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Global Health, Haiti, Infectious Disease, Public Health, Technology

A sanitation solution: Stanford students introduce dry toilets in Haiti

A sanitation solution: Stanford students introduce dry toilets in Haiti

sanitation-toilet-movedIn the United States, we often take for granted the relationship between health and sanitation. Not so in Haiti, where some people dispose of their feces in plastic bags they throw into waterways. As a result, waterborne diseases like cholera are common.

But what’s to be done? Flush toilets guzzle gallons of water and depend on an entire sewage system — an unfeasible option in many developing nations. To fill the gap, a pair of Stanford civil and environmental engineering graduate students have developed a program called re.source, which provides dry household toilets, and empties them for about $5 a month.

From a recent Stanford News story:

Unlike most sanitation solutions that only address one part of a dysfunctional supply chain, container-based sanitation models, such as the re.source service, tackle the whole sanitation chain. The re.source toilets separate solid and liquid waste into sealable containers, and dispense a cover material made of crushed peanut shells and sugarcane fibers that eliminates odors and insect infestations. The solid waste is regularly removed by a service, which takes it to a disposal or processing site to be converted to compost and sold to agricultural businesses.

The re.source students — Kory Russel and Sebastien Tilmans — work under the guidance of Jenna Davis, PhD, an associate professor of civil and environmental engineering. They started small, with a free pilot phase in 130 households in a Haitian slum, but the service has expanded to include 300 additional households with plans to introduce a service in the capital, Port-au-Prince.

The project is part of a larger Stanford focus on water issues ranging from safe drinking water to environmental concerns.

Previously: Waste not, want not, say global sanitation innovators, Stanford pump project makes clean water no longer a pipe dream and Award-winning Stanford documentary to air on PBS tonight
Photo by Rob Jordan

Bioengineering, Cardiovascular Medicine, Stanford News, Technology

Following the heart and the mind in biodesign

Following the heart and the mind in biodesign

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.

15125593898_7ee05d0a60_zWhen I showed up to meet with the Biodesign fellows, Debayan Saha greeted me by saying, “We are arguing – please join us.”

The source of the argument turned out to be a thorny one. The team had previously attended cardiovascular disease clinics and from those visits identified more than 300 possible needs that, if addressed, might improve patient care.

Now, their job was to narrow down those 300+ needs to the one they would eventually develop a prototype device to address.

Part of the process Stanford Biodesign fellows learn is a rigorous method for identifying medical needs that also make business sense to address. The first step: eliminate the duds.

In this round, the each team member had individually rated the needs according to their individual levels of interest on a scale of 1 to 4. That interest could reflect the fact that they think the technology is interesting, or the fact that the need is one they would be excited about addressing.

Now they were trying to rate the needs on the same 1 to 4 scale according to the number of people who would benefit if it were addressed. The combination of these two ratings—one subjective and the other objective—would produce a shorter list of needs that were both of interest to the fellows and would benefit enough people that any future company could be successful

That objective rating was the source of the polite disagreement I had walked into. As one example, if a particular need applied to people who had a stroke, should they assume that all people who have had a stroke would benefit from a solution (giving the need a higher rating of 4), or would only a small subset benefit (giving the need a lower rating of 1 or 2)?

By and large Harsh Sheth, MD, leaned toward 4s while Shashi Ranjan, PhD, leaned toward 2s. Saha mostly just leaned back. Much discussion ensued.

In the end the team managed to assign a single score indicating the number of people represented by each need. When combined with their subjective scores, the group was able to eliminate the lowest scoring needs and reduce the list to a mere 133.

One interesting thing I learned is that this careful rubric is harder to apply in India, where good numbers about how many people have particular conditions are harder to come by. Ranjan told me that even in India they would likely use U.S. numbers for some conditions and just scale up to the Indian population. I mentally added this lack of good data to the list of reasons Stanford-India Biodesign Program executive director (U.S.) Rajiv Doshi, MD, told me that biodesign is more challenging in India.

Previously: Writing a “very specific sentence” is critical for good biodesign and Good medical technology starts with patients’ needs
Photo by Yasmeen

Clinical Trials, In the News, Research, Stanford News, Technology

Lights, camera, action: Stanford cardiologist discusses MyHeart Counts on ABC’s Nightline

Lights, camera, action: Stanford cardiologist discusses MyHeart Counts on ABC's Nightline

GMA shoot - 560

Apple’s new ResearchKit, and Stanford Medicine’s MyHeart Counts iPhone app, were highlighted on ABC’s Nightline on Friday. Michael McConnell, MD, professor of cardiovascular medicine and principal investigator for the MyHeart Counts study, was interviewed, telling business correspondent Rebecca Jarvis around the 4-minute mark that the app will “definitely” change the way his job works. “It gives us a whole new way to do research,” he explained. “Traditionally reaching many people to participate in research studies is quite challenging. The ability to reach people through their phone is one major advance.”

Previously: Build it (an easy way to join research studies) and the volunteers will comeMyHeart Counts app debuts with a splash and Stanford launches iPhone app to study heart health
Photo by Margarita Gallardo

Ask Stanford Med, Global Health, Stanford News, Technology

Stanford-India Biodesign co-founder: Our hope is to “inspire others and create a ripple effect” in India

Stanford-India Biodesign co-founder: Our hope is to "inspire others and create a ripple effect" in India

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.

shutterstock_258773231Rajiv Doshi, MD, is the executive director (U.S.) of the Stanford-India Biodesign Program and was part of the Stanford team that initially flew to India in 2007 to propose the program to the Government of India. He has commercialized devices to treat sleep apnea and snoring and later served on boards of multiple medical device companies. In 2012 he was named by Forbes India as one of the top 18 Indian scientists who are changing the world.

Doshi answered questions about the early days of the Stanford-India Biodesign program and the hurdles entrepreneurs face in India.

Why did you want to start the Stanford-India Biodesign program?

Starting the program was both an opportunity and an obligation. My belief was that this was going to be a difficult challenge spanning perhaps a decade. We were working with a partner [the Indian government] where we didn’t know the people very well and we didn’t know many of their systems. We had never assembled such an international collaboration of this scale. If we failed then at least we tried and did our best. If we were successful then we would have helped a lot of people. I felt that this was a once in a lifetime opportunity to have an impact of this scale.

What were some of the hurdles the early fellows faced when they tried to develop technologies in India?

Probably the number one problem they face in India is that there is really little mentorship as we know it here. Few people in India have successfully developed a medical device from scratch so it is really hard to find mentors who are already domain experts in medical technology. The next issue is raising capital. There is very little early stage venture capital focused on medical technology in India.

Then there are challenges with research and development. Imagine you’re creating a difficult-to-make medical device that has small, complicated parts. Odds are the suppliers aren’t available for all these parts in India. Then there’s manufacturing and supply chain issues. Let’s say the entrepreneurs are able to develop a product, then they may struggle to find an in-country manufacturer to make this product. In many cases, in-country manufacturing capabilities just aren’t at the same level as you would see here or in Singapore, Germany or other locations. So you start stacking these challenges together and you realize that they are pretty serious.

Does it get easier once they’ve developed the device?

No, I think the greatest challenges are related to commercialization – after development has been completed. Let’s imagine you created a great product, you’ve figured out all these issues. Your next challenge is then to market your product and convince healthcare providers in India to start using your product. This takes time and money to support your marketing and sales efforts. Additionally, many of the providers may not be as trained as their US or UK counterparts and may be less likely to adopt your product if it requires a certain level of training. Finally, there is the issue of who is going to pay for the product. In India, only about 25 percent of people have basic health insurance so any device in India needs to be quite low cost to be broadly used.

Continue Reading »

Big data, Clinical Trials, Ethics, Public Health, Research, Stanford News, Technology

Build it (an easy way to join research studies) and the volunteers will come

Build it (an easy way to join research studies) and the volunteers will come

stanford-myheart-counts-iphone6-hero

Just nine days after the launch of Stanford Medicine’s MyHeart Counts iPhone app, 27,836 people have consented to participate in this research study on cardiovascular health.

“To recruit that many patients into a traditional clinical trial would take years and hundreds of thousands of dollars,” said Michael McConnell, MD, professor of cardiovascular medicine and principal investigator for the MyHeart Counts study.

MyHeart Counts was built with Apple’s new ResearchKit, a software development framework that can be used to create apps that turn an iPhone into a research and data collection tool. Leveraging a smartphone’s built-in accelerometers, gyroscopes, camera and GPS sensors, medical researchers can easily and inexpensively collect streams of data on exercise, diet and biometrics. Unlike most traditional clinical trials, which capture only a snapshot of patient data, ResearchKit studies are able to collect data from thousands of participants simultaneously, over long periods of time.

While the potential for this technology to accelerate medical research is tantalizing, the ethical issues of this shift in researcher-volunteer interactions took Stanford researchers and collaborator Sage Bionetworks nine months to work out.

“One of the big challenges in designing this study was to develop an ethical mechanism for informed consent on mobile devices,” David Magnus, PhD, director of the Stanford Center for Biomedical Ethics, told me. “It was essential that volunteers understand the nature of the research and what it means for them.”

The concept of informed consent is an important tenet of any research institution’s commitment to respect individuals and to “do no harm.” Without face-to-face meeting between a researcher and volunteer, there could be misunderstandings about risks, benefits and time commitments.

Stanford bioethicists are on the leading edge of addressing the communications challenges of these new frontiers in medical research. Rethinking long, text-based consent forms, they are exploring alternatives, such as audio, video, animation and interactivity.

For example, a team of bioethicists from Stanford and the University of Washington recently released animated videos that explain comparative-effectiveness research within medical practices to potential volunteers. Next, they’ll be developing media-rich tools to explain the risks and benefits of research that uses electronic medical records and stored biological samples.

To solicit ideas on how to best regulate this brave new world of informed consent, the U.S. Food and Drug Administration just posted draft guidance on “Use of Electronic Informed Consent in Clinical Investigations.” Public comments will be accepted through May 7, 2015.

To sign up for the MyHeart Counts study, visit the iTunes store.

Previously: Harnessing mobile health technologies to transform human healthMyHeart Counts app debuts with a splashStanford launches iPhone app to study heart health and Video explains why doctors don’t always know best
Photo by iMore

Addiction, Media, Medicine and Society, Mental Health, Technology

Patient tells how social media helped her overcome the “shame” of her eating disorder

Patient tells how social media helped her overcome the "shame" of her eating disorder

3375657138_d025fc4092_bMany of us turn to our friends and families for encouragement when times are tough. So it’s no wonder that social media sites have also become important sources of emotional support for people with illnesses.

Recently, a story over on MindBodyGreen highlighted how one woman used Facebook as a tool to help her overcome the shame and deception that hampered her recovery from her eating disorder. As Lindsey Hall explains:

Two months into rehab, I was still struggling with letting go of the games of my eating disorder. Transitioning from in-patient to out, I’d been rapidly finding myself falling backwards instead of forwards.

Here I was, 24 years old, still living some days bagel by bagel, still opening the door to deception, and guilt and shame. I knew on some level that admitting to my eating disorder on social media would be a way for me to stop the show. I knew I needed to own this struggle in order to own all of myself, and to continue on my journey learning the art of self-acceptance.

As Hall describes in the story, her decision to make her eating disorder public on Facebook was a leap of faith with no guarantee that it was the right thing to do:

I’ll never really know what drove me to write that Facebook status, but I posted it anyway to the open arms of nearly 2,500 “friends” and family, to people that had met me once at a bar or sat next to on a plane. Having lived so long behind a smoke screen, I was ready to expose myself. I needed to feel bare, even while broken, in order to be able to clean my slate, and start from scratch in reconstructing my life.

The feedback Hall received from her gutsy post on Facebook and the subsequent blog posts and stories about her eating disorder haven’t always been positive, but as Hall explains, that wasn’t that point. Hall’s eating disorder is public information now, and this new level of accountability has helped her keep her eating habits on track.

Previously: Incorporating the family in helping teens overcome eating disordersA growing consensus for revamping anorexia nervosa treatmentPossible predictors of longer-term recovery from eating disordersGrieving on Facebook: A personal story and How patients use social media to foster support systems, connect with physicians
Photo by .craig

Big data, Public Health, Research, Technology

Harnessing mobile health technologies to transform human health

Harnessing mobile health technologies to transform human health

McConnell-YeungAn estimated seven in ten U.S. adults say they track at least one health indicator, and 21 percent of this group use some form of technology to track their health data, according to data from the Pew Research Center. But these figures are likely to skyrocket thanks to health platforms such as Google Fit, Apple’s HealthKit and AT&T ForHealth, which use sensors built into smartphones and wireless fitness devices to record physical activity.

This data deluge is a goldmine for biomedical research and drug development, particularly with the introduction of Apple’s ResearchKit. The software, which powers the Stanford-developed MyHeart Counts app, allows users to better understand their health data while providing researchers the opportunity to access it for future studies.

In a recent Huffington Post article, Ida Sim, MD, PhD, professor of medicine at University of California, San Francisco, noted that such technologies hold the potential to encourage the general public to participate in medical studies and make the research community more collaborative and open. “There’s a new movement in academic research called participatory research, where patients are part of the groups that should be asking: ‘What questions are interesting? What should we test?’” Sim said in the piece. “The public could start seeing research as something that isn’t imposed on [them], but as an activity that we all do together so that we can learn together.”

This May, Sim, who co-directs of Biomedical Informatics at UCSF’s Clinical and Translational Sciences Institute, will speak at Stanford’s Big Data in Biomedicine Conference on how health information collected on mobile devices holds the potential to inform clinical decisions and transform health care. As a co-founder of non-profit Open mHealth, she and colleagues are leading the charge to build open source software that facilitates sharing and integration of digital health data.

Below she outlines how leveraging mobile health data can improve how physicians diagnose, treat and prevent disease and the challenges in facilitating the sharing and integration of this vast treasure trove of data.

What are the large-scale opportunities to harness the rapidly growing reservoir of information to improve biomedical research and human health?

We can use this data to do a variety of things like combining genomic information and behavior data from wearables to discover new insights into health and disease.

We can also move from what works on average to more tailored programs focused on the idea of what works for me. For example, if we employ A/B-like testing with digital health, genomics, and other data combined, we can understand which interventions work for an individual and under what contexts, allowing for more tailored healthcare.

Finally, we can learn about a person beyond their clinical visit – which is only a small slice of their “health pie.” By getting multiple health snapshots, doctors will be able to provide patients with better medical support and preventative strategies that support overall physical and mental well-being.

What are the major challenges in unlocking the potential of digital health data?

When we write a sentence, we construct the sentence with grammar. We use vocabulary to fill in the blanks to give meaning to the sentence. Meaning is lost when either the grammar or the vocabulary is ambiguous or not shared between parties. In a similar way, making sense of data from various digital health devices is challenging when the devices don’t represent data the same way.

Currently, wearable devices and other healthcare tools describe the data they collect using their own languages that are not shared or integrated with other devices. For example, a Wi-Fi enabled weight scale might represent data as “weight: 88” but we have no clue if that means 88 kg, femptograms, lbs, or stones. A calorie counter might represent calories as “calories: 400” but we have no clue if this was calories expended or calories consumed. For clinicians, these kinds of ambiguities are show stoppers that lock up the potential of digital health data.

In addition, data from the devices themselves are stored in silos, meaning that it is not easy for patients or clinicians to combine and view multiple data streams together. Blood pressure from one device isn’t syncing with weight data from another, which can lead to an incomplete picture of a patient’s health over time.

If we strive for greater interoperability with a common language and structure for both understanding and integrating digital health data, we can help to bring clinical and patient needs together for better health-care outcomes.

Continue Reading »

Bioengineering, Cardiovascular Medicine, Stanford News, Technology

Writing a “very specific sentence” is critical for good biodesign

Writing a "very specific sentence" is critical for good biodesign

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.

1 After several weeks spent following doctors through cardiovascular disease clinics, Debayan Saha, Shashi Ranjan, PhD, and Harsh Sheth, MD, together identified 315 apparent medical needs ranging from better ways of monitoring patients to improvements of existing devices. During the course of their six-month fellowship, they’ll develop a prototype device to solve just one.

The first step toward picking that one is to better define the 315.

This is more complicated than it seems. For example, one of the needs they’d originally written down involved real-time monitoring of certain molecules in the patient’s blood. They revised that phrasing because it defined the solution – real time – rather than the problem, which is the need for doctors to have more accurate information about the patient’s blood so they can make better treatment decisions. “One solution to the problem might be real-time, but there might be another way,” Sheth said.

Similarly, another need they identified had to do with a device that was inconvenient for doctors to use during a medical procedure. Did they need to improve the device to make a procedure more efficient, or was the need specifically for a smaller device? With another device, they debated whether the real need was to reduce the patient’s pain or to reduce the blood loss.

Some of these decisions might sound like splitting hairs – whether the problem is pain or blood loss, there is a clear need for a better device. But the distinction makes a difference down the road. If they chose to focus on the pain rather than the blood loss, that would effect what insurance will pay for its use and intellectual property – factors that make a difference in whether or not a device can get funding and eventually reach patients.

“We need a very specific sentence to make very clear the need we are trying to solve,” Saha said.

Eventually the team will sort through this list of needs to identify the single focus of the remainder of their time.

One thing I found interesting: In fourteen years of the program, each year with several teams working on the same medical field, no two teams have ever developed devices to satisfy the same need.

Previously: Good medical technology starts with patients’ needs and Biodesign program welcomes last class from India
Photo of Shashi Ranjan and Harsh Sheth on a clinical visit by Kurt Hickman

Cardiovascular Medicine, In the News, Medical Apps, Research, Stanford News, Technology

MyHeart Counts app debuts with a splash

MyHeart Counts app debuts with a splash

At Stanford Medicine, we’ve been anticipating the debut of MyHeart Counts, an iPhone app and cardiovascular research study, for some time. The researchers told us it had the potential to be the largest study of measured physical activity and heart health, and we were pretty darn excited. And we were also pleased to see the buzz surrounding Apple’s Monday morning announcement of ResearchKit, the app’s open source software host. Both MyHeart Counts and ResearchKit have been warmly received by both the tech and medical community and, just days after its release, the number of MyHeart Counts users is already in the tens of thousands.

We’re talking about data in medical research that’s never been encountered before

“Following the news, many researchers who spoke to The Huffington Post could barely contain how thrilled they were about the new iPhone feature, calling it ‘revolutionary,’ ‘groundbreaking’ and a ‘new dawn’ when it comes to scientific research,”  wrote on Tuesday. She went on to outline seven ways ResearchKit could change research for the better, and she quoted Stanford’s Alan Yeung, MD, an app architect and medical director of the Stanford Cardiovascular Health:

In most medical studies, 10,000 is a large number, but if we can really hit our mark and have a million people download it, you can do much larger population studies than anything that has been done in the past. So even though we might be slightly restricted in the beginning, we have plans to reach everybody in the world if possible.

This amount of data has never been available before, and if we multiply it by a million, let’s say, we’re talking about data in medical research that’s never been encountered before.

Enrolling 10,000 people in a medical study would normally take a year and the collaboration of at least 50 medical centers, Yeung told Bloomberg. “That’s the power of the phone.”

He said he also believes the app will make it less likely for participants to enter false reports because the device itself will keep track of their exercise. Researchers also plan to test how best to help people modify their behavior.

And the app isn’t just for avid techies or exercise enthusiasts. Physician-blogger Mike Sevilla, MD, wrote earlier this week that ResearchKit has the potential to improve medical care. “Imagine the synergy that will be created with the right app technology, engaged patients and interactive medical teams. Just mind blowing… The potential here is limitless.”

Strong words for a strong app. Check it out for yourself (there’s more info in the video above), because, yes, your heart counts.

Previously: Stanford launches iPhone app to study heart health, Even moderate exercise appears to provide heart-health benefits to middle-aged women and What needs to happen for wearable devices to improve people’s health?
Image by Ken

Cardiovascular Medicine, Research, Stanford News, Technology

Stanford launches iPhone app to study heart health

Stanford launches iPhone app to study heart health

Dr. Alan Yeung,  MD., Chief (Clinical) Division of Cardiovascular Medicine Interventional Cardiology,and Dr Michael McConnell, MD.,  with a new health app for iPhone on Thursday, February 26, 2015. ( Norbert von der Groeben/ Stanford School of Medicine )

A new, first-of-its-kind iPhone app, designed by Stanford Medicine heart experts as a fun way for users to learn about their own heart health while at the same helping to advance the field of cardiovascular medicine, was launched today.

The app, called MyHeart Counts, takes advantage of the iPhone’s built-in motion sensors to collect data on physical activity and other cardiac risk factors for a research study. It’s now available for free in the App Store. As I describe in our press release:

The free app uses the new ResearchKit framework announced today by Apple to present users with a simple way to participate in the study, complete tasks and answer surveys from their iPhone. The app will deliver a comprehensive assessment of each user’s heart health and provide information on how to improve it. It will also be used to study various methods — designed to be both easy and fun — for using smartphones and other wearable devices to enhance heart-healthy habits.

“MyHeart Counts aims to be the largest study of measured physical activity and cardiovascular health to date,” [said Stanford cardiologist Michael McConnell, MD, lead investigator for the study]. “We want people to join in this research effort to give fundamental new insights into how activity helps your heart, across all ages, genders, cultures and countries.”

Users start by providing some basic health information – age, weight, blood pressure – all kept confidential, and are then asked to record a week of activity. The app in return provides the user with a number representing their “heart age.” For example, if you’re 40 years old, and your heart age is reported as 20 years, that’s good news. If those numbers are reversed, there might be something to worry about.

The ultimate goal of the study, McConnell and his collaborator Alan Yeung, MD, told me, is to provide scientific evidence as to the effectiveness of the myriad methods of behavioral motivation techniques marketed through wearable devices to improve health. The idea is to use hard data to find out what really works:

Recently, there has been an explosion in the marketing of wearable devices to record and report information about behaviors, such as physical activity or sleep patterns, to improve health, but there is limited scientific evidence available to show whether they are effective, McConnell said.

As a physician who regularly sees patients in the clinic, McConnell knows first hand how hard it can be to change a patient’s behavior. Physical activity has been shown to be far more effective in improving health than medication, but getting patients to be more active isn’t easy.

“Preventive medicine hasn’t worked by having doctors make to-do lists for their patient, then seeing them six months later and hoping they did everything on the list,” McConnell told me. “The future needs a much more ongoing engagement with people’s health. We need to understand how to reach out to modify behavior long before we end up having to see someone for a heart attack or stroke.”

Previously: Lack of exercise shown to have largest impact on heart disease risk for women over the age of 30
Photo, of Alan Yeung (left) and Michael McConnell, by Norbert von der Groeben

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