Public Health

Stanford engineers have developed a nanoparticle that could lead to a new way to purify water. In a press release, writer Andrew Myers provides details on the work – which involves the use of magnetism to clear the synthetic “nanoscavenger” from the water – and describes researchers’ hope to “create a ‘one-pot solution’ that tackles water afflicted by a diverse mixture of contaminants.” Given that 1.6 million people die each year from diarrheal diseases stemming from lack of access to safe drinking water and basic sanitation, such purification technology could have big public-health implications.

Previously: Waste not, want not, say global sanitation innovators

In this short animation, John Hengeveld, marketing director for high performance computing at Intel, shares his story of undergoing an appendectomy and learning that, as a result of a burst appendix, a rare and cancer-causing material was now circulating in his body. Currently, there are few good treatment options for his condition, but Hengeveld hopes that by harnessing computers to perform scientific research this could change. Watch the video to learn how computers can help researchers accelerate the scientific process by simulating biomedical experiments to develop new methods of fighting disease.

Previously: Obama’s new open-data policy aims to boost access to federal data for entrepreneurs, researchers and Stanford computer scientist shows stem cell researchers the power of big data

Rotavirus, the most common cause of severe diarrhea among infants and young children, causes somewhere approaching a half million deaths annually, 100,000 of them in India and half of those among children less than a year old.

So the positive results announced today for a Phase III clinical trial of a rotavirus vaccine developed and manufactured in India are great news. The new vaccine cut cases of severe rotavirus-induced diarrhea by more than half – 56 percent – during the first year of life, with protection continuing into the second year of life. That compares favorably with the efficacy of the currently licensed rotavirus vaccines in low-income parts of the globe.

An Indian company, Bharat Biotech, sponsored the randomized, double-blind, placebo-controlled study and will soon file for registration of the vaccine in India.

The trial was conducted at three sites in India. About 6,800 infants who were between six and eight weeks old when they were enrolled received either the vaccine or a placebo in three doses spread over about two months, simultaneously with their routine immunizations for polio.

Stanford virologist Harry Greenberg, MD, a professor of medicine and of microbiology and immunology and the medical school’s senior associate dean for research, is a member of the senior scientific advisory group involved in all aspects of the vaccine’s development. Greenberg’s own past research was instrumental in producing the first-ever rotavirus vaccine, licensed in 1998. That vaccine was pulled off the market upon the discovery of a rare but life-threatening side effect called intussusception. But a study published in the New England Journal of Medicine in 2011 showed that intussusception risk is not only vastly outweighed by the benefits of vaccination, but may actually be at least as strongly associated with rotavirus infection itself as with the vaccine.

Two companies’ competing rotavirus vaccines are already licensed. But with one costing about $37 per two-dose course and the other going for about $50 per three-dose course, they’re prohibitively expensive for the vast majority of Indians. Bharat, the Indian biotech, has stated that it will sell this vaccine (its brand name is ROTAVAC) for a dollar a dose. At that price, assuming the product’s approval, it will save many, many thousands of lives every year.

Previously: Trials, and tribulations, of a rotavirus vaccine
Photo by QUOI Media

Ambulance response time can vary widely across cities, depending on traffic patterns and the location of the emergency situation. As a volunteer medic in Jerusalem, Elli Beer witnessed firsthand how a few minutes can make a significant difference in saving a life. His frustration with poor ambulance response times led him to develop an all-volunteer rescue service called United Hatzalah.

In this recently posted TEDMED talk, Beer talks passionately about how a small neighborhood group dedicated to responding to nearby emergencies evolved into United Hatzalah’s network of 2,000 volunteers. Today, volunteers respond to incidents on “ambu-cycles,” motorcycles carrying the same equipment as a conventional ambulance but lacking the ability to transport patients, and have treated more than 200,000 people in the past year. Beer has rolled out the service in Brazil and Panama and plans to expand to India.

Previously: Comparing the cost-effectiveness of helicopter transport and ambulances for trauma victims and On using social media to improve emergency-preparedness efforts

In an unusual collaboration, officials from the health-care and nuclear industries met last July to discuss each field’s similarities and differences between four topic areas, including diagnostic and prognostic technologies and human factors that affect risk and reliability. The Association for the Advancement of Medical Instrumentation recently released a 120-page monograph detailing the lessons learned during the tw0-day workshop.

Today’s issue of Inside Stanford Medicine includes a Q&A with David Gaba, MD, professor of anesthesia and the associate dean for immersive and simulation-based learning at the School of Medicine, discussing his participation in last year’s meeting and what health-care providers can learn from the nuclear industry.  He says:

One big one is the need for standard operating procedures, where possible, which also retain flexibility as needed. A major spinoff of this principle, used extensively in nuclear power, is to provide graphically enhanced written protocols for emergency situations. It is long recognized that nuclear power operators cannot remember everything they need to know in managing an adverse event in a nuclear plant — memory is too fallible. Thus, the use of written procedures is a mainstay in this setting. Health care has long depended largely on the individual skill and memory of physicians and nurses. Protocols and checklists or emergency manuals were decried as cheat sheets or cribs. We now know that the best people use these kinds of supports — not because they are stupid but because that is the best way to get the best results in tough situations. My lab and other colleagues at Stanford have been working for some time on written cognitive aids and emergency manuals for anesthesia professionals. These have now been disseminated to all the anesthetizing locations in Stanford’s hospitals and those of its close affiliates. This lesson has clearly come from the nuclear industry and from others such as aviation.

Another lesson from the nuclear industry is the importance of the safety culture in an organization. When the organization favors throughput so heavily that people cut corners on safety, or when personnel are afraid to speak up when they see something unsafe, the risk climbs.

Something near and dear to my heart is the utility of simulation for training of skilled professionals. My lab’s development of simulators and simulation-based curricula in health care was triggered by knowing a little bit about how they are used in aviation and other industries like nuclear power. But I actually had no idea, until this workshop, just how much simulation is required for nuclear power operators. They spend six weeks doing their usual shifts in the control room, and the seventh week is spent in training simulations. All year round, no matter how much prior experience they have. Health care is just scratching the surface in simulation compared to that, but at least we have started our way down a similar road.

Previously: Sully Sullenberger talks about patient safety

Past research suggests that poor sleep during adolescence can have “lasting consequences” on the brain. Now a new study offers additional insights into the negative health effects of sleep deprivation on teens’ health.

In the study, researchers analyzed data collected from more than 10,000 adolescents as part of the National Comorbidity Survey Adolescent Supplement.  As MedPage Today reports, their findings show that prolonged fatigue is associated with mood and anxiety disorders among teens:

In a nationally representative sample of adolescents ages 13 to 18, 3% reported having extreme fatigue lasting at least 3 months and about half of those who did also had mood or anxiety disorders, according to Kathleen Merikangas, PhD, of the National Institute of Mental Health in Bethesda, Md., and colleagues.

Having both prolonged fatigue and a mood or anxiety disorder was associated with poorer physical and mental health and greater use of healthcare services compared with having only one of the disorders, the researchers reported online in the American Journal of Psychiatry.

“This suggests that the presence of fatigue may be used in clinical practice as an indicator of a more severe depressive or anxiety disorder,” Merikangas and colleagues wrote.

Stanford physician Michelle Primeau, MD, recently explored the topic of how teen sleep habits affect mood in a recent Stanford Center for Sleep Sciences and Medicine blog entry on the Huffington Post. In her post, she explains why teens in particular are at risk of chronic partial sleep deprivation:

Teenagers need to sleep about nine hours, and as they get older, they tend to sleep less. This is not because they need less, but because they are busier with school, jobs, extracurricular activities, and friends. Their biology also will often shift so that they tend to fall asleep later and want to sleep in later, an occurrence that may represent delayed sleep phase syndrome. This may explains why your teenager is so hard to wake up on Saturdays. But this shift to a later bedtime, both of social and biologic causes, in combination with fixed early school times, means that many teenagers are walking around sleep deprived.

Previously: Can sleep help prevent sports injuries in teens?, Study shows link between lack of sleep and obesity in teen boys, Study shows lack of sleep during adolescence may have “lasting consequences” on the brain, Teens and sleep: A Q&A, Sleep deprivation may increase young adults’ risk of mental distress, obesity, Districts pushing back bells for the sake of teens’ sleep and Lack of sleep may be harmful to a teen’s well-being
Photo by lunchtimemama

When we think of the AIDS epidemic, many of us turn to the developing world, overlooking the fact that HIV is very much a problem here in the United States. Every year some 50,000 people in this country are newly diagnosed with HIV, and many of these individuals previously had no idea they were infected with the virus.

To help prevent further spread of the disease, which affects an estimated 1.2 million Americans, the U.S. Preventive Services Task Force has issued (.pdf) a final recommendation that every adult between 15 and 65 be screened for the virus. Younger adolescents and older adults considered at risk also should be screened, as well as all pregnant women in labor whose HIV status is not known, the task force suggests.

“Treatment for HIV has advanced remarkably, helping people live longer and healthier lives, and reducing HIV transmission,” Stanford professor Douglas K. Owens, MD, one of the members of the task force, told me last week. “Treatment is most effective when offered early in the course of HIV disease, typically well before people have symptoms, and screening enables people to learn they have HIV in time to get the full benefit from treatment.”

“Screening  is especially important because up to quarter of people who have HIV do not know they have it,” Owens added.

Studies have shown that people who are infected with the virus are significantly less likely to pass it along if they are receiving ARV treatment, which reduces the amount of virus circulating in the blood. Moreover, people who are infected are more likely to do better – suffering fewer opportunistic infections – if they receive treatment early on, rather than wait until symptoms occur and the disease becomes more advanced. For these reasons, identifying infected individuals through universal screening makes good public health sense.

The task force’s latest recommendation, published in the new issue of the Annals of Internal Medicine, is in keeping with the guidelines of the American College of Physicians, the American Academy of Pediatrics and the federal Centers for Disease Control and Prevention. Owens talked more about this issue with me last fall, after the task force’s draft recommendations were released.

Previously: Stanford expert discusses recommendation for universal HIV screening, Task force issues draft recommendation for universal HIV screening and National HIV screening and testing could be very cost-effective

Society is increasingly becoming more data-driven. Noting the power of vast reservoirs of public information, the federal government launched the Big Data Research and Development Initiative — a $200 million commitment to “greatly improve the tools and techniques needed to access, organize and glean discoveries from huge volumes of digital data.” And the National Institutes of Health expanded its stake in the federal initiative in hopes of speeding up the translation of biomedical discoveries into bedside applications.

In an effort to bring together innovative thinkers from information-technology corporations, startups, venture-capital firms and academia to capitalize on the wealth of opportunities using data-mining in biomedicine, Stanford Medicine and Oxford University are sponsoring a three-day conference from May 22-24. Curious to know more about the event and promise of big data, I reached out to Atul Butte, MD, PhD, Stanford systems-medicine chief and the conference’s scientific program committee chair. Below he shares why he’s passionate about how data-mining can transform scientific research and health care and discusses the conference program.

A recent Stanford Medicine article called data-mining the “fastest, least costly, most effective path to improving people’s health” that you know. Can you explain why you believe this to be the case?

Data-driven science, or data-mining, works faster and effectively because we are already sitting on billions of measurements made across the health system! Every time a physician orders a medication, every time a nurse or pharmacist dispenses a drug, every time a blood test is performed, every x-ray or CT scan that’s performed… all of this information ends up in a database today. So the part of science or innovation that involves collecting the measurements is actually the easiest part now, because the measurements are already there, just waiting for the right question to be asked.

In the same article, you said “hiding within [existing] mounds of data is knowledge that could change the life of a patient, or change the world” – and that if you didn’t analyze those data or show others how to, you feared no one will. How did you grow so passionate about this area?

I think we in the biomedical field make these measurements, but we often don’t realize how these measurements can interrelate or be used together. Our example from one of our recent articles was on our use of two big sets of public data. One set covered the molecular changes seen in tissues affected by diseases, and another set covered the molecular changes seen in cells treated by drugs. We realized that we could partner just these two public data sets together, to get new ideas of what other diseases might be treatable by these drugs. And, we could do this in a purely computational approach – an approach that is nearly infinitely scalable to more diseases, more investigators and more ideas. When I see hard working investigators working tirelessly to make highly accurate and significant measurements, but so few people taking advantage of that data, I can’t help but be passionate!

Earlier this year, you published a study, which involved combing through large amounts of data, to find that beta carotene may protect people with a common genetic risk factor for type-2 diabetes. Can you describe other recent findings that have stemmed from researchers’ use of this “big data” approach?

Stanford professor Russ Altman, MD, PhD, and his team recently showed how search engine logs can be mined to discover side effect of release drugs that might not have shown up during the initial clinical trials on those drugs. Similarly, Nigam Shah, MBBS, PhD, assistant professor of medicine, showed how similar side effects for drugs are sitting in physician clinical notes. Both text-based clinical notes and search engine logs are massive sources of big data that to date have barely been tapped for medical research.

What was the catalyst for launching the Big Data in Biomedicine conference?

The Li Ka Shing Foundation has played the leading role in bringing us together with Oxford University in planning events on big data. Our first, smaller conference was held in Oxford last November. Based on the success of that event, we realized we could host a larger conference at Stanford and open it up to the public. We couldn’t have done this without the support of the Li Ka Shing Foundation.

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Emergency helicopter transport can be pricey and, as recent reports of aircraft crashes show, potentially dangerous. Such downsides have sparked some concerns that transporting trauma patients by air may not be worth the risk. So researchers at Stanford set out to investigate how often medical helicopters needed to help save critically injured patients’ lives in order to be considered cost-effective when compared with ambulances.

Researchers published their findings (subscription required) online this month in the Annals of Emergency Medicine. My colleague explains their results in a release:

The researchers found that if an additional 1.6 percent of seriously injured patients survive after being transported by helicopter from the scene of injury to a level-1 or level-2 trauma center, then such transport should be considered cost-effective. In other words, if 90 percent of seriously injured trauma victims survive with the help of ground transport, 91.6 need to survive with the help of helicopter transport for it to be considered cost-effective.

The study… does not address whether most helicopter transport actually meets the additional 1.6 percent survivorship threshold.

“What we aimed to do is reduce the uncertainty about the factors that drive the cost-effective use of this important critical care resource,” said the study’s lead author, M. Kit Delgado, MD, MS, an instructor in the Division of Emergency Medicine. “The goal is to continue to save the lives of those who need air transport, but spare flight personnel the additional risks of flying – and patients with minor injuries the additional cost – when helicopter transport is not likely to be cost-effective.” (Helicopter medical services generally bill patients’ insurance providers directly, but patients may have to pay some of the bill out of pocket, or, if they’re uninsured, possibly all of it.)

The findings only apply to situations and locations where patients could be taken by both ambulance and helicopter to a trauma center. Researchers said that in scenarios where ground transportation to a trauma center wasn’t feasible, then transport by helicopter was preferable.

Photo by Brett Neilson

My best friend finally succeeded in his efforts to stop smoking when he experienced a highly motivating life change: Fatherhood. Likewise, many women discover that wanting to have a safe and healthy pregnancy gives them unprecedented desire to kick their tobacco habit. Knowing the research and clinical evidence may be useful to parents-to-be who have some questions about smoking:

1. Quitting smoking is very hard – does it really make enough difference to be worth it?  Yes. To get one sense of the impact of smoking on fetal development, recall the widespread panic in the 1980s about “crack cocaine babies.” Subsequent research has shown that the damage to fetuses of cigarette smoking is in fact worse than that of crack cocaine use. Even if it didn’t benefit the fetus (and later, the infant) for a mother to quit smoking, it would still be worth using the extra motivation to quit that pregnancy provides for the sake of the mother’s long term health.
2. When is the best time to try to quit? Early. In an excellent lecture I saw last week, Professor Zachary Stowe, MD, with the University of Arkansas for Medical Sciences, pointed out that the soonest a woman can know she is pregnant is 4-6 weeks after conception, at which point fetal organogenesis is well underway. Further, Stowe and other researchers have conducted research identifying nicotine and its metabolites in the fetal compartment even after the mother has stopped smoking. Dr. Stowe therefore suggests that rather than waiting to quit until after stopping birth control or after pregnancy has been confirmed by a test, a mother-to-be should wait two weeks after quitting smoking before going off birth control. Note: Even if you didn’t do this, quitting smoking at any point later in the pregnancy is still good for the fetus (and for you too).
3. I smoke, but I’m not carrying the baby, so why does it matter whether I quit? This isn’t just about mom. Passively absorbed smoke contributes to nicotine in the fetal compartment, meaning that even if the mother quits, smoking by her partner may affect the fetus. Also, an added benefit to a couple of quitting together is suggested by research and clinical experience in addiction treatment: Relapse is more likely when the visible, auditory and olfactory cues of substance use remain in the environment. Hence, a mom-to-be is going to have a much harder time quitting cigarettes if her partner remains a smoker. More positively, if two people quit together they can remove those cues from the environment and also have built-in social support for resisting the cravings they both may experience.
4. Where can we get help with smoking cessation? Free resources are just a click away here. If you need extra support, consult your physician, who can help you both with smoking cessation and with other conditions you may have (e.g., depression) that make it hard to quit.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.

Previously: Craving a cigarette but trying to quit? A supportive text message might help, Exercise may help smokers kick the nicotine habit and remain smoke-free, Kicking the smoking habit for good and Can daily texts help smokers kick their nicotine addiction?
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