prod others to consider the continued inadequacies of medical care today, and what can be done to improve them.

Previously: Stanford study shows many LGBT med students stay in the closet, Study shows funding for LGBT health research lacking, offers solutions and Gay, lesbian, bisexual and transgendered health issues not being taught in medical school
Photo by nancydowd

History, Medical Schools, Stanford News

The “terribly exciting” days of Stanford’s young Department of Medicine

The "terribly exciting" days of Stanford's young Department of Medicine

Stan Schrier

In the summer of 1959, not long after Stan Schrier, MD, joined Stanford’s Department of Medicine as an assistant professor, he attended his first meeting with just 12 other faculty members.

Where many would see a sparsely filled room, Schrier saw possibility. “It was pretty clear that we had a very small department and the place was going to build,” he recalled in a recently published article.

Those early days were “terribly exciting,” reminisced Schrier. “As young assistant professors with not many of the older faculty around we had enormous leverage. We proposed programs that, in fact, took place, and that have led to what we see now — an enormously powerful department with strengths in basic science and translational medicine.”

He has collected many stories like this over the span of his 56-year career. “We’re an extraordinarily different place today. Instead of 12 or 15, there are 400 in the Department of Medicine. We have people at ValleyCare Medical Center, and we have people at the Palo Alto VA, to say nothing of the enormous expansion of Stanford Hospital.”

Schrier, who is now 86, continues to see patients in the hematology clinic and still has plenty of teaching opportunities.

As if that’s not enough for a man who was alive during the Depression, he also studies the impact of anemia on older patients with congestive heart failure.

“The best time of my life is now,” he said. “And though I’m supposed to be retired, I’m actually an ‘active emeritus.’”

Previously: Exploring the history and study of sleep with William Dement, The history of U.S. health care in about 1,000 words and A trip down memory lane: Stories from the early days of the School of Medicine
Photo by Norbert von der Groeben

History, Patient Care, Stanford News, Transplants

A look back at one of Stanford’s first kidney donors

A look back at one of Stanford's first kidney donors

Inga GoodnightMuch of medical science writing involves reporting on the next potentially lifesaving treatment. But sometimes it’s rewarding to look back. The recent death of one of Stanford’s first kidney donors had me doing just that – and exploring a time when this now-common procedure was cutting edge.

Inga Goodnight, who died at the age of 99 in April, donated her kidney to her son Gary, who went on to live another 37 years.

As I wrote in a just-published article on their story:

Today, kidney transplants are established procedures; more than 17,000 were performed in the United States last year. Improvements in surgery and immunosuppressive drugs have increased the number of potential kidney matches. Studies have shown that donors have no increased health risks compared with the general public.

But in 1965, when Gary became the third patient to receive a kidney transplant at Stanford, many things were unknown. Doctors were still determining proper dosages for the immunosuppressive drugs, and they didn’t know if Gary’s body would reject the kidney or if he would even survive the first year.

While it was known that a person could live with one kidney, no one knew if there would be long-term health impacts for Inga. And unlike modern laparoscopic surgery, with its tiny incisions and short hospital stays, the surgery to remove the Inga’s kidney involved a large incision that cut through abdominal muscles and required a long recovery.

While these advancements in medicine were interesting, I found my conversation with Bill Goodnight (Inga’s son and Gary’s brother) about his memories from this time equally informative. In many ways their attitudes towards Gary’s condition and treatment seemed quite modern.

Gary Goodnight was aware that his kidneys weren’t going to last and actively followed the news about the emerging field of transplants. Both Bill and his mother had themselves tested to see which might make a good match. And, similar to today’s patients and families with life threatening conditions, the Goodnight family approached the procedure with hope.

Kim Smuga-Otto is a student in UC Santa Cruz’s science communication program and a writing intern in the medical school’s Office of Communication and Public Affairs.

Previously: Double kidney transplants leave Hawaii siblings raring to goKidney-transplant recipients party without drugs – immune suppressing anti-rejection drugs, that is and Well blog: Minnesota man denied insurance for donating kidney
Photo courtesy of Bill Goodnight

Events, Global Health, History, Pediatrics, Surgery, Transplants

From Costa Rica to Stanford: Pediatric liver transplant surgeon shares his story

From Costa Rica to Stanford: Pediatric liver transplant surgeon shares his story

Esquivel - croppedThese days, Carlos Esquivel, MD, PhD, is best known as one of the top pediatric liver transplant surgeons. But just a few decades ago, he worked as a generalist physician in an ill-equipped Costa Rican village located across from a river teeming with man-sized crocodiles.

Esquivel told a gripping tale of his journey from his native Costa Rica to Stanford during a recent Café Scientifque presentation. He described how he spent only a year in remote San Vito before traveling to the United States and joining the lab of innovative surgeon F.W. Blaisdell, MD, who took Esquivel under his wing and treated him like a son. On to Sweden, where Esquivel earned his post-doctorate degree, before mastering his transplantation skills with Thomas Starzl, MD, PhD, who is known as the “father of trasnplantation” and conducted the first human liver transplant in 1963.

Back then, transplant surgeons wore knee-high fishing waders to perform transplantations — they were that messy, Esquivel said. And few dared to do liver transplants in children. Fast-forward to today: Transplant surgeries are shorter, much less bloody, and much more survivable thanks to the improvements in technology and immunosuppressant drugs. Last year, the team at Lucile Packard Children’s Hospital Stanford tallied a 100 percent one-year survival rate, Esquivel told the audience.

Now, the primary problem is the shortage of organs. More than 120,000 people in the United States are waiting for a new organ. Kidneys are most in-demand, but thousands of people are also waiting for new livers. And like kidneys, livers can be taken from living donors, Esquivel said. Sometimes, an adult liver can even be split in two, saving the lives of another adult and a child.

Livers can regenerate, making it an ideal organ to donate. However, the donation surgery can cause complications and donation is a choice that potential donors — and their doctors — should consider carefully, Esquivel said.

Esquivel said surgeries are physically taxing, but also take a great deal of mental preparation. Before surgeries, he said he runs through all the scenarios, trying to prepare for every possibility.

To raise awareness about organ donation, Esquivel, an avid cyclist, completed an across-the-county bicycle race with a former transplant patient. And he has high hopes for the future. Once, transplanted livers only lasted 12 to 15 years, but today, some livers last as long as 30 years, Esquivel said.

Previously: How mentorship shaped a Stanford surgeon’s 30 years of liver transplants, Raising awareness about rare diseases and Record number of organ transplants saves five lives in a day
Photo courtesy of Lucile Packard Foundation for Children’s Health/ Toni Gauthier

Ethics, Genetics, History, In the News, Medicine and Society, Microbiology, Stanford News

Stanford faculty lend voices to call for “genome editing” guidelines

Stanford faculty lend voices to call for "genome editing" guidelines

baby feetStanford law professor Hank Greely, JD, and biochemist Paul Berg, PhD, are two of 20 scientists who have signed a letter in today’s issue of Science Express discussing the need to develop guidelines to regulate genome editing tools like the recently discovered Crispr/Cas9. Researchers are particularly concerned that the technology could be used to alter human embryos. From the commentary:

The simplicity of the CRISPR-Cas9 system enables any researcher with knowledge of molecular biology to modify genomes, making feasible many experiments that were previously difficult or impossible to conduct. […]

We recommend taking immediate steps toward ensuring that the application of genome engineering technology is performed safely and ethically.

We’ve written a bit here before about the Crispr system, which essentially lets researchers swap one section of DNA for another with high specificity. The potential uses, for both research or therapy, are touted as nearly endless. But, as Greely pointed out in an email to me: “Making babies using genomic engineering right now would be reckless – it would be unknowably risky to the lives of those babies, none of whom consented to the procedure. For me, those safety issues are paramount in human germ line modification, but there are also other issues that have sparked social concern. It would be prudent for science to slow down while society as a whole discusses all the issues – safety and beyond.”

The list of others who signed the commentary reads like a veritable who’s who of biology and bioethics. It includes Caltech’s David Baltimore, PhD; U.C. Berkeley’s Michael Botchan, PhD; Harvard’s George Church, PhD; and George Q. Daley, MD, PhD; University of Wisconsin bioethicist R. Alta Charo, JD; and Crispr/Cas9 developer Jennifer Doudna, PhD. (Another group of scientists published a similar letter in Nature last Friday.)

The call to action echos one in the 1970s in response to the discovery of the DNA snipping ability of restriction endonucleases, which launched the era of DNA cloning. Berg, who shared the 1980 Nobel Prize in Chemistry for this discovery, organized a historic meeting at Asilomar in 1975 known as the International Congress on Recombinant DNA Molecules to discuss concerns and establish guidelines for the use of the powerful enzymes.

Berg was prescient in an article in Nature in 2008 discussing the Asilomar meeting:

That said, there is a lesson in Asilomar for all of science: the best way to respond to concerns created by emerging knowledge or early-stage technologies is for scientists from publicly-funded institutions to find common cause with the wider public about the best way to regulate — as early as possible. Once scientists from corporations begin to dominate the research enterprise, it will simply be too late.

Previously: Policing the editor: Stanford scientists devise way to monitor CRISPR effectiveness and The challenge – and opportunity – of regulating new ideas in science and technology
Photo by gabi manashe

Applied Biotechnology, Biomed Bites, Genetics, History, Research, Videos

Basic research underlies effort to thwart “greatest threat to face humanity”

Basic research underlies effort to thwart "greatest threat to face humanity"

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

Stanley Cohen, MD, isn’t a household name. But it probably should be. The Stanford geneticist was instrumental in the discovery of DNA cloning – the technology that underlies innumerable advances in biotechnology and medicine, and led to the founding of biotech giant Genentech.

It wasn’t always thought possible to snip out a gene, stitch it into a new stretch of DNA – often in a different organism – and have it produce a desired protein.

In the video above, Cohen emphasizes that striving to achieve a concrete – and profitable – goal didn’t enable the discovery of gene cloning. First, researchers had to work to understand the basic biological processes. “In order to apply knowledge, it’s necessary to get that knowledge somehow.”

These days, Cohen isn’t resting on his laurels. Instead, he’s striving to thwart what he considers perhaps the “greatest threat to humanity,” drug-resistent microbes.

“My lab is still interested in understanding microbial drug resistance and the way in which microbes exploit host genes to carry out microbial functions such as entering cells, reproducing in cells and exiting from cells,” he said. Scientists need that basic knowledge to develop strategies to thwart the process, he added.

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

Previously: The history of biotech in seven bite-sized chunks, The dawn of DNA cloning: Reflections on the 40th anniversary and Why basic research is the venture capital of the biomedical world

Aging, History, Medicine and Literature, Medicine and Society, Stanford News

Stanford humanities scholar examines "the youngest society on Earth"

Stanford humanities scholar examines "the youngest society on Earth"

Young and old faces Over the past decades, our society has undergone a process of “juvenescence” that, according to Stanford professor Robert Harrison, PhD, makes it the “youngest on Earth.” For the first time in human history, he says, “the young have become a model of emulation for the older population, rather than the other way around” (as quoted in Stanford Report). The post-war period “has unleashed extraordinary youthful energies in our species and represents one of the momentous revolutions in human cultural history.”

Harrison is a professor of Italian literature whose new book Juvenescence: A Cultural History of Our Age examines the cultural forces that have brought about this development. The term “juvenescence” draws on the biological concept of neoteny, or the retention of juvenile characteristics through adulthood. Harrison’s research spans literature, philosophy, and evolutionary science.

His basic argument is that “juvenescence” can refer to either a positive or a negative change, and it isn’t clear which more accurately describes our current situation. The positive sense is one of cultural rejuvenation, while the negative one denotes juvenilization. Harrison explains, citing examples from his book:

Rejuvenation is about recognizing heritage and legacy, and incorporating and re-appropriating historical perspective in the present – like the Founding Fathers did when they created a new nation by drawing on ancient models of republicanism and creatively retrieving many legacies of the past… Unlike rejuvenation, juvenilization is characterized by the loss of cultural memory and a shallowing of our historical age.

…I feel ambivalent about where we are culturally in this age of ours.  It is hard to say whether we are on the cusp of a wholesale rejuvenation of human culture or whether we are tumbling into a dangerous and irresponsible juvenility.

Several aspects of our society suggest juvenilization. Most citizens of the developed world today enjoy the luxury of remaining childishly innocent about what they operate, consume, and depend on in daily life, while “in terms of dress codes, mentality, lifestyles and marketing, the world that we live in is astonishingly youthful and in many respects infantile.” Our culture’s emphasis on innovation and change honors the youthful drive that brings renewal and progress, but, without firm roots in the stability and wisdom of older generations and longstanding institutions, this risks being a meaningless chase after novelty. Youth’s genius is a luxury that requires solid foundations.

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History, Neuroscience, Research, Science, Stanford News

Illustration from 1881 resolves century-old brain controversy

Illustration from 1881 resolves century-old brain controversy

Figure2_WernickeThese days, a person can get through graduate school in the sciences practically without touching a physical publication. Most journals are available online going back decades. So it was a bit unusual when graduate student Jason Yeatman and postdoctoral scholar Kevin Weiner found themselves in the basement of Lane Medical Library trying to get to the bottom of a medical mystery.

It all started when Yeatman found a nerve pathway in brain images he’d taken as part of his work studying brain changes as kids learn to read.  This pathway didn’t appear anywhere in the available literature. He and Weiner became curious how this pathway – which clearly showed up in their work – could have escaped the notice of previous neuroscientists.

Their curiosity eventually led them back to an 1881 publication, still available in the basement of Lane Medical Library, where Carl Wernicke, MD, described identifying this brain pathway. Weier said, “That was a really cool experience that most people don’t have anymore, when you have to check your belongings at the door because the book you are about to look at is worth thousands of dollars per page. You are literally smelling 100 year-old ink as you find the images you have been searching for.”

Wernicke’s discovery contradicted theories by the eminent neuroanatomist at the time, Theodor Meynert, MD. I describe the controversy that led to this pathway expulsion from the literature in this Stanford News story:

Meynert strongly believed that all of the brain’s association pathways run from front to back – horizontal. This pathway, which Wernicke had called the vertical occipital fasciculus, or VOF, ran vertically. Although Yeatman and Weiner found references to the VOF under a variety of different names in texts published for about 30 years after Wernicke’s original discovery, Meynert never accepted the VOF and references to it became contentious before eventually disappearing entirely from the literature.

The group, whose work was published this week in the Proceedings of the National Academy of Sciences, says this was all more than just an exercise in curiosity. Psychologist Brian Wandell, PhD, in whose lab Yeatman was working, says it also shows the value of modern publishing methods, where making data available means scientists worldwide can try to reproduce results. He says it’s now less likely that a dispute could lead to a discovery being lost to history.

Image courtesy of PNAS

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