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Events, Medicine and Literature, Medicine and Society

Intersection of arts and medicine a benefit to both, report finds

Intersection of arts and medicine a benefit to both, report finds

An article today on Cleveland.com notes that, at least in Northeast Ohio, collaboration between medicine and the arts benefits both camps as well as the region’s economic health. A preliminary report from the non-profit Community Partnership for Arts and Culture looks at ways art and medicine enrich one another in Cleveland and provides recommendations for enhancing those partnerships. From the news piece:

The report identifies four principal ways in which the art and medicine intersect productively:

• The use of arts and culture in medical settings;

• Participatory programs that involve patients and communities in activities and therapies that promote positive medical outcomes and general wellness;

• The potential shown by arts and culture to serve as a rallying point from which public health and social equity can be addressed; and

• The enrichment of medical training.

Meanwhile, at Stanford, art and science lovers prepare for this evening’s Medicine and the Muse symposium, featuring author Khaled Hosseini, MD. Stay tuned for a recap on Scope next week.

Previously: Stanford’s Medicine and the Muse symposium features author of “The Kite Runner”, Literature and medicine at life’s end and Thoughts on the arts and humanities in shaping a medical career

Autism, Behavioral Science, Pediatrics, Stanford News

Home videos could help diagnose autism, says new Stanford study

Home videos could help diagnose autism, says new Stanford study

Autism is more complex to diagnose than many other childhood conditions. There’s no physical sign or lab test; rather, making the diagnosis requires careful observation for clues such as poor language and social skills or repetitive behaviors. Standard diagnostic tests take several hours of a professional’s time, and families may wait months to see someone who can assess their child.

But new research from Stanford and Harvard Medical School suggests that faster diagnoses might become possible. The research team, whose findings appear today in PLOS ONE, tested whether short home videos could be harnessed to speed the process. Using a scoring system that was pared down from the “gold standard” diagnostic test, they assessed kids’ behavior in 100 short videos pulled from YouTube. About half of the videos showed children with autism; the rest did not. The scoring system classified 97 percent of the videos accurately.

The system is unlikely to replace traditional diagnostic methods, but could help relieve the diagnostic bottleneck, study author Dennis Wall, PhD, explained in our press release:

“For instance, we could use this system for clinical triage, as a way to channel traffic so that children can get the kind of attention they need as early as possible,” Wall said. Children who clearly have autism might be diagnosed primarily with videos and quickly started on therapy, freeing clinicians to spend more time evaluating children whose diagnosis is less clear-cut.

Home videos also provide information that is otherwise unavailable to those making the diagnosis, Wall said:

Another potential advantage of using video for diagnosis is that young children often behave differently in a doctor’s office than at home.

“Clinical settings are often stark, artificial and can elicit behaviors that are abnormal,” Wall said. “The odds are stacked against the diagnostic professional because the child is in an unknown environment with strangers.”

The researchers plan to explore whether the same method could also be used for making other behavior-based diagnoses, such as detecting attention-deficit hyperactivity disorder or adult-onset neurologic conditions such as Alzheimer’s or Parkinson’s disease.

Previously: Using Kinect cameras to automate autism diagnosis, Director of Stanford Autism Center responds to your questions on research and treatment and New imaging analysis reveals distinct features of the autistic brain

Dermatology, Ethics, Health Costs, Research, Stanford News

Drug samples lead to more expensive prescriptions, Stanford study finds

Drug samples lead to more expensive prescriptions, Stanford study finds

drugs on money - big

It’s been years (fortunately) since I’ve needed a prescription for anything more than a simple antibiotic. But when I did, I remember I was always thankful on those occasions when my doctor offered a free sample of a medication to try before (or sometimes instead of) pulling out the prescription pad. I appreciated the chance to see if a medication would work for me, and I was happy for any opportunity to save myself (or, at times, my insurance company) a few dollars. The fact that the samples were invariably for drugs that were still on patent (known as brand name drugs or branded generics) to a particular company certainly escaped me.

Now, a study by Stanford dermatologist Al Lane, MD, highlights the dark side of such free samples, which are provided to doctors by the pharmaceutical companies who make the drugs. The research, along with an accompanying editorial, is published today in JAMA Dermatology. As Lane comments in my release on the work:

Physicians may not be aware of the cost difference between brand-name and generic drugs and patients may not realize that, by accepting samples, they could be unintentionally channeled into subsequently receiving a prescription for a more expensive medication.

Specifically, Lane and medical student Michael Hurley found that dermatologists with access to free drug samples wrote prescriptions for medications with a retail price of about twice that of prescriptions written by dermatologists without access to samples. All of the patients had the same first-time diagnosis of adult acne. The difference is nothing to sniff at – $465 for docs who accepted samples and about $200 for docs who did not. What’s more, the overall prescribing patterns of the two groups of physicians showed almost no overlap. Physicians without access to samples prescribed mainly generic drugs (83 percent of the time), whereas those with access to samples prescribed generics much less frequently (21 percent of the time). Only one drug of the top ten most commonly prescribed by physicians without access to samples even made it into the top ten list of physicians who did accept samples.

The distribution of free drug samples in this country is big business. It’s been estimated that pharmaceutical companies give away samples of medications with a retail value of about $16 billion every year. But many physicians feel the availability of samples doesn’t sway their prescribing choices, and instead feel the samples allow them more flexibility to treat their patients. Lane himself thought so, until Stanford Medicine prohibited physicians to accept samples or other industry gifts in 2006. As he explains in the release:

At one time, we at Stanford really felt that samples were a very important part of our practice. It seemed a good way to help poorer patients, who maybe couldn’t afford to pay for medications out-of-pocket, and we had the perception that this was very beneficial for patients. But the important question physicians should be asking themselves now is whether any potential, and as yet unproven, benefit in patient compliance, satisfaction or adherence is really worth the increased cost to patients and the health-care system.

Clearly Lane has had a change of heart, in part based on the data in the study. Now he’s hoping to get the word out to other physicians. He and Hurley conclude in the paper, “The negative consequences of free drug samples affect clinical practice on a national level, and policies should be in place to properly mitigate their inappropriate influence on prescribing patterns.”

Previously: Consumers’ behavior responsible for $163 billion in wasteful pharmacy-related costs and Stanford’s medical school expands its policy to limit industry access
Photo by StockMonkeys.com

Cancer, In the News, Patient Care

Is cancer too complex for targeted therapies?

Cancer. It’s been called “The Big C,” but the more we study it, the more it resembles hundreds of little c’s, each with its own unique molecular makeup. The differentiation exists both among patients with cancers in the same site (the various sub-types of breast cancer, for example) as well as within a single patient. This latter phenomenon is referred to as “intra-patient tumor heterogeneity,” and it has profound implications for the future of cancer treatment, including the viability of so-called “targeted therapies” receiving so much attention and hope.

Many cancer tumors tend to be chaotic mixes of different cell types, some more aggressive – and therefore more dangerous – than others. Chemotherapy and the emerging category of more specific “targeted therapeutics” work by acting on a known characteristic of a particular cancer cell type, like accelerated replication rates or a specific genetic mutation.  But in a complex tumor, not all cells will exhibit that specific characteristic, or at least not do so at the same time. Also, it is possible for cancer cells to adapt and become resistant to a particular therapy, in a partially analogous way in which evolution works on a macroscopic scale.

A recent opinion piece published online in the journal The Scientist points out that intra-patient heterogeneity can also involve treatment-relevant difference between the primary tumor and metastases, as well as among metastases. Written by Stanford Cancer Institute Director Beverly Mitchell, MD; David Rubenson, associate director for administration and strategic planning; and Daniel S. Kapp, MD, professor emeritus of radiation oncology at Stanford, the article discusses these matters in detail and lays out many of the significant scientific and clinical questions surrounding the potential for treating cancers with targeted therapies. This fall, the Stanford Cancer Institute will convene an international symposium to discuss these questions and a range of related issues.

Information on the symposium, titled “Intra-patient Tumor Heterogeneity: Implications for Targeted Therapy,” will soon be available on the Stanford Cancer Institute website.

Previously: Director of the Stanford Cancer Institute discusses advances in cancer care and research

In the News, Neuroscience, Technology

Facial expression recognition software could predict student engagement in learning

Facial expression recognition software could predict student engagement in learning

bored faceTest day approaching? Get your game face on. A study of a computer program that recognizes and interprets facial expressions has found that identifying students’ level of engagement while learning may predict their performance in the class. Computer scientists at the University of California, San Diego and Emotient, a San Diego-based company that developed the facial-recognition software used in the study, teamed with psychologists at Virginia Commonwealth and Virginia State universities to look at “when and why students get disengaged,” study lead author Jacob Whitehill, PhD, researcher in UC San Diego’s Qualcomm Institute and Emotient co-founder, said in a release.

The authors write in the study, which was published in an early online version in the journal IEEE Transactions on Affective Computing:

In this paper we explore approaches for automatic recognition of engagement from students’ facial expressions. We studied whether human observers can reliably judge engagement from the face; analyzed the signals observers use to make these judgments; and automated the process using machine learning.

“Automatic engagement detection provides an opportunity for educators to adjust their curriculum for higher impact, either in real time or in subsequent lessons,” Whitehill said in the release. ”Automatic engagement detection could be a valuable asset for developing adaptive educational games, improving intelligent tutoring systems and tailoring massive open online courses, or MOOCs.”

Previously: Looks of fear and disgust help us to see threats, study showsProviding medical, educational and technological tools in Zimbabwe and Whiz Kids: Teaching anatomy with augmented reality
Photo by Jesús Gorriti

Medical Education, SMS Unplugged

My fifth-year comeback

My fifth-year comeback

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

gallegos_blog3In a little over a month I’ll be finishing my master’s program; 10 days later I start the first rotation of my fourth year. I’ve begun to feel a mix of emotions. Anxiety as I review medical topics, trying to bring them out of distant corners in my memory where (I hope) they still exist. Excitement at the idea of getting back to patient contact, which even through the stress of being a medical student I have never doubted is where I want to be. To psych myself up, I’ve reflected on the clerkships that I’ve completed (read: survived); below are lessons, encounters and unforgettable moments that I’m blessed to have experienced.

Pediatrics: Yes, it was difficult to see kids when they were sick. It was also hard to complete a physical exam on fussy children. The laughter and high-fives made up for both, though. Even patients with chronic illness were inspirational, resilient and great to sit and talk with. What made my peds rotation even better: the wooden heart that a patient decorated for me, thinking that I was her “real doctor.” Win.

Psychiatry: While I completed my rotation in a locked ward, I never felt threatened around the patients. On the contrary, I was surprised by the connections that I formed with them. My takeaway memory:
Me to my wandering schizophrenia patient: “Mr. H, do you know where you are? What day it is?”
Mr. H: “Yes, I do… Why? Are you not oriented yourself, Sir?”
Given how tired I was at the time… likely not. Touché.

Ob/GYN: At the risk of sounding pretentious, I’m proud I can say that I’ve helped bring life into this world. Childbearing and childbirth, in its complexity, is beyond beautiful. Overwhelming? Yes. Amazing? Definitely. I wasn’t able to convince any new mothers to name their children after me, but I was offered a job as a birthing nurse given my awesome coaching skills. We’ll see how med school works out.

Family Medicine: The level of connection  between the doctors I worked with and their patients was incredible. Working to address all the patients’ issues in short appointments was trying, and often impossible, but the gratitude of patients was humbling. It was interesting, too, to see the incorporation of complementary medicine – and try it out. Acupuncture? Check.

Surgery: The smell of post-op infections is something I’ll never forget. So is the time a grateful patient stopped me in a hospital corridor to remind me that I placed an NG tube for him (with success). Beyond unforgettable: massaging a patient’s heart through their chest after a thoracotomy. I don’t see myself as a future surgeon, but I respect the skill. Also hard to forget: tying many, many, knots (mostly on strings attached to nothing).

Medicine/Sub-I: The hardest yet most instructive month of my life. The level of responsibility for patients was overwhelming and empowering. I oversaw patients from tears on admission to smiles on discharge. I experienced for the first time the death of a patient along with a deeper connection with his family than I would have thought possible as a student. I don’t miss my pager going off many times, but I do miss that patients asked for me.

Going into clerkships I felt uneasy about being in a position to care for people given that I was still in the process of learning medicine. What I’ve come to realize is that often the medicine I learn in books is best utilized alongside other care we can offer: a conversation, an inviting smile, a genuine concern. I can’t wait to wear my Medical Student badge and white coat again.

Moises Gallegos is a medical student in between his third and fourth year. He’ll be going into emergency medicine, and he’s interested in public-health topics such as health education, health promotion and global health.

Photo box courtesy of Moises Gallegos

Global Health, Infectious Disease, Public Health, Research, Stanford News

Using video surveillance to gain insights into hand washing behavior

Using video surveillance to gain insights into hand washing behavior

13715-handwashing_newsSimply washing your hands can reduce the reduce respiratory illnesses, such as colds, in the general public by 21 percent, cut the number of people who get sick with diarrhea by 31 percent and lower diarrheal illness in people with weakened immune systems by 58 percent, according to data from the Centers for Disease Control and Prevention.

Despite these compelling facts, and many years of global awareness campaigns, hand-cleaning rates remain far below full compliance — particularly in low-income, developing world settings. But using video surveillance to observe hygiene practices can offers insights that may help improve design, monitoring and evaluation of hand-washing campaigns, according to a new Stanford study.

For the study, researchers installed video cameras at the washing stations outside latrines of four public schools in the Kibera slum of Nairobi, Kenya. Teachers were informed in advance and parents and administrators granted their permission for the experiment. Their findings were highlighted in a Stanford News article published yesterday:

  • Both video observation and in-person observation demonstrated longer hand cleaning times for hand washing with soap as compared to rubbing with sanitizer.
  • Students at schools equipped with soap and water, instead of sanitizer, were 1.3 times more likely to wash their hands during simultaneous video surveillance and in-person observation when compared with periods of in-person observation alone.
  • Overall, when students were alone at a hand-cleaning station, hand cleaning rates averaged 48 percent, compared to 71 percent when at least one other student was present.

Based on their findings, study authors recommended the following approaches for boosting hand washing:

  • Placement of hand cleaning materials in public locations
  • Scheduling specific times for bathroom breaks between classes
  • Designating specific students to be hand hygiene “champions”
  • Formation of student clubs to demonstrate and promote hand hygiene to classmates

Previously: Examining the effectiveness of hand sanitizers, Survey outlines barriers to handwashing in schools, Examining hand hygiene in the emergency department, Good advice from Washyourhandsington and Hey, health workers: Washing your hands is good for your patients
Photo by Amy Pickering

Autism, In the News, Pediatrics, Research

Using theater’s sensory experiences to help children with autism

Using theater's sensory experiences to help children with autism

Gesamkunstwerk, my favorite German word and a term commonly associated with the operas of Richard Wagner, can be translated as a “total work of art” playing to many of the senses and synthesizing numerous art forms. The word came to mind as I read about a pilot study using theater as an environment for children with autism-spectrum disorders  to explore “communication, social interaction, and imagination skills – the ‘triad of impairments’ seen in autism,” a New Scientist piece notes, “engaging all the children’s senses at once.”

Twenty-two children ages 7-12 attended one weekly 45-minute session for 10 weeks involving improvisation exercises led by trained performers in enclosed make-believe environments such as a forest or outer space.

From the piece:

As well as looking at whether behaviours used to diagnose autism changed after the drama sessions, the researchers also assessed emotion recognition, imitation, IQ and theory of mind – the ability to infer what others are thinking and feeling. Subjective ratings were also gathered from parents and teachers and follow-up assessments were conducted up to a year later.

At the early assessments, all children showed some improvement. The most significant change was in the number of facial expressions recognised, a key communication skill. Nine children improved on this. Six children improved on their level of social interaction. The majority of these changes were also seen at the follow-up assessments.

The project’s lead psychologist, David Wilkinson, PhD, at the University of Kent, told New Scientist, ”It’s an opportunity for children to create their own narratives in an unconstrained, unfamiliar environment.” He continued, “They find this empowering, and we know from the psychology literature that individuals who are empowered enjoy increased attention skills and an improved sense of well-being.”

Previously: Making museums more inviting for autistic children and their familiesStanford study reveals why human voices are less rewarding for kids with autismDirector of Stanford Autism Center responds to your questions on research and treatment and A mother’s story on what she learned from her autistic son

Behavioral Science, Ethics, Medicine and Society, Research, Stanford News

Breaking down happiness into measurable goals

Breaking down happiness into measurable goals

sunflowersSo you want to be happy. Can you be more specific? A study published in the Journal of Experimental Social Psychology found that concrete, rather than abstract, goals for happiness tend to be more successful. Jennifer Aaker, PhD, Stanford social psychologist and marketing professor, and colleagues performed six field and laboratory experiments and found that participants who performed specific acts of kindness – such as recycling or making someone smile – reported greater happiness than participants whose prosocial goals were less precise – such as helping the environment or people more broadly.

From a Stanford News article:

The reason is that when you pursue concretely framed goals, your expectations of success are more likely to be met in reality. On the other hand, broad and abstract goals may bring about happiness’ dark side – unrealistic expectations.

Acting directly and specifically in service to others brings greater happiness to the giver, the study found. The piece continues:

For example, an experiment involving bone marrow transplants focused on the whether giving those who need bone marrow transplants “greater hope” – the abstract goal – or giving those who need bone marrow transplants a “better chance of finding a donor” – the concrete goal – made a giver more happy.

The answer: Helping someone find a donor resulted in more happiness for the giver. This, the researchers wrote, was driven by givers’ perceptions that their actual acts better met their expectations of accomplishing their goal of helping another person.

Previously: Study shows happiness and meaning in life may be different goalsAre you happy now? Stanford Roundtable spotlights the science of happiness and wellbeing and Stanford faculty and students launch social media campaign to expand bone marrow donor registry
Photo by Iryna Yeroshko

Autoimmune Disease, Chronic Disease, Patient Care, Pediatrics

A wake-up call from a young e-patient: “I need to be heard”

We’ve partnered with Inspire, a company that builds and manages online support communities for patients and caregivers, to launch a patient-focused series here on Scope. Once a month, patients affected by serious and often chronic diseases share their unique stories. Our latest comes from 15-year-old Morgan Gleason, who lives with the autoimmune disease juvenile dermatomyositis. 

Before June 18, 2010, the day I was diagnosed, I knew the medical system the way that most kids do. I went to the doctor for immunizations, physicals, sore throats and bones that might be broken. Then, I developed a rash on my joints. I started sleeping more than normal, was very weak in my muscles, and experienced frequent stomachaches and headaches.

At the age of 11, after a year of these symptoms, I was diagnosed with a rare autoimmune disease called juvenile dermatomyositis. I suddenly was in a whole new medical system. I had to learn to swallow pills, wait for hours in doctors offices, spend nights in the hospital, worry about what was happening, deal with some not-so-nice doctors and nurses, and endure a lot of pain. I also watched my parents get frustrated with figuring out medical bills and trying to understand all of the claim statements and appeal denials.

Now I take 21 pills a day, get two infusions a month by an IV, and give myself an injection once a week. I have more specialists than my grandparents, and I spend a lot of time as a patient.

This January, I was hospitalized for the second time in four months for meningitis due to a reaction from a treatment I received. After four days of little sleep and an excruciating headache, I made a video about my hospital experience and posted it online. To my surprise, the video got a lot of attention. Forbes, Time, the Huffington Post and other outlets wrote about it. I believe that the video was popular because my experience was a common one and struck a nerve with others.

I am appreciative of the care I have been given. I love the hospital where I get my treatment, and I think it’s a great hospital. The medical students, residents, attending physicians, and specialists are great doctors. The nurses are also really great. This is not an issue with the individual people or hospitals. The issue is much bigger, and it’s the way the system as a whole is designed.

My video had a few main points. I was frustrated that I couldn’t get any rest in the hospital. The system is designed around the schedules of the doctors and the desire to discharge patients by noon instead of around the circumstances and needs of the patient. Second, the doctors come in individually instead of coming together and addressing all the concerns at one time. Third, when patients are awoken from deep sleep, they’re not going to be as engaged as they would be when they are alert and comfortable. Finally, patients, and even children and teenagers, appreciate having the doctor talk with them instead of having the doctors talk over them or away from them in the hallway.

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