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FDA, Media, Research, Science Policy, Sexual Health, Women's Health

“A historic moment for women”: FDA approves the first drug to treat hypoactive sexual desire disorder

"A historic moment for women": FDA approves the first drug to treat hypoactive sexual desire disorder

20705116491_5351758c67_zRoughly 16 million women over the age of 50 suffer from low sex drive. Yet, until recently, there were no FDA-approved medications to treat the lack of sexual thoughts and desire experienced by women with hypoactive sexual desire disorder (HSDD).

That’s why the U.S. Food and Drug Administration’s recent approval of the drug flibanserin (sold under the brand name Addyi™) to treat women with HSDD, is such big news.

“It’s a historic moment for women,” said Leah Millheiser, MD, director of Stanford’s Female Sexual Medicine Program, in a story published today in the San Francisco Chronicle. HSDD, Millheiser explains, is more than the occasional loss of sexual desire that can result from changes in hormones, stress and discontent in a relationship. “These are women who want to have sex with their partner, they’re attracted to their partner and used to love having sex,” Millheiser said. “It’s as if someone turned off the lightbulb.”

It’s tempting to equate flibanserin to Viagra (the drug approved to treat erectile disfunction in men), but this is clinically inaccurate. As explained in the article, Viagra treats erectile dysfunction by increasing blood flow to the penis, while flibanserin works on the brain.

From the story:

The drug [flibanserin] was first developed as an antidepressant. Like other antidepressants, it works on the brain’s serotonin levels, but researchers say it works on different serotonin receptors than other similar antidepressants.

It didn’t work to relieve depression, as it turned out, but patients reported increased sexual desire.

In clinical trials, researchers said 53 percent of women who took the drug reported an increased desire for sex and 29 percent said the drug decreased their level of distress over their condition. In the trials, the number of “satisfying sexual events” reported by participants essentially doubled from an average of 2.5 per month before they received flibanserin to five while taking it.

Millheiser credits Viagra for helping to pave the way for this new approved treatment for HSDD.  “As a result of Viagra, there was an explosion in research and understanding into what sexual dysfunction is and how we treat it,” she said. “It took 17 years to … get to this day,” she said.

Previously: When hormonal issues interfere with mental healthFemale sexual health expert responds to delay in approval for “Viagra for women and Speaking up about female sexual dysfunction
Photo by Day Donaldson

Global Health, Medical Education, Medicine and Society, Patient Care, Public Health

Exploring the benefits of pursuing anthropology and medicine

Exploring the benefits of pursuing anthropology and medicine

3470650293_60b27d6539_zAs a PhD student in medical anthropology, and having come from a very “medical family,” pursuing an MD has been a kind of shadow-dream of mine. For a year or two in high school, I was convinced that neonatology was the path for me; now I’m a doula and research the culture of childbirth.

Some people do live the double dream, and I recently interviewed two of them: Jenny Miao Hua at the University of Chicago and Rosalind Franklin University’s Chicago Medical School, and Stanford’s Amrapali Maitra, both of whom are medical anthropologists pursuing PhD/MD degrees. (Amrapali has brought an anthropological perspective to Scope through our SMS Unplugged series.)

The two came to their joint degree from different sides: Hua was an anthropology student interested in Chinese medicine and the body, while Maitra was enrolled in medical school and became serious about understanding the social context of illness. Each intends to pursue internal medicine, and each, incidentally, has family connections in the site she chose to research. We talked shop for quite a while, and what I found most interesting was their thoughts on what anthropology brings to clinical practice:

Maitra: On the broadest level, anthropology gives you an immense empathy for your patients and allows you to see them as people. It sounds cliché, but with the focus on efficiency and evidence-based medicine that has taken over American biomedical practice, even the most kind and caring individual can lose [his or her] empathy. And the kind of empathy you get from anthropology is not just sympathizing with the person, but really understanding where they’re coming from, historically and because of their life position: why they live in a certain neighborhood or have a certain diet. It allows you to think creatively about what they’re able to do or not do in pursuing their own health.

Hua: With anthropological training, students understand the various ways pathologies are dependent on larger socioeconomic forces. As a practicing physician, the person who comes through the door is never a textbook patient, so within a very short amount of time you have to pick up on this deep history, and when you’re not careful you end up stereotyping and profiling. Anthropology brings a more nuanced way of thinking about patients: they’re not just uniform biological entities, but hybrids of biology, society, and culture.

Maitra: I’ve seen so many clinic visits where I can tell, as the anthropologist in the room, that the attending physician and patient just have completely different agendas. There are simple questions like those Arthur Kleinman has laid out, asking what about the pain bothers her, why she thinks she’s having it, what she hopes to get out of the encounter. I see some doctors use these, and their visits go so much better. They’re able to build an alliance with their patient that’s very therapeutic.

That’s anthropology on the individual level, but on another level it allows you to recognize that certain things are trends. It allows you to think systematically about different kinds of structural violence. For example, why is it that so many people whose occupation is picking strawberries come in with knee and back pain issues? Treating pain is not going to solve the problem. It’s about getting to the root of the occupational hazards of being a farm worker.

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Neuroscience, Pediatrics, Research

Stanford team uses brain scans to forecast development of kids’ math skills

Stanford team uses brain scans to forecast development of kids' math skills

multiplication-table-2Back in the third grade, I did not like math. It was boring! It was hard! Why did I have to memorize the times tables, anyway?

Did this mean I would have trouble with math for the rest of my life, or would I get over my eight-year-old’s funk and end up being good at it? At the time, there was no way to know. But now, in a longitudinal study published today in The Journal of Neuroscience, a team of Stanford researchers show that scans of third graders’ brains forecast which children will eventually do well in math and which of them will continue to struggle.

The resting MRI scans collected in the study evaluated the brain’s structure and connectivity between different brain regions in 43 eight-year-olds of normal intelligence. The researchers also gave the children several standardized tests outside the scanner. They then re-tested the kids’ math skills regularly for the next six years.

The brain scans were better than standard IQ, math or other tests at predicting how the children’s math skills would develop. Larger volume and greater connectedness of specific brain regions at age eight was linked to better math skills down the road. From our press release:

“A long-term goal of this research is to identify children who might benefit most from targeted math intervention at an early age,” said senior author Vinod Menon, PhD, professor of psychiatry and behavioral sciences. “Mathematical skills are crucial in our increasingly technological society, and our new data show which brain features forecast future growth in math abilities.”

In addition to identifying at-risk kids, the scans may help scientists design better ways to help them. Because the new work gives a baseline understanding of brain features in children with normal math skills, it may help guide efforts to strengthen the brains of kids with math difficulties. The researchers, who are now exploring how math tutoring changes the brain, encourage parents and teachers not to give up on children who have a hard time with math:

“Just because a child is currently struggling doesn’t necessarily mean he or she will be a poor learner in the future,” said [Tanya] Evans, [PhD, first author of the new study].

As for me, math never became my favorite subject. But I did eventually shake my early aversion to it. Since my job requires me to understand a range of mathematical concepts, I’m grateful — and I hope the new work being done at Stanford will allow today’s struggling third-graders to someday say the same.

Previously: A not so fearful symmetry: Applying neuroscience findings to teaching math, Peering into the brain to predict kids’ responses to math tutoring and New research tracks “math anxiety” in the brain
Photo by jmawork

Global Health, Health Policy, Stanford News

E-cigarettes a growing cause for concern in the developing world

E-cigarettes a growing cause for concern in the developing world

11505926173_7be7ca343b_zIt is a common misconception that e-cigarettes are a problem only in wealthy nations, say two Stanford global health researchers in a commentary published today in the Journal of the American Medical Association. In the piece, co-authors Michele Barry, MD, FACP and Andrew Chang, MD, call attention to the widespread availability of e-cigarettes in the developing world and a growing concern over the potential health implications unique to low- and middle-income countries.

Chang, an internal medicine resident in Stanford’s Global Health track planning to specialize in cardiology, has been closely tracking the conversation around global tobacco control, but noticed e-cigarettes have been largely absent from the discussion. With support from Barry, director of the Center for Innovation in Global Health, Chang dug deeper and found that while U.S. health officials and researchers have been grappling with uncertainties around e-cigarette regulation and health impacts, the rise of e-cigarettes has in fact become a global threat.

The authors point to a 2014 survey from the World Health Organization suggesting that already, more than half of the world’s population is living in countries where e-cigarettes – or electronic nicotine delivery systems (ENDS) – are available. Public awareness in many of these countries is high and the devices are cheap.

But in some parts of the world, notably Africa and South Asia, there is little to no data on e-cigarette awareness and usage trends. This is of particular concern, say Barry and Chang, as regions like Africa and South Asia represent vast potential markets and are likely to be hit hardest by the growth of e-cigarettes.

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Microbiology, Pregnancy, Research, Stanford News

Stanford microbiome research offers new clues to the mystery of preterm birth

Stanford microbiome research offers new clues to the mystery of preterm birth

preemie-holdinghandsPremature birth affects 450,000 U.S. babies each year and is the leading cause of newborn deaths. But in about half of cases, doctors never figure out what triggered premature labor in the pregnant mom.

Now, there’s a new clue: A Stanford study, published today, gives important details of how the microbiome – the body’s community of bacteria – behaves in women whose pregnancies go to the full 40-week term, and what’s different in women whose babies come three weeks, or more, early. A specific pattern of vaginal bacteria was linked to greater risk of preterm delivery, and the longer the pattern persisted, the greater the risk, the study found.

The work is one piece of a larger effort by the March of Dimes Prematurity Research Center at Stanford to bring experts from many branches of science together to work on preterm birth. The researchers collected weekly bacterial samples throughout pregnancy from four body sites for 49 pregnant women, of whom 15 delivered prematurely. Patterns of vaginal bacteria that were dominated by lactobacillus bacteria were linked to low prematurity risk. Such patterns had already been shown to be linked to health in non-pregnant women.

A pattern of high bacterial diversity, low lactobacillus and high levels of gardnerella and ureaplasma bacteria was linked to higher prematurity risk, the study also showed. This was especially true if the high-diversity pattern persisted for several weeks. From our press release about the new research:

“I think our data suggest that if the microbiome plays a role in premature birth, it may be something that is long in the making,” said the study’s lead author, Daniel DiGiulio, MD, a research associate and clinical instructor in medicine. “It may be that an event in the first trimester or early second trimester, or even prior to pregnancy, starts the clock ticking.”

The researchers also followed the women’s bacterial communities for up to a year after their deliveries and found that all new mothers shifted to the high-risk pattern, regardless of if their babies were born early or on time or if they had a c-section or vaginal delivery. This finding may help explain why women with closely-spaced pregnancies are more likely to have a preterm baby the second time around, however more work is needed to better understand this discovery, concluded researchers.

Ultimately, the research team hopes to use their findings to develop interventions that could prevent preterm birth. That would definitely be good news for moms and babies.

Previously: Counseling parents of the earliest-born preemies: A mom and two physicians talk about the challenges, Stanford/VA study finds link between PTSD and premature birth and Maternal obesity linked to earliest premature births, says Stanford study
Photo by bradleyolin

Addiction, In the News, Myths, Patient Care, Public Health, Public Safety

“24/7 Sobriety” program may offer a simple fix for drunken driving

"24/7 Sobriety" program may offer a simple fix for drunken driving

8684229367_2826035583_zEvery now and then I read a story that takes what I think I know about a certain topic and turns it upside down. Today, my understanding of programs to reduce drunk driving were upended by an article written by Keith Humphreys, PhD, professor of psychiatry and behavioral science at Stanford.

As Humphreys explains, many people mistakenly believe that no one can overcome a drinking problem without treatment involving a professional’s help. This, he says, is a myth, and the success of the “24/7 Sobriety” program highlights the importance of exploring and adopting new ways to combat drunken driving. From the Wall Street Journal article:

Offenders in 24/7 Sobriety can drive all they want to, but they are under a court order not to drink. Every morning and evening, for an average of five months, they visit a police facility to take a breathalyzer test. Unlike most consequences imposed by the criminal justice system, the penalties for noncompliance are swift, certain and modest. Drinking results in mandatory arrest, with a night or two in jail as the typical penalty.

The results have been stunning. Since 2005, the program has administered more than 7 million breathalyzer tests to over 30,000 participants. Offenders have both showed up and passed the test at a rate of over 99%.

Counties that used the 24/7 Sobriety program also had a 12% decrease in repeat drunken-driving arrests and a 9% drop in domestic-violence arrests, according to a 2013 study.

A possible reason why this program works — when attempts to help people with drinking problems often fail — is that the twice daily breathalyzer tests have immediate consequences, Humphreys explains. “It turns out that people with drug and alcohol problems are just like the rest of us. Their behavior is affected much more by what is definitely going to happen today than by what might or might not happen far in the future, even if the potential future consequences are more serious.”

Previously: Can the “24/7 sobriety” model reduce drunken disorderly conduct and violence in London?Alcoholism: Not just a man’s problem and Stopping criminal men from drinking reduces domestic violence
Photo by: KOMUnews

Neuroscience, Research

Exploring the role of prion-like proteins in memory disorders

Exploring the role of prion-like proteins in memory disorders

Over on the Mind the Brain blog, Stanford psychiatrist Shaili Jain, MD, discusses disorders of memory, including post-traumatic stress disorder and Alzheimer’s, with Nobel Laureate Eric Kandel, MD.

Ongoing research conducted by Kandel has helped scientists better understand the basic molecular mechanisms underlying learning and memory. His latest study showed how prion-like proteins, which are similar to the prions behind bovine spongiform encephalopathy and Creutzfeld-Jakob disease, are key for maintaining long-term memories in mice – and likely other mammals.

In Jain’s conversation with Kandel, she asks him how these new findings may translate clinically and impact patients diagnosed with memory disorders. He responds:

We are already there in some areas. We have far to go in other areas, but I will give you an example. We have a pretty good understanding of Alzheimer’s disease. We know the toxicity of beta amyloid. We do not know why the drugs that are directed against beta amyloid do not work, but one possibility that is being seriously entertained is that by the time the patient comes to see a physician, they have had the disease for ten years. That is a very long time and you lose a lot of nerve cells in ten years, and drugs do not bring nerve cells back once they are dead.

We need to diagnose the disease earlier and a major effort now, in Alzheimer’s research, is early diagnosis. Imaging, cerebral spinal fluid, genetic warning signals etc.

The other thing is it has proven possible to define an independent disorder, age related memory loss. Recent work from our lab, and that of Scott Small, has shown there is a separate entity, independent of AD, called Age Related Memory Loss. We have identified the molecular pathways involved in that disorder. We have treatments that work very effectively in animals. I think the time is going to come soon when these will be tried in people.

All of these came out from a basic science and work with experimental animals. So even though we are in the very early stage of understanding the really complex functions of the brain, we are making progress and all of this will hopefully have some therapeutic impact.

Previously: Memory of everyday events may be compromised by sleep apnea, Malfunctioning glia – brain cells that aren’t nerve cells – may contribute big time to ALS and other neurological disorders and The state of Alzheimer’s research: A conversation with Stanford neurologist Michael Greicius

Medicine and Literature, Stanford News

Charlotte Jacobs on finding “snippets during every day” to balance careers in medicine and literature

Charlotte Jacobs on finding "snippets during every day" to balance careers in medicine and literature

Stanford oncologist Charlotte Jacobs, MD, loved reading biographies as a child. But it wasn’t until years later, while on sabbatical at Stanford, that she decided to take a creative writing course and begin cultivating a second career as a biographer.

Her first biography, Henry Kaplan and the Story of Hodgkin’s Disease, was published in 2010 and chronicled the life and work of one of the foremost physician-scientists in the history of cancer medicine. Her latest book, Jonas Salk: A LIFE, tells the remarkable story of the man who conquered polio. The New York Times called Jacobs latest biography, “science writing at its best.”

In a recently published Q&A on the Department of Medicine website, Jacobs discusses how she balances her roles as mother, physician and author. “I could find snippets during every day to write. Even today I find that to be the case,” she says.

On the topic of being able to meld her doctor life with her writer life, Jacobs says:

I don’t meld the two at all. When I’m writing or doing research on one of my books, I’m totally focused on that. And when I’m with my patients, I’m totally focused on them. One thing I learned from Henry Kaplan, who had a whirlwind of activity surrounding him, was that when he was in the exam room, the patient was his only concern.

“I do think my background in science helped me be a better writer, though. I chose subjects who were in the field of science or medicine because that is what I know. One of the hardest tasks was interpreting my subjects’ work to the general public. I used to think if my next-door neighbor, who was a smart housewife, couldn’t understand and enjoy the books, I had failed.

“Knowing academic medicine also helped. Jonas Salk ran into major political hurdles, and he was not treated kindly—some of which was his own doing. Having spent my entire career in academic medicine, I could understand the world in which he worked.

Previously: Stanford doctor-author brings historic figure Jonas Salk to lifePrescribing a story? Medicine meets literature in “narrative medicine”, Literature and medicine at life’s end, Poetry’s connection to medicine and the body and More than medicine: Stanford medical students embrace their artistic passions through unique program

Behavioral Science, Mental Health, NIH, Public Health, Research

Developing certain skills may help you cultivate a positive outlook

34835574_9e61cfe6bb_zMany of us have heard that having a positive outlook on life can improve our mental and physical health. Yet, if you’re like me, you’ve noticed that it can be hard to focus on the bright side of things when you’re feeling anything but positive.

That’s why I was drawn to this article in the National Institutes of Health (NIH) newsletter. It discusses several NIH-funded studies on the topic and explains what it means to have a positive outlook and how a positive mood can affect your health. The really helpful information, from my perspective, is it also explains how developing certain skills, like meditation and self-reflection, can make you can feel more positive more often. From the NIH story:

Having a positive outlook doesn’t mean you never feel negative emotions, such as sadness or anger, says Dr. Barbara L. Fredrickson, a psychologist and expert on emotional wellness at the University of North Carolina, Chapel Hill. “All emotions—whether positive or negative—are adaptive in the right circumstances. The key seems to be finding a balance between the two,” she says.

The research teams used a variety of techniques to learn about the underlying mechanisms of positive and negative emotions and what it is that enables people to bounce back from difficult times.

Among those who appear more resilient and better able to hold on to positive emotions are people who’ve practiced various forms of meditation. In fact, growing evidence suggests that several techniques—including meditation, cognitive therapy (a type of psychotherapy), and self-reflection (thinking about the things you find important)—can help people develop the skills needed to make positive, healthful changes.

“Research points to the importance of certain kinds of training that can alter brain circuits in a way that will promote positive responses,” Davidson says. “It’s led us to conclude that well-being can be considered as a life skill. If you practice, you can actually get better at it.”

Previously: Navigating a rare genetic disorder with a positive attitudePromoting healthy eating and a positive body image on college campusesWhen life gives you lemons: Study suggests the benefits of a positive outlook are context dependent and The power of positive moods in improving cognitive function among older adults
Photo by: premasagar

Behavioral Science, Emergency Medicine, Health Disparities, Pain, Patient Care, Pediatrics, Research

Blacks, Hispanics and low-income kids with stomach aches treated differently in ERs

Blacks, Hispanics and low-income kids with stomach aches treated differently in ERs

crying-613389_1280When a child arrives in the emergency room complaining of a stomach pain, appendicitis is the last thing you want to miss, says KT Park, MD, assistant professor of pediatrics.

“The question is, ‘Does this patient have appendicitis – yes or no?,” he said. It is the most common immediate emergency that could bring a child into the emergency room with abdominal pain. If not treated in a timely manner, the appendix can burst, leading to infection or a host of other serious complications.

But kids arrive in the emergency room complaining of stomach aches all the time; most with perfectly healthy appendices. And what if you’re a doctor who has seen seven kids with more minor stomach problems one day? It might be tricky to spot that first case of appendicitis.

Unfortunately, misdiagnosis happens more often when the pediatric patient is black, Hispanic or low-income, according to a study published today in PLOS ONE led by Park and Stanford medical student Louise Wang.

“Our goal in this study is getting the word out about abdominal pain and appendicitis and the importance of the decisions made in the emergency room,” Wang said.

The researchers analyzed national data from 2 million pediatric visits to emergency rooms between 2004 and 2011 complaining primarily of abdominal pain. They found that blacks, Hispanics and low-income children were less likely to receive imaging that could help their physicians diagnose serious conditions like appendicitis. These patients were also less likely to be admitted to the hospital, but more likely to suffer perforated appendicitis, a clue that perhaps they didn’t receive adequate treatment in time, Park said. For example, low-income blacks were 65 percent more likely to have a perforated appendix compared to other children.

The study was not able to precisely determine why these disparities exist, Wang said. “What is the driving influence of these outcomes? Are these kids being mismanaged in the emergency department, or are they presenting at a later time in a more serious condition?,” she asked.

She and Park have a few ideas, based on other findings and their personal experience. Minorities and low-income families are more likely to use the emergency room as a first-stop for more minor conditions, rather than visiting their primary care doctor or pediatrician.

“This is a very delicate topic,” Park said. “Physicians are humans and there is potentially some intuitive thinking that goes on about the probabilities of various diagnoses more common in certain patient groups, potentially leading to differences in how clinicians perceive the acuity of a patient’s status.”

Appendicitis can be tricky to diagnose, a task made even harder when patients are young and unable to clearly describe their pain, Park said.

“The psychology of physicians is an area needing further evaluation,” Park said. “We have internal biases that we often are not even aware of. We want to be objective, but it’s never a black-and-white decision making tree.”

Previously: A young child, a falling cabinet, and a Life Flight rescue, New test could lead to increase of women diagnosed with heart attack and Exploring how the Affordable Care Act has affected number of young adults visiting the ER
Photo by amandacatherine

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