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Imaging, Public Safety

MRI use flushes gadolinium into San Francisco Bay

MRI use flushes gadolinium into San Francisco Bay

22951789105_b548e1e5d6_o_Flickr_ScienceActivismThe levels of gadolinium in the San Francisco Bay have been steadily increasing over the past two decades, according to a study recently published in Environmental Science & Technology. Gadolinium is a rare-earth metal and the potential long-term effects of its environmental exposure have not been studied in detail.

Russell Flegal, PhD, and his research team at UC Santa Cruz collected and analyzed water samples throughout the San Francisco Bay from 1993 to 2013, as part of the San Francisco Bay Regional Monitoring Program.

They found the gadolinium levels to be much higher in the southern end of the Bay, which is home to about 5 million people and densely populated with medical and industrial facilities, than in the central and northern regions. They also observed a sevenfold rise in gadolinium concentration in the South Bay over that time period.

The study attributes the rising level of gadolinium contamination largely to the growing number of magnetic resonance imaging (MRI) scans performed with a gadolinium contrast agent. A gadolinium contrast agent is used for about 30 percent of MRI scans to improve the clarity of the images. It is injected into the patient and then excreted out of the body in urine within 24 hours.

Lewis Shin, MD, assistant professor of radiology and a MRI radiologist, explained to me the importance of using intravenous gadolinium contrast agents:

Gadolinium contrast agents allow us to detect abnormalities that would otherwise be hidden from view and to improve our characterization of the abnormalities that we do find. Gadolinium is not always used; for example, if a physician is just concerned about identifying a herniated disk in the spine, an MRI without contrast agent is sufficient.

However, gadolinium is routinely administered to detect and characterize lesions if there is a clinical concern of cancer. Also, if a patient was previously treated for cancer, gadolinium administration is often extremely helpful to detect early recurrences. MRI with a gadolinium contrast agent greatly improves our ability to make an accurate diagnosis not only for cancer but for many other disease processes as well.

According to the UCSC researchers, gadolinium is not removed by standard wastewater treatment technologies, so it is discharged by wastewater treatment plants into surface waters that reach the Bay.

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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

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

Public Safety, Stanford Medicine Unplugged

Medical tips for holiday travel

Medical tips for holiday travel

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

plane in skyThe holiday travel season is in full swing, and millions of people are off visiting their loved ones. So a seminar I recently attended on in-flight emergencies was quite timely.

I had been looking forward to the seminar, which was led by emergency medicine faculty members, all week. During the holidays, I have to travel on several different flights to get home, and occasionally, a flight attendant has asked on the loudspeaker if there is a doctor on-board. I was excited to finally be in the know.

Much of the conversation during the first part of the seminar focused on a New England Journal of Medicine article on how physicians should handle in-flight emergencies. It noted that the most common reported medical event during a commercial flight is fainting; the most fatal is a heart attack. Interestingly, heart attacks make up only 0.3 percent of in-flight emergencies, but they cause 86 percent of in-flight deaths.

For the second part of the seminar, emergency medicine faculty told us anecdotes about times when they had been called on during a flight – some stories were haunting, others interesting tidbits – and walked through three different simulations. The law about medical professionals helping people during in-flight emergencies is vague regarding medical students. But I know this: If a doctor is called during one of my upcoming flights, I sure hope someone onboard is more qualified than I am.

In all, I gathered several practical tips that could be helpful to readers. If you are traveling and concerned about in-flight medical events, please consider this:

  • Print or clearly write a list of medications you are currently taking. Include how often you take them and at what dose. Keep this readily accessible on the flight.
  • Make sure to travel with these medications in your carry-on in case your checked luggage is lost.
  • If you are traveling with someone you can confide in, make sure they know if you have any current illnesses. If not, please add this information to your list of medications.
  • If you have an allergy to any medication, please write this on your list. Write what kind of reaction you have, whether it is a tightening in your throat or a rash.
  • If you or a loved one does experience a medical event, stay calm.

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Applied Biotechnology, Ethics, Medicine and Society, Public Safety, Science Policy, Stanford News

Stanford experts slam government’s myopic biosecurity oversight

Stanford experts slam government's myopic biosecurity oversight

blindfoldedJust because we can, does that mean we should?

In a hard-hitting editorial in Science, three Stanford thinkers – Stanford microbe wizard David Relman, MD; synthetic biologist Megan Palmer, PhD, of Stanford’s Center for International Security and Cooperation; and political theorist Francis Fukuyama, PhD, of the Freeman Spogli Institute for International Studies – have issued a scathing wake-up call to the scientific community and the federal government, sternly questioning the latter’s current plans for ensuring biosafety and biosecurity in the United States.

“Our strategies and institutions for managing biological risk in emerging technologies have not matured much in the last 40 years,” they write, adding:

With the advent of recombinant-DNA technology, scientific leaders resorted to halting research when confronted with uncertainty and public alarm about the risks of their work. To determine a framework for managing risk, they gathered at the now-fabled 1975 Asilomar meeting. Their conclusions led to the recombinant DNA guidelines still used today, and Asilomar is often invoked as a successful model for scientific self-governance.

But, the authors suggest, Asilomar’s legacy may not be all it’s cracked up to be:

Asilomar created risky expectations: that leading biological scientists are best suited for and wholly capable of designing their own systems of governance and that emerging issues can be treated as primarily technical matters.

“Unfortunately,” the editorial goes on to say, “today’s leadership on biological risk reflects Asilomar’s risky legacy: prioritizing scientific and technical expertise over expertise in governance, risk management, and organizational behavior.” Political leaders have largely ceded a strategic leadership role, leaving it up to the scientific community itself to judge the ethical and social implications of its own work.

“Leadership biased toward those that conduct the work in question can promote a culture dismissive of outside criticism and embolden a culture of invincibility” regarding emerging biotechnology risks,” the authors write.

The world of today is not the world of 1975. Since then, the scope and scale of biological science and technology have changed radically. To wit: The increased ease of reading and writing genetic information means that securing materials in a handful of established labs is not feasible, the editorial states. Like it or not, the tools for putting potentially dangerous knowledge into practice are increasingly portable.

For a scary scenario of what such new facility portends, please see this article I wrote a couple of years ago, which begins with the rhetorical question: “What if nuclear bombs could reproduce?”

With so much at stake, we may not want to restrict oversight of scientific advances to those who are making the advances. There’s knowledge, and there’s wisdom.

Previously: How-to manual for making bioweapons found on captured Islamic State computer, Microbial mushroom cloud: How real is the threat of bioterrorism? (Very) and Stanford bioterrorism expert comments on new review of anthrax case
Photo by Mirko Tobias Schafer

Global Health, Infectious Disease, Public Health, Public Safety

Stanford team develops a method to prevent the viral infection that causes dengue fever

Stanford team develops a method to prevent the viral infection that causes dengue fever

327708441_433edf50d4_zDengue fever is the most widespread and fastest growing mosquito-borne virus in the world. It infects an estimated 390 million people each year — nearly twice the number of people infected annually by malaria — and unlike malaria, there is no vaccine or treatment.

Despite the severity and worldwide frequency of the disease, dengue fever receives relatively little press in the United States. But soon this trend may change. Just recently an outbreak of dengue fever struck Hawaii’s Big Island and the reach of this tropical disease is expected to spread.

Now, a team of Stanford researchers led by Judith Frydman, PhD, have developed a new way to target the disease by using a drug compound that tinkers with a critical cellular pathway in the host, blocking the virus at multiple steps. Frydman is a professor of biology and of genetics.

A Stanford News story explains:

Frydman’s group focused on Hsp70, a type of protein found in most organisms and known as a “chaperone.” Hsp70’s main job is to help other proteins fold into their functional shape, and to then protect them from damage by environmental stresses. DENV (dengue fever), like many other viruses, also relies on Hsp70, to help replicate the viral genome, and ultimately produce the viral proteins it needs to take control of the host cells and spread infection.

Frydman’s team discovered that using a specific compound to inhibit Hsp70 in human blood cells blocks the virus without harming the cells. This compound is effective against different strains and types of dengue fever and it blocks other insect-borne diseases, including West Nile virus, yellow fever and tick-borne encephalitis.

“Our findings have major implications for our understanding of the interface between viral and chaperone biology, and provide a new way of thinking about strategies to develop a novel class of antivirals,” Frydman said.

Previously: Exploiting insect microbiomes to curb malaria and dengueFighting fire with fire? Using bacteria to inhibit the spread of dengue and Dengue fever in New Caledonia
Photo by Andy Simonds

Bioengineering, Cancer, Imaging, Public Safety, Research, Stanford News, Technology

A new way to scan for plastic explosives could someday detect cancerous tumors

A new way to scan for plastic explosives could someday detect cancerous tumors

14591799636_128fbe50ee_zSci-fi shows and superhero films are full of gadgets and beings that have the power to remotely scan their environment for hidden things. For us mere mortals this superability may sound unachievable, but now Stanford engineers are working to develop a safe and portable way to detect concealed objects by scanning with microwaves and ultrasound.

As this Stanford Report story explains, the idea began with a challenge posed by the Defense Advanced Research Projects Agency: Design a way to detect buried plastic explosives from a safe distance without touching the surface of the ground.

A team of electrical engineers led by assistant professor Amin Arbabian, PhD, and research professor Pierre Khuri-Yakub, PhD, took up the challenge, paying homage to the scanning device made popular by sci-fi show Star Trek in the process. They created a tricorder-like device that senses the ultrasonic waves created by objects as they expand and contract when warmed by electromagnetic energy (e.g., light and microwaves).

Here’s the really interesting part: Because everything expands and contracts when heated — but not at identical rates — this scanning tool could have medical applications as well. For example, blood vessels that sprout from cancerous tumors absorb heat differently than surrounding tissue. So, blood vessels radiating from tumors could appear as “ultrasound hotspots” when scanned with the tricorder device.

The team is working to make this device ready to detect the presence of tumors and other health anomalies sometime within the next decade or so.

Previously: Beam me up! Detecting disease with non-invasive technology and Tiny size, big impact: Ultrasound powers miniature medical implant
Photo by Joe Haupt

Mental Health, Public Health, Public Safety, Sleep, Stanford News

From A to ZZZZs: The trouble with teen sleep

From A to ZZZZs: The trouble with teen sleep

go_to_bed_fullWhen I recently began working on a story on teen sleep for Stanford Medicine magazine, I was afraid I might not find teens who were troubled by sleep issues and willing to talk about them. I need not have worried: Virtually every teen I encountered had a story to tell about consistently having late nights stressing out over tests or papers or texting friends and cruising the web. It also wasn’t unusual for teens to say that they kept their cell phones on at night in case they got a message from a friend who needed to talk.

Some were tortured by the lack of sleep, often nodding off in class, but said they felt compelled to stay up in order to compete academically in these high-pressure local communities that worship at the altar of academic achievement.

“I’ve heard horror stories of being sleep-deprived,” one 17-year-old told me. “You’re not able to focus on homework, you feel moody and are not able to pay attention in class.”

Another teen reinforced what the National Sleep Foundation found in a recent poll – that 87 percent of American teens are chronically sleep-deprived. “You could probably talk to any teen when they reach their breaking point,” she told me. “You’ve pushed yourself so much and not slept enough and you just lose it.”

In my research, I learned that these students pay a heavy price, potentially compromising their physical and mental health. Study after study in the medical literature sounded the alarm over what can go wrong when teens suffer chronic sleep deprivation: drowsy driving incidents, poor academic performance, anxiety, depression, suicidal thoughts and even suicide attempts.

“I think high school is the real danger spot in terms of sleep deprivation,” Stanford’s William Dement, MD, PhD, the famed sleep researcher, told me. “It’s a huge problem.”

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Pediatrics, Podcasts, Public Safety, Women's Health

Jimmy Carter: The final campaign

Jimmy Carter:  The final campaign

People Jimmy CarterShortly after leaving the White House in 1980, Jimmy and Rosalynn established the Carter Center. It is from there that their efforts at “waging peace, fighting disease and building hope” – the center’s mission – have been launched.

Along with his global travels to advance democracies around the world, his projects in global health, and his time building for Habitat for Humanity, Jimmy Carter is also a prolific writer. He’s written twenty-eight books. One of his most recent – A Call to Action, Women, Religion, Violence, and Powerdetails the discrimination that women and girls face worldwide. Widely recognized for his Christian beliefs and noted as a Sunday school teacher for more than 70 years – Carter challenges those who use religious texts to deny women equality. In a Call to Action, he writes, “Women and girls have been discriminated against too long in a twisted interpretation of the word of God.”

For the latest Stanford Medicine, a special on issue on pediatric research and care, I spoke with Carter about girls and women’s equality – an issue that he said would receive his highest priority in his final years. But this summer brought disturbing health news, and a different priority has entered his life: treating metastatic cancer that has spread to his brain.

I worked in the Carter White House. Like many others who served there, I wasn’t prepared for this news – we viewed Jimmy Carter to be indestructible. Even the word “cancer” in regards to Carter seems oxymoronic when you know firsthand his indomitable spirit and boundless energy.

I spoke with him for this 1:2:1 podcast and Q&A before his diagnosis. Later in the summer, I followed up with an email wishing him well and a speedy recovery, and he responded: “Thanks, Paul. I am at ease, and grateful. Jimmy”

And then late last month, just two days before Carter’s 91st birthday, Habitat for Humanity announced that his medical team approved his traveling to Nepal in November to build a home there. (Note from editor: Habitat for Humanity has cancelled the trip due to safety concerns.) Talk about an indomitable spirit and boundless energy.

Previously: Stanford Medicine magazine tells why a healthy childhood matters and Lobbying Congress on bill to stop violence against women
Illustration by Gérard DuBois

Pediatrics, Public Safety, Stanford News

A reminder to parents to be careful of open windows

A reminder to parents to be careful of open windows

7867279958_6d74bdf4f7_z croppedPreventing falls from windows may not be something that’s on the mind of every parent – especially this time of year. But as the Indian summer continues here in the Bay Area and elsewhere, windows in homes may be left open, leaving kids vulnerable to accidents.

Over on the Healthier, Happier Lives Blog yesterday, Daniel Imler, MD, assistant professor of pediatric emergency medicine, talked about injuries caused by falls, noting that the most common kinds are extremity fractures, traumatic brain injuries, and damage to the cervical spine. After saying that “window screens only offer minimal help,” he also outlined some preventive tips for parents:

Move furniture away from windows and prevent children from climbing over. Locking all closed doors and windows is a great preventative measure as well. If you do open a window safety locks can help keep the window open only 4 inches for safety. Some families choose to install windows that open from the top down on floors above the ground level.

Previously: A young child, a falling cabinet, and a Life Flight rescueCarseats save lives, but only if kids are buckled in and Rattled by one child’s injury, a whole family becomes accident-prone
Photo by Kalexander2010

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