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In the News, Parenting, Pregnancy, Public Health, Public Safety, Women's Health

Exploring new recommendations to diagnose prenatal and postpartum depression

Exploring new recommendations to diagnose prenatal and postpartum depression

Although having a child is usually considered a happy event, an estimated 10 to 15 percent of women living in the U.S. develop some form of maternal depression. In response to new research and increased awareness about the problem, the U.S. Preventive Services Task Force revised their 2009 recommendations for screening procedures to diagnose and treat prenatal and postpartum depression.

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The guidelines, published last week in the Journal of the American Medical Association, now recommend screening for depression in the general adult population and they highlight the potential benefits of screening for pregnant and postpartum women.

Earlier this week, KQED Forum delved into the basis and potential implications of these new recommendations by exploring the topic with a panel of experts including Katherine Williams, MD, director  of Stanford’s Women’s Wellness Clinic.

Williams (who begins speaking at the 10:25 mark) stated that one of the most important aspects of the revised recommendations is its discussion of psychotherapy and how it can and, as Williams says, should be used as the first form of treatment for pregnant or nursing moms who are suffering from depression. The entire hour-long discussion is worth a listen.

Previously: A telephone lifeline for moms with postpartum depression“2020 Mom Project” promotes awareness of perinatal mood disordersAh…OM: Study shows prenatal yoga may relieve anxiety in pregnant women and Helping moms emerge from the darkness of postpartum depression
Photo by Sarah Zucca

In the News, Public Health, Sleep

How to tell if you’re sleep deprived

How to tell if you're sleep deprived

mad cartoonAre you chronically cranky or hungry (or, worse, hangry)? Are you clumsy or prone to nodding off during a show? Those are just a few of the signs that you may be sleep-deprived — signs that are hilariously depicted through a series of TV and movie clips in a fun new Bustle piece. The article caught my attention because it includes comments from Stanford sleep expert Rafael Pelayo, MD, (who explains why being short on z’s can make it difficult to fall asleep at one’s normal bedtime), but I also quite like the wise words of writer Chrissa Hardy:

Functioning isn’t thriving, just as surviving isn’t really living. The bare minimum is never the goal, and sleeping the shortest amount of time in order to get through the following day is no way to present your best self to the world.

In other words, go get some sleep.

Previously: Stanford doc gives teens a crash course on the dangers of sleep deprivationStanford docs discuss all things sleepExploring the effect of sleep loss on health and What are the consequences of sleep deprivation?
Photo by Ben Piddington

Chronic Disease, Global Health, Medical Apps, Public Health, Public Safety, Research

The right tool for the job: Creating a waterborne disease reporting system for Nepal

Fig 3When I last spoke with cholera expert Eric Jorge Nelson, MD, PhD, he was about to field test a tool to help doctors in Bangladesh diagnose, treat and report cholera outbreaks in real time using a smartphone app. Now that this reporting system is up and running, he’s working to create similar reporting systems for doctors elsewhere. But, as he learned in the remote regions of Nepal, a high-tech approach isn’t always the best approach.

Nelson was invited to Nepal by his colleague Jason Andrews, MD, an infectious disease expert who works with the Dhulikhel Hospital, to share his expertise on recognizing, responding to and containing cholera outbreaks.

Like Bangladesh, Nepal has seasonal outbreaks of waterborne diseases, including cholera, Typhoid, viral hepatitis and dysentery, that ebb and flow with the monsoon seasons. What made the situation in Nepal urgent, Nelson told me, is that waterborne diseases can also arise after natural disasters, and a 7.8 magnitude earthquake struck Nepal last spring and more than 100 aftershocks have hit the region since.

An added complication, Andrews explained, was that Nepal’s government wasn’t scaling up waterborne disease surveillance in the rural areas following the earthquakes. “Our colleagues at Dhulikhel Hospital, by contrast, were extremely proactive and committed to setting up a system before an outbreak hit,” Andrews said.

Nelson was only in Nepal for about 48 hours, but during those two days he and Andrews began to tackle the problem of how to prevent a large-scale cholera outbreak there. At first, it seemed plausible that the smartphone app designed for Bangladesh would work in Nepal — but Nelson said they quickly realized that Nepal’s post-earthquake infrastructure wasn’t suited to a smartphone reporting system.

“There were few resources in Nepal and little time to ramp-up a reporting system,” Nelson said. “Charging a smartphone requires a stable power supply, and although the 3G networks within the city were fine, they weren’t good in the canyons.”

This is where Andrews’ expertise came in. His knowledge of Nepal and experience building surveillance systems with “just the bare bones” (as he put it) helped the team reverse engineer the smartphone app Nelson used in Bangladesh and use elements of it to create a paper-based surveillance system that’s better suited to the post-earthquake situation in rural Nepal.

“This was a risky endeavor,” Andrews said. “We didn’t have funding so we drew upon our own existing resources. Funding takes a while, the earthquake was in April and the monsoon hits in June. If we had waited, the monsoon season would have passed. We realized we could scale this up really quickly with minimal resources and it was worth the risk.”

Now, the team’s paper-based system has been working for several months and Nepal’s government is interested in replicating the model at a larger level.

“I learned two important lessons during my trip to Nepal,” Nelson told me. “I learned the power of winnowing a complicated process, like our smartphone app, down. I also learned how we can broaden what we did in Bangladesh for a wider community.”

He continued: “Hopefully we are emerging from the idea that mobile technology is a panacea. We need to be open to considering high — or low — tech strategies depending on what the on-the-ground situation is. We happened to have two very different design challenges in Bangladesh and Nepal: Mobile was best for Bangladesh and paper was best for Nepal. You have to build what the end-user desires, is feasible and is viable. I think the mhealth field is waking up to this reality.”

Previously: A tale of two earthquakes: Stanford doctor discusses responses to the Nepal and Haiti disastersReporting and treating cholera: Soon, there could be an app for thatDay 1: Arriving in Nepal to aid earthquake victims and Using social media to fight cholera
Photo courtesy of U.u.H. Schmel and R.K. Mahato

Patient Care, Pediatrics, Public Health

Superheroes to the rescue: A creative approach to educating kids about asthma

Superheroes to the rescue: A creative approach to educating kids about asthma

Asthma affects more than 6 million children and leads to approximately 1.8 million visits to the emergency room annually in the United States, according to the Centers for Disease Control and Prevention.

In order to effectively manage asthma and help eliminate trips to the emergency room, physicians must identify the correct daily control and emergency rescue medications for their patients. However, educating young patients and their families is also critical.

“Patient education needs to be done at every visit,” Richard Moss, MD, professor of pediatrics, emeritus at Lucile Packard Children’s Hospital Stanford, recently told me. “This includes a review of the asthma symptoms, proper use of medications, written action plan, test results and educational handouts. The key is continuity of care and reiteration of important information at every visit.”

Last month, NBC News featured the work of an Illinois physician who has taken a non-traditional approach to patient education. Alex Thomas, MD, a cartoonist and pediatric allergist at the Center for Asthma and Allergy, created a multimedia asthma education program called Iggy and the Inhalers, which includes comic books, YouTube videos, posters, trading cards and stickers. I recently spoke with Thomas about this program and Booster Shot Comics, a partnership between Thomas and a health-communication specialist.

What motivated you to create the Iggy and the Inhalers comic book?

I started drawing Iggy characters when I was 11 years old. I grew up with asthma myself, so I drew as a way to understand my medications – turning them into superhero characters. My mom is an allergist, and she had a patient support group for kids with asthma. So I started drawing little comic strips about Iggy in the support group newsletter.

An interest in asthma and asthma education ultimately led me to go to medical school and become a pediatric allergist. When I was working on the pediatric wards, I noticed that a lot of kids were being admitted and readmitted to the hospital for asthma exacerbation due to confusion about their medications. So I eventually revisited my Iggy characters to create educational materials for physicians and patients, with the help of health communication specialist Gary Ashwal.

Can you describe the characters in Iggy and the Inhalers?

Iggy the Inhaler is the main character who teaches kids about the physiology of asthma. He has two teammates. One is Broncho the Bronchodilator, a rescue inhaler for quick relief of symptoms. The other partner is Coltron the Controller, a control inhaler that kids with persistent asthma need to take on a daily basis. There are also asthma trigger villains: Smokey Joe, Moldar, Pollenoid, Dust Mite, Roach and Hairy.

We wanted to create dynamic characters that embodied the mechanism of the medications that they represent, so kids can intuitively understand how the medications actually work. When kids look at a rescue inhaler, they imagine Broncho loosening the muscle bands around the airway because he’s a cowboy with a lasso. Whereas when they look at a control inhaler, they imagine Coltron decreasing inflammation inside the airways using his fire extinguisher arm.

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Addiction, Cancer, Genetics, Public Health, Research, Stanford News

For some African Americans, light smokers may not have lower lung cancer risk than heavy ones

For some African Americans, light smokers may not have lower lung cancer risk than heavy ones

CigaretteAlthough the relationship between smoking and lung cancer has been established beyond any doubt, it’s still difficult to know how a patient’s ethnicity might play into risk assessment. But it’s clear that it has a role. Lung cancer is the leading cause of cancer death in this country, and it disproportionately affects African Americans. Doctors are struggling to understand the interactions between genes and environment that contribute to lung cancer risk in all populations.

Physician scientist Sean David, MD, DPhil, and a multidisciplinary team of colleagues recently published in EBioMedicine the results of a study suggesting that African Americans who carry a panel of risky genetic sequences may be at higher risk for the disease, even if they are light smokers.

The study involved analyses of more than 7,000 Women’s Health Initiative participants and nearly 2,000 participants in a lung cancer case-control study with collaborators from multiple institutions in the United States.

As David explained to me in an email:

All smokers are at heightened risk for lung cancer, particularly those possessing high-risk genotypes. Our study suggests that African American light smokers are not at lower risk than heavy smokers if they possess certain genotypes, but that smoking more cigarettes does markedly increase lung cancer risk in individuals without these high-risk genotypes. These conclusions reinforce the message that light or heavy smoking is a risky proposition for African Americans, who can benefit from smoking cessation and evidence-based lung cancer screening services.

The researchers identified six nucleotide changes that appeared to affect the relationship between cigarettes smoked per day and lung cancer risk in African American smokers – all on chromosome 15. Although the nucleotide changes, called single nucleotide polymorphisms, or SNPs, had been associated with lung cancer risk in previous studies, this is the first time the risk has been tied to daily cigarette exposure in African Americans.

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Events, Public Health, Research, Science

What matters to Stanford’s Lucy Shapiro, and why

What matters to Stanford's Lucy Shapiro, and why

Shapiro getting National Medal of ScienceFasten your seatbelt: Developmental biologist Lucy Shapiro, PhD, is driving, and we’re zooming through her achievement-packed 40-year career in less than an hour.

Speaking this week as part of the “What Matters to Me and Why” series hosted by the Stanford Office of Religious Life, Shapiro said the topic prompted her to ponder why she was so passionate about the world of molecules and cells, a world invisible to most people.

To figure it out, Shapiro said she had to think back to when she was 13, applying for high schools. After consulting with her parents, Shapiro decided to apply for one of New York City’s elite public schools that focused on art and music. Unbeknownst to her parents, however, she decided she wasn’t going to take the exam in music as planned. Instead, she checked out a book on drawing from the library, taught herself to draw and passed the entrance exam by producing a portfolio of art.

These past 40 years have just been beautiful.

“That was really a defining moment. I learned I could change the trajectory of my own life by some action,” Shapiro said.

With that lesson firmly engrained — and with some well-timed assistance from mentors — Shapiro was off. There were detours, of course. Her senior college thesis was on Dante — interesting, Shapiro said, but “it didn’t make my heart sing.”

When prompted to go back to school and take an organic chemistry course, Shapiro discovered her true love.

“It sounds corny, but it was like the sky cleared. [Chemistry] was the most beautiful thing I had ever seen. It was clear that was how my mind worked,” Shapiro said.

She went on to make discoveries about the three-dimensional development of cells, compounds called RNA polymerases and many other advances in molecular biology, along the way mentoring scores of students and budding scientists. Her awards are numerous and include the prestigious National Medal of Science.

Now, she’s particularly passionate about the threat posed by pathogens, which are rapidly out-evolving the drugs available to rein them in. In response, she has helped found two pharmaceutical companies and is an active public speaker.

During her talk she offered numerous words of wisdom, including:

  • On discoveries: “It’s just indescribable when you discover something. It can be little, it doesn’t have to be earth-shattering. It is so exciting.”
  • On spirituality: “To me, science is religion. My love and passion for the scientific world is spiritual.”
  • On her career: “These past 40 years have just been beautiful. I still can’t wait to get into the lab each morning.”

There’s more. Much more. If you ever have the opportunity to hear her speak, I highly recommend it. It will be quite a ride.

Previously: Stanford scientist Lucy Shapiro: “It never occurred to me to question the things I wanted to do”, National Medal of Science winner Lucy Shapiro: “It’s the most exciting thing in the world to be a scientist” and Stanford’s Lucy Shapiro receives National Medal of Science
Photo of Shapiro accepting the National Medal of Science in 2013, courtesy of the White House

Pregnancy, Public Health, Women's Health

Reducing cesarean delivery rates, without jeopardizing safety

Reducing cesarean delivery rates, without jeopardizing safety

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Approximately one-third of all babies born in the United States are currently delivered by cesarean section, according to the Centers for Disease Control and Prevention. Although cesarean delivery can be life saving for both the mother and child, the rapid increase in the cesarean birth rate between 1996 and 2011 raised significant concern that cesarean delivery is being overused.

This concern has led to initiatives to lower the c-section rates, including a new plan funded by the Oakland-based California HealthCare Foundation (CHCF) to lower California’s c-section rate for low-risk mothers to 23.9 percent in the next five years — in alignment with the federal government’s Healthy People 2020’s national target.

A recent KQED Science article describes these efforts to reduce the state’s c-section rates. The story also explores the controversial issue that a healthy pregnant woman’s likelihood of having a cesarean birth varies depending on the hospital, based on a recent analysis of maternity care. For instance, the CHCF’s assessment report found that Lucile Packard Children’s Hospital Stanford has a c-section rate of 23.0 percent and the Coastal Communities Hospital in Santa Ana has a rate of 42.9 percent.

Deirdre Lyell, MD, professor of obstetrics and gynecology, clarified the issue in a recent email:

Nationally and internationally, there is concern that cesarean rates as a whole are too high. CHCF and others have shown a wide range in cesarean rates by hospital around the country, and even within hospitals among individual physicians. Hospitals with very high rates should examine the underlying reasons. However, the “ideal rate” depends on the characteristics of the patient population, and it would be inappropriate to apply one goal to all women. For example, a non-obese 25-year old who has had a prior vaginal delivery has a better likelihood of delivering her baby vaginally than does an obese 45-year old first-time mom.

At Stanford, we follow the “Safe Prevention of the Primary Cesarean Delivery” guidelines outlined by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. We care for a higher risk maternal and higher risk fetal population, and share with our patients a common goal for delivery: a safe mom and a safe baby, while not performing cesareans unnecessarily. Avoidance of the first cesarean helps reduce the potential risks in the future.

Jennifer Huber, PhD, is a science writer with extensive technical communications experience as an academic research scientist, freelance science journalist, and writing instructor.

Previously: C-section rates up to 19 percent help save women and their newborns, global study findsUnneeded cesareans are risky and expensive, and  “The mama Sherpas”: Exploring the work of nurse-midwives and their collaborations with doctors
Photo by Salim Fadhley

Health and Fitness, Microbiology, Nutrition, Public Health, Research, Stanford News

Can low-fiber diets’ damage to our gut-microbial ecosystems get passed down over generations?

Can low-fiber diets' damage to our gut-microbial ecosystems get passed down over generations?

fast food decisionsUh-oh.

A study conducted in mice raises suspicions that we humans may be halfway down the road to the permanent loss of friendly gut-dwelling bacteria who’ve been our constant companions for hundreds of millennia. That’s probably not good.

Virtually all health experts agree that low-fiber diets are sub-optimal. One big reason: Fiber, which can’t be digested by human enzymes, is the main food source for the friendly bacteria that colonize our colons. Thousands of distinct bacterial species thrive within every healthy mammal’s large intestine. Far from being victimized by these colonic cohabitants, we’d be hard put to live without them. They fend off pathogens, train our immune systems, help us digest food we’d otherwise be unable to use and even guide the development of our tissues.

From a news release I wrote about the new study, which was spearheaded by Stanford microbiology/nutrition explorers  (and husband/wife team) Justin Sonnenburg, PhD, and Erica Sonnenburg, PhD, and published in Nature:

[Previous] surveys of humans’ gut-dwelling microbes have shown that the diversity of bacterial species inhabiting the intestines of individual members of hunter-gatherer and rural agrarian populations greatly exceeds that of individuals living in modern industrialized societies. … In fact, these studies indicate the complete absence, throughout industrialized populations, of numerous bacterial species that are shared among many of the hunter-gatherer and rural agrarian populations surveyed, despite those groups’ being dispersed across vast geographic expanses ranging from Africa to South America to Papua New Guinea.

Another piece of information: The proliferation of nearly fiber-free, processed convenience foods since the mid-20th century has resulted in average-per-capita fiber consumption in industrialized societies of about 15 grams per day. That’s as little as one-tenth of the intake among the world’s dwindling hunter-gatherer and rural agrarian populations, whose living conditions and dietary intake presumably most closely resemble those of our common human ancestors.

Perhaps the most significant sources of our intestinal bacterial populations is our immediate family, especially our mothers during childbirth and infancy. So, if our low-fiber diets are depleting our intestinal ecosystems, could that depletion get passed down from one generation to the next?

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Bioengineering, Immunology, Public Health, Research

Working towards a lifelong, universal flu vaccine

Working towards a lifelong, universal flu vaccine

4919795171_771ae41b50_b_flickr_BlakePatterson_300x247To prepare for holiday socializing, I always roll up my sleeve to get an annual flu shot. I would much rather share food and gifts than a virus with my friends and family. And I don’t want to spend my precious vacation time sick.

However, seasonal flu vaccines are not always effective. There are thousands of strains of influenza virus and each can mutate over the course of the flu season. Seasonal vaccines only protect against a few of the most likely strains. As a result, flu-associated deaths range from 3,000 to 49,000 Americans per flu season, according to the U.S. Centers for Disease Control and Prevention.

Scientists have long sought a lifelong vaccine that would be effective against any variety of influenza, and they are now making significant progress towards this goal.

I recently spoke with Ian Wilson, PhD, a leading structural and computational biologist at the Scripps Research Institute, about his team’s universal flu vaccine research. He told me:

Our research has identified a good target for such a vaccine on a protein called hemagglutinin (HA) that is present on the surface of all influenza viruses. The HA protein has two major components: the head portion, which mutates and varies from strain to strain, and the stem, which is similar across most flu strains. We know that the HA stem is the virus’s most vulnerable spot, and provokes the greatest breadth of immune response. So a synthetic version of the stem was designed, called a mini-HA that mimicked the HA stem.

A key part of Wilson’s flu research took place at the Stanford Synchrotron Radiation Lightsource at SLAC National Accelerator Laboratory, where the scientists used a technique called x-ray crystallography to look at the atomic structure of the mini-HA at each stage of its development. I wrote a recent news article about their efforts.

Though this is important research, more work needs to be done. “We still need to perform human trials and also want to develop a vaccine that protects against all types of influenza that cause human pandemics,” Wilson said.

Jennifer Huber, PhD, is a science writer with extensive technical communications experience as an academic research scientist, freelance science journalist, and writing instructor.

Previously: Working to create a universal flu vaccineScience Friday-style podcast explains work toward a universal flu vaccine and Experts and 8-year-olds agree: It’s worth getting a flu shot
Photo by Blake Patterson

Global Health, Public Health, Research, Stanford News

A moment in the sun for the tsetse fly – and the Stanford researcher studying its effect on Africa

A moment in the sun for the tsetse fly - and the Stanford researcher studying its effect on Africa

tsetse flyThanks to a study published earlier this year, the tsetse fly has garnered attention from The Economist, The Guardian, Humanosphere, and – most recently – from the Department of Medicine’s Annual Report.

What makes this flying pest so important? In the American Economic Review paper, Stanford’s Marcella Alsan, MD, PhD, showed that by spreading sleeping sickness the tsetse fly may have significantly affected Africa’s economic development.

In precolonial Africa, sleeping sickness killed livestock en masse in areas where the fly was prevalent. Alsan, a Stanford Health Policy core faculty member whose work focuses on the relationship between health and socioeconomic disparities, asserts that where cows and other livestock were not available in large numbers, farmers did not develop progressive agricultural methods. This produced lower crop yields and limited mobility for people and goods.

“Communicable disease has often been explored as a cause of Africa’s underdevelopment,” Alsan says in this Department of Medicine piece. “Although the literature has investigated the role of human pathogens on economic performance, it is largely silent on the impact of veterinary disease.”

Because fewer domesticated animals limited their transportation options and because sleeping sickness among humans thinned population densities, people living in tsetse-heavy areas of Africa were less likely to develop a centralized political system, making economic development more difficult. The lack of centralization continues to affect the continent today.

“The evidence suggests current economic performance is affected by the tsetse through the channel of precolonial political centralization,” Alsan wrote in the American Economic Review piece.

This work may help to determine why many African communities lack the development of wealthier countries. “It’s incredibly important to shine light on issues that are Africa-specific and therefore may not garner as much attention as those economic and medical issues that affect wealthier regions of the world,” Alsan noted.

Nicole Feldman is the communications associate at Stanford Health Policy.
Photo by David Dennis

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