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Medical Education, Medical Schools, Medicine and Society, Stanford News, Surgery

How two women from different worlds are changing the face of surgery

How two women from different worlds are changing the face of surgery

IMG_1038“I hope you’re not serious about doing something in medicine.”

These words are all too familiar to Annete Bongiwe Moyo, a senior medical student at the University of Zimbabwe College of Health Sciences in Harare, Zimbabwe, and a former Stanford visiting scholar. In Zimbabwe, where the proportion of men to women in medical school is roughly 3:1, women are encouraged to take up professions as teachers, artists, caregivers – not doctors. And for a woman thinking about becoming a surgeon, well, she might as well keep dreaming.

Though the odds were stacked against her, Moyo made the decision to become a doctor at a very young age. But it wasn’t until she met Stanford surgeon Sherry Wren, MD, that she started to believe that becoming a surgeon was a realistic goal.

The outlook for women in surgery in Zimbabwe is not terribly unlike that in the U.S. when Wren began her residency at Yale University almost 30 years ago. After receiving her medical degree from Loyola University, Wren became the first woman from the university to specialize in surgery. At that time, only 12 percent of surgical residents were women, and the number of women surgeons in the workforce was far less.

But Wren has never let her womanhood hold her back. In fact, her powerhouse personality, fearlessness and passion for her work are the very traits that define her. She has worked all over the world, applying her skill and resourcefulness to provide the best possible care, often with extremely limited resources in remote locations. In many of these places, Wren is often the first woman surgeon anyone has ever seen.

Shocked too was Moyo when Wren appeared on her surgery rotation at the University of Zimbabwe two years ago. Here’s how Moyo recalls their first encounter – one that would have a lasting impact:

[Wren] was a visiting professor in a grand rounds. Medical students are not usually invited to grand rounds, but that day, we were permitted to attend. When the presentation was done, she asked a question, and when she looked my way, she could tell I knew the answer. She called on me, but one of my professors said ‘Wait, she’s a third year student, she may not know what you’re talking about.’ But Prof. Wren insisted, and I answered correctly. So she asked another question, and I got it right. And then another, and I got it right again.

The mood had shifted in the room. No one expected a junior female medical student could be capable of such an eloquent response. No one had ever given her the chance.

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Neuroscience, Stanford News, Surgery, Technology

Stanford researchers provide insights into how human neurons control muscle movement

Stanford researchers provide insights into how human neurons control muscle movement

Brain-Controlled_Prosthetic_Arm_2A few years ago, a team led by Stanford researcher Krishna Shenoy, PhD, published a paper that proposed a new theory for how neurons in the brain controlled the movement of muscles: Rather than sending out signals with parceled bits of information about the direction and size of movement, Shenoy’s team found that groups of neurons fired in rhythmic patterns to get muscles to act.

That research, done in 2012, was in animals. Now, Shenoy and Stanford neurosurgeon Jamie Henderson, MD, have followed up on that work to demonstrate that human neurons function in the same way, in what the researchers call a dynamical system. The work is described in a paper published in the scientific journal eLife today. In our news release on the study, the lead author, postdoctoral scholar Chethan Pandarinath, PhD, said of the work:

The earlier research with animals showed that many of the firing patterns that seem so confusing when we look at individual neurons become clear when we look at large groups of neurons together as a dynamical system.

The researchers implanted electrode arrays into the brains of two patients with amyotrophic lateral sclerosis (ALS), a neurodegenerative condition also known as Lou Gehrig’s disease. The new study provides further support for the initial findings and also lays the groundwork for advanced prosthetics like robotic arms that can be controlled by a person’s thoughts. The team is planning on working on computer algorithms that translate neural signals into electrical impulses that control prosthetic limbs.

Previously: Researchers find neurons fire rhythmically to create movement, Krishna Shenoy discusses the future of neural prosthetics at TEDxStanford, How does the brain plan movement? Stanford grad students explain in a video and Stanford researchers uncover the neural process behind reaction time
Photo by FDA

Medical Education, Patient Care, Stanford News, Surgery, Videos

Why become a doctor? A personal story from a Stanford plastic surgeon

Why become a doctor? A personal story from a Stanford plastic surgeon

Recent graduates: Never fear if you haven’t picked a career yet; it’s never too late to figure out what you want to do when you grow up. I’m on my third career, and Rahim Nazerali, MD, now an assistant professor of surgery at Stanford, is on his second.

He explains in this recent Stanford Health Care video:

I had a career in international health and I felt like I wasn’t interacting with enough people, I was doing a lot of behind the desk work and I never really interacted with the people I was affecting. I entered medicine for that reason.

And when he entered medical school at Brown University, Nazerali thought he would pursue emergency medicine or orthopedics. But he was wrong again. In the video, he describes a surgery — which he watched on his first day on a plastic surgery rotation — that convinced him that this field was the one for him. Plastic surgeons converted a gaping post-tumor chest hole into a natural looking chest: “You could hardly even tell that anyone was there,” Nazerali said. “At that point, I thought, ‘I want to do that.'”

Now, he’s on the front lines of patient care, where he hopes to stay.

“Many patients come back in after they have their confidence back, after they have their life back, after they have their time with their family back,” Nazerali said. “That’s what makes it really rewarding.”

Previously: Why become a doctor? A personal story from a Stanford oncologist, Students draw inspiration from Jimmy Kimmel Live! to up the cool factor of research careers and Stanford’s senior associate dean of medical education talks admission, career paths

Cancer, Imaging, Research, Stanford News, Surgery

Better tumor-imaging contrast agent: the surgical equivalent of “cut along dotted line”?

cut horseIt would be tough for most people to take a snubbed-nose scissors to an 8-1/2″ x 11″ sheet of blank paper and carve out a perfect silhouette of, say, a horse from scratch. But any kid can be an artist if it means merely cutting along a boundary separating two zones of different colors.

Tumor-excision surgery requires an artist’s touch. It can be tough to distinguish cancerous from healthy tissues, yet the surgeon needs to approach perfection in precisely removing every possible trace of the tumor while leaving as much healthy tissue intact as possible. To help surgeons out, technologists have been designing contrast agents that target only tumor cells, thus providing at least a dotted line for scalpel wielders.

Stanford pathologist and molecular-probe designer Matthew Bogyo, PhD, in a study published in ACS Chemical Biology, has now demonstrated, using mouse models of breast, lung and colon cancer, the effectiveness of a fluorescence-emitting optical contrast agent that selectively accumulates in tumors and can be used to guide surgery. In effect, the probe lights up the tumor, providing a convenient, high-resolution dotted line for its excision.

Perhaps more striking, the new study showed that this probe, designed by Bogyo’s group, is compatible with a robotic remote minimally invasive surgery system that is already enjoying widespread commercial use. Intuitive Surgical, Inc., the company that sells this system, collaborated on the study.

Previously: Stanford researchers explore new ways of identifying colon cancer, Cat guts, car crashes, and warp-speed Toxoplasma infections and Compound clogs Plasmodium’s in-house garbage disposal, hitting malaria parasite where it hurts
Photo by Merryl Zorza

Medical Education, Mental Health, Nutrition, Stanford News, Surgery

Keeping an even keel: Stanford surgery residents learn to balance work and life

Keeping an even keel: Stanford surgery residents learn to balance work and life

med students in sailboat

Residency is one of the most intense times in a surgeon’s training, and it can take a toll physically and mentally on newly minted medical school graduates as they learn to cope.

To help them counter that stress, Stanford’s Department of Surgery started the Balance in Life Program for its residents. The program, and one of its team-building exercises – a sailing lesson in one of the world’s best sailing spots, the San Francisco Bay – were highlighted in a recent Inside Stanford Medicine story.

As described in the piece, the program is dedicated to the memory of Greg Feldman, MD, a former chief surgical resident at Stanford who committed suicide in 2010. The program provides basics like easy-to-access healthy meals, group therapy sessions and social activities, and Ralph Greco, MD, the program’s director said of it:

A lot of people would argue with the notion that such a program is necessary… I know our day of sailing may raise some eyebrows, but our faculty decided that we should do whatever we could to give these young people the tools they need to help them deal with the vicissitudes of life and medicine through the rest of their careers.

The article also notes that the program attracts residents interested in work-life balance to Stanford:

“The fact that we have this Balance in Life Program is great for recruitment of like-minded individuals,” [resident Micaela Esquivel, MD,] said. “I can tell medical students considering us that they would be hard-pressed to find another program that cares enough about their well-being to offer what we do.”

Previously: A call to action to improve balance and reduce stress in the lives of resident physicians, Surgeon offers his perspective on balancing life and work, Program for residents reflects “massive change” in surgeon mentality and New surgeons take time out for mental health
Photo by Norbert von der Groeben

Cancer, Medical Education, Stanford News, Surgery, Videos, Women's Health

Why become a doctor? A personal story from a Stanford oncologist

Why become a doctor? A personal story from a Stanford oncologist

Why become a doctor? It certainly isn’t easy, and it requires years of study and a sizable financial investment. If you ask physicians how, and why, they selected their careers, you’ll get a variety of stories that offer insight into the many benefits of pursuing medicine.

Pelin Cinar, MD, a GI oncologist here, tells her own story in this recent Stanford Health Care video.

As a child, Cinar was impressed with the respect her uncle, a gynecologist, received from family members. Then, in high school, her mother was diagnosed with cancer. Meanwhile, she began pursuing the courses that matched her interest in science. Her mother recovered but then relapsed when Cinar was in college and taking pre-med requirements.

During her medical education at the University of California-Irvine, Cinar discovered that all of her favorite rotations and subjects were based on oncology. “It took off from there,” she says in the video.

Previously: Students draw inspiration from Jimmy Kimmel Live! to up the cool factor of research, Stanford’s senior associate dean of medical education talks admissions, career paths and Thoughts on the arts and humanities in shaping a medical career

Bioengineering, Cardiovascular Medicine, Stanford News, Surgery, Technology

A jugaad for keeping pacemakers in place

A jugaad for keeping pacemakers in place

This post is part of the Biodesign’s Jugaad series following a group of Stanford Biodesign fellows from India. (Jugaad is a Hindi word that means an inexpensive, innovative solution.) The fellows will spend months immersed in the interdisciplinary environment of Stanford Bio-X, learning the Biodesign process of researching clinical needs and prototyping a medical device. The Biodesign program is now in its 14th year, and past fellows have successfully launched 36 companies focused on developing devices for unmet medical needs.

IMG_6308After months of observing clinics and winnowing down the most pressing (and commercially viable) medical needs, the Stanford-India Biodesign team has developed what looks like nothing so much as a very elaborate clothespin. It is intended to help doctors ensure that coiled pacemaker leads that screw into heart tissue stay put. Currently, about five percent of those leads fall out, requiring costly additional surgery. Worldwide, the number of people whose leads fall out is estimated at 80,000 to 100,000.

Debayan Saha says their prototype is a perfect example of Indian Jugaad. It’s made of what looks like the contents of a scrap pile, and he says could both work and be cheap to produce in it’s current low-tech form. But just because it’s inexpensive doesn’t mean it’s not cleverly designed. That’s what the Indian team brings to Biodesign, he said – smart technology at low cost.

“Getting the prototype exactly right made use of all the resources we have here at Stanford,” Saha said. “But the final product is something we could produce at very low cost.” Creating technology in a developing country requires creative solutions to keep that technology affordable.

IMG_6326The group has a provisional patent on their device and they will present their it to the entire biodesign team June 8. Until that presentation they are keeping it’s exact function under wraps. They did recently test the prototype in a lamb heart, with good results. They were consistently able to screw the pacemaker lead more securely into the heart tissue.

Harsh Sheth, MD, said the team (which also includes Shashi Ranjan, PhD) will be heading back to India at the end of June and will repeat the same process there – visiting clinics, assessing needs, and prototyping a solution. He said they might later return to their Stanford prototype or keep working on whatever they design in India.

Previously: From popsicle sticks to improved medical careThe next challenge for biodesign: constraining health-care costs and Stanford-India Biodesign co-founder: Our hope is to “inspire others and create a ripple effect” in India
Photos, of Debayan Saha screwing a pacemaker lead into a lamb heart using their prototype, and of the coiled screw going into the heart, courtesy of Amy Adams

Global Health, Health Disparities, Health Policy, Patient Care, Public Health, Surgery

Billions lack surgical care; report calls for change

Billions lack surgical care; report calls for change

In this country, we take it for granted that we will have access to needed surgeries, whether it’s the repair of a broken leg or an operation to remove an infected appendix or a malignant tumor. But for as many as 5 billion people – or two-thirds of the world’s population – these basic procedures are out of reach.

A major new report by the Lancet Commission sheds light on this enormous surgery gap and argues that building surgical infrastructure in low- and middle-income countries is critical both from an economic, as well as a human, perspective.

“Surgery hasn’t been part of the dialogue with respect to health system strengthening. It’s been a hugely neglected item,” said Stanford trauma surgeon Thomas Weiser, MD, who contributed to the 58-page report. The commission includes 25 leading experts from the fields of surgery and anesthesia, with contributions from more than 110 countries.

In its report, the commission notes that in 2010, nearly one-third of all deaths (16.9 million) were attributable to conditions readily treated by surgery, such as appendicitis, hernia, fractures, obstructed labor, congenital abnormalities and breast and cervical cancer. That is more than the number of deaths from HIV/AIDS, tuberculosis and malaria combined. And although there have been many gains in global health in the last 25 years, the quality and availability of surgical services in many regions have stagnated or declined, while the demand for surgery continues to rise.

“The global community cannot continue to ignore this problem – millions of people are already dying unnecessarily, and the need for equitable and affordable access to surgical services is projected to increase in the coming decades, as many of the worst affected countries face rising rates of cancer, cardiovascular disease and road accidents,” said Lars Hagander, MD, of Lund University in Sweden and one of the lead authors.

Weiser and his colleagues provide new estimates of the global shortfall, calculating that some 143 million additional surgeries are needed to save lives and prevent disability, with the largest number of neglected patients living in South Asia (57.8 million), East Asia (27.9 million) and southern sub-Saharan Africa (18.9 million).

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Research, Science, Stanford News, Surgery

Will scars become a thing of the past? Stanford scientists identify cellular culprit

Will scars become a thing of the past? Stanford scientists identify cellular culprit

346801775_c5a1e37a6d_zI have a scar on my chin from a fall I took while rollerskating when I was about 12. One minute I was blithely zooming along to Bob Seger’s hit Against the Wind (earworm alert!), reveling in my new ability to skillfully cross one foot in front of the other and thinking about that cute boy by the snack counter, and the next I was chin down skidding across the flat, grey and (I then realized) very hard floor to come to rest against the wooden wall in an ignominious heap.

Although the experience left an impression on my psyche, as well as my skin, I can’t claim any long-lasting problem from the thin line on my chin. After all, nearly all of us have something similar. But scars can also be debilitating and even dangerous.

Now plastic and reconstructive surgeon Michael Longaker, MD, and pathologist and stem cell expert Irving Weissman, MD, have identified the cell type in mice that is responsible for much of the development of a scar. They’ve shown that blocking this cell’s activity with a small molecule can reduce the degree of scarring. Because a similar drug molecule is already approved for use in humans to treat Type 2 diabetes, the researchers are hopeful that they can begin clinical trials in humans soon. The research was published today in Science.

As Longaker explained in our release on the study:

The biomedical burden of scarring is enormous. About 80 million incisions a year in this country heal with a scar, and that’s just on the skin alone. Internal scarring is responsible for many medical conditions, including liver cirrhosis, pulmonary fibrosis, intestinal adhesions and even the damage left behind after a heart attack.

Longaker and his colleagues found that a subset of a skin cell called a fibroblast is responsible for much of the collagen deposition that leads to scarring. Inhibiting the activity of a protein on the surface of the cells significantly reduced the amount of scarring during wound healing in laboratory mice – from about 30 percent of the original wound area down to about 5 percent -the researchers found. Furthermore, they showed the cells are also involved in the thickening and darkening of skin exposed to radiation therapy for cancer, as well as the spread of melanoma cancer cells in the animals.

Longaker’s been interested in how the skin heals for decades–ever since he learned as a student that, prior to the third trimester, human fetuses heal from trauma or surgery without any scarring. Now he’s excited to learn whether there’s a way to recapture that long-lost ability as adults and at least reduce the degree of scarring during skin repair.

“I’ve been obsessed with scarring for 25 years,” Longaker told me. “Now we’re bringing together the fields of wound healing and tumor development in remarkable new ways. It’s incredibly exciting.”

Longaker and Weissman are both also members of the Stanford Cancer Institute.

Previously: New medicine? A look at advances in wound healing, Stanford-developed device shown to reduce the size of existing scars in clinical trial and Mast cells not required for wound healing, according to Stanford study
Photo by Paulo Alegria

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

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

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

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

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

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

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

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

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

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

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

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