In the News

News coverage of the first-of-its-kind World Health Organization (WHO) report on preterm birth has been headlined by the staggering number of preterm births (15 million a year, worldwide) and by dismal U.S. statistics that show a far higher preterm birth rate here than in any other developed country.

But some of the coverage mentions another shocking fact about babies born a week or more early: In about half of these early deliveries, we can’t pinpoint a clear reason that the baby arrived too soon. And the reasons we’ve already identified for preterm delivery probably don’t tell the whole story. For instance, the New York Times reports that

Dr. Gordon C. S. Smith, an expert in [preterm birth] at the University of Cambridge, noted that his native Scotland had many of the same risk factors as the United States — teenage pregnancies, poverty, obesity and older mothers — and yet had much lower rates.

“If somebody had a simple explanation of why the U.K. and Europe do much better, I wouldn’t believe them,” Dr. Smith said. “The reality is, for most preterm births, we just don’t understand the cause.”

But researchers at Stanford are working to change that. Last year, a generous funding commitment from the March of Dimes facilitated the opening of the March of Dimes Prematurity Research Center at Stanford University School of Medicine, which is taking a new approach to studying the causes of preterm birth. The “transdisciplinary” research center pulls scientists from across many disciplines together for collaboration at every stage of research, from developing hypotheses to analyzing the results.

Today I asked Gary Shaw, DrPH, co-investigator of the center and a professor of pediatrics at Stanford, for his take on the WHO report.

“The report highlights that this is a bigger problem than we had previously thought,” Shaw said. “We don’t know the causes of preterm birth, but we know we need a new approach toward finding answers.”

Factors as diverse as an expectant mother’s age, blood pressure, socioeconomic status, perceived stress level and the presence of infections are already known to influence preterm birth. So it makes sense to bring together experts a diversity of fields, many of whom may not have ever thought about preterm birth, to find out how such factors could interact to ultimately determine whether or not a baby arrives early, he said.

“This is a different way to approach team science… a different way to tackle a complex problem,” Shaw told me. “And Stanford and the March of Dimes are the first to take on this new approach.”

Previously: Hormone could prevent 10,000 preterm births per year, New research center aims to understand premature birth, Device designed to better detect preterm labor and Moms who were born prematurely more likely to have premature babies themselves
Photo by The Hudson Family

As we’ve previously written on Scope, researchers are developing new ways to use Twitter messages, Facebook interactions and Google queries to anticipate surges in influenza cases, gain insights into the spread of viruses and track other public health trends. Now researchers are turning to data on sales of over-the-counter medicines in an effort to quickly identify disease outbreaks.

The Atlantic reports:

Data from the [National Retail Data Monitor] show that sales of over-the-counter products like cough medicines and electrolytes actually spike before visits to the emergency room do. The lead time can be significant — in the case of respiratory and gastrointestinal illnesses, it was about two and a half weeks, according to one paper. Another study examined pediatric patients at a Pittsburgh hospital and found that over 40 percent of parents had bought over-the-counter meds an average 1.88 days before bringing their children into the ER.

Being able to identify a possible disease outbreak probably won’t do much to keep the pathogens from spreading, but it could help prepare first-responders and other health professionals. In 2010, it took weeks for official sources to report details of a cholera epidemic in Haiti that killed 7,000 and infected half a million others. But on Twitter, news of the disease traveled far more quickly, according to a study published in the American Journal of Tropical Medicine and Hygiene.

Previously: Study shows Google Flu Trends data, patient spikes at emergency departments closely correlated, Facebook app models how viruses spread through human interaction, Mining Twitter data to track public health trends and Following Google Flu Trends, researchers use queries to track MRSA
Photo by levanah

Watching Angelina and Angelica Sabuco run, play and chase each other like any other pair of two-year-olds, it’s hard to believe the twin sisters  were born conjoined at the chest and abdomen.

The girls, who were separated in a 10-hour surgery Nov. 1 at Lucile Packard Children’s Hospital, have bounced back quickly from the surgery that required cutting apart their livers and completely reconstructing their chest walls. They returned to the hospital today to meet the local media for an update on their progress.

From a Packard Children’s press release about the girls’ continued recovery:

“They have really bounced back,” said lead surgeon Gary Hartman, MD, of his sixth conjoined twins surgery. “Each time I see them in the clinic, they are more mobile and better adjusted. It’s been a very smooth recovery.”

“They love to run around, go out, and play with other children now,” said mother Ginady Sabuco. “We are so grateful to Packard Children’s.” …

As part of their recovery, the girls had physical and occupational therapy to build their strength, endurance, gross- and fine-motor skills. They also continue to see Hartman and plastic surgeon Peter Lorenz, MD, to monitor the healing of their abdomens and chests.

“They are healing right on track,” said Lorenz, who implanted a custom-made resorbable plate in each girl’s chest where the sternum should be. The plates are expected to dissolve later this year as the grafted bones fuse. “We expect their chests to become more normally shaped as they grow, and have already seen a good improvement,” added Lorenz.

Previously: Formerly conjoined twins get ready to head home

A New Scientist story published today highlights work by Swedish researchers to identify the basic molecular structure of the skin layer that forms our body’s watertight barrier. The findings may help further efforts to develop new technology to deliver drugs directly through the skin.

In the (small) study, researchers shaved a layer of skin from volunteers’ arms, cooled the tissue to below -140 Celsius in a high-pressure freezer and then sliced the skin samples into layers 25-50 nanometers thick. The tissue was then examined using an electron microscope. Helen Thomson writes:

What the researchers saw surprised them. Lipids have a hydrophilic (water-attracting) head and two hydrophobic (water-repelling) tails. Normally, the two tails point in the same direction, giving the molecule a hairpin-like appearance.

A group of lipid molecules typically arrange themselves into a two-layered sheet – or bilayer – with all of the tails pointing inwards. However, the lipid molecules in between the cells of the stratum corneum are splayed outwards so that the two tails of each molecule point in opposite directions.

…

This uniquely structured fatty layer prevents any water from getting past in either direction – except where the skin layer is modified to form pores. “There’s no water present within this extracellular space,” says [study author Lars Norlen, MD, PhD.] “It cannot perturb the barrier so it’s completely robust to hydration, which is necessary for the changing environment that we live in.”

The research team now plans to use the findings to create a computer model to use in developing a method for screen drugs that could potentially be administered through the skin.

Photo by Monik Markus

We have the tools to prevent and cure malaria (distribution of mosquito nets, antimalarial treatment and insecticides has knocked malaria deaths down by more than a quarter worldwide since 2000), but the bite of infected mosquitoes still sickens millions. In 2010 the disease killed 655,000 people, mostly African children, according to the World Health Organization.

Today is World Malaria Day 2012, a day of awareness led by Roll Back Malaria, a global partnership launched by WHO, UNICEF, the United Nations Development Program and the World Bank to mobilize a coordinated response to malaria. WHO has announced a new initiative to scale up testing, treatment and surveillance, and news organizations and blogs have been weighing in all day on the world’s progress in malaria control.

In a PLoS blog entry, Estrella Lasry, MSc, MD, a physician working for Doctors Without Borders/Médecins Sans Frontières, writes that she finds worldwide progress encouraging but sees shortfalls. She describes a recent visit to the Katanga province in the Democratic Republic of Congo:

During my trip I visited three new sites and one longstanding project. All faced enormous gaps in medicines, diagnostics and malaria control activities. In some areas the last bed net distribution was 3 years ago, and no indoor residual spraying had been done in over a year.

Lasry isn’t the only person who sees continued need for improvement. According to a new study in Malaria Journal, there have been 75 documented instances of malaria resurgence worldwide since the 1930s – and the majority of these were associated with a weakening of malaria control programs. As leader author Justin Cohen, PhD, MPH, says on Medical News Today:

Malaria control programs have been shown to be extremely successful in reducing the number of cases of malaria to very low levels, but history demonstrates that gains can be lost rapidly if financial and political support is not sustained. Finding ways to ensure continued funding for malaria control today will be crucial to building on the gains of the past decade.

Thoughtful assessment on progress is also necessary, Lasry concludes, saying we need to acknowledge and deliver better tools and strategies to “regions where efforts are inadequate, and failing – countries like DRC that are afflicted by conflict, instability and/or simply mired at the bottom of the development scale.”

Previously: Taming of the malaria parasite? Study takes us one step closer to vaccine, Human-sized microwaves to treat malaria? and R.I.P. DDT: Now, how to bury malaria?
Photo by eyeweed

We’ve previously written on Scope about the our country’s growing problem with prescription drug abuse, specifically in New York and Florida. Now comes a concerning report showing that more than half of Americans fail to follow doctors’ orders when taking medication or take others’ pills.

In the report, slated to be released later this week, Quest Diagnostics examined nearly 76,000 urine samples submitted from doctors’ offices and Quest’s patient-service centers last year and matched them with patients’ medical records. Participants’ identities were protected and results from drug-rehabilitation clinics were excluded. The Health Blog reports:

The results indicated 63% of people on prescription drugs strayed from their doctor’s orders, Quest says, and many of the drugs found were painkillers, sedatives or amphetamines that weren’t prescribed for the sampled patient. Researchers tested for 26 commonly prescribed and abused medications and for illegal drugs, such as marijuana and cocaine. Samples were taken from 46 states and the District of Columbia.

…

Of the people that didn’t follow their doctors’ orders, two in five weren’t taking any medications even though they had been prescribed, suggesting some people can’t afford them, skip treatments or even divert them to the black market, Quest says. The remaining 60% of misusers were taking medications that weren’t prescribed by their doctors.

Many people also combined drugs without a doctor’s oversight, which is dangerous because of how some medications can interact with each other, Cohen says. Results of misuse were consistent across income levels, gender and the level of health coverage, he adds. One limitation of the study, it notes, is that some patients may have been tested because their doctors suspected misuse. Others were randomly selected.

Previously: New York’s growing oxycodone problem, Prescription drug addiction: How the epidemic is shaking up the policy world, Study shows prescribing higher doses of pain meds may increase risk of overdose and Florida’s prescription-drug problem
Photo by Robbie Sproule

Speaking of the importance of a broad educational experience for future physicians, a recent American Medical News story takes a closer look at the increasing popularity of dual-degree programs among medical students in the United States. Numerous schools, including Stanford, offer multi-degree programs, and the rise in students seeking to earn two advanced degrees at once has led some schools to create new programs.

Carolyne Krupa writes:

Combined enrollment nationwide in MD/PhD, MD/JD and MD/MBA programs alone has increased 36%, from 3,921 in 2002 to 5,349 in 2011, according to the Assn. of American Medical Colleges. Most of them, 5,023, are in MD/PhD programs. The AAMC suspects its MD/JD and MD/MBA tallies are undercounted.

…

The number of dual-degree programs also continues to grow. In some cases, medical schools are branching out to other universities. For example, a partnership started in 2007 between Mayo Medical School and Arizona State University allowed the medical school to offer several new dual-degree options in areas such as business, law, biomedical informatics, biomedical engineering, mass communications, and clinical and translational science.

Previously: New program teaches MDs how to be journalists

I’m a big fan of San Francisco Giant Brian Wilson (I’ve got a “Brian Wilson frozen in carbonite” statue sitting on my desk to prove it), so when I heard last week that the injured pitcher would need Tommy John surgery I was more than a little bummed. I did know that Tommy John is no longer synomous with “career-ending” (Wilson could be back on the mound in 12-15 months), but what I didn’t know – until this morning – is the history behind the procedure and the man for whom it’s named.

A CNN article provides a detailed look at Tommy John (medically known as ulnar collateral ligament reconstruction surgery), and offers a look back to July 1974, after the player John felt a “searing pain” in his elbow while pitching a game:

Dr. Frank Jobe was the Los Angeles Dodgers’ orthopedic surgeon and a good friend of John’s. After several examinations, Jobe gave the pitcher grim news: if he didn’t have surgery, he would never play major league baseball again. For John, the notion was unthinkable. And while he trusted Jobe and considered him a friend, the surgery had never been attempted by a medical professional.

“He told me what he was going to do,” John recalled, “He said, if you’ve pulled it off the bone, then what we’ll do is just reattach it to the bone and it will be no problem. But if it’s not, I’m going to have to take this tendon from your right forearm and graft it into your left elbow.”

John, a college math major, asked his surgeon friend for the odds of a successful outcome. Jobe put the odds at 1%.

“Well, I was valedictorian of my high school class and 1% or 2% in 100 is far better than zero percent in 100,” he said.

The article details what happened with John (I won’t spoil it for you if you don’t know) and also reveals what the former player thinks about having his name attached to “such a high-profile medical procedure:”

“If I’d known you could throw a perfect game with this, I would have tried a little harder,” quipped John, now 68. When he refers to the operation, without hesitation, he calls it Tommy John surgery, saying it’s an honor to have the operation referred to by his name.

Photo by StuSeeger

If you found yourself biting your nails while following the news on recent shortages in cancer-drug supply, you may have been bandaging your fingers after a February announcement that the United States was close to running out of a critical component of chemotherapy treatment for children. Now Stanford’s Michael Link, MD, professor of pediatrics and current president of the American Society for Clinical Oncology, provides some insight on the topic for an Inside Stanford Medicine Q&A.

An excerpt from Link’s interview with science writer Erin Digitale, PhD:

Q: How is the so-called “gray market” involved in drug shortages?

Link: The shortages have created an opportunity for secondary drug distributors to make additional profits. With early knowledge of potential drug shortages, they have hoarded chemotherapy drugs in anticipation and sold them at amounts that are 650 percent to 3,000 percent of the original prices. This activity, referred to as a gray market, is actually a form of price gouging. The gray market has raised additional concerns about the reliability of drugs being sold to practices, because the pedigree of the drugs is uncertain. There is limited to no ability to trace their chain of custody, nor can we be sure they have been handled, stored and transported as required. It is estimated that the gray market accounts for up to 50 percent of drug sales during a drug shortage.

Previously: An in-depth look at the even-deeper problem of drug supply and Childhood leukemia patient on methotrexate shortage

Long before my mom lovingly scolded me for wearing high-heeled shoes while pregnant, she used to routinely plead with me to not carry my (usually heavy) backpack on one shoulder. “You’re going to hurt your back,” she warned. But wearing straps on both shoulders was very uncool (in southern Wisconsin, where I grew up, anyway), and so I dismissed my well-meaning mother with a hand wave and a reminder of my favorite mantra. “Style over comfort, Mom.”

As it turns out (and no big surprise here) my mom was on to something: Lugging around heavy books for months and years on end really can hurt your back. Today on the Well blog, Jane Brody paints the not-so-pretty picture:

Among the risks described by Dr. Pierre D’Hemecourt, a sports medicine specialist at Children’s Hospital Boston, are stress fractures in the back, inflammation of growth cartilage, back and neck strain, and nerve damage in the neck and shoulders.

The federal Consumer Product Safety Commission calculated that carrying a 12-pound backpack to and from school and lifting it 10 times a day for an entire school year puts a cumulative load on youngsters’ bodies of 21,600 pounds — the equivalent of six mid-sized cars.

…

Not surprisingly, one in four students [in a recent study on backpacks and back health] said they had suffered back pain for more than 15 days during the previous year; scoliosis — curvature of the spine — accounted for 70 percent of those with pain. The remaining 30 percent had either low back pain or contractures — continuous, involuntary muscle contractions. Girls faced a greater risk of back pain than boys, and their risk increased with age (and, presumably, years of lugging around their heavy packs).

Brody goes on to provide tips for ways to reduce a backpack’s load and minimize a child’s risks of developing problems, and her last one is to “never… carry the pack on one shoulder.” I have a feeling my mom is smiling, knowingly, as she reads this.

Photo by Elizabeth/Table4Five

A few weeks ago my colleague reported on a new tool that allows women at high risk for breast and ovarian cancer to assess how certain preventive measures might benefit them. Today’s San Francisco Chronicle includes a feature on the online tool and describes how one patient with the BRCA2 mutation turned to it when deciding whether to have her ovaries removed:

By using the tool, [Raychel] Kubby Adler learned her risk of developing ovarian cancer may remain relatively low whether she opts to have the surgery now at age 40 or waits until she’s 45.

“It’s enough to validate that I still want to be thinking about this, but maybe I can take a breather,” Kubby Adler said. She said she would discuss the findings with her doctor.

…

That’s exactly what [co-developer Allison Kurian, MD,] wants patients to do – to use it as a starting point for more discussion.

Video games specially designed to help users identify and address negative thoughts may be useful in treating depression among teens, according to findings recently published in the British Medical Journal.

In the study, researchers in New Zealand assigned 187 teens with mild to moderate depression to either play a video game or participate in conventional therapy sessions with counselors at schools and youth clinics. During the video game, called SPARX, players select an avatar and navigate seven realms of a 3D fantasy world. Each realm is designed to teach teens classic mental behavioral skills for treating depression. For example, on one level users battle their way through a swamp where they’re attacked by black, smoldering balls called GNATS, which stands for Gloomy Negative Automatic Thoughts.

WebMD reports:

Researchers used psychological tests to assess depression before, during, and three months after the study, which was funded by New Zealand’s Ministry of Health.

Both standard therapy and “SPARX” reduced levels of anxiety and depression by about one-third. And the video game helped more kids recover from their depression. About 44% achieved remission in the “SPARX” group compared to 26% in usual care. The research is significant, [lead researcher Sally N. Merry, PhD,] says, because the vast majority of depressed teens never get help.

Stanford researchers are also investigating the use of computer games to treat depression and anxiety in both teens and adults. An article in the latest issue of Stanford Medicine describes ongoing studies by Amit Etkin, MD, PhD, to evaluate games involving a range of activities from solving math equations to clicking on bubbles containing words with positive emotions. Another story discusses a study in the lab of Ian Gotlib, PhD, where a test measuring how quickly teen girls recognize a sad face versus a happy one on a computer screen is helping researchers to better identify adolescents who might have a vulnerability to mood disorders.

Previously: Lucile Packard Children’s Hospital partners with high schools on student mental health programs and Using fMRI to understand and potentially prevent depression in girls
Photo by Kaptain Kobold

Speaking at a Harvard event last night, Anne Wojcicki, co-founder and CEO of personal-genetics company 23andMe, discussed the benefits of crowd-sourced science over the more conventional scientific research model. The Health Blog reports this afternoon:

In her talk… Wojcicki got more personal about why “I don’t want to bet (my health) on the people or system that is currently in place today. I want to learn from the crowd.”

Hoping to help a friend with a family history of pancreatic cancer, Wojcicki asked 23andMe researchers to send out a cancer family history survey to people in the database with gene mutations known to be associated with cancer. She wanted to know if they or anyone in their families had cancer, and to combine the answers with their genetic data. The researchers will then determine if there are any genetic associations that eventually might lead to potential new therapies.

She got over 12,000 responses in 36 hours and the data is still being analyzed. “Being able to do research in a real-time way is the way research needs to be done in the future,’’ she told the crowd.

She continued to say that while not every scientific question can be answered by crowd sourcing, the approach could be particularly useful in studying health prevention or rare diseases. Wojcicki is scheduled to speak at the Medicine X conference at Stanford in September.

More news about Stanford Medicine X is available in the Medicine X category.

A story in today’s Los Angeles Times reports that U.S. hospitalizations for eating disorder treatment dropped sharply – by 23 percent – between 2007-08 and 2008-09. Not only are fewer patients being hospitalized, they’re receiving treatment earlier in their disease, the story says:

A new breed of patient is getting treatment well before the disease drags them into a downward spiral toward starvation, sustained heart damage, weak bones, kidney damage, long hospitalizations and numerous relapses.

Given that eating disorders are relatively common and potentially lethal, this is fantastic news. One of the biggest challenges associated with treating eating disorders is that these diseases become self-reinforcing over time. For instance, biochemical and brain changes associated with anorexia nervosa become more and more entrenched the longer the disorder goes untreated. Patients who receive early treatment have the best shot at recovery.

Part of the reason for the improved outlook is that patients can now receive therapies that have had their effectiveness scientifically evaluated. James Lock, MD, PhD, the director of psychiatric services at the Comprehensive Eating Disorders Program at Lucile Packard Children’s Hospital, has led some particularly important trials of anorexia nervosa treatments. And he has shown the power of an approach that avoids hospitalizing young anorexia patients:

For teens with anorexia, the first-line treatment is something called family-based therapy, in which parents and siblings work with the patient at home to help restore normal eating habits, said Dr. James Lock, an adolescent psychiatrist at Stanford University who specializes in treating eating disorders. Treating patients at home instead of in a hospital setting is less disruptive to their lives and is thought to promote recovery.

The therapy cures about 40% of patients in three to six months, and another 40% to 50% improve but remain ill, studies have found. The remaining 10% stay the same or get worse.

More information about Lock’s research on eating disorders is available in press releases I’ve written about his studies of family therapy for anorexia nervosa and treatments for bulimia nervosa.

Previously: Exploring the connection between food and brain function, How anorexia is striking what many consider to be an unlikely group: boys and young men and What a teenager wishes her parents knew about eating disorders

Elevated stress levels among women with breast cancer and patients’ methods of coping may contribute to memory and attention impairments commonly experienced after undergoing chemotherapy treatment, according to findings recently published in the Journal for Clinical Psychology in Medical Settings.

In the small study (subscription required), a group of breast cancer patients completed neuropsychological testing and psychological questionnaires following surgery for breast cancer and prior to any subsequent treatments. The Huffington Post reports:

Researchers found that 27 percent of [participants] had evidence of verbal fluency deficits, and 14 percent of them had some sort of memory impairment.

How much stress the women reported having was correlated with these impairments, according to the study.

The researchers suggested that women can cope with stress by acknowledging their feelings.

“Teaching patients proactive ways to deal with stress can help them improve their quality of life as well as maintain their cognitive function,” [study co-author Stephanie Reid-Arndt, PhD,] said in a statement.

Previously: Stanford study shows effects of chemotherapy and breast cancer on brain function