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Patient Care, Pregnancy, Stanford News, Women's Health

New obstetric hemorrhage tool kit released today

New obstetric hemorrhage tool kit released today

pregnantbelly-3A few years ago, when my niece was born, my sister had a severe postpartum hemorrhage. I remember getting off the phone with my mom, who had just delivered the simultaneous news of the baby’s birth and my sister’s serious condition, and feeling terrified. My sister was being taken into surgery to try to stop the bleeding. What if she died? In the U.S., deaths from postpartum hemorrhage are rare, but they do happen.

The first thing that gave me a sense of reassurance, strangely, was a search of the medical database PubMed. After I got off the phone, I sat at my laptop looking at a multicolored flow chart that summarized how to stop an obstetric hemorrhage. All of the steps taken by my sister’s medical team were listed. Although she was hundreds of miles away, I felt comforted by the knowledge that her doctors were following well-established, evidence-based guidelines for what to do.

It wasn’t until a few minutes later that I realized the flow chart was developed by doctors I know. It was part of the Obstetric Hemorrhage Toolkit, a set of guidelines published by the California Maternal Quality Care Collaborative (CMQCC). I had first heard of the toolkit from a Stanford obstetric anesthesiologist who helped put it together, but had never imagined it might save someone in my family.

The toolkit was developed because maternal hemorrhages are rare, risky, and extremely time-sensitive. The kit gives medical teams the information they need to rehearse for, recognize and treat these hemorrhages immediately, without wasting minutes that could save the patient’s life.

Today, the CMQCC is releasing a new version of the toolkit. The update strengthens several areas of the kit, providing clearer parameters for use of certain medications and blood products and more information about how to support patients and families after a maternal hemorrhage, for instance.

And the flow chart I found calming is still there, on page 21 of this .pdf file. I’m so happy to see it again because, for me, it symbolizes the doctors, patients and families who will benefit from the kit in the future.

As for my family’s story, my mom called back later on the evening of my niece’s birth to tell me that the bleeding had stopped and my sister was recovering. Her introduction to motherhood was rougher than most, but today my sister and her daughter are fine: My favorite moment of a recent family gathering was seeing my chubby-cheeked niece racing toward me yelling “Aunnnnntie Errrrin!” with my beloved sister in hot pursuit behind her.

Previously: In poorest countries, increase in midwives could save mothers and their babies, Cardiac arrest in pregnancy: New consensus statement addresses CPR for expectant moms and Program focuses on treatment of placental disorders
Photo by bies

Cancer, Genetics, In the News, Women's Health

Angelina Jolie Pitt’s New York Times essay praised by Stanford cancer expert

Angelina Jolie Pitt's New York Times essay praised by Stanford cancer expert

4294641229_c78b406658_zYou’ve likely heard today about Angelina Jolie Pitt’s New York Times essay regarding her decision to have her ovaries and fallopian tubes removed. Women who carry mutations in the BRCA1 or BRCA2 genes have a significantly increased risk for breast and ovarian cancer; Jolie carries such a mutation, and in 2013 she shared publicly her decision to have her breasts removed to reduce her risk of cancer.

Jolie Pitt shares her decision-making process and notes that though she won’t be able to have any more children and though she still remains prone to cancer, she feels “at ease with whatever will come.” She closes her latest essay by writing, “It is not easy to make these decisions. But it is possible to take control and tackle head-on any health issue. You can seek advice, learn about the options and make choices that are right for you.”

After reading the piece I reached out to Stanford cancer geneticist Allison Kurian, MD, who told me:

Angelina Jolie made a very courageous decision to share her experience publicly.  The surgery she chose is strongly recommended for all women with BRCA1/2 mutations by age 40, since it’s the only way to prevent an ovarian cancer in these high-risk women, and early detection doesn’t work. This is a life-saving intervention for high-risk women.

Kurian is associate director of the Stanford Program in Clinical Cancer Genetics and a member of the Stanford Cancer Institute. In 2012 she published on online tool to help women with BRCA mutations understand their treatment options.

Previously: Helping inform tough cancer-related decisions, NIH Director highlights Stanford research on breast cancer surgery choices and Breast cancer patients are getting more bilateral mastectomies – but not any survival benefit
Photo by Marco Musso

Cardiovascular Medicine, In the News, Pediatrics, Surgery

Marathon surgery at Stanford gives 6-year-old boy a chance to thrive

Marathon surgery at Stanford gives 6-year-old boy a chance to thrive

image.img.320.highA rare chromosomal disorder called Williams syndrome left 6-year-old Jordan Ervin with a host of medical problems, including severe heart defects. But it also gave him a gregarious personality and an infectious smile, one that made the multiple medical appointments and hospitalizations much easier to handle, according to his mother, Seville Spearman.

“Jordan is such a champ,’’  Spearman said in a recent Inside Stanford Medicine article. “He’s always been just a really happy kid.”

And in December, he became a much healthier one thanks to the skillful work of Stanford cardiothoracic surgeon Frank Hanley, MD. More from the piece:

It was a complicated case. The stenotic arteries caused severe pulmonary hypertension. In less-severe cases, in which there is only one area of stenosis near or at the pulmonary valve, doctors can perform a fairly simple surgical catheter procedure that uses a tiny balloon to expand the artery. But Jordan had multiple narrowings: 12 in his left lung and 14 in the right lung. The balloon technique is much less effective in this scenario, and no other surgical techniques have been developed to treat these stenoses. So Jordan would need a different approach.

That approach was developed by Hanley, who receives referrals from all over the world. He’s the pioneer of a one-stage, fix-all-the-defects surgery called unifocalization.

“We’re definitely on the leading edge of this kind of surgery,’’ said Hanley, who holds the Lawrence Crowley, MD, Endowed Professorship in Child Health. “Jordan is going to have perfectly normal life expectancy.”

Ervin is back in school in Illinois, where his parents are delighted with the outcome. His mother said in the story, “Everything is back to normal, but I will never take anything for granted again.”

Previously: How better understanding Williams syndrome could advance autism research, Pediatric surgeon fixes “heart that can’t be fixed” and Patient is “living to live instead of living to survive,” thanks to heart repair surgery
Photo by Norbert von der Groeben

Cardiovascular Medicine, Chronic Disease, Genetics, Public Health, Research

International team led by Stanford researchers identifies gene linked to insulin resistance

International team led by Stanford researchers identifies gene linked to insulin resistance

261445720_2f253a1336_zBack in the 1970s and 1980s, Stanford’s Gerald Reaven, MD, had the darndest time convincing others that type 2 diabetes wasn’t caused by a lack of insulin. No one would believe him that, as we now know, type 2 diabetics are insulin resistant — their cells no longer respond to insulin’s cue to take in glucose.

Fast-forward a few years. Insulin resistance has been implicated in a slew of symptoms such as high blood pressure and heart troubles known as metabolic syndrome — it isn’t just a problem for diabetes. Scientists knew that about half of insulin resistance was governed by weight, exercise and diet. But the heredity half was a mystery — until now.

Thanks to an international collaboration and many months of work, a team of researchers led by Joshua Knowles, MD, PhD, and Thomas Quertermous, MD, have found the first gene known to contribute to insulin resistance. It’s called NAT2, and when mutated, it leads to a greater chance for carriers to become insulin resistant.

From the release:

“It’s still early days,” Knowles said. “We’re just scratching the surface with the handful of variants that are related to insulin resistance that have been found.”

Researchers found NAT2 by compiling data from about 5,600 individuals for whom they had both genetic information and a direct test of insulin sensitivity. Measuring insulin sensitivity takes several hours and is usually done in research settings. No genes met the high standards demanded by genome-wide association studies. Yet NAT2 appeared promising, so researchers followed up with experiments using mice.

When they knocked out the analogous gene in mice, the mice’s cells took up less glucose in response to insulin. These mice also had higher fasting-glucose, insulin and triglyceride levels.

“Our goal was to try to get a better understanding of the foundation of insulin resistance,” Knowlessaid. “Ultimately, we hope this effort will lead to new drugs, new therapies and new diagnostic tests.”

Previously: New insulin-decreasing hormone discovered, named for goddess of starvation, Stanford researchers identify a new pathway governing growth of insulin-producing cells and Faulty fat cells may help explain how type 2 diabetes begins
Image by Andy Leppard

Health Costs, Health Policy, In the News, Patient Care, Public Health

Health-care policy expert Arnold Milstein weighs in on Medicare’s plan to prioritize “value over volume”

Health-care policy expert Arnold Milstein weighs in on Medicare's plan to prioritize "value over volume"

8266476742_4967a82707_zAmerican health-care spending is the highest in the world, yet some question whether that money really leads to improved patient outcomes. But significant reforms taking place within Medicare, the US’s biggest healthcare payer, over the next few years aim to quell these concerns and reduce costs while improving quality of care.

Health policy experts explained the context of these changes last week in a webinar hosted by Reporting on Health and supported by the NIH’s Health Care Management Foundation. The panel featured Stanford’s Arnold Milstein, MD, MPH, director of the Clinical Excellence Research Center, as well as health economist Austin Frakt, PhD, professor at Boston University School of Medicine, and Jordan Rau, a correspondent for Kaiser Health News.

Health-care’s dominant “fee for service” (FFS) model has been around “since doctors were getting paid in chickens,” said Rau in the webinar, but it has no link whatsoever to quality. Many think this model needs to be changed because it incentivizes physicians to do more (and more expensive) procedures, regardless of the effect they have on patient outcomes. “Better, less expensive care is a national imperative,” said Milstein. “The cost to society of inefficiently delivered care is creating enormous opportunity cost.”

Starting in 2011, Medicare began to tie payments to quality: Doctors get paid 2 percent more if quality goes up, and 6 percent less when it goes down, based on patient ratings and rates of readmission and infection. In 2014, quality-linked FFS accounted for around 80 percent of care, of which around 20 percent featured some more radical change. The new plan is that 50 percent of payments will be non-FFS by 2018.

Options to reform this model could include bundled fees (a flat rate per “episode” that includes all complications and follow-up care), accountable care organizations (ACOs) that take responsibility for all patient needs and costs, incentives for cross-provider cooperation, and population-based payment in which doctors receive a set fee for any patient (currently being pioneered in Maryland).

How will we know which changes to push? Milstein used a graph to indicate “positive value outliers,” institutions with high quality and low cost, whose strategies and techniques will be emulated to see if they can be effective elsewhere. He explained what researchers found makes them different:

[Positive value outliers] tended to have deeper, more personal relationship with their patients; their patients trusted that if they called these doctors on nights and weekends, someone who knew something about them would be rapidly responsive. Doctors’ vision of their responsibility to their patients extended far beyond producing a perfect office visit; it really meant being a steward for their patients’ best interests as their patients traversed emergency room doctors, hospitalists and medical specialists. And lastly, these doctors were not trying to be solo heroes – they did a wonderful job hiring and training medical assistants and taking advantage of a team… and it was associated with a substantial improvement in value. Our next step is to splice this DNA into average performing primary care practices and verify that this is indeed the right stuff.

Some other ideas for achieving the targets were mentioned, such as sending physicians to homes so patients don’t get admitted, or in the longer term, having an intensive-care unit (ICU) “airline control tower” with more perspective than those on the “frontline” of critical care, an idea Milstein said was studied across 56 American ICUs and resulted in a 25 percent mortality reduction.

Milstein said such approaches could lower baseline health-care costs by 30 percent, but moreover could slow the rate at which health-care spending outgrows the economy, which is the real measure of success. Innovators in this area, he said, will need to draw from behavioral and computer science to think about problems differently.

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Events, Pediatrics, Public Health, Research, Stanford News

Countdown to Childx: Q&A with pediatric health expert Alan Guttmacher

Countdown to Childx: Q&A with pediatric health expert Alan Guttmacher

jumpforjoyIt’s just a few weeks until the inaugural Childx conference, a TED-style meeting at Stanford that will highlight innovations in health problems of pregnancy, infancy and childhood. (Conference registration for the April 2-3 event is still open, with details available on the conference website.) Childx is attracting nationally and internationally prominent speakers: keynotes will be given by Alan Guttmacher, MD, head of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and by Rajiv Shah, MD, former head of USAID.

I spoke recently with Guttmacher about the upcoming conference. Because I spend most of my time working with scientists who focus their attention on specific research niches within obstetric and pediatric medicine, I was interested in getting his take on the “big picture” of these fields. An edited version of our conversation is below.

What are you planning to say in your keynote address at the Childx conference?

Children’s lives are about more than just health. While biomedical research is crucial to improving kids’ lives, we should put it in the larger context of kids’ lives and do not just research that has an impact on health, but also on children’s overall well-being.

Within the health sphere, I’ll talk about several areas where we need more research. We need to study how to do a better job of preventing prematurity, both to gain a better understanding of biological and environmental causes of preterm birth, and also of how to do a better job of employing the knowledge we already have.

Another topic I’ll address is vaccination: How do we both pursue the science of vaccination to figure out how to make more vaccines more effective, and also, how do we work with parents so they make decisions about kids’ lives that are in the best interests of the kids and are evidence based, rather than based on, say, something they recently read on the web?

I’ll also discuss the developmental origins of health and disease. Pediatricians have always been very invested in anticipatory guidance, telling families about the kinds of things to do to prevent future disease for their children. But this goes farther; this is the idea that health factors, not only in childhood but even in utero, have lifelong impact on health. For instance, what happens in pregnancy potentially has large impact on whether someone develops hypertension in their 60s or 70s. We’re beginning to do science that will tell us the connections between early factors and later health, that will actually influence health along the entire age span. It’s an area of very important research.

And I’ll address intellectual and developmental disabilities. We need research to figure out how to more effectively prevent intellectual and developmental disabilities, research to understand how to allow kids who have these disabilities to function more effectively in society, and also research to figure out how to have society function better in the lives of kids with intellectual and developmental disabilities.

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Events, In the News, Medical Education, Medical Schools, Stanford News

Match Day at Stanford sizzles with successful matches & good cheer

Match Day at Stanford sizzles with successful matches & good cheer

Rowza Rumma, hugs Jennifer DeCoste-Lopez, at Match Day 2015 at Stanford School of Medicine on March 20, 2015. ( Norbert von der Groeben/Stanford School of Medicine )Across the country at the exact same time — 9 AM in California — on the third Friday in March, graduating medical students assemble for Match Day, the day they receive their assignments to residencies.

It’s a spectacle — a cross between a graduation celebration replete with champagne and balloons and a theater audition with tears and heartbreak. The Stanford students, no surprise, are top-notch, so there were more grins than groans and plenty of congratulations and good cheer for all.

The stats themselves stand out: 77 students were matched Friday and they’re heading to 14 states, with California and Massachusetts leading the list. (A map showing where everyone is headed is below.) General medicine is the most popular specialty, followed by anesthesia, neurosurgery and pediatrics. No Stanford students were matched in urology, radiology and psychiatry.

Before the event, I checked in with two graduating students, Mia Kanak and Rowza Tur Rumma. Both are accomplished health professionals with interesting backgrounds and plans to make the world a better place. Kanak is a Tokyo native who hopes to help impoverished children. Rumma wants to translate the success of the world’s best operating rooms into practices that work in the poorest nations.

As I wrote in a story:

For [Rumma], the day was both exciting and nerve-wracking. “I think it’s hard to not have the jambalaya of those issues in our minds,” she said. Clutching the red envelope and a cell phone, she was dialing repeatedly, trying to get in touch with her parents in Bangladesh to share the moment with them.

Finally, her father on the phone, Rumma slit open the envelope, a relieved grin spreading across her face. “It’s Brigham,” she said, her first choice. Brigham and Women’s Hospital offers opportunities for its surgical residents to specialize in global health, just the program Tur Rumma was hoping for. For the residency, she was interviewed by Atul Gawande, the well-known author and surgeon, and was able to discuss her work during a summer program in Bangladesh, where she worked to implement — and adapt — a checklist of steps to reduce surgical complications adopted by the World Health Organization.

Kanak also secured her first choice, a berth in the Boston Children’s Hospital‘s pediatrics program.

“I want to say how proud all of us at Stanford Medicine are of your accomplishments today,” Dean Lloyd Minor, MD, told the group after envelopes had been torn open. “And now, on behalf of everyone, a toast to your success, to the impact you’re going to have on the lives of so many people moving forward: Best wishes!”

View Stanford Residency Match Day 2015 in a full screen map

Previously: Stanford Medicine’s Match Day, in pictures, It’s Match Day: Good luck, medical students!, At Match Day 2014, Stanford med students take first steps as residents and Image of the Week: Match Day 2012
Photo of Rowza Tur Rumma by Norbert von der Groeben; map by Kris Newby

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

Events, Medical Education, Stanford News

Stanford Medicine’s Match Day, in pictures

Stanford Medicine's Match Day, in pictures

There was a lot of excitement at the medical school campus today, where 77 students found out where they’ve been “matched” for their residencies. Norbert von der Groeben captured the celebration through a series of photos; watch for more on the morning’s event here on Monday.

Previously: It’s Match Day: Good luck, medical students! and At Match Day 2014, Stanford med students take first steps as residents

In the News, Pain, Patient Care, Research

More benefit than bite: Potential therapies from “pest” animals

More benefit than bite: Potential therapies from "pest" animals

512px-Scary_scorpionA painful spider bite can make you question why such creatures exist. Yet just because “pests” like spiders, scorpions, and snakes lack the appeal that kittens and puppies possess, it doesn’t mean they aren’t important or useful.

Yesterday, an article from Medical News Today drove this message home by highlighting some of the medical benefits we derive from six of the creatures we tend to complain the most about. As writer Honor Whiteman explains in the story, scientists are exploring ways to use toxins and substances produced by so-called pest animals, such as spiders scorpions, and reptiles, to treat chronic pain, repair nerves, and develop new ways to kill the human immunodeficiency virus.

From the piece:

In 2013, MNT [Medical News Today] reported on a study published in Antiviral Therapy, in which researchers revealed how a toxin found in bee venom – melittin – has the potential to destroy human immunodeficiency virus (HIV).

The investigators, from the Washington University School of Medicine, explained that melittin is able to make holes in the protective, double-layered membrane that surrounds the HIV virus. Delivering high levels of the toxin to the virus via nanoparticles could be an effective way to kill it.

A more recent study published in September 2014 claims bees may also be useful for creating a new class of antibiotics. Researchers from the Lund University in Sweden discovered lactic acid bacteria in fresh honey found in the stomachs of bees that has antimicrobial properties.

The story cites several other potential uses for venoms and animal-derived substances, such as my favorite example, Gila monster spit:

In 2007, a study by researchers from the University of North Carolina at Chapel Hill School of Medicine revealed how exenatide – a synthetic form of a compound found in the saliva of the Gila monster, called exendin-4 – may help people with diabetes control their condition and lose weight.

The compound works by causing the pancreas to produce more insulin when blood sugar is too high. In the study, 46% of patients who were given exenatide in combination with diabetes drug metformin had good control of their blood sugar, compared with only 13% of control participants.

As Whiteman explains in the article, many of these potential medical treatments are still in the early stages of development. Yet some therapies, such as the synthetic version of the compound found in Gila monster saliva, exenatide, are already in use, offering hope that other animal-derived medical treatments may be available in the future.

Previously: Tiny fruit flies as powerful diabetes modelFruit flies headed to the International Space Station to study the effects of weightlessness on the heartBiomedical Indiana Jones travels the world collecting venom for medical research and Tarantula venom peptide shows promise as a drug
Photo by H Dragon

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