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Research, Stanford News, Surgery

Immune cell linked to surgery recovery time, Stanford scientists find

Immune cell linked to surgery recovery time, Stanford scientists find

surgery shotWe don’t think about doctors getting sick, or about them feeling just as lousy and miserable as the rest of us when they’re recovering. But it happens.

“In medical school I had a chest surgery and had a horrible recovery — in the hospital 10 days, and exhausted for about two months,” recalled Dan Sessler, MD, professor and chair of the Department of Outcomes Research at the Cleveland Clinic, when I spoke with him recently. “I was so tired I couldn’t pick up a remote and turn on the television.”

Sessler did recover — his was a successful surgery — but going into the operation neither he nor his doctor had any inkling that Sessler wouldn’t experience the normal two-week recovery.

Now, research published online in the journal Anesthesiology could lead to an “immune stress test” where blood taken from a patient prior to surgery could help predict when the patients would be back on their feet. The investigators, including co-senior authors/Stanford physicians Garry Nolan, PhD, and Martin Angst, MD, collected blood from 25 hip replacement patients and exposed the blood to chemicals to mimic how the immune system would respond to a traumatic event like surgery. They found the behavior of a white blood cell called a monocyte was related to how quickly patients recovered.

The researchers are working to replicate the findings in a larger study of 80 patients, and they plan to adapt their findings into a test that can run on standard hospital lab machines. As I wrote in our press release about the practical benefits of such a test:

Knowing the likely recuperation times will help patients plan better for their return to work and other post-surgery commitments. For patients at risk for longer recovery times, doctors could schedule additional physical therapy or special care, or the surgery could be postponed while exercise, dietary changes and stress-release techniques are implemented.

As for Sessler, who was not involved in this study, he said he sees great value in adapting the paper’s results into a test. Predicting a patient’s recovery is “clinically important, and we don’t do a good job” of it, he said.

Kim Smuga-Otto is a student in UC Santa Cruz’s science communication program and a former writing intern in the medical school’s Office of Communication and Public Affairs.

Previously: Discovery may help predict how many days it will take for individual surgery patients to bounce back, New device identifies immune cells at an unprecedented level of detail, inside and out and The importance of human connection as part of the patient experience
Photo by ChaNaWiT

Medical Education, Mental Health, Research, Surgery, Women's Health

Stereotype perception linked to psychological health in female surgeons

Stereotype perception linked to psychological health in female surgeons

8116089104_be12619731_oFemale surgeons who believe there’s a stereotype that men are better doctors are more likely to suffer from psychological distress, according to a recent study led by a former Stanford resident.

First author Arghavan Salles, MD, PhD, looked at the correlation between the perception of a stereotype — whether individuals think others believe certain groups are superior physicians — and the overall mental well-being of residents.

The team surveyed 382 residents from 14 medical specialties. To examine views on stereotypes, participants were asked: “Do you think residents in your program expect men or women to generally be better [doctors]?” They were also given standard psychological assessments.

Female surgeons were the only group where stereotype perception was correlated with psychological health. Surgery has traditionally been dominated by men and remains a specialty chosen by about twice as many men as women, leading to the persistence of gender stereotypes.

“As a surgical resident, I was aware of the stereotype that men are better surgeons than women. Although I found the stereotype upsetting, I didn’t think about it too much,” Salles told me. Then, after studying stereotype perception while pursuing a doctorate in education, Salles decided to combine her two specialties to determine whether residents experience stereotype threat; a question that no one had asked before.

The link she found has implications for physician productivity and patient care, Salles said.

“I think it’s important to realize that in the world of medicine, although the ratio of males to females is changing, some of these old stereotypes still have an impact on the practitioners,” said co-senior author Claudia Mueller, MD, PhD.

The belief that others think women aren’t good enough adds an unnecessary stressor to the female residents’ already harried lives, Mueller said. It could also contribute to the high attrition rate of females in surgical disciplines, the study states.

Mueller said the study, which appears in the Journal of the American College of Surgeonsis noteworthy for its rare integration of two quite disparate fields, surgery and psychology.

The authors suggest that simply increasing the number of female surgeons may help dissipate the stereotype. Sharing information about the stereotype may also help, as could investigating any practices that may have a differential effect on men and women, the researchers write.

Salles is now querying residents, faculty members and members of the public to see how prevalent stereotypes about gender-based differences in ability actually are.

Previously: How two women from different worlds are changing the face of surgery, Keeping an even keel: Stanford surgery residents learn to balance work and life and Stanford Medicine magazine opens up the world of surgery
Photo by Phalinn Ooi

Cardiovascular Medicine, Patient Care, Surgery

61-year-old grandfather gets new heart valve at Lucile Packard Children’s Hospital Stanford

61-year-old grandfather gets new heart valve at Lucile Packard Children's Hospital Stanford

Dr. George Lui, M.D., Dr. Dan Murphy, M.D., Mr. Sang Hee Yoon, Mrs. Min Wha Yoon, and Dr. Katsuhide Maeda, M.D. at Stanford Children’s Health Care on Tuesday, October 6, 2015. ( Norbert von der Groeben/ Stanford School of Medicine )One little-known fact about children’s hospitals: A number of their patients are not children.

I wrote about one such patient recently, a 61-year-old San Jose grandfather who received a new heart valve at Lucile Packard Children’s Hospital Stanford in May. Sang Hee Yoon was born in South Korea at a time when many babies with heart defects died in infancy. He was one of the first people there to receive a surgical repair for his heart condition, called tetraology of Fallot. The repair worked well for many years, but eventually he needed a replacement for a malfunctioning heart valve.

When the time came, the doctors on our adult congenital heart disease team were here to help. My story explains the unusual challenges of their field, which is growing rapidly as 20,000 teenagers with congenital heart defects “graduate” to adult medical care each year:

“Patients come back at 40 or 50 years old, telling us, ‘My doctor said I was cured,’” said George Lui, MD, medical director of the Adult Congenital Heart Program at Stanford, a collaboration between the Heart Center at Lucile Packard Children’s Hospital and Stanford Health Care. Some patients’ childhood surgical repairs were initially judged so successful that they never expected to return to a cardiologist, said Lui… In other cases, the first surgery was so unusual and risky that the surgeon discouraged the patient from undergoing further operations.

But most adults with repaired congenital heart defects are not cured, doctors have learned. As the discipline has matured, cardiologists have honed their understanding of how to help patients like Yoon navigate the risks of living with lingering heart problems, as well as learning how congenital defects interact with cardiovascular problems people acquire with age.

Mr. Yoon’s new heart valve has made a big difference – he and his wife told me that his health is better than ever before. Prior to his surgery at Stanford, his malfunctioning heart valve meant that his body never quite got enough oxygen. He often felt achy or had tightness in his chest, especially at high altitudes. All that is resolved now. The couple’s four children and 10 grandchildren are thrilled:

“They are so happy about my condition,” [Yoon] said. “Not only family members but everybody I know is saying, ‘You look so healthy!’” The Yoons have already visited Kings Canyon National Park, a destination they chose for its mountainous scenery. “I feel such gratitude that now I can enjoy my new life,” Yoon said.

Previously: Patient is “living to live instead of living to survive” thanks to heart repair surgery, Little hearts, big tools and Surgeon building a heart valve that can grow and repair itself
Photo – of Mr. and Mrs. Yoon with his doctors (from left to right) George Lui, MD, Daniel Murphy, MD, and Katsuhide Maeda, MD – courtesy of Lucile Packard Children’s Hospital Stanford

Emergency Medicine, Pregnancy, Research, Surgery, Videos

Self-propelled powder moves against blood flow to staunch bleeding in hard-to-reach areas

Self-propelled powder moves against blood flow to staunch bleeding in hard-to-reach areas

If you nick your skin, it’s easy to stop the bleeding by applying a coagulant powder directly to the cut. Yet, bleeding wounds inside the body are beyond the reach of such blood-stopping powders.

Now, Christian Kastrup, PhD, an assistant professor at the University of British Columbia, and a team of researchers, biochemical engineers and emergency physicians, have developed a way to clot internal wounds by creating a self-propelled powder that moves against the flow of blood.

“Bleeding is the number one killer of young people, and maternal death from postpartum hemorrhage can be as high as one in 50 births in low resource settings so these are extreme problems,” Kastrup explained in a UBC press release. “People have developed hundreds of agents that can clot blood but the issue is that it’s hard to push these therapies against severe blood flow, especially far enough upstream to reach the leaking vessels. Here, for the first time, we’ve come up with an agent that can do that.”

To give blood-clotting powder a push, Kastrup and his colleagues added calcium carbonate to the coagulant powder. The carbonate forms porous micro-particles that latch onto the clotting agent (tranexamic acid). As the particles release carbon dioxide gas, fizzing and moving like mini-antacid tablets, they launch the clotting agent toward the source of bleeding.

More rigorous testing and development needs to be done before this agent is ready for use in humans, as the press release and study explain. But it’s possible that in the near future this powder could be used to treat otherwise unreachable cuts such as those in postpartum hemorrhages, sinus operations and internal combat wounds.

Previously: New obstetric hemorrhage tool kit released todayIn poorest countries, increase in midwives could save lives of mothers and their babiesTeen benefited by Stanford surgeon’s passion for trauma care
Video courtesy of UBC

Medical Education, Medical Schools, Sports, Surgery

Applying athletic and musical coaching techniques to surgical training

Applying athletic and musical coaching techniques to surgical training

5866567170_aa28901818_zPerforming in a harmonious group is a key characteristic in the success of athletes, musicians and surgeons. With this in mind, physicians at the University of Texas Medical Branch at Galveston worked with members of the Choral Arts Society of Washington D.C. and the U.S. National Rowing Team to develop a new coaching model for training surgeons that draws on strategies from the musical and sports world.

Findings (subscription required) from the study were recently published in a special edition of the journal Surgical Clinics of North America. A release offers more details about the training approach:

It has been shown that deliberate practice is crucial to expert performance. Deliberate practice, which entails setting a well-defined goal, being motivated to improve and having ample opportunities for practice and refinement of performance through structured feedback, is a hallmark of this model.

The model also employs a coaching team that is well rehearsed in the day’s training procedure and is in constant communication so that trainees receive immediate correction when needed.

“Coaching teams not only are more efficient at communicating but also have been shown to make fewer mistakes in high-risk and high-intensity work environments, compared with individuals,” said [Kimberly Brown, MD, associate professor of surgery at the University of Texas Medical Branch at Galveston.] “This fact is of greater relevance when performance requires multiple skills, judgments and experiences.”

Brown said that when all of the coaches and learners are actively engaged throughout the training session, the other team members also contribute more to their highest capacity. This leads to a multiplying effect on the team as a whole, resulting in a team’s best possible performance.

Previously: Spanish-speaking families prefer surgical care in their native language, study finds, Clementines help surgeons-in-training to practice and Surgical checklists and teamwork can save lives
Photo by Army Medicine

Patient Care, Pediatrics, Research, Stanford News, Surgery

Spanish-speaking families prefer surgical care in their native language, study finds

Spanish-speaking families prefer surgical care in their native language, study finds

Bruzoni-scrubsFive years ago, when Matias Bruzoni, MD, was a new pediatric surgical fellow at Lucile Packard Children’s Hospital Stanford, his fluency in Spanish meant that he often accompanied other surgeons to consult with Hispanic families who spoke little English.

“I went with the attending surgeon, and would help explain the operation in Spanish, and then the family would say to me ‘Great, would you mind being our surgeon?'” he recalled recently. “And I’d say, ‘But I’m a fellow’ and they would say ‘We’d rather stay with you.'”

The families greatly valued their linguistic and cultural connection to Bruzoni. As he had more of these interactions, Bruzoni realized the hospital’s entire pediatric general surgery team held a mostly untapped linguistic resource. Many of its members – including receptionists, nurse practitioners and triage staff – spoke fluent Spanish.

After Bruzoni finished his training, he organized this group of caregivers into the hospital’s Hispanic Center for Pediatric Surgery, which offers patients and families the ability to receive all of their pre- and post-surgical care in Spanish. Every interaction, from registering the patient to giving post-surgical instructions, happens in the families’ first language. Bruzoni wondered how this approach would compare to using trained medical interpreters, whose services are offered to all non-English-speaking families at the hospital.

A new study, published in the most recent issue of the Journal of Pediatric Surgery, shows what his research found. From our press release:

Spanish-speaking families that discussed their children’s care in Spanish reported a higher level of satisfaction and higher ratings of the quality of information they received compared with the families in the control group and those that worked through an interpreter. Spanish-speaking families rated the importance of discussing care in their native language more highly than English-speaking families, the study found.

Although socioeconomic status was not assessed in this study, Bruzoni noted that Hispanic families of low socioeconomic status may have an even greater need than others to receive care in their native language. “There is a big cultural barrier,” Bruzoni said. “Because of these patients’ circumstances, it is even more important to work with them using their own language.”

Bruzoni plans to continue studying how to deliver better surgical care to California’s growing population of Hispanic children.

Previously: Stanford student earns national recognition for research on medical communication, An app to break through language barriers with patients and Advice for parents whose kids need surgery
Photo courtesy of Lucile Packard Children’s Hospital Stanford

Patient Care, Pediatrics, Public Health, Stanford News, Surgery

Story highlights teens’ life-changing weight loss

Story highlights teens' life-changing weight loss

Over on the Healthy, Happier Lives blog today: A look at how bariatric surgery, combined with a strict diet plan and exercise regime, benefited two San Jose, Calif. teens. The siblings lost a combined total of more than 200 pounds and in the process have reduced their risk of obesity-related medical complications and improved their quality of life. “It’s been a life-changing transformation,” Sophia Yen, MD, an adolescent medicine specialist with Lucile Packard Children’s Hospital, commented.

Previously: The challenges of dieting and the promises of bariatric surgery and Bariatric surgery may help protect teen patients’ hearts

Global Health, Medical Education, Surgery

Bringing surgical training to female medical students in Zimbabwe

Bringing surgical training to female medical students in Zimbabwe

IMG_1468Earlier this summer, I shared the story of how two pioneering women are challenging the status quo in Zimbabwe by saying it’s okay for women take up careers in surgery. Now, this professor-student duo – Stanford surgeon Sherry Wren, MD, and surgeon-in-training Annete Bonigwe Moyo – have launched the first surgical skills training for female medical students at the University of Zimbabwe’s College of Health Sciences.

For a girl growing up in Zimbabwe like Moyo, expressing interest in surgery can be met with ridicule and doubt. But when Moyo met Wren two years ago, Moyo was inspired to change this perception.

She founded DREAM (Dedicated to Reach, Empower And Mentor women in surgery) to empower her female peers and increase participation in the profession. Wren has been a core advisor since the organization’s inception, helping to achieve their mission by providing mentorship and new educational opportunities for the women of DREAM.

“Surgery is a core subject in our medical undergraduate curriculum requiring the acquisition of cognitive diagnostic demands, as well as procedural skills,” Moyo, a senior medical student at the University of Zimbabwe, told me. “However, in spite of the advent of skills laboratories and simulators, undergraduate trainees are barely exposed to the procedural aspect of training. For many graduating medical students in these circumstances, surgery is a far-off thought, and few have the confidence to carry out basic surgical procedures as they go through their internship.”

IMG_1473In an effort to help medical students translate the knowledge gained in the classroom to the operating table, Wren recently facilitated a basic surgical skills training session hosted by DREAM – a first for medical students in Zimbabwe. The training was attended by 21 third, fourth and fifth year MBChB students – all of them women.

Moyo reported to me:

[Wren] began the session by helping the women appreciate standard operating room etiquette and protocol, sterile procedures, sharps and fluid safety, scrubbing, gowning and gloving. For most of the students present, this was the first time they were being walked through these important basic principles of surgery.

Excitement grew as [Wren] began teaching the women some basic surgical sutures on sterile towels… Soon the ladies were ready to apply their newly learned skills on loops of bowel procured to give a more real feel to the exercise. It was amazing to see how quickly what was initially a barely discernible pattern of uneven sutures transformed into neat even sutures…

By the end of the 3-hour session, the timid girl who was clueless as to how to handle the most basic of surgical instruments, or let alone tie a surgical knot, had become a confident future surgeon raring to do whatever it took to realize her dream.

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Cancer, Chronic Disease, Dermatology, Stanford News, Surgery, Transplants

Rebuilding Cassie’s smile: A lung transplant patient’s struggle with skin cancer

lung patientWhen I first met Cassie Stockton, she was seated in an exam chair in Stanford’s dermatology clinic, getting cosmetic skin treatments. Lovely and young, just 21 years old, it seemed a bit silly. How could she possibly need injectable lip fillers or laser skin treatments?

I knew Stockton had a lung transplant at 15 and that the immunosuppressant drugs she was required to take to keep her body from rejecting the donated lungs had made her susceptible to skin cancer. But it wasn’t until I researched her story in depth that I truly understood how she ended up needing regular cosmetic treatments here.

As I explain in my recently published Stanford Medicine article, her story began at birth:

Born premature, [Cassie] was intubated the first two weeks of life, then sent home with her mother and an oxygen tank. She remained on oxygen 24 hours a day for the first two years of her life. Eventually, she was diagnosed with bronchopulmonary dysplasia, a chronic lung disorder …

Sixteen years later, the donated gift of new lungs saved her life – but it left scars, both emotional and physical:

The day Stockton woke up out of the anesthesia six years ago after a 13-hour surgery at the Transplant Center at Lucile Packard Children’s Hospital Stanford, she breathed in oxygen with newly transplanted lungs, and breathed out sobs. Tears streamed down her face. “At first, I thought she was in pain,” says her mother, Jennifer Scott, who stood by her side. But that wasn’t it. Stockton was overwhelmingly sad because she now knew her new lungs were the gift of a child. It was Dec. 6, 2009, just before Christmas. The death of someone else’s child had given her a whole new life.

And now:

Every four months, she and her fiancé make the four-hour drive from their home in Bakersfield, California, past the oil rigs and cattle farms to Stanford’s Redwood City-based dermatology clinic for her skin cancer screening. It’s been two years of treatments: freezings, laserings, a total of eight outpatient skin surgeries — the most significant resulting in the removal of the left half of her lower lip. The dermatologic surgeon removes the skin cancers, and then gets to work to repair the damage. “It’s heart-breaking to have to remove the lip of a 21-year-old woman,” says Tyler Hollmig, MD, clinical assistant professor of dermatology and director of the Stanford Laser and Aesthetic Dermatology Clinic, who leads Stockton’s treatment and keeps her looking like the young woman she is, restoring her skin, rebuilding her lip, making sure she keeps her smile.

Stockton doesn’t complain about any of the struggles she’s had post transplant. She knows she got a second chance at life. And, she tells me, it’s her job to take care of the lungs given to her by that child who died.

Previously: This summer’s Stanford Medicine magazine shows some skin
Photo by Max Aguilera-Hellweg

Dermatology, Evolution, Pediatrics, Research, Science, Stanford News, Surgery

To boldly go into a scar-free future: Stanford researchers tackle wound healing

To boldly go into a scar-free future: Stanford researchers tackle wound healing

scarshipAs I’ve written about here before, Stanford scientists Michael Longaker, MD, and Irving Weissman, MD, are eager to find a way to minimize the scarring that arises after surgery or skin trauma. I profiled the work again in the latest issue of Stanford Medicine magazine, which focuses on all aspects of skin health.

My story, called “Scarship Enterprise,” discusses how scarring may have evolved to fulfill early humans’ need for speed in a cutthroat world:

“We are the only species that heals with a pathological scar, called a keloid, which can overgrow the site of the original wound,” says Longaker. “Humans are a tight-skinned species, and scarring is a late evolutionary event that probably arose in response to a need, as hunter-gatherers, to heal quickly to avoid infection or detection by predators. We’ve evolved for speedy repair.”

Check out the piece if you’re interested in reading more about this or learning how scarring happens, or why, prior to the third trimester, fetuses heal flawlessly after surgery. (Surprisingly, at least to me, many animals also heal without scarring!)

Previously: This summer’s Stanford Medicine magazine shows some skinWill scars become a thing of the past? Stanford scientists identify cellular culprit, New medicine? A look at advances in wound healing and Stanford-developed device shown to reduce the size of existing scars in clinical trial
Illustration by Matt Bandsuch

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